M2E Too! Mellick's Multimedia EduBlog
E Too! Blog by Larry Mellick, MD, presents important clinical pearls using multimedia.
By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.
Monday, February 1, 2016
I find the repair of eyelid and ear lacerations sometimes daunting. In fact, I often allow the ophthalmology service to take the lead with eyelid injuries and plastic surgery to manage severely lacerated ears. Not only are the repair of these unique skin-over-cartilage structures at risk of serious complications, they are also potentially time-consuming.
Ear cartilage is completely dependent on the overlying skin for survival and has unique risks for infection. Perichondritis is a feared complication that is sometimes resistant to treatment and can result in disfiguring complications.
This video allows us to review the basic principles of ear cartilage laceration repair. The truth is that this repair doesn't need to be daunting if you systematically addresses the unique needs of the injured ear:
- Cartilage needs to be covered with skin. The cartilage has no other source of blood supply, oxygen, and nutrients without the overlying skin tightly adhering to it. Consequently, you do everything possible to make sure the skin and cartilage are married up tightly. In fact, experts recommend that you trim away and sacrifice the excess cartilage if skin is missing.
- Cartilage is relatively fragile and vulnerable to tearing during suturing. Cartilage is fragile, and its saving grace is the tough perichondrium layers on its service. Experts recommend sutures be placed simultaneously through the skin and perichondrium rather than the full-thickness of the cartilage. Not only does this ensure a tight adherent relationship between the skin and cartilage, it avoids absorbable sutures buried under the skin. The associated unavoidable inflammatory reactions of buried sutures can leave residual lumpy defects in the cartilage under the skin. Basically, the perichondrial sutures should be the deepest layer of closure.
- The cosmetic outcome is benefitted by your sequence of suturing. Starting to suture on the posterior aspect of the lacerated ear sets the stage for a more successful outcome on the cosmetically — more importantly, externally — exposed ear. You need to suture the anterior and lateral surfaces last.
Effective packing of the finished repair may also be important. Experts feel auricular hematomas are uncommon in simple auricular laceration repair, and some recommend against wound compression that could cause vascular compromise and poor healing. If packing seems indicated, put Xeroform strips into the ear crevices, gauze (4 x 4 inches) behind the ear, fluffed gauze over the ear, and a final pressure dressing to prevent hematoma formation.
And, last but not least, most clinicians will recommend prophylactic antibiotics for the wounds at greatest risk for infection.
Click here to watch the video.
Monday, January 4, 2016
“Like pulling teeth” is a commonly used idiom that refers to something difficult to accomplish. My video this month, however, would suggest that pulling teeth may actually not be all that tough.
I recently spent a week in Jamaica as part of a medical and dental team providing care under relatively harsh conditions. The layout of our makeshift clinics allowed me to work alongside a dentist and two dental assistants. Besides getting the opportunity to pull my first permanent tooth, I was able to enlist the dental team’s collaboration on a teaching video, in which we demonstrate the elemental steps of pulling a tooth.
This video was made in a medically austere environment during which we were plagued by flies and other insects, but it demonstrates nicely the equipment and procedural steps of a dental extraction. And with the right equipment, I found, it is not all that difficult to pull a tooth.
Watch Dr. Mellick’s video of a tooth extraction.
Tuesday, December 1, 2015
Obviously, the patient who presents with calf pain requires careful consideration for a deep vein thrombosis. But when the history doesn’t fit, you may find yourself scratching your head trying to figure out the other sources of calf pain. Sure, you can just pick your favorite ICD-10 diagnosis for right or left calf strain, write a prescription for ibuprofen, give some crutches, and send the patient out the door. But that makes the practice of emergency medicine less exciting and fulfilling. Why not take the two additional minutes required to sort out exactly the source of the calf pain? This blog post provides several pearls for a more sophisticated (and rewarding) examination of the calf muscles, the triceps surae.
The triceps surae include three separate calf muscles. The aponeuroses of the gastrocnemius, soleus, and plantaris unite to form the Achilles or calcaneal tendon. The calcaneal tendon forms the longest and most powerful tendon in the human body. You won’t find the plantaris muscle in six to eight percent of the population, but that is not a big deal because the plantaris is considered largely vestigial and rarely involved in calf strains. The other muscles of the triceps surae, the gastrocnemius and soleus muscles, however, are vulnerable to injury. The gastrocnemius muscle especially so because it crosses two joints and has a high density of type two fast-twitch muscle fibers. The soleus muscle is sometimes injured in isolation, so differentiating strains of the gastrocnemius or soleus muscles is important for treatment and diagnosis. A combination of palpation, strength testing, and stretching is required to localize injuries to the gastrocnemius or soleus.
Palpation should occur along the entire length of the muscles and the aponeuroses to identify tenderness, swelling, thickening, defects, and masses, if present. Gastrocnemius strains typically present with tenderness in the medial belly or the musculotendinous junction. The pain is often lateral with soleus strains, but the painful soleus is also activated when the posterior calf is palpated. The video shows how to isolate the soleus by alternately tightening and relaxing the gastrocnemius muscles and palpating for the tender soleus muscle. Concomitant tears of the soleus and gastrocnemius do occur, but thankfully are much less common. When that happens, it can complicate the clinical picture.
