POTD: Testicular Dislocation

Today’s Trauma Tuesday POTD is about a rare but dangerous type of straddle injury in males: testicular dislocation.

Most commonly found in young males involved in a decelerating motorcycle accident, testicular dislocation presents with severe unilateral or bilateral scrotal and/or inguinal pain. Because there may be multiple other distracting injuries incurred as a result of the accident, a genitourinary exam will be vital in identifying this injury.

On exam, you will find that the testicle has been dislocated from its normal home in the scrotum to another location due to blunt force tearing the fascia of the spermatic cord. Half of the time, that location is the inguinal pouch, and you may find a palpable mass representing the testis at the inguinal crease. The corresponding hemiscrotum will be empty. Interestingly, unilateral and bilateral testicular dislocation appears to occur at the same rate, so don’t forget to check the other side as well. Other locations the dislocated testis may end up are the penis, the perineum, and the abdomen.

Manual reduction may be attempted but is often limited by intractable pain and therefore infrequently successful. There also may be concomitant torsion. Emergent urology consult for operative intervention is usually indicated.

Prolonged dislocation may affect fertility and increases the risk of testicular malignancy in the future

Sources:

Zavras N, Siatelis A, Misiakos E, Bagias G, Papachristos V, Machairas A. Testicular Dislocation After Scrotal Trauma: A Case Report and Brief Literature Review. (2014) Urology case reports. 2 (3): 101-4.

S. L. Schwartz, G. Faerber. Dislocation of the testis as a delayed presentation of scrotal trauma. (1994) Urology.

EMS Protocol of the Week - Respiratory Distress / Failure / Acute Pulmonary Edema (Adult)

Moving on from the pediatric respiratory distress/failure protocol to its adult counterpart this week, given that adults are just larger versions of kids (PEM colleagues – just kidding! please don’t hit me). Prehospital management of the adult in respiratory distress generally boils down to APE or asthma/COPD, with the occasional interesting obstructed airway case. The latter two instances are given their own distinct protocols to shine, so pulmonary edema gets to bulk of the attention here. As previously discussed with the older version of the protocols, we have the benefit if NYC of having BLS providers trained in the initiation of CPAP. ALS can continue NIPPV management but also obviously have advanced airway capabilities as needed. They’ll also administer nitroglycerin, either as a sublingual tablet or a spray, as SBP allows. As the OLMC doc, you’ll be answering the phone to authorize either a benzodiazepine to assist with anxiolysis or furosemide to initiate diuresis, as the situation demands.  

As a bonus, I’ve also included protocol Appendix P, which provides EMTs and paramedics with inclusion and exclusion criteria for the initiation of CPAP. Interested in more EMS educational nuggets like this? Head to www.nycremsco.org or the North Side OLMC protocol binder for more!

Dave

POTD: Trigger Point Injections

Today, I wanted to write about the first bedside procedure I learned how to perform as an intern: the trigger point injection. I’ve heard that many residents have never done one of these, so I wanted to share that they have worked very well for me.

Musculoskeletal pain is a very common complaint in the ED and many of us have a special cocktail we refer to when treating it, usually involving a combination of topical analgesics, NSAIDs, and muscle relaxants. However, there is a time when these oral medications aren’t enough in the ED, or the patient has already failed outpatient management, and that is when the pain involves a trigger point.

A trigger point is a palpable area of muscle spasm that feels extra taut, which many of us commonly call a “knot.” While a patient will commonly complain of a broad region of pain, the pain is typically originating from the trigger point and the remainder is referred pain. Trigger points are significantly more tender than the surrounding region and pain is easily reproducible on palpation. There is no imaging to identify a trigger point (not even ultrasound); you have to feel it.

You can find everything you need easily: an alcohol swab, 1-2 mL local anesthetic (1-2% lidocaine without epinephrine, 0.25-0.5% bupivacaine, OR a 50-50 combination of the two), a 22 to 25 gauge needle, and a band-aid.

The procedure is fast and easy, and relief is nearly instantaneous when done correctly.

Steps:

1. Identify the trigger point and clean the area around it with the alcohol swab.

2. Insert the needle at a 30-degree angle, deep enough to penetrate the point (make sure your needle is long enough for deeper muscles!) When you hit the knot, you may elicit a “twitch” response, which is pathognomonic for a trigger point. Inject some anesthetic.

3. Pull out almost to the surface of the skin and redirect to deliver a small amount of anesthetic to each of the 4 quadrants of the trigger point. It is important to pull out almost all the way to avoid hematoma.

4. Apply a band-aid when complete.

Contraindications:

1. Overlying cellulitis

2. Nearby critical anatomical structure

3. Allergy to local anesthetic

4. Coagulopathy or bleeding disorder

5. Can’t feel a trigger point, or can't find a maximal point of tenderness – not a contraindication… but wouldn’t recommend, mainly because you and the patient are unlikely to be satisfied. And you’re more likely to become one of those people who say that trigger point injections don’t work!

Be well,

Maisa Siddique, PGY3

Sources

https://www.aliem.com/trigger-point-injection-musculoskeletal-pain/

https://www.acep.org/patient-care/map/map-trigger-point-injection-tool/