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The Procedural Pause by James R. Roberts, MD,
& Martha Roberts, ACNP, PNP​

​Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, PNP, are the team behind The Procedural Pause.

The blog will focus on procedures that emergency physicians, residents, and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

This blog conveys personal opinions and experiences, and application of the information here remains the professional responsibility of the clinician. Tthis blog is not intended to dictate standard of care, but is a clinical guide, not a legal document. Do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

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Monday, April 1, 2019

Seventy-five percent of trauma injuries involve some kind of thoracic insult, a quarter of which need a procedural intervention like a chest tube. (Surg Clin North Am 2007;87[1]:95; http://bit.ly/2HaoX90.) Long-term illness, lung disease, and post-operative complications may cause pleural effusions or a pneumothorax, so treating these conditions quickly can significantly decrease patient morbidity and mortality. 

Other indications for chest tube placement include:

  • Trauma: Pneumothorax, hemopneumothorax, or tension pneumothorax
  • Long-term illness: Pleural effusion (cancer, pneumonia)
  • Infection: Empyema, purulent pleuritis
  • Post-surgery, especially after lung, heart, or esophageal surgery
  • Bronchoscopy

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A CT showing a chest tube in the right lung and pneumothorax in the left lung from trauma. Scan courtesy of Clinical Cases.

Inserting a chest tube is literally hit or miss. If you miss, you may seriously compromise the outcome, so you need to embrace a few simple concepts: know your landmarks, know your technique and tools, and know the cautions and what can go wrong.

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This 49-year-old morbidly obese woman had a spontaneous pneumothorax four days after elective bronchoscopy. Note the misplaced pigtail catheter in the subcutaneous tissue to the left of the fifth intercostal space on the right side of the patient's rib cage. The standard approach was used for this insertion without success.

The Basics

Chest tube insertion should be well-rehearsed and instinctive. You should not hesitate to insert a life-saving tube into a pleural cavity immediately to drain air, blood, bile, or pus. Obtaining a thorough history and chest x-ray is absolutely pivotal to your diagnosis. Know your landmarks before insertion: the fourth and fifth intercostal space and the anterior-axial line. Go up and over the rib as you insert chest tubes. Avoid the lower rib margin to prevent injury to the neurovascular bundle.

You can use one of several tube thoracostomy techniques. Most clinicians prefer standard or classic insertion, that is, blunt dissection (incision, Kelly clamp, finger placement, tube placement). Others may prefer the Seldinger technique using pigtails, but these are usually reserved for pneumothorax only. Pigtails can be placed anteriorly or laterally. It may be difficult to place them laterally in obese patients.

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Use ultrasound to identify landmarks. Find the space between the fourth and fifth ribs. Chest wall anatomy should be confirmed before placement to minimize complications. Use a pen to draw out the safe zone to assist with placement. Photo by Martha Roberts.

Insertion Devices and Techniques

  • Classic approach, blunt dissection
  • Seldinger approach, pigtail insertion
  • Trocar insertion
  • Handheld insertion device such as the Reactor
  • Needle thoracostomy

The Trocar

An alternative method utilizes blunt or sharp trocar insertion. These devices are metal or plastic obturators with a sharpened or blunt tip and a hollow tube. The trocar method requires first making an incision in the same place as for the classic technique. A Kelly clamp may or may not be used. The trocar is blindly advanced to the pleura and then forced through the pleura into the chest cavity. The obturator is removed, and the chest tube remains in place. But is it safe to use a trocar chest tube?

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Sharp trocar tips and trocar storage tubes. Photos by Martha Roberts.

Medscape notes that targeted guidewire (pigtail) and trocar-guided placement are considered high risk for complications in the ED, and that the standard or classic technique should be used for emergent thoracostomy. ("Tube Thoracostomy." Nov. 16, 2018; http://bit.ly/2EiYfZ2.) One study noted that even experienced respiratory physicians and thoracic surgeons may overpenetrate the trocar and cause visceral injuries. (Thorax 2010;65[1]:5.)

