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The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, CEN, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Wednesday, June 11, 2014
This is what you signed up for, right? A career where you are a multitasking, highly-skilled medical practitioner in a fast-paced emergency department. This place is predictably unpredictable, but you are saving lives, and it feels good! The problem is, you cannot help feeling unappreciated, underpaid, overwhelmed, and exhausted. You are finally living the dream, but the dream consists of working weekends, double-call, and every other holiday. You miss lunch while still gaining a few pounds. You gain incredible insight into a very broken care system. Feeling more like a nightmare? It’s certainly not what you expected.
 
Now you have to deal with demanding patients who expect customer service perks. The patients who say, “Do more tests,” and insist on instant gratification. The audacity! You are frustrated that your clientele is telling you how to do your job. The degree behind your name means nothing because Google has allowed your patient to complete a self-diagnosis. This place is for emergencies, not primary care. These complaints are not emergent at all.
 
You feel justified by your disdain because you are not alone. Your colleagues exchange glances when a patient demands a head CT, or you hear a deep sigh from a co-worker when a patient asks for a stat MRI for back pain he has had for eight years. The nurses agree that your narcotic-seeking patient is simply that, and needs security to escort him out. Mr. Jones is back again for a refill of his blood pressure medication. Now you see one more person just signed in with a stubbed toe.
 
This is not what you signed up for at all. Breathe. Stop for a minute and regroup. Now, slap yourself. Maybe you need to slap yourself twice. This is what you signed up for! The ED is not just for emergent concerns. It is a care center where people know there are doctors and nurses. It is not just for emergencies like strokes, MIs, and blunt trauma! It is for patient care, in general, and their satisfaction. Until you realize patient satisfaction is part of the care plan, then you are going to continue to live a miserable existence in your department. Let us explain.
 
Back when organized medicine was — wait a second — has it ever been organized? No. Never. There are buildings with roofs, medications, tools, and machines that help you make decisions, but it’s not exactly organized. The ED is full of chaos. What about resources — or lack thereof? Your local resources exist, but most of the time they are almost impossible to utilize. Now, add the following fun facts: Your patient may not be able to read or write or speak English. He might be elderly or broke. When these types of patients ask you for a helping hand, why do you act so annoyed? We all know your badge doesn’t say S. Smith, Waiter. It doesn’t say J. Jerk, either.
 
Your badge says Emergency Physician or Nurse or Physician Assistant or Nurse Practitioner. This role is more than knowing how to diagnose and treat heart failure or catch early sepsis. This role is about providing total patient care and making people feel better, even the ones who don’t quite get it. It is about making people happy and motivated to play an active role in their own health care. After all, a happy patient trusts you, and isn’t that what this is all about?
Recent personal opinion columns scold and mock our demanding patients and hospitals that stress concern about patient satisfaction scores. Most of these rants reiterate the same themes about non-emergent patients demanding non-emergent testing or treatment. Many ED providers complain that patients don’t understand our overwhelming jobs, and visit us with complaints that should be seen somewhere else. Well, the ED is that somewhere else.
 
Providers whine that nonsensical satisfaction scores should not be part of our job evaluation. The patient’s opinion should not be a factor or used as an evaluation tool. Nonurgent patients should understand we are busy with other emergencies, and they need to wait. This may be true, but we don’t need to broadcast to them that maybe they are not as important. We also don’t get to say their patient satisfaction scores simply don’t matter, that only the admissions’ and critical patients’ scores are read.
It’s controversial. Patient satisfaction, however, is important in the ED and so are the scores — to an extent. What people think about your care should matter to you and your facility. It should be measured and monitored. You should want to change your practice based on negative feedback.
 
Also important are refills, toe pain, dental pain, and well checkups. The ED is not just for emergencies, and it will always be that way. It doesn’t matter what a patient’s needs are; you must provide aid. The challenge is not the difficult intubation or rushing a stroke patient to the CT scanner within the window. Those steps are easy for you because they define your job. The real challenge is to accept that the ED will never be what you want it to be or operate the way you see fit.
 
