tricks of the trade/EM

[EMEDPA]

I was thinking that there are a # of procedures done routinely in em that are not taught very well and would like to start an occassional series regarding how to do some of these. davis posted" how I I+D abscess" a while ago along these same lines and it was well received so here goes:

hypothetical situation: necklace bead in nose of 3 yr old child.

typical presentation: fb reported to parents in nares< 1 day.common items are beans, beads, popcorn, etc

commonly utilized techniques that I have seen tried without much success:

suction- if it could be blown/sucked out they wouldn't be in the er.

glue/dermabond on qtip-doesn't work

forceps-bloody mess

having parents occlude 1 nostril and blow in mouth to expel out offending side-see suction above- always recommended by ent, never works

 

my standard technique: using a malleable/blunt loop type ear currette I shape it into a hockey stick type bend anD slide it along the lateral wall of the nares behind or adjacent to the object. applying a bit of anterior pressure the object invariably pops out. no blood, no mess. since starting this technique have not had to call ent once for an o.r. fb removal

[BobbyHillJr]

Thanks for the tip--I am new to ED practice and I will definitely try this.

[Guest texsurromom]

Now where were you when my son got a cell phone button stuck up his nose? :) Thanks for sharing that... we are at the ENT's every two weeks for something else and I may ask him to demonstrate for me so I have a better understanding.

[tlahut]

E,

 

More FB approaches. Definitely an important area, since there is potential for true airway compromise. Nightmare is a dislodged FB going with down ® mainstem bronchus. These have worked for me.

 

1] Blow to expel:

 

Occlude unaffected nostril and, using pediatric Ambu bag with facemask placed over mouth (but not the occluded nares), blow in mouth to expel out of the offending side. (All those PALS instructors out there will frown at cracking the pediatric "code" cart.)

 

Best used with squirmier kids, since facial manipulation is always "iffy" when you need a steady hand.

 

(I’m presuming we’re not doing Ketamine?!? Right???)

 

Poorer result when FD is NOT round, since complete occlusion is needed for expelling with air.

 

Minimal risk of barotrauma to TMs or lungs, if you coordinate with inspiring, (just after the scream, but with beginnning of inspiring.)

 

 

2] Arthroscopy Alligator

 

For better or worse, after years in the OR, I’m a veteran of many surgical interventions. In the past, I’ve asked the charge nurse for an arthroscopic alligator clamp (or grasper / grabber) "borrowed" from the hospital OR supply. This is a typical type, but many versions are out there.

http://www.dotmed.com/listing/71086

 

For particularly small objects, which tend to lodge deeply into the nasal passage, being able to slide this set of tiny jaws into a tight space is very slick.

 

Poorer results, though, with really hard & smooth items, like a pearl. However, will grab plastic and organic items very well.

 

 

3] Only once in my ER career have I use a Frazier suction to remove an ENT foreign body. It was a wad of crumbly clay, mixed with the mucous. Quite yucky.

http://www.busseinc.com/suction/suction_fraziers.htm

Tremendous potential for iatrogenic damage. Not generally recommended.

 

 

4] Hockey-stick ear curette is a favorite approach. Thanks for the description. Steady hand is a plus.

 

 

5] Punt:

Our local ENT attendings generally are happy to follow these patients in the office, so I’ve referred some after discussion with ENT, provided the FB is in a stable location.

 

They often say something to the effect of, " Well, give it your best shot, but I’ll be happy to see them tomorrow."

 

Communication with the parents in the decision making process is an excellent strategy, since child inevitably will be crying.

 

But weighing minimal costs, in terms of limited patient distress, to the great benefit of creating a safe airway with a prompt, good outcome is well worth learning the various skills here.

 

All the best,

 

-Tom

 

.

[JENpa2005]

Thanks for the tips!!!! I am starting my first job in Emergency medicine next month, all these tips will be AWESOME.

 

thank you

[CornellSPA]

Great stuff! I have found a little viscous lido on a q-tip anterior to the FB, applied before inserting anything helps abit too--it numbs the area and provides abit of lubrication as the item slides out. Then take a spare suture and make a necklace out of the items for the kids to take home!

[Guest Paoha]

You are a natural with peds I'd bet. What a terrific way to inject a clinical, often frightening experience with some human feeling and get a smile in your day. Just as important as extraction (esp. with peds)

[paintx]

slide a pedi foley catheter past FB, inflate bulb, pull out. Works every time.

[EMEDPA]

time for another slick trick:

the use of small 2-4 mm punch biopsies in the e.d. setting can be helpful in several situations:

after local anesthesia a punch biopsy can be used to :

1.remove a superficial/embedded fb, including a ticks head

2. remove a core of tissue likely to contain pseudomonas after a nail through sneaker type injury

 

after the core of tissue is removed the area can be further irrigated to remove any residual microscopic particles. antibiotic prophylaxis should still be used when indiactaed but removing the offending fb or contaminated tissue significantly decreases the likelihood of a later infection

[Guest mtdfwtx]

slide a pedi foley catheter past FB, inflate bulb, pull out. Works every time.

 

 

This one worked like a charm on my 4 year old who stuck a raisin up his nose, which of course swelled up into a plump, juicy "grape". The pediatrician in the UCC tried it after a few different attempts.

