Tag Archives: #foamed

Reduction of Uncomplicated Shoulder Dislocation in the ED

At long last, UK EMIG QuickHits returns from hiatus with a rundown on shoulder dislocations and how to handle them in the ED, from 4th year UK med student Michael Greene


-Shoulder joint dislocations are a common reason for a visit to the emergency department (50% of all joint complications treated in the ED) so it’s important to be familiar with them

-Pathophysiology: Glenohumeral dislocation. Usually occurs with indirect force applied to the shoulder through the arm during abduction and external rotation, leading to the humeral head slipping out of the glenoid fossa.

-Up to 95% are anterior dislocations but posterior and inferior dislocations occur

-Further subdivided into subcoracoid, subglenoid, subclavicular, or intrathoracic, depending on where the humeral head ends up

-Workup: Most important is history and physical. Shoulder x-ray in three planes (AP, lateral, axillary) is the initial imaging modality of choice.

-As with any MSK injury, be sure to do a neurovascular check distal to the dislocation, including the axillary nerve innervation of cutaneous deltoid distribution. If vascular or neurological deficits are identified, more rapid reduction is required.

-Management: Rapid, closed reduction! The sooner the reduction is performed the easier it is, as prolonged dislocation increases the muscle spasms and tightness which is keeping the humeral head from moving back into place

-For all methods (see below for more details) listen or feel for the clunk. With the awake patient, look for relief of pain and improvement of range of motion

-Complications: Bankart’s lesions and Hill-Sach’s deformities. While initial x-rays should pick them up, more subtle presentations may only be seen on CT or MRI.

-Post-reduction care: sling for three weeks to let the shoulder girdle recover and tighten. Ortho follow-up, particularly with recurrence or complications

Also… most things here apply only to anterior shoulder dislocations. Posterior or inferior dislocations are less common and more prone to long-lasting complications. An ortho consult is always in order for these.

Keep reading for a more in-depth take on shoulder dislocation reductions

As mentioned above, the shoulder is most commonly dislocated joint. It’s the most mobile joint in the human body, but with great mobility comes great instability. As we can see in the image below, there’s not much keeping the humeral head nestled in the glenoid fossa besides soft tissue stabilizers like rotator cuff muscles, ligaments and the joint capsule. It is most commonly dislocated anteriorly via indirect pressure applied to the arm during abduction and extrinsic rotation. It can be sub-categorized based on where the humeral head ends up: subcoracoid, subglenoid (the two most common) or subclavicular or intrathoracic (both very rare).  There is a bimodal distribution in the patient population seen with shoulder dislocations: young, active men and elderly women.

shoulder anatomy

Image source: via https://www.studyblue.com/notes/note/n/shoulder/deck/1978417

Presentation: Patients typically come in with a history of trauma supporting their flexed, externally rotated arm. The shoulder will have a classic squared off appearance and a gap between the humeral head and the acromion can be palpated. Usually not the trickiest diagnosis, although the image below is dramatic.


Image source: http://www.firstaidevents.com/articles/dislocation-of-the-shoulder

X-ray will verify the dislocation and can also visualize any associated bony lesions or fractures


Image source: Case courtesy of Dr Frank Gaillard, From case 7958

Reduction methods:

The goal of reduction is to restore pain-free, functional anatomy and range of motion while maintaining shoulder stability. In order to accomplish this, the muscular spasm which occurs during dislocation and keeps the humeral head from spontaneous reduction must be overcome to relocate the humeral head into the glenoid fossa.

There are as many methods to do this as there are ways to dislocate your shoulder, but we’re going to highlight some of the most popular. For all methods, listen or feel for the clunk. With an awake patient, look for relief of pain and improvement of range of motion


  • Often used in the ED for its simplicity and ability to quickly overcome tight muscles from prolonged dislocation
  • Detractors point to the increased use of force and potential neurovascular complications or enlargement of bony complications


Image source: dundeemedstudentnotes.wordpress.com


  • Patient lies in the prone position with the effected arm hanging off the bed, attached to a 5-10lb weight
  • Over the course of 20-30 minutes the muscles of the shoulder girdle will grow tired and relax, allowing the humerus to slip back into place


Image source: intranet.tdmu.edu.ua


  • Forward elevation: arm initially is elevated 10 to 20 degrees in forward flexion and slight abduction. Forward flexion is continued until the arm is directly overhead. Abduction is increased, and outward traction is applied to complete the reduction.