Trocar insertion techniques may be valuable if there is extensive chest trauma or multiple broken ribs and a risk to the provider entering the chest cavity with an unprotected finger. Trocars may also be useful in morbidly obese patients or in rural settings with limited resources.

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Have your setup with Pleur-evac and suction ready to go before becoming sterile or making an incision. Photo by Martha Roberts.

Trocar Safety

Four of seven reports in a meta-analysis of trocar insertion safety concluded that the technique was associated with a significantly higher rate of tube malposition and complications. (Interact Cardiovasc Thorac Surg 2014;19[1]:125; http://bit.ly/2Sv5F0b.) One of the retrospective reviews in the analysis found the rate of tube malposition to be similar in groups using the trocar and blunt dissection. The authors, however, abandoned the trocar technique because of severe complications like lung and stomach injuries. Other studies in this meta-analysis showed that the trocar was "as safe as and even more effective than blunt dissection alone." A randomized prospective study in cadavers also included in the meta-analysis found fewer complications with blunt tip trocars than sharp ones.

The authors advised avoiding the blind trocar technique for chest tube placement in adults because of the higher incidence of malposition and complications. They recommended using the blunt dissection technique with digital exploration of the pleural cavity before chest tube placement. One of the studies, however, found that blunt dissection into the pleural space, followed by the use of a trocar to direct the chest tube, was as safe as and more effective than blunt dissection alone. (J Cardiothorac Surg 2010;5:21; http://bit.ly/2BPtzOD.)

The type of trocar you choose is also important. A Scandinavian study in 100 human cadavers found misplacements and organ injuries occurred more frequently using sharp-tipped trocars than blunt ones. Success rates were 92 percent using blunt tips v. 86 percent using sharp-tipped trocars. Neither type of trocar showed a significant decrease in time to complete the procedure. (Scand J Trauma Resusc Emerg Med 2012;20:10; http://bit.ly/2IFXgHO.)

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Watch this informal but informative discussion about trocar insertion with C. Trey Dobson, MD, and Dedrick Luikens, DO.

Pearls

  • The British Thoracic Society released well-researched guidelines in 2010 about chest tube emergencies and insertion skills. (Thorax 2010;65[Suppl 2]; http://bit.ly/2Ua2wET.)
  • The society recommends performing erect, posteroanterior inspiratory chest x-rays for suspected pleural effusion and to confirm tube placement. If identification is difficult, increase specificity by adding supine or lateral decubitus x-rays, ultrasound, and finally CT (in that order) to aid in diagnosis. Ultrasound is an emerging technology for assessing tube placement, but chest x-ray is standard of care. (Medscape. "Tube Thoracostomy." Nov. 16, 2018; http://bit.ly/2IGtiU9.)
  • Ultrasound does, however, detect pleural fluid septations with greater sensitivity than CT, and it can be useful during procedures to reduce the risk of organ puncture, according to the British Thoracic Society guidelines.
  • Keep in mind the potential toxicity of lidocaine for localized injection. The maximum dose is 4-7 mg/kg (0.4 to 0.7 mL/kg), depending on whether epinephrine is used. (UpToDate, "Subcutaneous Infiltration of Local Anesthetics," April 3, 2019; http://bit.ly/2H8AeH1.)
  • Consider less common causes of pleural exudates such as tuberculosis, pulmonary embolism, autoimmune disorders, asbestos, pancreatitis, sarcoidosis, lymphoma, post-MI, and post-CABG. Yellow nail syndrome, drugs, and fungal infection can rarely cause this condition.
  • Malignant effusions can be diagnosed by pleural fluid cytology in about 60 percent of cases, but MRI and PET are the most effective, according to the British Thoracic Society guidelines.
  • Give prophylactic antibiotics when chest tubes are placed in trauma patients, particularly in those with penetrating injury. A meta-analysis of five trials found antibiotics significantly decreased the risk of empyema in patients with blunt or penetrating thoracic trauma compared with placebo. (UpToDate, "Placement and management of thoracostomy tubes and catheters in adults and children," Feb. 19, 2019; http://bit.ly/2GNrHdo.)
  • All kinds of things can go wrong. Read about them in the International Journal of Critical Illness & Injury Science (2014;4[2]:143): http://bit.ly/2T3i1BP.