Taking advantage of the different anatomical origins for the gastrocnemius and soleus muscles allows the examiner to isolate the activation of the muscles by varying the degree of knee flexion. This can be used for testing strength, pain, and flexibility. When the knee is in maximal flexion, the soleus becomes the primary force generator in plantar flexion. Conversely, when the knee is in full extension, the gastrocnemius the greater contributor. When the knee is flexed and pain is elicited with plantar flexion of the foot, in other words, one can be pretty confident that the soleus muscle has been injured.
The second video demonstrates the Thompson test, which assesses for complete disruption of the Achilles tendon. I have found this to be a very reliable examination. If the soleus contributions to the calcaneal (Achilles) tendon remains intact, it is possible to have some residual plantar flexion movement when the calf is squeezed by the examiner.
Watch how to isolate the soleus here.
Monday, November 2, 2015
I have been treating specifically localized sacroiliac pain with injections of bupivacaine and methylprednisolone for several years. It seems that every few months I have a patient who presents with localized pain and can benefit from this procedure. The only patients on whom I perform these injections are those who localize their pain to the back dimples, also known as the dimples of Venus or fossae lumbales laterales.
Anatomically, it is known that beneath these dimples are the superior aspects of the sacroiliac joints. These sacral sulci are anatomically just above the posterior superior iliac spine and also the junction of the base of the sacrum with the posterior iliac crest on either side. These indentations are created by a short ligament stretching between the skin and the posterior superior iliac spine. The only ones I inject with consistent, successful pain relief are patients with low back pain localized exactly to this area. These injections are potentially going into a joint space, and must be done using excellent sterile technique.
I am pretty sure that this video may be criticized by some pain interventionalists who do sacroiliac injections using ultrasound, MRI, or fluoroscopic C-arms. A good friend of mine who happens to be a pain specialist, in fact, said in an recent email, “Generally, not a great way to do it. Hard enough to accomplish with ultrasound or C-arm imaging.” Nevertheless, my twin brother, who is also a fellowship-trained pain specialist, said he does these or similar injections “all the time.”
Whether these injections are periarticular or intraarticular is not clear, but pain relief occurs consistently. And it may not matter because a number of reports describe excellent results with steroid and anesthetic injections periarticular.
Painful areas localized with one finger at the dimples of Venus are injected using a 1.5-inch needle buried deep into the tissues with a total of 3 mL consisting of 2.5 mL of bupivacaine and 0.6 mL (40 mg) of methylprednisolone. The needle typically goes through a deep fascia or ligament layer of tissue. Relief is almost immediate for the patient. This is a simple procedure that I probably perform every two to three months, and I seem to have a very high success rate for relieving a painful condition. The patient in this video still had pain relief several days later when I spoke with her daughter.
Thursday, October 1, 2015
We received three consecutive pediatric trauma patients on backboards and in cervical collars during a recent shift in the pediatric ED. What was obvious with all three of these patients was their lack of a neutral cervical spine. Their airways simultaneously appeared to be partially compromised as large occiputs caused cervical flexion, their chins were pushed upward, and their mouths were forced closed as the cervical collars’ chin stabilizers were scrunched against their chest walls.
The heads of children are disproportionately large compared with their bodies. The cartoonist, Charles Schulz, captured the essence of this in Charlie Brown. When placed in a supine position, a child’s relatively large head causes forward flexion of the neck on the body. This forward flexion or supine kyphosis has been described in an article by Herzenberg et al. as a cause of anterior translation of the fractured cervical spine in pediatric trauma patients. (J Bone Joint Surg Am 1989;71:15.) (The movement of the fractured cervical spines demonstrated in this article was dramatic.) This neck flexion also has the potential for compromising the airway. As is currently taught in most Pediatric Advanced Life Support (PALS) courses, the open airway is best accomplished by placing padding under the shoulders of these children.
Nypaver et al. studied neutral position and defined it in their study as using enough padding under the shoulders to bring the long axis of the cervical spine perpendicular to the transverse axis of the head. (Ann Emerg Med 1994;23:208.) Placing padding under the shoulders of a supine child to align the tragus of the ear and the apex of the shoulder appears to maintain a neutral cervical spine. This is one relatively rare clinical setting where a single maneuver can simultaneously accomplish two potentially life-saving interventions. I discussed the association between an “open airway and neutral cervical spine” in a 1993 letter to the editor. (Pediatr Emerg Care 1993;9:128.)
I’ve hoped for decades that the “open airway-neutral cervical spine” concept would catch on as teaching dogma. Unfortunately, based on my observations, it just doesn’t seem to be on the radar of most EMS training programs or if it is being consistently taught, the concept is rapidly forgotten by practicing paramedics and EMTs.
Click here to watch the video.