COMMENTARY

More Emergency 'MacGyver' Tips for Physicians

Robert Glatter, MD; Amy Faith Ho, MD

Disclosures

May 08, 2019

This transcript has been edited for clarity.

Robert Glatter, MD: In part two of our continuing series on emergency 'MacGyver' tips for physicians, Dr Amy Faith Ho, assistant medical director at John Peter Smith Hospital in Fort Worth, Texas, outlines some useful tricks of the trade for managing nausea and vomiting, fracture reduction, evaluating an open joint, treating headaches, and repairing dental fractures, as well as a nifty trick to locate a contact lens in someone's eye. Welcome back, Dr Ho. It is great to have you with us again.

Rubbing Alcohol for Nausea

Glatter: Let's jump right in. Alcohol pads for nausea and vomiting: This is something I read about in the Annals of Emergency Medicine[1,2] a year or two ago, and it really fascinated me. Since then, I've seen people in our emergency department (ED) use this technique. What are your thoughts on this? Do any studies back this up?

Amy Faith Ho, MD: I'm a big fan of any trick you can use in the ED and also teach patients to use at home. The study in the Annals of Emergency Medicine [2] compared inhaling rubbing alcohol versus ondansetron (Zofran), and rubbing alcohol won. This approach isn't that novel. The anesthesia literature has also published on using isopropyl alcohol for postoperative nausea. Studies have found that it reduces nausea severity by more than 50%—better than ondansetron (Zofran), metoclopramide (Reglan), or promethazine (Phenergan), and better than placebo.[2,3,4,5,6] Pretty incredible for a 99-cent bottle of alcohol! A 2012 Cochrane review[7] found that it was effective at reducing the need for other antiemetics.

You can deliver this in several different ways. You can buy a big bottle of commercial rubbing alcohol from the drugstore; pour some into a small cup; and have the patient take a deep breath, in through the nose and out through the mouth, about three times every 15 minutes.

Another technique is to use a syringe. Pull the plunger out of the syringe, then take an alcohol prep pad and push it into the empty syringe; then replace the plunger, keeping some air in the syringe. Put it up to the patient's nose, and then just push a puff of air into the nose. This puts a little burst of alcohol vapor up into the nose. Do this three times every 15 minutes. I have found that it works incredibly well. People are always surprised and this is something they can take home that doesn't need a prescription.

Glatter: Any thoughts about nebulizing the alcohol?

Ho: I sometimes will use a nebulizer, with about 5 cc of alcohol. Sometimes I will take an atomizer and squirt maybe 1 or 2 cc directly into the nares. There is isopropyl toxicity, so I don't want to overdo it.

We don't have much evidence on how isopropyl alcohol is absorbed when you nebulize, which is why I tend not to use a nebulizer. I worry about possible toxicity. Also, the mechanism of why rubbing alcohol works is completely unknown. Some think it may work at the chemoreceptor trigger zone, but that also persuades me to move away from giving too much.

Glatter: The literature also talks about olfactory distraction and compared isopropyl alcohol with cinnamon, cardamom, and other different aromas and found that that seems to lead to this confusional state.

Ho: Other studies have compared rubbing alcohol versus aromatherapy and found that rubbing alcohol is superior.[7]

Topical Lidocaine for Cough and Headache

Glatter: Moving on but still talking about anesthetics, tell us about using lidocaine for headache and for coughs. What are your thoughts?

Ho: Lidocaine is almost my first-line treatment for cough and headache now, especially as the world is moving away from opiates. We are not giving codeine anymore, and lidocaine is a great substitute. For cough, it's simple.

You take about 5 mL of 4% topical lidocaine solution (approximately 200 mg) and nebulize it. You squirt it into the nebulizer chamber and have the patient breathe it in. It is believed that this essentially numbs the bronchospasm and stops the cough.[8] The only side effects for patients are that it doesn't taste great and it can sometimes cause a slight burning sensation. For most patients, the cough resolves within about 10 minutes. Some have come back and told me that the relief lasted for many hours.

Glatter: In asthmatics, would you worry about bronchoconstriction? It's been reported there can be some constriction effect initially.[9] Is that something to be concerned about?

Ho: Yes. I've also read about that. Several of the studies that looked at this specifically studied asthma patients with a persistent cough, and they found very few side effects.[8,9] Toxicity is usually the biggest concern. The lowest dose I have seen with reported toxicity has been approximately 300 mg nebulized. You should always shoot for a much lower dose—100 or 200 mg nebulized, and as long as you don't exceed that, it should be fine.