Friday, March 1, 2019

​Immediate relocation of ankle dislocations is necessary to preserve the vascular or neurological integrity of the lower extremity and relieve extreme pain. Literature reviews reveal that early reduction followed by a short period of immobilization (six to 12 weeks) and functional or physical rehabilitation produce good clinical outcomes. (Injury 2017;48[10]:2027).

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Left ankle dislocation from a football accident. Photo by M. Roberts.

Ankle dislocations occur from blunt or traumatic incidents such as sporting events (football, gymnastics), motor vehicle crashes, falling, or jumping. Patients may state that their toes were pointed down or plantar-flexed during the impact or that their ankles were already turned far inward or outward. (Surg Clin North Am 1965;45[1]:79.) Significant force is required to produce an ankle dislocation.

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An x-ray of an ankle joint in the AP view showing fracture-dislocation of the ankle. Source: Creative Commons.

At-Risk Populations

  • Sporting accidents (31%) and motor vehicle crashes (30%) are the most common causes of acute ankle dislocation. (Injury 2017;48[10]:2027.)
  • These injuries usually happen to men and boys.
  • Obese patients and those who smoke are at higher risk. (Bone Joint Res 2013;2[6]:102; http://bit.ly/2DGG94d.)
  • Prior history of ankle fracture, strains, or sprains increases risk.

Ankle Anatomy Review

  • Three bones make up the ankle joint: the tibia, fibula, and talus. Below the ankle joint is the subtalar joint, which is between the talus and the calcaneus.
  • Ankle dislocations tear multiple ligaments and the joint can be unstable, including the deltoid and calcaneonavicular ligament (spring ligament), the anterior talofibular ligament (ATFL), the posterior talofibular ligament (PTFL), and the syndesmosis (includes AITFL, PITFL, TTFL, IOL, ITL).
  • Types of dislocations are anterior, posterior, medial, lateral, superior, or combined.
  • Posterior dislocations (46% of the time) are most common. (Injury 2017;48[10]:2027.) The talus bone is often pushed behind the other ankle bones. Dislocations may also be pushed to either side, to the front, or upward. Disruption of the mortise is variable. (Foot Ankle 1988;9[2]:64.)
  • Ankle dislocation without a fracture is a rare diagnosis. (Clin Orthop Relat Res 2001;[382]:179.) It's more likely to have a fracture-dislocation than a sprain or tear dislocation alone.
  • Neurovascular compromise is also rare, although possible.

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AP image of a normal left ankle in an adult (left). Lateral drawing of the left ankle (right). Source: Creative Commons.

Types of Ankle Dislocations

  • Posterior dislocation: The talus moves backward in relation to the tibia (plantar flexion during the injury).
  • Anterior dislocation: The talus is pushed forward in relation to the tibia (dorsiflexion during the injury).
  • Lateral dislocation: The ankle is twisted from inversion or eversion with associated malleolar fractures.
  • Superior dislocation (pilon injury): The talus is pushed upward in the space between the tibia and the fibula, typically from axial loading such as jumping, falling from a height, or having a foot on the brake pedal in a motor vehicle crash.


Complicated bimalleolar fracture of the ankle and questionable dislocation. Consider CT after reduction of the ankle in such cases.

What to Do?

  • Give intravenous pain medication (opioids are a good choice) and immediate procedural sedation if necessary.
  • Obtain x-ray imaging in the AP, lateral, mortise, and oblique views. The mortise and oblique views are taken with an internal rotation of 10-20 degrees, placing the medial and lateral malleoli in the same horizontal plane, which provides optimum viewing of the tibial plafond and talar dome. (Medscape. April 28, 2016; http://bit.ly/2UljqQk.)
  • Perform closed reduction of the joint and stabilize.
  • Repair any laceration. Larger lacerations or open fractures most likely need immediate orthopedic surgical repair.
  • Obtain bedside fluoroscopy or post-reduction films. Check out our November 2015 blog post on fluoroscopy for a refresher! (http://bit.ly/2Gd5FiP.)
  • Splint immediately at 90 degrees at the ankle. Use short posterior leg splint with short stirrup reinforcement for dislocation without significant fractures and long posterior leg splint with short stirrup reinforcement for fracture-dislocations.
  • Use elevation and ice, and give more pain control. (Roberts and Hedges' Procedures in Emergency Medicine and Acute Care, 7th Edition. Philadelphia: Elsevier; 2017.)