    Figure 25. Milch Technique

    Image source: www.ebmedicine.net/


  • The patient is seated in a chair, and the affected arm is supported by the patient’s unaffected extremity.

    A 3-foot loop of stockinette is placed along the forearm with the elbow at 90 degrees.

    The patient sits up and gets some support from the physician. Traction is directed downward on the forearm by a foot in the loop, while the forearm is supported and the provider’s other hand is free for pressure or rotation as needed.

External rotation

Scapular manipulation

Involves repositioning the glenoid fossa rather than the humeral head; can be used with minimal analgesia or muscle relaxation. Traction on the arm is placed either by the hanging method or by an assistant. During gentle traction, the inferior tip of the scapula is rotated medially, while the superior portion of the scapula is stabilized.

shoulder manipulation

image source: www.hawaii.edu/medicine/pediatrics/pemxray/v4c12.html


  • Leverage, adduction, and internal rotation

    -No longer recommended because of a high incidence of associated complications (axillary nerve injury, humeral shaft and neck fractures, capsular damage)


  • Like the Kocher, not used as much due to potential for complications
  • Traction with the foot in the axilla


image source: http://www.wjgnet.com/2218-5836/full/v5/i1/57.htm

Pain control:

Procedural sedation with benzos, opiates, propofol, ketamine or etomidate has long been the mainstay for reductions in the ED. It’s common, providers are familiar with it, it can give some muscular relaxation and the patients are easy to work with, for obvious reasons. However, it is expensive and requires continual observation and cardiopulmonary monitoring during the course of the sedation.

For those whose time and manpower is limited, intra-articular lidocaine injections have proven to be effective. For the horde of ultrasound enthusiasts, ultrasound-guided interscalene brachial plexus block can also provide effective regional anesthesia for reduction. Some advantages of these methods and avoiding procedural sedation are to reduce cardiopulmonary compromise, to reduce staffing required for monitoring, reduce ED length of stay, and reduce cost. There are some risks, well addressed elsewhere, of vascular puncture during injection and temporary phrenic or recurrent laryngeal nerve paresis, although this is operator dependent.

To rehash some basic anatomy, the brachial plexus runs from C5-T1, under the clavicle, to the axilla and provides innervation to the upper extremities. The interscalene block of the brachial plexus involves the infiltration of lidocaine at the level of the trunks, seen below, which when viewed in the transverse with ultrasound gives you the classic “traffic-light” sign of the three stacked nerve trunks.


Image source: mymedlife


Image source: ACEP


Image source: Neuraxiom


The common pimp question complications from shoulder dislocation are the Hill-Sach’s and Bankart’s lesions. They are basically the glenoid and the humerus acting on each other. In the Hill-Sach’s deformity, the humeral head is the injured party and in the Bankart’s lesion, the glenoid rim is injured. I keep them straight by the H’s: [H]ill-Sach’s=[H]umeral head

Hill-Sach’s deformity: compression fracture of the humeral head from sliding across the glenoid rim

Bankart’s lesion: avulsion fracture of glenoid rim from impact of humeral head


Image source: littlemedic.org

More bony injury: greater tuberosity fracture, coracoid fracture, humeral neck/shaft fracture

Ligamentous injury: inferior glenohumeral ligament, more common in younger patients

Muscular: rotator cuff strains and tears, more common in older patients

Neurological: axillary nerve, supplying motor innervation to teres minor and deltoid, and sensory innervation to lateral upper arm over the deltoid.

