When EM Docs were asked about their uses of MADs, their responses included fentanyl, Narcan, Versed, lidocaine for headache, awake intubations and nasopharyngolaryngoscopy, lidocaine with epinephrine or tranexamic acid for epistaxis, and ketamine.

Use Sugar to Reduce Penile Edema

A case report was presented with a patient who arrived with an edematous penis secondary to a metal ring he had placed at the base of his penis. Other EM Docs helped

Figure 2. This patient’s elevated aVR was associated with three-vessel disease.
ECGs courtesy of Tony Macasaet, MD, emergency department medical director at Vernon Memorial Healthcare in Viroqua, Wisconsin.

by suggesting a well-documented, but not widely known, “trick of the trade” use of sugar for reduction of edema, similar to the use of sugar for rectal prolapse. Several articles were referenced including “Paraphimosis–Pour Some Sugar On Me.”³ This article described the steps as follows: 1) Mix 50 mL of 50 percent dextrose solution with 2 percent lidocaine jelly, 2) place gauze into the solution, 3) place soaked gauze on the glans of the penis, 4) cover with condom or condom foley, 5) wait one hour, and 6) reduce the paraphimosis.
Another referenced article, “Paraphimosis Treatment & Management,” describes this method: 1) Apply 2% lidocaine gel to the penile skin for a few minutes to an hour before penile manipulation to reduce pain, 2) wrap the penis in plastic and apply ice packs, 3) use compressive elastic dressings, and 4) apply direct circumferential manual compression.

Haldol for Vomiting

Many of the EM Docs discussed successfully relieving vomiting in patients with gastroparesis and cyclic vomiting with doses of Haldol, ranging from 2 to 5 mg IV. Some also add 25 to 50 mg of IV Benadryl. Approximately 50 EM Docs reported using Haldol for vomiting with success on multiple occasions.

“Haloperidol for Treatment of Cannabinoid Hyperemesis” reports a case of cannabinoid hyperemesis syndrome (CHS) and cyclical vomiting where the CHS improved significantly after treatment with haloperidol in the emergency department.⁵

The dose was one puff of 10 percent lidocaine or normal saline per nostril. After intervention, the mean visual analog scale scores were significantly lower in the lidocaine group than the placebo group at 1, 5, 15, and 30 minutes.

Pay Attention to aVR

The patient with the ECGs in Figure 2 presented talking, then became unresponsive with pulseless ventricular tachycardia, was cardioverted, woke up, and had the second ECG performed. He was sent for catheterization and had critical left main stenosis and severe three-vessel disease.