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Short or long posterior splint with important stirrup reinforcement to keep the joint stable. Have all supplies ready to go before you start the procedure. The use of multiple bandages is suggested. This is a two-person job. Watch a video of how this is done.

Long-Term Complications

  • Chronic pain, stiffness, and immobility
  • Infection. Open fractures need antibiotics. (J Trauma Acute Care Surg 2014;77[3]:400.)
  • Nonunion of the bone, or avascular necrosis
  • Multiple surgeries, pins, plates, or other
  • Vascular or nerve damage
  • DVT
  • Use caution for patients with diabetes and peripheral vascular disease, smokers, obesity, advanced age, and pediatric growth plates.

Discharge vs. Surgery

Discharging closed ankle dislocations is acceptable in the emergency department as long as patients have no neurovascular compromise, open fracture, or other orthopedic complications. Acute surgical ankles with open fractures need immediate orthopedic consult washout, repair, and possible pinning or plating, depending on the extent of the injury. Many closed dislocations without fracture can be splinted by EPs with urgent follow-up. This scenario is unusual. Expert consult before discharge is strongly advised. An orthopedic specialist should be involved in all ankle dislocations during the ED visit, closed or open.

Next Appointment: Schedule patients with closed, stable relocations to be seen urgently by orthopedics within five days. Give enough pain control for these injuries to last them until their appointment.

Antibiotics: A Surgical Infection Society guideline recommends that open fractures receive intravenous antibiotics and IM tetanus prophylaxis. Data support a short course of first-generation cephalosporins as soon as possible after injury to lower the risk of infection. (Surg Infect [Larchmt] 2006;7[4]:379.)

Hematoma Block? This may be used as an alternative to conscious sedation. It offers a comparable amount of analgesia without the cardiovascular risk, cost, and time. (J Foot Ankle Surg 2011;50[4]:507.)

Malleolar Fractures: Bimalleolar and trimalleolar fractures are unstable and require operative fixation.

Splinting: Patients should be splinted with the ankle joint at 90 degrees, not bear weight, and be referred to an orthopedist within a few days. (UpToDate. June 8, 2018; http://bit.ly/2UnJElp.)

Rehab: Research about early weight-bearing and physical therapy is ongoing. Rehabilitation for most ankle fractures can be carried out with a basic home exercise program of stretching, range of motion, strengthening, and balance exercises. (JAMA 2015;314[13]:1376; http://bit.ly/2UosAM8.)

Friday, February 1, 2019

​The slit lamp is a straightforward and user-friendly machine designed to make ocular exams easy. All the buttons, knobs, and lights, however, can be intimidating. This should not dissuade practitioners from getting cozy, driving the joystick, and evaluating ocular issues.


An ED slit lamp with an LED light and magnification power up to 40x. Photo by M. Roberts.

ED slit lamps are designed to be a bit more basic in function than those found in an ophthalmologist's office. Many EDs may house more complex machinery, but the vast majority of microscope and light arm combination is set at one length with one lens and one to two magnification options. Machines may be equipped with several filters (blue, red-free, green, gray), but cobalt blue is really the only one you need to rule out corneal abrasions. More basic versions of slit lamps in the ED still allow for full corneal and retinal exams.

Consider a few things before performing a slit lamp ocular exam:

  • Evaluate the space and lighting in the room. You should be able to darken the room, and make sure you have enough room; the machine often takes up a lot of space next to a stretcher.
  • Check the machine and set up. Test the machine to ensure it turns on, and obtain a wheeled stool for yourself and a chair for the patient.
  • Consider the ability of the patient to participate in the exam. Check the patient's ocular pressure using a tonometry pen before completing a slit lamp exam. See our November 2018 blog post for more tips on how to complete a tonometry exam.
  • Prepare other equipment: tetracaine or proparacaine for ocular anesthesia; tissues or gauze for the patient to blot her eyes; fluorescein dye to visualize corneal abrasions; pH paper if there is concern for acid or alkaline burns; cotton swabs for lid eversion in the case of foreign body; an 18 g needle for deep foreign bodies; a corneal burr for rust ring removal; and normal saline in 10 mL syringes for quick ocular washout.