Vascular: axillary artery; look for it in association with axillary nerve injury

Joint instability and recurrent dislocation is the ultimate outcome for many of these complications, especially Hill-Sach’s, Bankart’s, and inferior glenohumeral ligament injury. All of these complications need an ortho consult, and surgical intervention can help prevent recurrence.

Additional info:

For all you wilderness med maniacs out there, here’s a study published by the Wilderness Medical Society of a reduction method that can be done without assistance, equipment or medications. All it takes is patience and a willing patient.



Cunningham’s method

FARES method

-All things shoulder dislocation and reduction:


-Ultrasound-guided interscalene block guide:




-As always: Rosen’s, Tintinalli’s

Contributor: Michael Greene

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Getting the Point – Soft Tissue Foreign Bodies

This week, I’ll be sharing a slew of handy information to keep in mind when dealing with foreign bodies in the Emergency Medicine setting.  This post is also an introduction of sorts – Since taking over editor-in-chief duties from Sakib, the founder of this blog, my work thus far has been mostly behind the scenes editing.   I’ve also done some back-editing on recent posts that should make scrolling through the Quickhits site while browsing topics much easier.  I hope you enjoy!  (PS – I apologize for any puns in advance)

Corey Warf, EiC

First, the Quickhit:


  • Foreign bodies in tissue generate an inflammatory response which varies in intensity based on the composition of the object:  inert materials (glass, plastic, metal) generating less of a response than organic materials such as bone, spines, woody plants, or vegetative material.
  • Likewise, risk of infection varies based on foreign body material: inert materials are relatively low risk, while organic materials pose a much higher risk of infection.
  • Composition of infections often vary based on material as well: tooth fragments increase the risk of polymicrobial infections while woody materials may increase the risk of fungal infections, e.g.

Presentation and Exam

  • Lacerating or penetrating injuries with an object that may break, shatter, or splinter have higher odds of a foreign body being present in the wound.
  • Wounds deeper than 5mm or those that cannot be fully explored have a higher risk of foreign body presence.
  • An adult who senses a foreign body’s presence in a wound has double the risk of a retained foreign body, compared to an adult who does not sense a foreign body with a similar injury (Note: this only holds true for adults, not pediatric populations, even if verbal).
  • Keys to a good exam are adequate lighting, hemostasis, and anesthesia.  Try to visualize the entirety of the wound.  Puncture wounds can be extended with a scalpel to improve visualization.
  • For deeper wounds involving glass or metal, insert a closed hemostat and withdraw – scraping on the way out may indicate a retained foreign body.


  • If a foreign body is suspected, order imaging!
  • Appropriate imaging studies varies based on situation – no single imaging modality is appropriate for every situation.
  • Radiopaque objects such as leaded glass, metal, bone, rocks, and some plastics can be detected with X-ray; however, x-ray often does a poor job with organic materials that are not hard bone.
  • CT scan is fairly sensitive for foreign bodies, but has the drawbacks of increased cost and radiation exposure.  Also, a weird quirk of CT scan is that wood can sometimes mimic the appearance of air bubbles in soft tissue, which may confuse a foreign body (not-as-bad) with a gas-producing infection (extremely-very-hyper-bad).  So keep that in mind.
  • Bedside ultrasound has the benefits of being quick, non-irradiating, and performable by the physician at the bedside.  As an added bonus, it allows for guided removal of hyperechoic foreign bodies such as glass.  However, it can be a difficult skill to master, and false positives may lead to you digging around tissue.  Other hyperechoic structures (soft tissue calcifications, bones, tendons) can mask the presence of foreign bodies.
  • Again – there is no single best imaging study to order for all situations.  Think about the injuring material and its properties.  Physics may be boring, but a little bit of knowledge can go a long way.

