October 24, 2018
Performing Procedures Like a Boss, in the ED Without an IV
Background: Establishing IV access has become the norm for patients presenting to the ED. However with increasing patient volumes, difficulty and delays in acquiring IV access, it seems that anything that could expedite care, reduce pain and suffering, and improve patient care would be welcomed in the ED. There are several tricks I have learned along the way to achieve just this: No IV access, no problem…performing procedures like a boss…
Isopropyl Alcohol Nasal Inhalation for Nausea?
Previous studies on the use of isopropyl alcohol for nausea were published in the post-operative setting. It is not clear from these studies if isopropyl alcohol will effectively treat nausea in all patients or only patients with nausea attributable to anesthetic agents. There have been two trials looking at isopropyl alcohol for the treatment of nausea and vomiting in the ED trying to answer this question
The first trial  was published in 2016. It was a single center, randomized, double-blind, placebo-controlled trial of nasal inhalation of isopropyl alcohol versus placebo (normal saline solution) in treating nausea. The primary outcome was reduction in nausea 10 minutes post inhalation. The results are shown below…
- 84 consecutive patient recruited
- 80 patients completed the study
- 10 Minutes Post Inhalation Median Nausea Verbal Numeric Response Scale Score:
- Isopropyl Alcohol Arm: 3
- Placebo Arm: 6
- Effect Size = 3 (95% CI 2 – 4)
- No difference in median pain or subsequent need for rescue anti-emetics
- This was a convenience sample enrolling patients during periods of time when study investigators were available. This creates a sampling bias due to the fact that not all potential patients could be enrolled, and therefore the sample is not representative of the entire population of patients presenting with nausea and vomiting
- The 10 minute study period provides limited information about the duration of symptom relief
- The primary outcome of verbal numeric response scale score is a subjective score. It would have been more objective to use things such as number of vomiting episodes, ED length of stay, patient disposition, or duration of relief of nausea symptoms
The second trial  evaluating the effectiveness of isopropyl alcohol for treatment of nausea and vomiting was published in 2018. This study was another single center, randomized, blinded, placebo-controlled trial randomized to inhaled isopropyl alcohol + 4mg oral ondansetron, inhaled isopropyl alcohol + oral placebo, or inhaled saline solution placebo + 4mg oral ondansetron. The primary outcome was mean nausea reduction measured on a 100mm visual analog scale from enrollment to 30 minutes post treatment
- 122 patients enrolled
- 120 patients completed the study
- Mean Decrease in Nausea Visual Analog Scale Score (0 – 100mm)
- Inhaled Isopropyl Alcohol + Oral Ondansetron: 30 mm
- Inhaled Isopropyl Alcohol + Oral Placebo: 32mm
- Inhaled Saline Solution Placebo + Oral Ondansetron: 9mm
- Proportion of Patients Requiring Rescue Antiemetic Therapy:
- Inhaled Isopropyl Alcohol + Oral Ondansetron: 27.5%
- Inhaled Isopropyl Alcohol + Oral Placebo: 25.0%
- Inhaled Saline Solution Placebo + Oral Ondansetron: 45.0%
- Patients with intravenous access were excluded from this study, potentially selecting a healthier subset of patients with nausea and vomiting.
- As with the trial in 2016, selection bias is a possibility given the recruitment of patients in a convenience sample
- There was no strict dosing frequency of inhaled medications, making it difficult to know the true duration of symptom relief, but the authors state they wanted to examine the “real-world” applicability
Clinical Bottom Line:Isopropyl alcohol is a simple and inexpensive agent that appears to be effective in quelling nausea symptoms in patients without IV access.
Sphenopalatine Ganglion Block for Frontal Headache?