The most important part about mastering the slit lamp exam is to have everything you need prior to having the patient put her face in the chin rest. Set up the machine for your comfort before examining the patient. This includes setting the focal length of the lens, adjusting the height and width of the slit lamp beam or light, and positioning the overall table.

Watch our video to see how to successfully set up a slit lamp machine for an exam in less than five minutes.

Troubleshooting issues with the machine:

  • Is it plugged in?
  • Is it turned on?
  • Is the bulb blown?
  • Is the beam horizontal or vertical?
  • Is the width a slit or a circle?
  • Is the intensity too bright or dull?

Jim Weighs In

  • It's important to have the patient keep his forehead close to the strap so his eye does not go out of focus.
  • Clean the chin strap and forehead bar with alcohol prep before positioning the patient.

Martha Weighs In

  • Wash your hands, and wear gloves for ocular exams.
  • Use the joystick at the base of the slit lamp to fine-tune your image.
  • Most manufacturers suggest waiting a full two to three minutes after turning on the light to reach maximum intensity and illumination.

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The round silver knob, left, is used to adjust the slit length, slit rotation, cobalt blue filter, and fixation star control. The smaller lever above it changes other filters (i.e., red-free, green). The illumination head with an LED bulb, right. Photos by M. Roberts.

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Eyepieces and diopters should be initially set to zero, left. The joystick, right, is for fine-tuning and precise movements during the examination. Photos by M. Roberts. 


This diagram shows what the buttons do and where to locate certain features of the slit lamp.

Monday, December 31, 2018

Rectal exams are difficult for the patient and require true expertise. You cannot expect to complete a good rectal exam or remove a rectal foreign body without the correct information, good bedside relationship, and the right equipment.

Ensuring your patient has confidence in your ability is vital. Take the time to get to know what equipment is available in your ED. It's important to know what to do before a patient comes to your department with a rectal complaint.

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Most departments have a box dedicated to the anoscope. It typically will have two handles for light sources and two sizes of obturators with casing. The items that are not opened will remain sterile, but all other items must be sent to central processing for cleaning and sterilization after use. Photos by Martha Roberts.

The majority of patients who need rectal examinations typically require simple digital exam and proper questioning. A formal anoscopic exam may be necessary if a patient has inserted an object into his rectum that needs removal. It may also be useful to evaluate rectal pain, bleeding, and hemorrhoids. This may often require an x-ray of the abdomen or pelvis.

The anoscope is an excellent tool to complete the full exam. Pelvic speculums may be used if one is not available. A rectal block or expert consultation is warranted if the procedure requires more intricate steps.

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Obturators and scopes in two various sizes. Photos by Martha Roberts.

A patient with a rectal foreign body is often afraid to discuss what happened. Occasionally, patients may not know if objects are still present. This should not shock you or deter your questioning. Your task is to discuss this objectively with the patient in a nonjudgmental way. They are more likely to discuss the object inserted if they feel comfortable with you. It is important to know when, how, and where but never why.

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This patient at first said she fell on top of something before saying she purposely placed an object in her vagina. No foreign body was found on vaginal exam, but a plain A/P radiograph of the pelvis showed a foreign body in the rectum. After several rounds of questioning and some lorazepam to calm her, she explained what happened. We let surgery handle the case under sedation because the item, a vibrator, had several pieces and was too far inserted for simple bedside retrieval.

Occasionally, patients may have objects that migrated, like a patient with a recent gastrointestinal procedure that involved esophageal clipping. The clip had migrated into the rectum and could not be passed.

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These images show various endoscopic clips and a feeding tube in the abdomen. The square clip at the anal canal was identified as an Ovesco or bear claw clip, which was used in an upper GI procedure the patient had months earlier. The clip is hard, sharp, and dangerous. This patient required expert consultation once our anoscopic exam failed to remove the piece adhered to the anal canal.

