Trick of the Trade: Fluorescein eyedrops

This is a guest post by Dr. Ian Brown (Stanford):

The Roberts textbook describes the procedure of corneal fluorescein staining as touching a moistened fluorescein strip to the cornea.  Maybe it is an irrational fear of a paper cut to the sclera, or a fear of touching an already abraded cornea with the paper, but I try to find an alternative. I have seen physicians hold the eye open with one hand, hold the fluorescein with a second hand and then drip tetracaine on the paper and let it drip into the eye with a third hand. I, unfortunately, only have two hands.

Trick of the Trade:
Make your own fluorescein eyedrops




Procedure:

1. Remove the back plunger from a 3 mL syringe
2. Insert the fluorescein strip into the back of the syringe
3. Replace the plunger
4. Aspirate about 1 ml of normal saline into syringe
5. Remove the needle

Voila! You now have a syringe of fluorescein eye drops.

Tips:

1. Prepare this outside the room.  If the patient sees the large gauge needle you use to draw up the saline, they often freak out.
2. To apply any eye drop, have the patient lean back with eyes closed.  Place 2 drops in medial canthus.  When the patient open their eyes, the drops run in.

Modern EM: Case 1 and 2 - Strep Throat

A sister and brother, aged 7 and 14, respectively present with pharyngitis.  The 7F has sore throat, cough, fever, and post-tussive vomiting for 1 day.  She has posterior pharyngeal erythema, no lymphadenopathy, no exudate, no petechiae, and looks like a viral URI.

The 14M had culture confirmed GAS pharyngitis 3 weeks ago, was treated with PCN-VK and symptoms resolved.  Now, he's in the ED with signs and symptoms of pharyngitis again, including dysphagia, fever, cough, posterior pharyngeal erythema, swollen tonsils, LAD, and petechiae on his hard palate.

Resources used:

• MD Calc
• EMRA Abx Guide
• Micromedix
• EM Literature of Note
• Twitter
• WikEM

I ordered cultures on each of them and then I opened up MDCalc (I have shortcuts saved to all my devices' desktops) to the Modified Centor Score for Strep Pharyngitis.  The easy-to-use calculator tells me that I won't treat the 7F unless positive cultures come back, and the 14M will get empirically covered.

But what antibiotic do I give him?  It seems that he failed PCN-VK.  Traditionally, many have reached for azithromycin next but I had just read a plea by Dr. Ryan Radecki on his blog EM Literature of Note to stop using macrolides for strep throat based on a study out of Rush that reported cases of rheumatic fever secondary to macrolide resistance.  The paper also notes as high as a 15% US single center resistance rates.

If not a z-pack, then what?  I opened the EMRA Abx guide which recommended cephalexin or clindamycin.  I chose cephalexin, rechecked in Micromedix the indications and dosing, and felt confident I had made the right choice.  I also noted to myself that if in the future I were treating a child with a history of PCN anaphylaxis, then clindamycin would be my choice.

I went home that night, read the paper and tweeted Ryan.  He and Dr. Graham Walker (MD Calc) were already having a conversation about the issue and I asked them what their second line choice of antibiotic is?

Finally, I went on my favorite quick reference resource WikEM.  Their entry on strep pharyngitis was recommending azithromycin as the second line drug.  I updated the site, and referenced the article.

This is a 3-part guest series by Dr. Timothy Peck, who is launching his own blog at ModernEM.blogspot.com. Check it out!