Headache is a common complaint seen in the ED. In addition to differentiating life-threatening causes from benign etiologies, physicians must also treat the pain associated with the headache. Unfortunately, this often requires IV medications. The sphenopalatine ganglion block may be a fast acting and effective treatment that could avoid IV access and have minimal adverse effects. In 2015, Schaffer et al published a multicenter (2 facilities), randomized, double-blind, placebo-controlled trial evaluating bupivacaine anesthesia vs saline solution (0.3mL per side) of the sphenopalatine ganglion for acute headache . Their primary outcome was 50% reduction of pain at 15 minutes.
- 87 patients recruited and met inclusion criteria
- 50% Reduction in Pain at 15 Minutes:
- Bupivacaine Group: 48.8%
- Placebo Group: 41.3%
- Absolute Risk Difference 7.5% (95% CI -13% – 27.1%)
- Headache Free at 24 Hours:
- Bupivacaine Group: 72.2%
- Placebo Group: 47.5%
- Absolute Difference 24.7% (95% CI 2.6% – 43.6%)
- It is thought that the sphenopalatine ganglion causes parasympathetic-mediated vasodilation of the cerebral vasculature, which is what produces headache. Therefore, anesthetizing the ganglion could attenuate vasodilation and relieve the headache.
- The literature on the use of sphenopalatine ganglion block for frontal headaches, is mixed in terms of efficacy, but to date, no harm from the procedure has been reported.
- What is not clear from this study is if 15 minutes is the optimal time for assessment of sphenopalatine ganglion blocks with bupivacaine, as more patients at 24 hours had relief of their headaches (hypothesis generating). Bupivacaine can take longer to absorb and take effect (i.e. 20min), so would we have seen an increase in the improvement of headaches say at 1 or 2 hours?
Clinical Bottom Line: Don’t give up on the sphenopalatine ganglion block. This studies lack of primary outcome benefit, may simply be from inadequate timing of assessment. The sphenopalatine ganglion block is low cost, easy to perform, and to date, no harms from the procedure itself have been reported. Why not give it a try while awaiting IV access?
Modified Valsalva Maneuver for Stable SVT?
The Valsalva maneuver is recommended in textbooks and many algorithms as a first line treatment of patients with hemodynamically stable SVT. In the literature however the success rate of the standard Valsalva maneuver alone is poor (5 – 20%). The next option includes AV nodal blockade with adenosine, which often gives patients a sense of doom when the medication is given. The modified Valsalva maneuver helps increase vagal stimulation (parasympathetic drive) and venous return to potentially increase the rate of conversion of SVT.
This was a multicenter, randomized controlled, parallel-group trial in 10 emergency departments in England . Patients were randomized in a 1:1 fashion to modified Valsalva maneuver vs standard semi-recumbent Valsalva maneuver. The primary outcome was return to sinus rhythm at 1 minute after intervention.
- 428 patients included in the primary analysis
- Return to NSR at 1 min:
- Standard Valsalva: 17%
- Modified Valsalva: 43%
- Absolute Difference 26.2%
- NNT = 4
- Zero serious adverse events
- Modified Valsalva Maneuver: In a semi-recumbent position (sitting) patients produce 40 mm hg pressure for 15 seconds and then are repositioned in a supine position with a passive leg raise immediately after the Valsalva strain.
- Few things in medicine are no cost, are well tolerated, and have zero serious adverse events.
- The vagal portion of the modified Valsalva maneuver is effort dependent for success.I emphasize this to patients before we start the procedure.
- Blowing in to an empty 10 ml syringe just enough to move the plunger will achieve a pressure similar to 40mmHg
Clinical Bottom Line: In patients with hemodynamically stable SVT, a modified Valsalva maneuver should be the first maneuver attempted to convert SVT. It is simple, no cost, well tolerated, and with zero serious adverse events.
Peritonsillar Abscess Drainage?
There are some things in medicine that just don’t have research to prove efficacy, but just make sense. This is true of peritonsillar abscess drainage in the ED. Good luck finding any studies evaluating some of the tips and tricks we are going to review here.