These objects are sharp and can cause harm if you do a digital exam. Take a thorough history before doing a digital rectal exam. You can remove the object if you feel confident that you can without an anoscopic exam. If not, complete a full anorectal exam using these pearls:

The Approach

  • Identify the foreign body in the rectum.
  • Remove it with an anoscope.
  • Use a rectal block if needed for pain control.

Key Concepts

  • Inspect the anus and perform a block if needed.
  • Insert the scope into the rectum properly using excessive lubricant.
  • Remove the obturator and visualize the rectum.
  • Inspect the anorectal mucosa while withdrawing the scope.
  • Rotate 90 degrees and visualize a full 360 degrees.

The Pause

  • Involve specialists early if colorectal or surgical consultation is needed. It is not appropriate to do multiple rectal exams and anoscopic exams for patients with difficult foreign bodies. This can cause trauma and physical and emotional harm to patients.
  • Immediately discuss the procedure with the patient. Most if not all patients would like to know what objects or equipment might be involved in the process. Show them the equipment and explain the procedure before starting. Maintain a nonjudgmental attitude that is reassuring for the patient. Consider prior medical history such as anxiety, depression, and PTSD.
  • Offer anxiolytics or pain relief during this procedure. This may mean the use of oral or IV benzodiazepines or narcotics. Propofol may be indicated for procedural sedation if the object is far up in the rectum.

The Procedure

  • Allow patients to be comfortable. The lithotomy position is preferred. Another way to complete this procedure is to have the patient lay on his side in a left lateral position or fetal position. A partner may help hold the gluteal cleft open for larger patients. A patient may prefer to be on his back if a gynecological bed is available.
  • Always tell a patient what you will do before touching him.
  • Insert all equipment slowly and give relaxing messages to your patient.
  • Excessive lubricant is suggested.
  • Be patient. It may take a few deep breaths or encouragement to relax the muscles of the anus.
  • See our video below to see how to insert the anoscope.
  • Once you have targeted your object, you will need to remove it with the right equipment. Make sure you have forceps, tweezers, and hemostats ready. Do not make a patient wait while an assistant gathers this equipment.
  • A rectal block prior to internal exam may be appropriate, especially if painful hemorrhoids are present.
  • Draw up two 10 mL syringes of 1% lidocaine. Anorectal blocks involve anesthetizing the subcutaneous tissue of the anus using a 27 g needle (about 2 cm) with 1% lidocaine or bupivacaine.
  • First complete a subcutaneous circle of local anesthesia around the anus, about 2 cm in diameter. Inject at the 12, 3, 6, and 9 o'clock positions. Inject 3-4 ml in each area while holding your needle at a 45-degree angle laterally. See our video for technique.
  • You can then dilate the rectum with a speculum or obturator for your exam and complete further pain relief blocks. Be sure to visualize a 360-degree spectrum of the rectum.

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Watch a video showing how to use an anoscope and how to do a rectal block.

Cautions

  • Sharp foreign bodies need expert consultation. These can be dangerous for the patient and can tear the skin and rectum. It can also be dangerous for the provider and cause injury.
  • Patients must be comfortable and relaxed. Attempt to do this without medications, but occasionally oral or IV anxiolytics such as lorazepam or diazepam are appropriate. Pain control is not typically necessary, but it depends on your assessment.
  • Moderate sedation with propofol may also be an option. Discuss options with the patient and your surgical team.
  • Perforation of the rectal mucosa can lead to abscess formation.
  • Food, wood, and glass can cause perianal infections and lead to sepsis.
  • Because of potential complications, rectal foreign bodies should be regarded as serious emergencies and treated expeditiously.

Tuesday, December 4, 2018

The atomizer is a handy tool to instill life-saving medication into the nose, and you should consider stocking them if you don't already. An atomizer can be used to administer naloxone and countless other drugs as well as for moderate sedation and pain control. Pediatric and adult patients alike can benefit from intranasal fentanyl or Versed. Studies on intranasal epinephrine for anaphylaxis also look promising, but it does require a higher dose—5 mg instead of 0.3 mg. (Asian Pac J Allergy Immunol 2016;34[1]:38; http://bit.ly/2Prpjhb.)

