The Nasopharyngeal Endoscope - Your New Best Friend

Often we are faced with patients with swollen uvulae (sp??), throat foreign body sensations, etc., and we desperately want to peek into that mysterious land known as the hypopharynx and see what the deal is. Just the other day I had an elderly yet high functioning man come into our shop with the stated chief complaint of, "I feel like there's a grapefruit in my throat!"

At our institution--a tertiary teaching hospital--the default is to call ENT to "come down and scope them."  However, if you're a DIY-minded emergentologist like us, that doesn't sit right.  And why should it?  While it has a bit of a learning curve it's a reasonably easy procedure that is definitely within our scope of practice (no pun intended). 

Boring disclaimer: We will not be addressing fiberoptic intubations with this post.  That is indeed an incredibly useful skill that despite the demand is not commonly mastered in our field in our time, but we'll tackle that barracuda at a different time.

To get started, you'll need to collect a few things.  Obviously you'll need some sort of flexible endoscope, but you'll also want to get a hold of some 4% lidocaine and an atomizer for local anesthesia. Nebulized lidocaine or 5% cocaine are also options.   You'll want to also use Afrin or Neo-Synephrine as an nasal decongestant as well.  

And be liberal with these guys!  You want them as comfortable as possible, so also give it time to work (we're talking 10-15 minutes, so go take care of other things for a spell while the meds take effect).

Allow the patient to sit up with their head free--you need to give them the ability to pull away in case you poke them in a turbinate.  You also should be directly in front of the patient to accommodate a smooth passage

Lubricate the tip, and slowly advance under the inferior turbinate until you get to the soft palate.  If you fog up at all, don't worry about a defogger--tapping the tip against mucosa will work just fine.  At that point curve down, and after advancing a bit you should have a great view.  You should clearly see any FB's or airway compromise.  Make sure you see the entire structure, including the piriform sinuses.  Check for mobility of the cords while having the patient say, "Eeeeeeee!"

When it's time to withdraw, make sure you come out gently, centering on the tissue so that you don't drag at all.  Easy, right?!?!?  Put it in your toolbox, because this one we can totally handle.  However, and just as it is for any other procedure we write about here, this post is for EDUCATIONAL PURPOSES ONLY.  Be smart!

jps

Sources:

Tom Ashfield's YouTube Page

Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition.  Chapter 63.

Airwaycam.com

The Bier Block

For fracture reductions in the ED, there are obviously several analgesic options in your armamentarium.  There's the tried and true hematoma block, there's sometimes tricky yet potentially rewarding regional nerve blocks, and then there's time and labor intensive but enormously effective moderate sedation.  But what about intravenous regional anesthesia, AKA the fabled Bier Block?  

Stop the record for a second, did I just say intra-VENOUS regional anesthesia?  You heard me--and surgeons and anesthesiologists have been doing it in the OR for years.  Indications also include distal fractures that require reduction, major lacerations, foreign body removal, abscess drainage--pretty much any procedure on distal extremities that hurts like stink. The procedure is simple: the limb is exsanguinated with pneumatic cuffs, and a local anesthetic is pushed as distally in the limb as possible (via a 20 or 22 gauge catheter--the hand is a great place to go).  The procedure is performed, and the cuffs are slowly removed.  The patient is fully alert but comfortable, and receives no systemic sedation.  

Your list of supples are as below, and should be easily obtained in any shop.

Specifically, you dose your lidocaine at 3 mg/kg, injected as a 0.5% saline bolus.  You achieve this by mixing it with equal parts saline in a 60 cc syringe.  Example: a 70 kg patient would get 210 mg of lidocaine, which would come out to be 21 cc of solution, then mixed with another 21 cc of saline.  Then inflate the cuff and attach the Esmarch sequentially as listed above, or just use two separate cuffs.  Once you're done, make sure to 1.) Wait until the total on-cuff time is 30 minutes and 2.) cycle the cuff off, slowly deflating for 5 seconds, then re-inflating for 1 to 2 miniutes.

How safe is this?  It sounds frighteningly bold but there has actually never been a recorded case of a mortality, at least from a patient that has had lidocaine as the anesthetic.  The only real recognized absolute contraindication is a lidocaine allergy.  Relative contraindications include Raynaud's, Buerger's disease, crush injuries, and sickle cell disease (homozygotes).

The history is quite interesting, dating back to the eponymous August Gustav Bier himself, a surgeon who appeared to be ahead of his time.  Surprisingly, the concept arose from the belief from the time that  sequestering an infection (in this case tuberculosis) into one extremity via congestion from a tourniquet  promoted healing.   While testing this wacky hypothesis in 1908 he somehow also came to the conclusion that injected these exsanguinated limbs via venous cutdown with novocaine (the "new" cocaine at the time), he obtained fantastic analgesia that was rapidly reversible.

 Unfortunately, like several other groundbreaking physicians (Reiter, Wagener, Clara, Seitelberger, etc.) he also happened to be a Nazi.  Why'd you have to go there, dude?

Let's get back from the stone ages here so you can catch Dr. Al Sacchetti performing the procedure.  Note that the patient experiences zero pain during the procedure and is fully alert. 

Depending where you're at, your nurses may not be a big fan of this, as it does require additional staff and arguably may be more complex and time consuming than regular procedural sedation.

Finally, just as it is for any other procedure we write about here, this post is for educational purposes ONLY.  Please do not assume you are a Biermeister Supreme after this and start pushing boluses of lidocaine on people.  Be smart.

jps


Sources:  

Zundert, A. et al.  Centennial of Intravenous Regional Anesthesia. Bier's Block. (1908-2008). Regional Anesthesia and Pain Medicine.  2008 Sept.-Oct; 33(5): 483-9.

Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition.  Chapter 23.

Procedures Club.....Wait For It....Begin!

Welcome proceduralists!  My illustrious colleague Dr. Pirotte and I are here to announce our new brainchild, Procedures Club, a blog for emergency physicians, by emergency physicians.  We will be covering rarely done but often discussed procedures, obscure procedures, and Macgyver-like maneuvers that impress the youths.

Just a disclaimer: this site is meant for EDUCATIONAL PURPOSES ONLY, and is intended for medical professionals.  Beavis and Butthead copycats, look elsewhere.

Stay tuned, friends.

jps