September 2007

Contributed by readers/Edited by Donald B. Middleton, MD

Think Shingles
A patient complaint of localized pain should always raise the specter of shingles. Herpes zoster is often painful prior to forming a rash and may affect areas of the body that suggest other diagnoses such as myocardial infarction or appendicitis. Thanks to Dr. Gus Garmel in Santa Clara, California, for the reminder.

Reflex Tendency
Having a tough time getting an Achilles tendon reflex? Dr. Jennifer Donohue of Lake Oswego, Oregon, advises having the patient kneel on a chair, facing away from you, then tapping the Achilles tendons. This idea works well for most people, but a patient who has had a stroke or has bad knees might not be able to kneel properly. In that case, have the patient sit in a chair with his feet on the floor. This loosens the Achilles tendons and enables you to elicit reflexes more easily.

Tube TALK
Before inserting a nasogastric tube, Dr. Charles Evans of Stockbridge, Georgia, administers 3 to 5 ml of 1% lidocaine with a nebulizer mask to numb the nasal passages and upper airways. The tube will then pass easily and painlessly without causing any muscular dysfunction. I have found 2.5 ml of 4% lidocaine via nebulizer mask after bilateral nasal sprays of oxymetazoline to be the most efficient means of anesthetizing the nasopharynax. Either way, the patient appreciates the reduced discomfort.

Seven Signs
When evaluating chronically ill babies, Dr. Marson Ma, Jr., of Detroit, Michigan, adds three more vital signs to the traditional quartet of heart rate, blood pressure, temperature, and respirations. He advises also checking the blood glucose level, a pulse oximetry reading, and weight change from the last measured weight or birth weight. The glucose level and weight change can help detect metabolic disorders, neglect, and similar problems. Pulse oximetry may uncover pulmonary, cardiac, and hemoglobin defects. Additionally, measuring oxygen saturation in both the right hand and foot can help detect cardiac shunts.

A Little Dab’ll Do Ya
From Bear Creek, Pennsylvania, Ms. Amy Opachko, PA-C, reminds everyone that hair next to a laceration can be kept out of the wound with a dab of topical antibiotic ointment. If acrylic glue is being used to close the laceration, a small dot of the adhesive can do the same job.

Fluid Situation
When Dr. Mark Allen of Middle-town, Connecticut, aspirates a joint, he inserts a 3- to 5-inch section of intravenous extension tubing between the needle and the syringe. The tubing allows him to stabilize the needle in the joint with his dominant hand and to move the position of the syringe or change it if he encounters a large effusion. Often, an assistant will control the syringe, while Dr. Allen holds the needle still. This technique sounds ideal for large effusions where it is likely a large amount of fluid will have to be removed.

Lidocaine Limits
Wondering what the limit is for lidocaine when it is used as a topical anesthetic on mucus membranes or injected into wounds? From Nashville, Tennessee, Dr. Sam Pearson suggests that 4 mg/kg of plain 1% lidocaine and 7 mg/kg of 1% lidocaine with epinephrine (which is absorbed more slowly) are the generally tolerated upper limits for avoiding serious complications such as seizures and cardiovascular collapse. His formula for administering plain 1% lidocaine is: patient weight in kilograms
3 4 mg/kg ÷ 10 mg/ml = maximum number of milliliters of lidocaine.

Feeling Drained
To reduce a persistent leak from the needle site after performing paracentesis, Dr. Keith Yablonicky in Los Angles, California, puts surgical lubricant on one side of a 4 in-x-4 in gauze pad that has been rolled into a ball. The lubricated side is placed over the puncture mark, then covered with a clear surgical dressing to create a tamponade effect. Other sources recommend using a Z-shape puncture: first put the needle through the skin, then slide the skin over the subcutaneous tissue about one inch before entering the abdominal cavity. For tense ascites, a combination of these two techniques might help.