AIRWAY VISUALIZATION – EXTERNAL “CEPHALIC” MANIPULATION

Here is a potential airway technique that may help with visualization: hold the laryngoscope in the left hand (the usual) but the right hand, instead of being at your side, is behind the patient’s head. You then move it around until you get the best view. Then you have an assistant hold the head in that spot.

 

A hospital in Southern California started doing that. The technique deserves some exploration. The work of Richard Levitan reminds us that the airway is most patent in the sniffing position. Extension does not really help but true sniffing position does. Sometimes you think you have enough and you need more.

 

I have not seen this technique studied but it probably deserves some attention.

 

TAKE HOME POINTS

-Consider external cephalic manipulation as an analogy to “external laryngeal manipulation” as a way of fine tuning the visualization during a tough intubation

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INDIRECT LARYNGOSCOPY

A patient presents with severe sore throat. You wonder about epiglottitis. You know that using a mirror to look at the epiglottis is a great way to check this but are not confident in your skills. What do you need?

 

Dental mirror – they are cheap, have your ED stock them

 

Light – can use a headlamp, the kind that are sold in outdoor stores. Get one with a spot beam rather than a flood light. Nice to have regular AAA batteries instead of the medical ones with cords that are always getting lost or damaged

 

Relaxed patient – explain to them what you are doing and rehearse it once first

 

Anatomy – have them lean forward, chin out

 

View – wrap gauze around their tongue. Don’t pull it out but hold it so they don’t have to sustain muscle contraction to keep the tongue out

 

No gag – not sure topical anesthetics really work. Try to avoid hitting their pharynx with the mirror until you are ready to lift the uvula and look. Have the patient fix vision in the distance. Have them say “eeeeeee.” Have them do slow panting style shallow breathing.

 

No fog – hydrogen peroxide or hot water will help prevent fogging

 

You look and it is hard to see. That reminds us the final thing you need – practice!

 

TAKE HOME POINTS

-Indirect laryngoscopy is a complex hand-eye skill that you can learn

-Get the right supplies and start doing this now. It may really help you one day.

FINGER TEST FOR NECROTIZING FASCIITIS

A patient presents with a deep muscle abscess. Is this necrotizing fasciitis? All too often I see the deliberation focus on things like the laboratory score or the imaging. The role of those things are being debated but what is beyond debate is to have the bedside skills for recognizing necrotizing infections.

 

Childers in 2001 and 2002 described the finger test as a diagnostic intervention at the bedside. It does not get enough attention. The instructions are to make a 2 cm incision down to fascia. “…if the tissues dissect with minimal resistance, the finger test is positive”

 

Other signs:

-lack of bleeding

-grey necrotic tissue

-dishwater purulence

 

There is no reason ED physicians should not know this and perform it. We are already making incisions to check for abscess. Know the 4 surgical signs of necrotizing fasciitis.

 

TAKE HOME POINTS

The 4 surgical signs of necrotizing fasciitis are:

-lack of resistant to finger spread

-lack of bleeding

-grey necrotic tissue

-dishwater purulence

 

Childers BJ Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients. Am Surg. 2002;68:109-16.

 

Andreasen TJ, Green SD, Childers BJ. Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans. Plast Reconstr Surg. 2001;107:1025-35.

BLADDER STIMULATION TECHNIQUES FOR NEWBORN CLEAN CATCH URINE COLLECTION

An infant presents with fever. The parents do not want a catheter placed in his penis. You want to check for urine infection. The resident suggests placing a bag. Are there any other options?

 

In 2013 Herreros-Fernendez described a technique of coaxing the child to urinate. She would tap the bladder at a rate of 100 taps per minute, and massage the low back. 86% of the time the child would urinate, with a median of 45 seconds. The population was strictly those less than 30 days of age, so it may not apply to older babies. The idea was inspired by bladder stimulation techniques used in adults with neurological diseases. There may be some element of a frontal lobe “release” reflex involved in the phenomenon.

 

The original study stacked the odds in their favor by feeding the babies, but follow-up studies all showed a greater than 50% success rate within 5 minutes. Thus, this technique is well worth trying in a low risk population.

 

Of note, the bladder tapping was 100 taps per minute. It is supposed to be gentle but the parents may quickly throw in the towel and ask for the catheter.

 

Take Home Points

-For the infant with a low suspicion of urinary tract infection, consider massage and bladder tapping to elicit a urination reflex

 

Herreros Fernández ML et al. A new technique for fast and safe collection of urine in newborns. Arch Dis Child. 2013;98:27-9.

JAW THRUST MASK GRIP

You are intubating a critically ill patient. The first intubation attempt fails and the patient experiences rapid oxygen desaturation. The respiratory therapist tries to ventilate the patient but air leaks out around the mask with each breath. The chest does not rise and the saturation is dropping.

 

What is the problem?

Sometimes the problem is an insufficient seal around the mouth but more often the problem is soft tissue obstruction. We intubate supine. The tongue occludes the airway. The air follows the path of least resistance, which is out the face, leaking around the mask.

 

What are the choices of grip?