[EMEDPA]

This one worked like a charm on my 4 year old who stuck a raisin up his nose, which of course swelled up into a plump, juicy "grape". The pediatrician in the UCC tried it after a few different attempts.

 

that trick works to remove fb's from any number of orifices...let's just leave it at that, ok....:)

[EMEDPA]

how I remove fb's from the eye:

1st topical anesthesia with tetracaine, etc

next try a moist qtip. many fb's are not embedded and come right off without digging for them.

for embedded fb's(from grinder, etc) I use an eye spud 1st. failing that I try an 18g needle next. for rust rings I use the eye burr.

remember to always evert lids to look for additional fb's.

with tiny fb's or those not seen on initial exam I always use a slit lamp. for large fb's I use magnification loupes.

always remeber to update tetanus for eye fb's and corneal abrasions. remember too that your removal of an embedded fb creates a corneal abrasion so treat with erythromycin eye ointment and some vicodin for a day or 2. also advise sunglasses as they will be light sensitive for a bit.

[EMEDPA]

just another rapid rhino story-

elderly htn/coumadin pt today with posterior epistaxis and inr=5.

size 7.5 rapid rhino after afrin worked like a charm....love these things....

( gave a bit( 5 mg) of subq vit k as well just for good measure but bleeding stopped before vit k given...

[jmj11]

Any suggestions on this one. It's been 12 years since I've worked the ER but this is a case that I couldn't help.

 

I had a (??) 3-4 year old girl who came in with a unilateral rhinorhea for over a month. Her ped had been treating her as a sinusitis.

 

I did look up her nose (which the mom said the ped had not done) and the right side was occluded. Looking through the otoscope, I could detect (in the midst of mucous) an edge of something white.

 

To make a long story short, it was a rolled up piece of dryer sheet (the kind that softens clothes). However, it had been up there so long that it was breaking up in little pieces each time I gasped it.

 

The little girl was not happy. Eventually (even after consulting with the SP) sent her down town to the ENT. They ended up admitting her and taking her to the OR under general anesthesia the next morning to remove it.

 

So a soft, pliable, deteriorating FB, any secrets that may have worked in the ED?

[EMEDPA]

Mike- I usually use a malleable metal ear currette for these. you can get it behind the object and remove it in 1 piece. I haven't had a lot of luck with foreps for the reasons you mentioned.

[JenGintheED]

I used to be a big fan of the rhino rocket, but lately I have been using merocel sponges and like them better. More comfortable, and they seem to work when rhino rockets fail.

 

Since the SEMPA conference, I have started packing the nose with cotton soaked in LET, them keeping them for 1h obs after hemostasis, encouraging them to walk around a bit. LET works nicely for me, and by doing the 1h obs I've caught a few that would have been repeat customers.

 

SEMPA conference rocks :p

[EMEDPA]

I don't use the rhino rocket I use the rapid rhino which is the next generation product with a balloon and coagulant. 15 second application/100% success rate for me even with posterior bleeds in pts on coumadin with htn.

http://www.arthrocareent.com/wt/page/rapidrhino

[bradtPA]

That stuff is pretty amazing; I will have to keep it in mind if I end up in the ED in a few months. And I remember the days when the doc on duty would shove a foley catheter up the nose to try to stop the bleed when we didn't have anything else:D.

[JenGintheED]

Your link is to the product we have in our ED. I didn't know that the rapid rhino and rhino rocket were not the same thing. Too many rhinos :) Anyone know what the difference is?

[EMEDPA]

Your link is to the product we have in our ED. I didn't know that the rapid rhino and rhino rocket were not the same thing. Too many rhinos :) Anyone know what the difference is?

 

rhino rocket is basically a foam chunk with an injector.

rapid rhino is a balloon covered with mesh that contains a coagulant. you soak it for 15 seconds in water to activate the coagulant then place it vertically along the septum and inflate with 5-10 cc of AIR to a level the pt can tolerate that also stops bleeding. inflate slowly because the pressure is not really comfortable if done quickly.

[Hemegroup]

that paints a funny picture...FWOOP

[JenGintheED]

Thanks, E! I don't think I've ever seen a rhino rocket, based on your description... I need to change my terminology.

[EMEDPA]

Thanks, E! I don't think I've ever seen a rhino rocket, based on your description... I need to change my terminology.

 

http://www.shippertmedical.com/product_info.php?cPath=63&products_id=513&osCsid=8uqekd7hl7jo1rofifp9725823

[rcdavis]

LOL with large lac involving wax paper thin skin.

 

Hate to steristrip, essentailly puts her on sponge baths for 2 weeks, but regular sutures simply pull thru the skin.

 

Learned this long ago:

 

apply a little benzoin to the wound edges, then cut 1/2 inch steri strips to apply parallel to the entire length of the edges (secured firmly by the benzoin), on both sides.

 

suture thru the steristrips (will hold 5/0, 6/0, even 4/0 interrupted, vertical or hortzontal mattresses). Pulls the wound together nicely, allows for eversion control, and familys are MUCH happier. leave in 2-3 weeks.

 

For me, works every time, tho is not as quick as asking nursing to simply "steri strip wound and d/c"

 

davis

[autumn_george]

EMEDPA: All the tips you give are identical to my EM instructors. You don't happen to teach in AZ do you? :)