Treatment and Disposition

  • Not all foreign bodies have to be removed!  Step One –  figure out if it even requires removal.
  • Good indications for removal include: toxic material; risk of infection; involvement of nerves, tendons, blood vessels or potential to migrate to those structures.
  • Some foreign bodies may require special removal techniques – see relevant discussion below.  Foreign bodies that are in very deep tissue or embedded in hands or face may require special surgical consult or specialist follow-up.
  • After removal, closure depends on infection risk.  Low-risk wounds can be closed with primary intent – all the good evidence shows that these wounds do not require prophylactic antibiotic use.
  • Wounds at risk for infection (think heavily contaminated materials, like teeth fragments) may require healing by secondary intent or delayed primary closure.  However, in the absence of active infection, prophylactic antibiotic use is currently of unclear benefit at best (I guess if there were active infection, it would no longer be considered “prophylactic antibiotic use” anyway).
  • Ensure the wound is cleaned and irrigated post-removal.
  • If suspected retained foreign bodies exist after removal, obtain a post-procedure radiograph.
  • After discharge, appropriately inform the patient of the risk for a retained foreign body and document, document, document – don’t let them show up 6 months later with a frivolous lawsuit because they had “no idea” a piece of glass would fall out of their arm (even though you told them multiple times).

Continue reading below for further discussion:

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Using Ultrasound in Central Line Placement

This week, we have a post from regular contributor Nick Mancuso on how to excel when performing a procedure common in the ED as well as upstairs: ultrasound guided central line placement.


The three most common veins used in central line placement are the internal jugular (IJ), subclavian (SV), and femoral (FV). I will focus on IJ placement and the use of dynamic ultrasound.


  • Sterile technique is paramount (if time permits).
  • Linear array probe is used with a sterile probe cover, and sterile gel. A CVC kit is obviously required, along with sterile personal protective equipment. This procedure can be done with one person, but two can be helpful especially during training.
  • Operator on the isiplateral side of the pt, pt in Trendelenburg, probe indicator to the left of operator, in transverse position.
  • Place probe superior to clavicle, IJV usually larger, lateral to carotid artery.
  • The IJV will compress with pressure, vs. the artery. If hypotensive or dehydrated, may disappear with inspiration.
  • Center vein on screen, lidocaine can be used to anesthetize pt. Use center of probe as guide, while not looking at monitor, stick pt skin with entry needle.
  • Look at monitor after puncture. Visualize needle or tissue compression. Puncture vein looking at monitor.
  • If needle can’t be visualized, a long-axis (longitudinal) view can help
  • It is extremely important to visualize the needle tip and not proceed with advancement of the needle without visualization of the tip.  The tip can be followed with slow fanning or sliding of the probe distally as you advance.  The most common mistake is not following the tip of the needle and letting the needle get “ahead of” the probe.  This leads to visualization of the proximal portion of the needle while the tip is in a different location in the neck, possibly causing complication.
Ultrasound visualization of neck vasculature

Ultrasound visualization of neck vasculature (Source)

Top: Internal jugular vein (IJV) and carotid artery (CA) in the transverse view with the transducer held on the skin without pressure (left) and with pressure (right). Note that with pressure, IJV appears compressed while the CA has retained its shape. Bottom: These blood vessels in the longitudinal plane. (Source: http://pie.med.utoronto.ca/OBAnesthesia/OBAnesthesia_content/OBA_ultrasonographyBasics_module.html)

Top: Internal jugular vein (IJV) and carotid artery (CA) in the transverse view with the transducer held on the skin without pressure (left) and with pressure (right). Note that with pressure, IJV appears compressed while the CA has retained its shape. Bottom: These blood vessels in the longitudinal plane. (Source)

Video: Ultrasound Guidance for Central Venous Access – SonoSite

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Anti-platelet therapy for stroke, what’s a ED Doc to do?

As a follow up to one of my esteemed colleague’s recent quick hit on the basics of strokes, I present some findings from time spent on the stroke unit these last few weeks.  Stroke is fairly popular here in the great state of Kentucky—we supremely enjoy our fried food, cigarettes, and lack of exercise (‘Merica!).  Therefore, stroke alerts are a fairly common occurrence in the ED and we keep our neurology friends busy (aka stroke team rounded for 10 hours a day).  But not everywhere is lucky enough to have an on call neurologist present for all stroke alerts.