  1. One handed grip, aka C or CE grip (generally acknowledged to be less optimal).
  2. Classic two handed grip – taking the problematic one handed grip, and doing it with the other hand too. Similar to the grip you would have if holding a soda can.
  3. Jaw thrust grip – similar to the grip you would have if lifting a gurney or plank, thumbs on top, fingers below doing the work of lifting. Or if you will, taking your soda can and dumping it out forward.

 

Some studies say CE grip or jaw thrust grip are equally effective. So why do you say jaw thrust is better?

Most of the time airway resistance (A) is lower than mask resistance (M). Anything will work in that situation. What really matters is what happens when A is greater than M. That isn’t addressed in most of these studies.

 

What happens when A is higher than M?

When airway resistance is higher than mask resistance, the operator grips harder to raise mask pressure. The fingers often compress the submandibular space. This presses the tongue against the posterior airway, and raises airway pressure further. The harder you grip, the more you close off the airway.

 

What is a better way?

JAW THRUST MASK GRIP

The best way to grip the mask is to press the mask to the face with the thumbs pointing forward. The fingers then fit over the angle of the jaw. If you want more pressure, you pull the fingers, which not only increases the seal pressure but also performs a jaw thrust maneuver. It pulls the tongue off of the palate.

 

Is there anything else that will help?

NASAL AND ORAL AIRWAYS

Place two nasal trumpets and an oral airway. Whether you have great technique or bad technique this will help. Don’t be afraid to “waste” some plastic here. I suspect that nasal trumpets also improve the effectiveness of apneic oxygenation via high flow rate nasal cannula.

 

Back to the case. You put the thumbs pointing forward on the mask and pull jaw thrust with digits 2-5. The leak is gone and the patient is re-oxygenated before your second attempt.

 

TAKE HOME POINTS

-Use the jaw thrust mask grip technique for ventilation

-Good mask ventilation is a crucial airway skill. Invest in it.

-If you are have ANY trouble, place nasal and oral airways

 

Suggested references:

Efficacy of facemask ventilation techniques in novice providers.

Gerstein NS, Carey MC, Braude DA, Tawil I, Petersen TR, Deriy L, Anderson MS.

J Clin Anesth. 2013;25:193-7

UNLOCKING SHOULDER DISLOCATIONS

A patient presents with a recurrent anterior shoulder dislocation. Milch fails but Spaso works. The next month she is back and the procedure feels different, with more resistance. This time Spaso fails and Milch works. Same shoulder, so what is different? Why did the efficacy reverse?

 

Milch’s 1938 article started with a question: why do some reductions seem impossible and then under general anesthesia they become very easy, almost going in spontaneously? It was the muscle and tendon opposition, he concluded, so his technique focused on putting the patient in the muscle neutral position overhead (hanging from a limb position). The various shoulder muscles would share equal stress and equal angles.

 

Milch’s idea has probably not yet been fully fulfilled – it was the idea that shoulder reduction is not about overcoming force but about untangling the humeral head from the adjacent muscles, tendons, and soft-tissues. That was the same idea that inspired Kocher.

 

We have all had the tough shoulder that would not go in with technique A, but after trying technique B, a second attempt with A yielded an effortless reduction. There seems to be an unlocking of the soft structures that occurs.

 

Now as to the unlocking. I suspect there is advantage in the difficult shoulder to running through a variety of techniques. Ideally we would know which soft structures are causing the locking, but the literature lacks consensus and I do not know to resolve that. So I run though a variety of techniques.

 

This is reductionistic but you can think of all techniques as the application of external rotation in different positions.

 

Kocher is external rotation in the adducted humerus, as are all the derivative techniques.

 

Milch is external rotation in the abducted elevated humerus (technically he advocated doing the external rotation on the way up).

 

Spaso is external rotation in the forward flexed shoulder.

 

Back to the bedside. Its your next shoulder attempt. The shoulder is locked in internal rotation. Your goal is to get it into external rotation. You try Kocher but there is too much resistance to external rotation. You laterally abduct to Milch and you came close but did not fully reduce the shoulder. Finally, you perform forward flexion (Spaso) which also does not work. You then go back to Kocher, which this time was successful.

 

Take Home Points:

-The obstruction to shoulder reduction is not bone position but soft structures

-The obstruction can apparently be unlocked through applying external rotation in various positions through the range of motion

-If your favorite technique does not work, range the shoulder, externally rotate, and try it again.


Check out medicalclassics.com for more on Milch. If the link does not work, here is the location.  https://medicalclassics.com/2016/09/05/1938-milchs-shoulder-reduction-techniqueabduction-external-rotation-and-pulsion/

 

KOCHER INTENDED FOR SUBCORACOID DISLOCATIONS, NOT SUBGLENOID

The Kocher technique, one of the oldest and most popular techniques, was developed for the subcoracoid anterior dislocation. Review Neil Cunningham’s resources at shoulderdislocation.net for insight on this, as well as his translation of the original Kocher article.

 

The goal of Kocher’s method, which was worked out on cadavers in 1870, is to roll the greater trochanter of the humeral head on the glenoid rim. It might have been named the “shoulder rim roll.” Here are the steps:

 

1) Adduct the elbow all the way to get the greater trochanter right next to the glenoid rim.