The atomizer is easy to use and can be attached to any syringe. Each spray creates a fine mist, which can penetrate the mucus membranes. You can administer about 0.5-1 mL of fluid per pump. Keep in mind the dosage of intranasal medications is often higher than that of IM, IV, and oral doses.

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Dr. James Roberts demonstrates the use of a traditional atomizer.

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Three 1 mL syringes with standard-sized atomizers. Photo by M. Roberts.

Opioid Struggle

More than 33,000 people died from opioid overdoses in 2015, including prescription pain relievers, heroin, and fentanyl. (National Institute on Drug Abuse. http://bit.ly/2PrdY0D.) Naloxone is a nonselective and competitive opioid receptor antagonist, and reverses central nervous system depression caused by opioids. It can be used intravenously, intramuscularly, intranasally, and even nebulized.

Naloxone has been around for almost 50 years. It is well researched, well studied, and abundantly used. The drug has been FDA-approved since 1971, and is on the World Health Organization's list of essential medications. (http://bit.ly/2PsySwb.)

If you are ever in doubt about whether to administer naloxone, err on the side of caution and give it. Do not wait for an intravenous line. The side effects (tachycardia, agitation, sweating, and vomiting) are minimal, and the benefits outweigh the risks. You may need to give additional doses, and some patients end up on naloxone drips to remain semi-conscious.

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Narcan (naloxone) individual spray units.

The general cost of Narcan nasal spray 2 mg/2 mL dose kits is less than $100. (GoodRx. http://bit.ly/2PqDRxf.) Many insurance companies will cover all, some, or part of the cost, up to a co-pay or outright cost of $144. Medicaid, however, may not pay for the atomizer, and those patients may need an IM injection kit. You will want to consider the patient's insurance plan when prescribing this; only 63 percent of Medicare Part D and Medicare Advantage plans cover generic naloxone and Narcan, according to GoodRx. (http://bit.ly/2PqDRxf.)

Pharmacies also sell generic naloxone for $20 to $40, and distribute a full naloxone kit with an atomizer or autoinjector, which includes everything needed to reverse an overdose. Some also distribute it without a prescription in more than 45 states. (USA Today. April 6, 2018; http://bit.ly/2PrvtOl.)

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Watch as Dr. Roberts and Ms. Roberts talk about all things atomizers and naloxone. Stay tuned at the end of the video for an interview with Edward Bernstein, MD, a professor and the vice chair for academic affairs in emergency medicine at the Boston University School of Medicine.

Jim Weighs In

  • Consider using naloxone for clonidine overdoses. (Ann Emerg Med 1986;15[10]:1229; Clin Toxicol [Phila] 2018;56[10]:873.) We get a lot of calls about this to poison control. Our current recommendation for clonidine overdoses includes trialing naloxone for severe confusion or mental status changes.
  • Children and suspected overdose patients who are unresponsive should receive a dose or two of naloxone.

Martha Weighs In

  • Commandeer another piece of valuable equipment in your ED if you do not have an atomizer. The nebulizer can be used with a naloxone solution just like you would do a breathing treatment. This can be critical when you do not have IV access. Pour the solution into the nebulizer, turn it on, and let the patient slowly wake up. Bolus IV doses may be necessary.
  • Do not dump the syringe liquid (2 mL) into the nostrils. It causes patients to gag and vomit and can be a huge aspiration risk.

Additional Links

  • Prescribe to Prevent (www.prescribetoprevent.org): This website is run by prescribers, pharmacists, public health workers, lawyers, and researchers working on overdose prevention and naloxone access, and offers information about prescribing and dispensing rescue kits and other resources.
  • Dr. Edward Bernstein's Project ASSERT (Alcohol & Substance abuse Services, Education and Referral to Treatment; http://bit.ly/2TlP8gN): This program in Boston Medical Center's emergency department helps patients find treatment and care. Read an abstract about Project ASSERT at http://bit.ly/2PyZCeo.