So you’re the ED doc and they might have a stroke. Qu’est-ce que tu vas faire*!?!

Firstly, a head CT.  This is the first branch of the decision tree.  As previously mentioned, strokes are either hemorrhagic or ischemic, and the management of each is entirely different (ie do they get tPa or not). Without regards to whether to use tPa or not, this will focus on the ischemic subtype.

And within this subtype of ischemic stroke patients who cannot receive tPa, one comes to another branch in the decision tree.  Is the patient in atrial fibrillation (afib)?  Usually this can be evident from physical exam (ie irregularly irregular pulse) and telemetry, but an EKG can be confirmatory.  The management of an ischemic stroke in afib (aka cardioembolic ischemic stroke) differs greatly from one that isn’t (aka noncardioembolic ischemic stroke).  Cardioembolic strokes requires anticoagulants (eg warfarin) while a non-cardioembolic stroke only requires anti-platelets (eg aspirin).  Once again, the following will only focus on non-cardioembolic stroke and choice of anti-platelet.

*That’s French speak for ‘What ya gonna do’

Aspirin is dece*

There is some controversy in the stroke world as to the initial choice of anti-platelet for secondary prophylaxis of non-cardioembolic ischemic strokes.  One thing most everyone can agree on though is the utility of aspirin.  Aspirin within 48 hours has shown to decrease stroke reoccurrence and improve long term outcomes in multiple trials and meta-analyses 1,2,8.

*Dece= decent in Caucasian phrasin’

So what about the other fancy anti-platelets? 

There have been a multitude of trials that one is welcome to read by following the references below but I present my personal summary for secondary prophylaxis based on what I’ve read in the trials:

– Aspirin is more effective than placebo1,2

-Aggrenox (dipyramidole+aspirin) is better than placebo3

-Plavix is better than aspirin in composite vascular endpoint (you can decide for yourself whether that’s truly better for stroke or not)7

-Aggrenox may be better than aspirin3,5

-Plavix and Aggrenox are equivalent4

– ASA+ Plavix is equivalent to plavix alone but increases risks of bad side effects (eg bleeding)6

– Ticlopidine is better than placebo9

-Ticlopidine may be better than aspirin but with increased costs, lab f/u (i.e. biweekly CBC’s the first 3 months due to risk of neutropenia), and worse side effects may decrease the cost/benefit ratio10

Blah blah too many words—Break it down, C Belch

So a patient comes in with signs of stroke.  Their CT is negative for bleed and they’re outside of the tPa window.  They’re not in afib.  What are you gonna do?  My personal guidelines based on the evidence:

–          Aggrenox or Plavix monotherapy are good initial choices for non-cardioembolic ischemic strokes and better than aspirin alone

–          Do NOT use aspirin + Plavix dual therapy for these types of strokes due to the increased risks of bleeding. Leave that combo for cardiologists.

–          Aspirin and ticlopidine are also good initial choices.  But aspirin may be less effective than Aggrenox or Plavix monotherapy and ticlopidine has a poor side effect profile and increased costs

Public Service announcement:  As always, each patient is different and requires a personalized and evidence based approach to medication choices based on side effect profile and individual patient preference.  I also reference below the American College of Chest physician’s recommendations11 —they set forth their own guidelines based on the evidence which are very similar to what is proposed above.  And if all else fails, ask your friendly neighborhood pharmacist.



