Archive | May, 2014

Kanavel’s 4 signs of infectious flexor tenosynovitis

29 May

intense pain accompanies any attempt to extend partly flexed fingertendon%20sheath-resized-600

 – this is absent in local involvement;

 – pain will be noted along the course of tendon with extension;

 – this is the earliest and most important sign;

 – in case of a local furuncle, in contrast, the finger can be held straight without much pain;


flexion posture: finger is held in flexion for comfort


uniform swelling involving entire finger in contrast to localized swelling in local inflammation


percussion tenderness along the course of the tendon sheath

 – tenderness is marked along the course of inflammed sheath in contrast to its absence in a localized inflammation


Submitted by J. Rothstein.


References:; picture

hyphema (in a pinch)

27 May

Hyphema is blood in anterior chamber of eye.

Usually caused by trauma– typically intraocular surgery or lac/abrasion.

Can obstruct vision.

Spontaneous may occur as well from neovascularization.

Require emergent ophtho eval.


In ED:

  • Tylenol for pain.
  • Steroids are controversial.
  • check IOP
  • Elevate HOB to 45 degrees.


Submitted by J. Rothstein.


References: emedicine article; picture

g-tube out?

23 May

Most G/J tubes require 1-2 weeks to form a mature tract.


If under that amount of time, non-operative or non-fluoro guided replacement in ED may form an inappropriate tract and place tube in incorrect location.  Ensure it has been adequate amount of time.


If so, prompt replacement with largest foley or g tube possible to ensure patency of tract in prompt manner is ideal.


If any signs of infection, do not replace either.


Submitted by J. Rothstein.


References: emedicine, picture

Breech delivery

22 May

In the ED, assisted breech delivery methods should be used.

Total breech extraction only used in case of breech second twin delivery. Otherwise, cervix may not tolerate procedure.

Assisted breech delivery:

If available, clearly get anesthesia/pediatrics/OBGYN into ED.

Episiotomy may assist with delivery. (less popular nowadays)

Pinard maneuver:

  • Wait until baby umbilicus at level of perineum.
  • Then place pressure on popliteal area of fetal legs to flex and help clear vagina.
  • Mother exerts pressure while physician applies gentle downward and out pressure to baby until see scapula and axilla.
  • Wrap dry towel around hips, continue traction with assistant applying fundal pressure to keep fetal head flexed.
  • Rotate 90 degrees and apply pressure to inner aspect of arm to sweep out.
  • Then rotate 180 degrees and same to other arm.
  • Then rotate to baby with back anterior.
  • Then keep head flexed with physician applying upward pressure to maxillary processes of baby with assistant applying fundal pressure, and gently deliver head.


Submitted by J. Rothstein.


References: medscape article; picture

lateral canthotomy: quick refresher

20 May

Indications for emergent  lateral canthotomy

  • Retrobulbar hematoma with vision loss, proptosis, and increased intraocular pressure.
  • Contraindicated in globe injury patients.


Procedure Quick Hits:

  • Inject lido into lateral canthus, inject when needle touches bone.
  • Crimp skin at lateral canthus of eye with hemostat- hold for 1-2 minutes.
  • Hold skin up with hemostat and use scissors to dissect toward the lateral aspect.
  • Sometimes that is sufficient to decrease IOP.  If not, then pull lower eyelid out and locate lateral canthus tendon. Dissect this with scissors pointing out.


Submitted by Josh Rothstein.


References: emedicine article; picture1; picture 2

CURB-65: pneumonia score refresher

19 May

broken down for easy reference:


1 point each:

  • Confusion
  • Uremia (BUN > 19 mg/dL)
  • Respiratory rate > 30
  • Blood pressure < 90 (systolic) or <=60 (diastolic)
  • 65 (age >= 65)


estimated 30-day mortality

  • 0 points: 0.6%
  • 1 point: 2.7%
  • 2 points: 6.8%
  • 3 points: 14%
  • 4-5 points: 27.8%



  • 0-1 point – consider outpatient treatment
  • 2 points – consider inpatient tx, or outpatient tx + close follow-up
  • 3 points – inpatient tx, +/- ICU
  • 4-5 points – ICU



CURB-65 > 2:

  • sensitivity 0.62
  • specificity 0.79


References: review, MDCalc, utilitypicture


carbon monoxide testing

13 May


Your next patient is a 30 yo who is brought in by EMS after being pulled out of a burning apartment building.  They’re awake, but complaining of a headache, and of course, you’re worried about carbon monoxide. 

How do you want to test for this, and what number/percent are you ok with?



2 most commonly found options in the ED: co-oximetry & serum carboxyhemoglobin testing


noninvasive pulse co-oximetry (similar to your pulse-ox, but for CO)

  • via some small studies: mean absolute error of 3.15% (vs. serum testing)
  • frame of reference: mean absolute variation between various blood gas analyzers – 2.4%


carboxyhemoglobin testing

  • relationship between COHb levels and poisoning severity is generally poor
  • no clinically relevant difference between arterial and venous COHb levels
    • 95% of samples range between 2.4% and -2.1% of each other
  • COHb level > 3% in non-smokers or > 10% in smokers suggests an abnormal CO exposure


References: EBMedicine article, picture