It is also a challenge of your character. Patients are going to remember you, and their opinion matters regardless of who they are and what their complaint is. Their opinion should also matter to you because this also defines your job. This should not be seen as a chore but as a job that you want to master. You may yearn to explain to people what constitutes a true emergency. In the end, though, whatever brought them to the ED is an emergency to them, and they need your help. Your definition doesn’t matter.
 
As ED providers, we prioritize. Most days, we make a difference and people appreciate our efforts. Other days, we see demanding patients who are not as privileged with our educated minds or who do not have the financial solution to their health care needs. We must accept that the ED is a mixing bowl of complicated cases and part of our job is to find a recipe that works for each patient. The ED is a place for compassion and creativeness, not for complaining, personal bias, or judgment.
 
No, we do not have to prescribe antibiotics for every cough or runny nose to boost our scores. Not every patient gets a CT or an x-ray just because he asks for it. Providers seem so annoyed by the requests. Find a middle ground with alternative options if you can. Considering patient satisfaction as a goal is not giving in to Press Ganey. It is important to reexamine how you practice and how you treat people, even the incredibly ill-advised ones. As providers, we are still allowed to exercise our clinical judgment to make a decision about patient care and not get irritated at patients when they ask for or demand things. Do not lose sight of creating a relationship through communication, trust, and ultimately, kind rapport. Don’t fall into the I’m-the-provider-and-I-know-best mentality. We can explain our thought process to patients and reassure them about our decisions whether to do testing.
 
Our jobs as ED providers include saving lives, but they also include considering patient satisfaction. These scores should not be exempt just because we make life-or-death decisions. Our profession should be respected and some patients need to wait, but being callous is never justified. Maybe we can look past the initial insults of certain patient complaints and find a deeper meaning. Not all of the scores are accurate or reflect the total picture of who we are as providers. No one is perfect, and we should accept that there is always room for growth and change.
 
We have a privileged job, but it does not mean we are allowed to be pompous. Patient satisfaction, courtesy callbacks, answering questions, and going the extra mile not only make a difference to our patients, they define our role as care providers. Rolling our eyes at our regulars will not make them stop coming. The next time you feel yourself wanting to say, “That is not my job in the ED,” think again. It is your job, and it is going to keep being your job. Consider patient feedback realistically. Treat everyone with compassion and courtesy, and I guarantee the rewards will not be what you expected.
 
How important is patient feedback to you?

Tuesday, May 06, 2014
Olecranon bursitis, also called baker’s or Popeye elbow, can be a painless or an irritating condition involving the bursa located near the proximal end of the ulna in the elbow over the olecranon. Normal bursae sacs generally are filled with a small amount of fluid, which helps the joint remain mobile. The sac can swell under the soft tissue from overuse or when the area sustains an injury from a bump or fall.
 
Normal bursae are usually small, but they can grow to be quite large, swollen, and occasionally even infected when they become irritated or inflamed. The swelling is obvious because the space in this area is limited, and drainage of the fluid may be necessary. Physical examination of patients with uninfected olecranon bursitis demonstrates an annoying but supple lump on the posterior elbow; it is unsightly yet only minimally symptomatic. It may have even gone away by itself in the past. Infected bursae usually reveal a warm, red, quite tender, and painful bulge over the elbow with limited range of motion. Patients feel most comfortable in the flexed position and have difficulty extending their elbow because of the pain and swelling.
 
Most aseptic/sterile swellings are merely cosmetic and not especially bothersome. Many come from resting the elbow on a bar while drinking. Recurrences are common after simple drainage. Very red, hot, and painful bursae enlargement usually means gout or an infected bursa. Infected bursa must be drained and treated with antibiotics, and a cure is not always easy. Infected bursae demonstrate less floppy swelling and more diffuse redness and tenderness.
 