Lighting Source: I have never understood why it has been the standard to use the otoscope off the wall and hold it behind a needle you are trying to put in the back of the oropharynx which happens to sit next to the carotid artery. One option is have the patient hold a laryngoscope for you. The issue I have with this is you have to crack a crash cart to get the needed light source. A better second option is removing the top half of a speculum and use that in the same way, as these are disposable and nowhere near as expensive. The beauty of this is the patient now has control of the light source which frees up one of your hands and secondly puts the light source in front of the needle
Anesthetize the Oropharynx: I like to do this with 5mL of nebulized 4% lidocaine, but an alternative would be to use 2 – 3cc of 1% lidocaine locally.
Always Use Protection: Trim the plastic sheath of your needle to prevent hitting deeper structures (i.e. the carotid artery)…Typically 1 – 1.5cm is all you need to access the PTA
Spinal Needle: Often times the barrel of a syringe can obscure your view with traditional needles, but using a longer spinal needle will give you more space within the oropharynx for visualization and use of an intra-cavitary ultrasound probe
Alternative Set Up: Another option which is nice requires two providers; one to insert the needle and the other to aspirate back on the syringe. You still use your spinal needle with protection, but instead of attaching a syringe directly to the needle you attach IV catheter extension tubing and then attach the syringe.
Shoulder Reduction with the Davos Technique?
Anterior shoulder dislocation is a commonly seen complaint in the ED. There are several different methods reported in the literature for the reduction of the dislocation, and this is probably because none of them are exactly 100% effective and many require procedural sedation. The authors of this paper  retrospectively evaluated 100 patients presenting with an antero-inferior shoulder dislocation treated in the ED. The authors describe a new technique called the Davos or Boss-Holzach-Matter Technique.
The Davos or Boss-Holzach-Matter Technique
- A non-traumatic, patient-controlled technique that does not require anesthesia
- Patient sits on the stretcher and flexes the ipsilateral knee to 90 degrees and places the foot flat on the bed surface.
- With fingers interlocked anterior to the shin, the patient gently leans backward with the neck hyperextended until the arms are fully extended, producing axial traction
- The patient also shrugs the shoulders anteriorly to help facilitate reduction
- The reported success rate is about 60%, but as high as 84.5% in subcoracoid anterior dislocations and 85.3% in patients under 40 years of age
- 100 patients
- 86 with successful reduction
- 0 neurologic complications
- 18 patients did not require analgesia
- 8 out of the 14 patients who failed reductions were patients who had psychiatric problems or dementia. This highlights the fact, that the patient must be cooperative for this technique to work.
- Due to the retrospective nature of this study, there was no real protocol regarding medications administered (i.e. 63 patient received IV opioids either pre-hospital or in the ED)
The second study evaluating the Davos technique was published in 2018  and was a randomized controlled trial of 60 patients comparing the Davos technique to the Spaso method for shoulder reduction.
Shoulder Reduction with the Spaso Technique?
- A non-traumatic, physician-controlled technique that does not require anesthesia
- Patient lies supine on stretcher
- The dislocated arm is lifted vertically by grasping the wrist and gentle traction is applied while the arm is externally rotated gently
- The reported success rate range from 67.6% in prospective studies to 85 – 90% in retrospective studies
- Pain Experienced by Patient During Reduction (Scale of 0 – 10):
- Davos: 3.57
- Spaso: 5.26
- P = 0.47
- No difference in reduction time (Davos 105s vs Spaso 90s; p = 0.60) or success rate (Davos 67% vs Spaso 77%; p = 0.39)
- No short term complications
One final paper  was a meta-analysis of 9 RCTs with 438 patients suffering acute anterior shoulder dislocations. These patients were randomized to intra-articular lidocaine vs IV analgesia and sedation for the manual closed reduction.