2) Externally rotate to roll the greater trochanter on the glenoid rim.

3) Forward flex the shoulder (sagittal plane) to tip the humeral head back toward the socket.

4) Internally rotate to complete the reduction.

 

Kocher’s words:

“Pressing the arm bent at the elbow towards the body, turning outward until resistance is felt, lifting of the outwardly rotated upper arm in the sagittal plane as far as possible, and finally slowly turning it inward” (translation by Cunningham)

 

DON’T USE THE SHOULDER RIM ROLL IF YOU AREN’T ROLLING ON THE RIM

The subglenoid dislocation will not be resolved with the Kocher technique because the external rotation phase will not latch onto anything. Kocher himself in his article specified that this was for subcoracoid dislocations, and said “the more therefore the head has departed from the coracoid process toward the interior … the less can be expected from the method.”

 

PITFALLS

-Make sure you fully adduct the elbow first.

-Avoid traction, which is what creates the need for sedation(Chitgopar Injury 2005).

-Avoid sedation. This is the best way to avoid too much force. Kocher’s method excluded the use of force. Perpendicular forces of opposing muscles can lead to fracture. If you get resistance, use another technique.

 

TAKE HOME POINTS:

-Kocher’s shoulder reduction was originally intended for subcoracoid dislocations, not for subglenoid.

-Do not use force with Kocher’s method.

 

References:

shoulderdislocation.net (see the lectures and translation of the original Kocher article)

Chitgopkar SD, Khan M. Painless reduction of anterior shoulder dislocation by Kocher’s method. Injury. 2005;36:1182-4.

USE THE SWALLOW PROVOCATION TEST TO ASSESS AIRWAY PROTECTION

A patient presents obtunded. You wonder about airway protection and consider intubation. Is there any way at the bedside to gather more information before choosing to intubate?

 

This has not been well studied in the ED population mentioned above, but if you are wondering whether the patient is going to aspirate oropharyngeal liquids, you could consider a safe trial of seeing how they handle liquids.

 

Called the “swallow provocation test” it is done by injecting a “swallowful,” (ie 10 cc) of water into the mouth of the patient.

 

I have had patients leave the secretions there (so I suctioned them out) and proceeded to intubation. I recall one severely alcohol intoxicated patient swish it around in his mouth like he was seeing what it was, then lean over and spit it on the floor (I wondered what he would have done if it were a drink more of his choosing). He did not get intubated, needless to say.

 

While this approach is not validated, neither is your current approach! So consider using this in situations where you are not sure what they need.

 

Take home points:

-If you are wondering how the patient will handle liquids in the mouth, inject water and find out.

PALPATE JUGULAR VENOUS DISTENSION

An obese patient presents with edema. You look for jugular venous distension and wonder if you see the ebbing in the neck (“Y descent”). Before you order BNP, there is one more thing you can do. Palpate the vein.

Large veins are palpable. In the days before we used ultrasound for central lines many of us had to learn to palpate central veins. They have thin walls and are full of fluid under low pressure, which is similar to the fluctuance of an abscess. An even better analogy would be a “water balloon” feel as you appose the walls of the vein and the edges are smooth against each other. This is sort of like those “magic eye” pictures that look scrambled but actually are three-dimensional. Some people simply can not perceive it. To those I say don’t give up, practice it, especially on yourself, and eventually you will get it.

Take Home Points:

If visualization is not obvious, palpate for jugular venous distension

MANUAL REDUCTION OF SPERMATIC CORD (TESTICULAR) TORSION

A patient presents with right-sided testicular pain and swelling for 1 hour, associated with nausea and vomiting. Physical examination shows tenderness and swelling in both the epididymis and testicle itself. The epididymis is anterior to the testicle, and palpation of the spermatic cord reveals a 1cm nodule about 2 cm above the testicle.

 

You call the urologist because the patient has spermatic cord torsion. While waiting you apply color Doppler ultrasound which confirms no flow. You try to untwist the testicle laterally but there is resistance and increase of pain. Should you wait for the urologist? Is there anything else you can do?

 

The idea that all torsion is medial, treated by “opening the book,” has been demonstrated to be false in every generation, yet the over-simplified teaching persists. Thanks to Sessions’ 2003 excellent article showing 1/3 incidence of lateral torsion, awareness is improving.

 

You go the opposite direction, detorsing medially. The patient experiences relief. Color Doppler ultrasound now shows arterial flow. Torsion can be up to 3 full turns so the patient still needs to go to the operating room. But you have restored arterial flow and improved the patient’s chance of testicular salvage.

 

Endpoints of manual reduction:

-lack of resistance to the reduction

-relief of pain

-resolution of abnormal lie

-testicle drops lower in the scrotum to a normal position

-may feel a “snap” into place (Hinman’s Atlas of Pediatric Urologic Surgery)

-untwisting of spermatic cord knot

-return of color ultrasound flow

 

Take Home Points:

-Torsion can occur in either direction, so use resistance and relief as your first endpoints

-Palpate the spermatic cord knot and note the lie and length as additional endpoints

-Use color Doppler ultrasound as the ultimate endpoint