External soft tissue view of the left elbow. (Photo by Martha Roberts)
 

This patient had nonseptic olecranon bursitis. (Photo by Martha Roberts)
 
The Approach to Nonseptic Bursal Swelling
• Radiographic evaluation of injury (only if concern for underlying bony injury)
• Bursal needle aspiration using ultrasound
• Specimen sampling, WBC, gram stain, and cell count to help determine if infected
• ACE wrap plus sling if needed; pain control
• Orthopedic follow-up
 
Radiographic views of the left elbow. The left lateral elbow shows moderate soft tissue swelling over the olecranon without bony injury, left. The left AP view of the elbow shows that the IV line was inappropriately placed in the affected arm. (Photos by Martha Roberts)
 
The Procedure
• Premedicate patients who may require analgesia.
• Place the patient in a position of comfort with the affected elbow within your arm’s reach. Effective positions include allowing the patient to give himself a hug by placing the arm across his chest or having him lie on his unaffected side with his elbow propped over a large drape.
• Place your US probe over the affected area and assess for the highest area of fluid collection. Mentally note this area using landmarks, and remove the probe once located.
• Apply antiseptic to the site. Apply sterile gloves.
• Inject 1-2 mls of 1% lidocaine using a prefilled 25g needle to anesthetize the affected area.
 

Properly positioning your patient is key to a successful procedure. (Photo by Martha Roberts)
 
Ultrasound showing large fluid-filled bursa sac over olecranon.
 
Gauze, aseptic cleaner, injection needle, and lidocaine. (Photo by Martha Roberts)
 
Lidocaine with epinephrine may be used. (Photo by Martha Roberts)
 
Identified injection site determined by guided US. (Photo by Martha Roberts)
 
• Remove the 25g needle, and wait one to two minutes.
• Insert 18g needle attached to 10 mL syringe to same entrance site, and begin draining the fluid from the bursa sac. Use a sterile technique. Consider using sterile US probe covers.
• It may be necessary to “milk” the area of fluid to help drain the site as you pull back on the syringe.
• Remove the 18g needle once aspiration is complete, and apply a BandAid or dressing.
• Send a specimen of the fluid to the lab with appropriate orders.
• Apply an ACE wrap over the site for compression, and offer the patient a sling for added support.
• Remind patients to do shoulder exercises if a sling is applied to avoid frozen shoulder complications. Do not splint the extremity.
• Arrange orthopedic follow-up within 24 to 72 hours and strict return precautions.
• NSAIDs are the treatment of choice for pain and decreased swelling. Oral steroids are not indicated.
 
Approximately 5 mLs of clear, yellow fluid were removed from the bursa. No blood or pus was noted. Results were properly labeled and sent to the lab. Occasionally this sterile fluid is blood-tinged. (Photo by Martha Roberts)

Septic bursitis usually results from a traumatic bony injury, and a wound or cellulitis will most likely be associated. Literature review reflects that more than 70 percent of septic arthritis cases are related to traumatic injury. (Roberts & Hedges. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.) Consider your high-risk populations to be those who are immunocompromised, diabetic, alcoholic (chronic injury or fall), or have jobs that may involve crawling on elbows or forearms.
 
Pus or cloudy discharge will be present on bursal aspiration, and is used to make a bedside diagnosis. Cell count may be more than 200,000 per mL. Gram stains may be negative about 30 to 50 percent of the time, even with septic bursitis. Cultures may reveal Staphylococcus aureus (80%) or streptococcal organisms; gram-negative cultures are rarely seen. (West J Med 1988;149(5):607.)
 
Septic bursitis does not always present with a fever. (Roberts & Hedges, 2014.) Treatment of septic bursitis for successful outpatient therapy (not diabetic or immunocompromised) includes clindamycin 450 mg PO three times a day for one week or Bactrim 2 DS tabs PO twice a day for one week. IV antibiotics such as vancomycin, clindamycin, and linezolid are given for severe cases during inpatient management. Remember, low WBC count and negative gram stain do not rule out infection. (Levine B. EMRA Antibiotics Guide. Emergency Medicine Residents’ Association, Irving, TX: 2012.)
 
Nonseptic bursitis may result from a gouty attack or arthritic flair. Drainage will be yellow-tinged or straw-colored but clear. It may also be slightly blood-tinged, and may have an erythrocyte count of 20,000-30,000 per mL. The leukocyte count may be 10,000-20,000 per mL, but is rarely high. Crystals may be seen and give rise to suspicion of gout. Overall, the cell count will be less than 6,000 per mL for nonseptic bursitis. (McAffe & Smith, 1988.)
 