Glatter: Moving on to headaches, lidocaine could definitely be useful for headaches, on the basis of its properties.

Ho: This is another favorite of mine. When we use lidocaine for headache, we are talking about a sphenopalatine ganglion block. The sphenopalatine ganglion is small nerve bundle that comes out at the back of the nasal cavity. It has been hypothesized that blockade of this ganglion reduces headaches by modulating the autonomic fibers by numbing the ganglion.[10]

Again, this is super-easy. I use an atomizer and draw up the highest concentration of lidocaine I can find, usually 2%-4%. Then I squirt 1 cc into each nostril, wait about 15 minutes, and see whether there's any improvement.

Another technique is to use a long cotton-tipped applicator soaked in the anesthetic. You put it gently up into the nares until you meet a little resistance just behind the nasal pharynx. You leave that for approximately 10 minutes. My preference is the atomizer because patients don't love having a Q-tip up their noses.

The evidence is pretty good about improvement.[11] It is an easy go-to with very few side effects, and definitely worth looking into for your patients with refractory headaches.

Glatter: Would you reach for this technique more for patients with cluster headache, migraine, or both?

Ho: I'm pretty nondiscriminatory between those two. The only time I would choose another technique is when someone has a posterior headache and when you push along the back of the neck, the pain radiates from there. Those headaches are usually more a tension type. In those cases, I will go for a greater occipital nerve block.

The greater occipital nerve is slightly medial and down from the mastoid. I will inject approximately 1-2 cc of 2% lidocaine and numb that nerve. Patients report immediate relief of the headache and the tension. But that's the only time I discriminate among the headaches.

Glatter: Both of these techniques are great for length of stay. Sometimes with these migraine cocktails, we keep patients for hours. Why not reach for this right off the bat, assuming no allergies or other contraindications?

Ho: And patients can drive home after. When we use the migraine cocktail, we usually also give metoclopramide (Reglan) or prochlorperazine (Compazine) plus diphenhydramine (Benadryl), and then people are sleepy. With lidocaine, they're in and out quickly, it makes them feel better, and it's absolutely great for length of stay.

Can't Find the Finger Traps? An Alternative for Colles Fracture

Glatter: Switching gears, your next patient has a bad Colles fracture and you can't find the finger traps. What do you do?

Ho: I love Colles reductions; they're so easy. You do a hematoma block and you hang the patient's forearm, and the fracture self-reduces. But those finger traps are so hard to find, especially on the night shift, with less staffing; no one knows where things are, maybe they haven't been restocked, or honestly, often we have them in the operating room and someone has to run up there to find them.

Instead, we use a gauze roll, as wide or as narrow as you want. There are various techniques for tying it around the fingers so that you can hang the forearm from an IV pole. And after 10 or 15 minutes, that Colles fracture self-reduces.

Take a gauze roll and fold it over lengthwise. Loop it around the index and the middle fingers, and then thread the long end through, between the index and middle finger. This creates a kind of a slip knot. You pull it up and secure it to the IV pole, and the arm can hang there. It has a nice tension. Because of the pulling tension, the fingers naturally curl, which also helps to secure it. Occasionally, I'll add a bit of tape, and that should last 10-20 minutes. If the patient is having discomfort, they may hold their hand up a bit and as they begin to feel more comfortable, they'll relax the hand and arm and self-reduce the fracture.

Academic Life in Emergency Medicine (ALiEM) published a video demonstrating how to build your own finger traps using a gauze roll.

Glatter: Some people worry when they see the fingers turning purple. They think the circulation is cut off completely, but obviously it's not the case. Other providers and clinical staff need to understand that it's okay for that 15-minute period, that the circulation will rebound.

Ho: I find that what helps the most is to use a wider gauze roll; the wider it is, the less of that you get. Sometimes I will spread out the gauze. After about 5 minutes or so, the gauze has become tight and thin, and I'll just spread it out a bit wider across the finger. That seems to help the circulation.

Glatter: This is a great technique. And you'll never have to look for finger traps again.

Dermabond for Tooth Fractures...

Glatter: Your next patient has a dental fracture and an avulsion. As you search for equipment, you seize upon an idea. Tell me about your idea for managing this.

Ho: Avulsion fracture is kind of a pain—you have to find the emergency dental box, the enamel, the calcium, and all that. It's messy and hard to deal with. There are great case reports and a couple of small studies of 40 or 50 patients looking at the use of octylcyanoacrylate (Dermabond) in fractured molar teeth.[12] This is especially useful in kids, who are so difficult to do repairs on.