  1. The International Stroke Trial (IST). Lancet. 1997 May 31; 349 (9065): 1569-81
  2. Chinese Acute Stroke Trial (CAST). Lancet 1997 Jun 7; 349 (9066): 1641-9
  3. European Stroke Prevention Study 2 (ESPS 2).  J Neurol Sci. 1996; 143(1-2): 1-13
  4. PRoFESS trial.  NEJM. 2008; 359 (12): 1238-1251
  5. European/Australasian Stroke Prevention in Reversible Ischemia Trial (ESPRIT).  Lancet. 2006; 367 (9534):  1665-1673
  6. MATCH trial.  Lancet. 2004. Jul 24-30; 364(9431):  331-7
  7. CAPRIE trial.  Lancet.  1996 Nov 16; 348(9038):  1329-39
  8. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, MI, and stroke in high risk pts.  (Antithrombotic Trialists’ Collaboration).  BMJ.  2002 Jan 12; 324 (7329):  71-86
  9. Canadian American Ticlopidine Study (CATS).  Lancet.  1989 Jun 3; 1(8649):  1215-20
  10. A randomized trial comparing ticlopidine HCL w/ asa for prevention of stroke in high risk pts.  (TASS).  NEJM.  1989 Aug 24; 321 (8):  501-7
  11. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence based clinical practice guidelines.  Feb 2012; 141 (2_suppl)

Compiled by: Chris Belcher

Miss anything? Forgot to include something important? Leave a comment and help us improve our knowledge base for medical students!

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Part two will cover the important basics about the flu treatment, chemoprophylaxis, high risk patient population w/ the flu management. This is a compilation of information provided by the CDC along with reference papers that have been clinically relevant as they have been referenced multiple times over the last few weeks during my rotation in the ED. 


Note that Tamiflu is now FDA approved for patients age 2-weeks and older (FDA NEWS RELEASE link)



Pregnant women

Oseltamivir is preferred for treatment of pregnant women. Pregnant women are recommended to receive the same antiviral dosing as nonpregnant persons

  • Zanamivir might be preferred by some providers because of its limited systemic absorption; however, respiratory complications that might be associated with zanamivir because of its inhaled route of administration need to be considered, especially in women at risk for respiratory problems
  • Pregnant women are known to be at higher risk for complications from infection with seasonal influenza viruses and severe disease among pregnant women was reported during past pandemics
  • Oseltamivir, zanamivir, rimantadine, and amantadine are “Pregnancy Category C” medications, indicating that data from clinical studies are not adequate to assess the safety of these medications for pregnant women

Persons w/ impaired renal function

Oseltamivir: For patients with creatinine clearance of 10–30 mL per minute, a reduction of the treatment dosage of oseltamivir to 75 mg once daily and in the chemoprophylaxis dosage to 75 mg every other day is recommended

  • Serum concentrations of oseltamivir carboxylate, the active metabolite of oseltamivir, increase with declining renal function.

Person w/ Immunosuppression

  • oseltamivir was safe and well tolerated when used during the control of an influenza outbreak among hematopoietic stem cell transplant recipients living in a residential facility
  • Source: (retrospective study: Vu D, Peck AJ, Nichols WG, et al. Safety and tolerability of oseltamivir prophylaxis in hematopoietic stem cell transplant recipients: a retrospective casecontrol study. Clin Infect Dis 2007;45:187–93.)


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It’s that time of year: Flu QuickHits (part 1)

Part one (written by second year Nick Mancuso) will cover the important basics about the flu epidemic this season. Great summary!

The 2012/13 vaccine contains the typical triad against an H1N1, H3N2, and an influenza B variant.

  • A/California/7/2009 (H1N1)-like virus
  • A/Victoria/361/2011 (H3N2)-like virus
  • B/Wisconsin/1/2010-like virus.

Symptoms overlap with many URI’s, however the classics:

Abrupt onset, Chills, Varying fever temps, Myalgias, Frontal/retro-orbital headache, Sore throat, Nausea/Vomiting


can be difficult because samples are sent to labs and take time to get results. A nasopharyngeal culture is taken. Most diagnosis is done at the bedside based on clinical criteria. Rapid tests are not accurate and results vary. (Check continue reading for more info about diagnostic tests!)


Read part 2!

For some cool data and graphs from the CDC continue reading…

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What is #FOAM and why this website matters to you?

Source: http://lifeinthefastlane.com/2012/10/come-join-the-foam-party/

Hope this will inspire more readers and more contributors to our growing website.

As always, thanksto all the wonderful blogs and podcasts we always refer back to. We strive to improve our site as we  are continually inspiried by EM docs leading the way with innovate change to medical education