 
Cautions
• Is your patient on blood thinners? You can still drain the bursa carefully. But make sure he is not taking over-the-counter medications that could be an issue if he is also taking Coumadin, ASA, or Plavix. Glucosamine sulfate, a popular but controversial supplement for treating osteoarthritis or inflammation, may be something the patient uses. You may want to advise him to avoid vitamin C and Omega 3s as well.
• If patients are looking for an “organic” treatment, suggest acupuncture, physical therapy, or massage. Always suggest orthopedic follow-up, however, as primary advice.
• What is the bigger picture? Olecranon bursitis may be caused from a lupus flair or uremia. Be sure the patient has proper follow-up. It doesn’t hurt to consider warning signs of other systemic diseases besides gout or arthritis.
• IV placement: Do not place intravenous lines in the affected arm if at all possible. As noted in the image above, the nurse placed a line in the arm with the known injury. The patient needed pain medication during the procedure, and it was difficult to administer because of positioning. Discuss this with your team if you are ordering labs or need IV access.
• Bursal aspiration: We all know your first thought may be to get rid of that sharp quickly! Don’t forget, however, that you need to send what you drain to the lab! Be careful with your fluid-filled syringe after you drain the bursa pocket. Do not recap the needle. Instead, immediately transfer the specimen to your sample containers and send it to the lab.
• Are you cleaning your ultrasound machine appropriately? This is as important as doing the procedure itself because we can’t do our jobs effectively without the right equipment. Be careful what you use to clean the machine because heavy cleaners or abrasive pads such as CaviWipes may cause irreversible damage. Remove gel from the transducer immediately after use with soft gauze. Refer to your specific model’s requirements for appropriate cleaning guidelines, but keep in mind a neutral pH is best.
 
Tip of the Week
Our friend Eugene Lee, MD, at Inova Fairfax Hospital ED reminds us that an open dialog with our orthopedic team is important and necessary. Previous treatments of bursitis should always be taken into consideration; chronic olecranon bursitis needs close follow-up. The orthopedic team should be consulted if you are at all considering injecting steroids into any bursa, especially if the bursa was recently or previously drained or a septic joint is suspected. Ruling out septic bursitis is imperative before injecting steroids into any bursa.
 
Some studies say, however, that 20 mg intrabursal injections of methylprednisolone acetate may be an effective treatment regimen for nonseptic olecranon bursitis. (Arch Intern Med 1989;149[11]:2527.) Please take into consideration, however, that the literature review of these data is limited because of sample and study size as well as inconsistent results. More information on this topic is welcome, and we encourage your comments!

Wednesday, April 02, 2014
The Approach: How to Help Heal
We promised you some information about soft tissue injuries, and you’ve got to hand it to us: we delivered! Last month, we discussed incision and drainage of large burns to the hand. Review it here before reading further:
http://bit.ly/RobertsBurn. This month, we want to take an in-depth look at wound care management for burns and highlight other pearls needed for top-notch healing.
 
You should try to follow a few simple rules when it comes to treating burn patients. Soft tissue skin injuries heal in stages and are dependent on direct and correct treatment of the area, nutrition, and hydration. Most providers fail to mention the benefits of protein and fluid intake to burn patients, especially if they are minor injuries. Nutrition and hydration play a major role in the healing process along with keeping the area clean, dry, and properly bandaged.
 
Be sure to familiarize yourself with the proper essential wound care materials: What is Kerlix? When do I use Xeroform? What type of splint is best? Know where things are in your emergency department stockroom. Actively involve and engage your patient in managing his burn care during your first application of the bandage. Print proper written instructions reiterating the information with phone numbers for local burn centers and specialists. Provide pain management, and take time to answer the “dumb question.” Infected burns are painful and can be debilitating, not to mention that patients are worried about the cosmetic appearance. Complications can be avoided if you spend the time talking to your patient about how to treat his injury properly.
 
The Procedure: Assessing the Damage and Treatment Essentials
Our previous hand injury is a great example of a volar hand burn that needs a bulky dressing and splint.
  
 
Other injuries include dorsum burns, treated in similar fashion with full debridement.