- 9 RCTs = 438 patients with acute shoulder dislocation
- Complication Rate
- Intra-articular lidocaine: 1.8%
- IV analgesia & sedation: 19.6%
- Successful Joint Reduction
- Intra-articular lidocaine: 79.4%
- IV analgesia & sedation: 89.0%
- No difference in patient satisfaction, or post-reduction pain relief
- Significantly less adverse events with intra-articular lidocaine vs IV analgesia & sedation:
- Respiratory Depression:
- Intra-articular lidocaine: 0%
- IV analgesia & sedation: 22.7%
- Intra-articular lidocaine: 0%
- IV analgesia & sedation: 13.7%
- Respiratory Depression:
- 15 – 20cc of 1% lidocaine into the joint space and waiting about 10 – 20 minutes should be enough to get local anesthesia of the joint.
Clinical Bottom Line: In awake, COOPERATIVE patients, the use of a patient-guided technique (Davos) or physician-guided technique (Spaso) is a sensible 1stand 2ndattempt technique with the addition of intra-articular lidocaine to reduce the need for general anesthesia.
Treatment of Acute Hemoptysis 
- 12 Case Reports
- 12/12 successful in halting hemoptysis
- One patient with bronchospasm that resolved with nebs
- No serious adverse events
- 500mg of TXA mixed with 10cc of NS given as Nebulizer
- Can help avoid intubation and reversal of anticoagulation
- Can also be used for post-tonsillectomy bleeds
- Clinical Bottom Line: In hemodynamically, stable patients with acute hemoptysis 500mg of TXA mixed with 10cc of NS given as a nebulizer can be a temporizing measure to halt bleeding
Performing Procedures Like a Boss, Without an IV:
- Isopropyl alcohol inhalation for nausea/vomiting is reasonable
- Sphenopalatine ganglion block for frontal headaches may have a roll
- Modified valsalva maneuver for stable SVT is superior to standard valsalva techniques
- Use a spinal needle with sheath (for better visibility and protection) and disposable speculum (to put the light source anteriorly) for peritonsillar abscess drainage
- Davos and Spaso techniques with intra-articular lidocaine could reduce procedural sedation with anterior shoulder dislocation
- Nebulized TXA can be a temporizing measure to halt acute bleeding in patients with acute hemoptysis
- Beadle KL et al. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med 2016. PMID: 26679977
- April MD et al. Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial. Ann Emerg Med 2018. PMID: 29463461
- Schaffer JT et al. Noninvasive Sphenopalatine Ganglion Block for Acute Headache in the Emergency Department: A Randomized Placebo-Controlled Trial. PMID: 25577713
- Appelboam A et al. Postural Modification to the Standard Valsalva Manoeuvre for emergency Treatment of Supraventricular Tachycardias (REVERT): A Randomised Controlled Trial. Lancet 2015. PMID: 26314489
- Stafylakis D et al. Reducing a Shoulder Dislocation Without Sweating. The Davos Technique and its Results. Evaluation of Non-Traumatic, Safe, and Simple Technique for Reducing Anterior Shoulder Dislocations. PMID: 26899512
- Jiang N. Intra-Articular Lidocaine Versus Intravenous Analgesia and Sedation for Manual closed Reduction of Acute Anterior Shoulder Dislocation: An Updated Meta-Analysis. J Clin Anesth 2014. PMID: 25066879
- Marcano-Fernandez FA et al. Teaching Patients How to Reduce a Shoulder Dislocation: A Randomized Clinical Trial Comparing the Boss-Hozach-Matter Self-Assisted Technique and the Spaso Method. J Bone Joint Surg Am 2018. PMID: 29509614
- Komura S et al. Hemoptysis? Try Inhaled Tranexamic Acid. J Emerg Med 2018. PMID: 29502864
For More Thoughts on This Topic Checkout:
- ALiEM: Trick of the Trade – Peritonsillar Abscess Needle Aspiration
- ALiEM: Trick of the Trade – Peritonsillar Abscess Aspiration Technique
- The SGEM: SGEM#144 – That Smell of Isopropyl Alcohol for Nausea in the Emergency Department
- LITFL: Spaso Technique
Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)
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