With Ellis I, II, and possibly III fractures, you dry off the tooth with gauze. I'll have someone hold suction right next to the tooth to keep it even drier. You can apply regular Dermabond and push the fracture together as you're able, and then coat the area with more Dermabond, and give it about 10 minutes. The patient will feel a burning sensation for about 10 seconds. After the first 20 seconds or so, it starts hardening well enough that you can leave the patient with a couple of small gauze pieces in the mouth to keep everything fairly dry. Within about 10 minutes, the bond has hardened really well.

This is great for getting patients in and out of the ED. Studies have found that this technique hasn't resulted in any cosmetic or functional problems compared with standard repair.[12,13,14] So, positive outcomes with a faster, easier-to-do technique.

Glatter: Do you need to secure the tooth with wires or any kind of support beyond just putting the tooth back together? Or in the case of alveolar fracture, do you need any splinting with some kind of wire mechanism?

Ho: Yes, I do like to use wires when it's a complete avulsion or that sort of thing. I will use Dermabond on the actual tooth—a tooth that has a crown fracture, for example. On top of that, I will take the metal nasal bridge from an oxygen mask or the metal from an N95 TB mask, and I'll use Dermabond as the splint. I coat the whole metal piece with Dermabond, dry off the mouth again, have someone hold the suction to keep the area dry, and then press it gently across at the splint. You have to hold everything still for 10-20 seconds. But that's usually enough to secure the tooth until the patient gets to their terminal care, which will be a dentist or oral surgeon.

...and Nail Bed Injuries

Glatter: Switching gears again, you look down and you see the patient's finger is completely lacerated. You think there might be a nail bed fracture. Can your Dermabond help with this?

Ho: Absolutely. Dermabond can be used to help with a number of those small nighttime injuries that are so time-consuming. The literature includes approximately 100 patients who were treated with Dermabond for nail bed injuries.[15,16] You can do two things with the Dermabond. You can fix the actual nail bed injury. For example, if the nail is already gone or you have removed the nail, then you can use the Dermabond instead of sutures to repair the nail bed. Dry it off, push it together, coat it with Dermabond, and hold for 10-15 seconds, and it will be fine.

Typically, when you're splinting the matrix and using either the nail (or sometimes people use the foil off the back of a suture kit), there are all these complex suturing techniques to keep it in place. Instead, you can put that nail back in place and then, right at the cuticle where the nail bed is slipping under the skin, you can coat that area with Dermabond, and it will hold it well enough to keep the nail in place for the week or so you need to be sure that the nail will grow back.

Glatter: That's great for patients who aren't able to follow up within a few days with the hand surgeon.

Ho: This is a great alternative for toes, for fingers, for patients who just don't want to have sutures, and especially for kids.

Fluorescein for Knees and Eyes

Glatter: Last but not least, you're getting to the end of the shift and your patient comes in with a huge laceration to the lateral aspect of his left knee and you're wondering, does he have an open joint? That demands either a saline load test or methylene blue. But you use something else.

Ho: You obviously have to challenge the joint. The problem with methylene blue is that if the joint is open and then you call the orthopodist, they will be angry because the methylene blue stains their field. But personally, I have a hard time seeing the clear normal saline.

Instead, I'll draw up as much normal saline as I need or get a premeasured saline flush, 10 or 20 cc, depending on the joint. And then I take that syringe, pull out the plunger, and drop a fluorescein strip inside. I usually use one fluorescein strip for every 10 cc. I try to do this on a sterile field. You'll see it turns this really nice yellow color. I also like to use the Wood lamp, because it gives you magnification and everything lights up. This is perfect for being able to see those small injuries to the joint that you sometimes have a difficult time seeing. And it is pure normal saline.

Glatter: Another nifty use for the fluorescein strip is that lost contact lens. This happens so many times. The patient insists there's a contact lens stuck in their eye, but you can't find it. We've had bounce-backs, and eventually we do find a contact lens. How do you quickly locate a contact lens in a situation like this?

Ho: I take a fluorescein strip, and again I put it into the back of a saline flush. Then I just use it like eye drops. Around a contact lens, you'll see the pools of yellow and you can see the contact. It's obvious, and you can easily remove it instead of fishing around for it. This is a great technique that avoids the old dab-and-touch-the-eye with the fluorescein strip.

Glatter: The suction cup technique is nice if you have one, but this really provides an additional step to locate the contact lens.

Dr Ho, thank you again for your time. We hope to have you back very soon.

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