Back in September of 2009 Michelle shared valuable Tricks of The Trade regarding drainage of PTA.
Today we revisit the topic and add two more tricks to avoid hitting "big red" a.k.a. the internal carotid artery.
Numero Uno: don't go in blind!
Ultrasound is a great adjunct in the diagnosis and treatment of skin and soft tissue infections. For PTA, after local anesthesia of the pharynx, the endocavitary probe a.k.a. transvaginal probe can be used to view the size and relationship of the abscess in question and the internal carotid artery.
Numero Dos: use a rubber bumper
In order to access the deep narrow cavity of the mouth without obscuring your many recommend a 3.5 inch 18-G spinal needle. An alternative to trimming the plastic sheath of the needle is to replace it all together with a rubber bumper- the top of a lavander-top-tube.
Demian Szyld is an Emergency Physician in Boston, MA and a guest blogger at Academic Life in Emergency Medicine.
Acknowledgments: I want to thank Suraj Puttanniah who told me that about the rubber bumper trick. He in turn heard it from our legendary attending David Gaieski. The US image is credited to Michael Blaivas, MD and can be found at http://www.sonoguide.com/smparts_ent.html
How about using the bumper together with the trimmed needle cover the needle comes with? The bumper alone could slip.
ReplyDeleteAfter aspirating I recommend going in with a hemostat to bluntly dissect a single hole into the abscess cavity. This is safe and provides ongoing drainage. Got this tip from an ENT
Hey Brady,
ReplyDeleteGood point about combining the test tube bumper and spinal needle protective cover for the PTA aspiration. I was just asked the other day from a resident about whether the bumper alone would slip. Having not tried this technique myself, my best answer was "don't push THAT hard!"
As for dissecting a hole, I think I'm still too chicken of dissecting the hole. I think it's an unfounded fear since I've just aspirated pus from the pocket. I'll in the future. Thanks for the tip.
Maybe our needles are not as sharp as yours but I find that going through the rubber bumper dulls the needle a bit. This makes the procedure a little more uncomfortable for the patient.
ReplyDeleteHmm - that would indeed pose a problem. In this case, I would consider using a trimmed plastic sheath that the spinal needle comes with. http://academiclifeinem.blogspot.com/2009/09/trick-of-trade-peritonsillar-abscess.html
ReplyDeleteIt is just nice to know of multiple ways of doing procedures. You never know when one approach might not work.