 
How to treat the blister is always a question for all burns. Preserve the skin and use it as a protective barrier for the first 24-48 hours for volar hand burns. After that, however, the wound requires debridement, and all dead skin has to be removed by our favorite local artist, the hand surgeon. The burn to the dorsum of the hand was debrided on the initial visit and treated in a similar fashion, with close follow-up. Here is a step-by-step approach on how to apply the proper dressing for this type of burn, which can be modified for any extremity burn depending on the affected area. Examples of burn dressings:

 
  • Provide necessary tetanus vaccination or booster.
  • Ensure that the patient has been adequately medicated for pain.
  • Provide a layer of gauze padding to the debrided sites when applying your bulky dressing. It’s key to have the gauze draw fluid away from the burned surface during healing.
  • Cover all affected areas with liberal but even amounts of your chosen barrier and healing cream (sulfadiazine/Silvadene for larger burns, bacitracin for smaller ones, etc.). Some apply an Adaptic pad or Xeroform to the affected areas before using gauze. Wet gauze sticks when the dressing is changed; this can also help with secondary debridement.
  • Note: Separate all fingers with gauze pads (A). This was not done in figure D, and skin maceration of normal skin occurred.
  • Tell the patient to make his first dressing change in 24-48 hours.
  • Start applying bulky dressing wrap. Do not apply a splint directly to the injured area without a bulky dressing barrier!
  • Apply a volar splint (for this burn because it is a palmar burn) or thumb-spica-like splint to accommodate injury. Be sure to have it in a dependent position where fingers are able to move freely if at all possible. The splint serves as a protective garment and skin stabilizer as healing occurs over the next seven to 21 days.
 
Discharge Paperwork Considerations
Provide your patient with written instructions for dressing changes at home:
1. Time your dressing change for half an hour after taking your pain medication.
2. You may need someone to help with your dressing changes.
3. Prepare all materials before you get started.
4. Remove all parts of the old dressing and remove or wash off the prior cream that was applied with liquid soap like Dove or Dial.
5. Inspect the area. Is it infected? Look for redness, swelling, warmth, and streaking. Some dislocation and discharge may be normal. Excessive amounts of either are not normal.
6. Perform range-of-motion exercises in the same ways you would use your hand, foot, finger, etc.
7. “Fluff up” your gauze by pulling at it slightly and stretching it before applying.
8. Apply the new ointment or cream with a sterile tongue blade or piece of gauze.
9. Apply “fluffed up” gauze. Do this in a bulky dressing style, as shown to you in the emergency department.
10. If you have a splint, apply it after.
11. Wound care is done daily.
(This list was adapted from “How to Change a Burn Dressing at Home: Patient Instructions” from Roberts & Hedges, Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.)
 
Cautions: Focus on Nutrition and Hydration
The past few decades of intense burn research prove that wound care, nutrition, and hydration are the keys to successful healing regardless of burn size or shape. The Journal of Parenteral and Enteral Nutrition knows a thing or two about nutrition and metabolic support. Evidence-based results for burn care support good nutrition, even for minor burns. A noted improved clinical status and decreased healing times are seen with low-fat nutrition in all types of burn patients. Low-fat nutrition, for example, decreases rates of infection and shortens overall healing times. Fish oil did not show any added clinical benefit. Overall, monitored nutrition during healing times for patients with burns can help modulate cortisol binding globulin and free circulating cortisol after severe stress. (J Parenter Enteral Nutr 1995;19[6]:482.)
 
A study in the British Journal of Nursing said disregarding nutritional status for burn patients may compromise healing times or prolong the stages of wound healing. Fatty acids are essential for cell structure, and play an active role in the inflammatory process. Increased levels of protein are necessary for collagen formation when the body is attempting to heal, and this also helps prevent wound dehiscence. Some studies show vitamin C also plays a role in the healing process, and it could be an added supplement. Vitamin C deficiencies can also contribute to fragile granulation tissue. Finally, some evidence suggests that low albumin and body mass index (BMI), adequate rest, and even some holistic approaches are essential for healing. (Brit J Nurs 2001;10:[1]:S42.)
 
Finally, it is well known and accepted that fluid replacement, even for minor burns, is essential to wound healing. Several approaches help determine the needed amounts of fluid resuscitation for burn patients. These rules do not apply just for inpatient admissions. Hospitalization should be considered if you are thinking of aggressive fluid resuscitation management for a patient. The Rule of 9s and the Parkland formula are good standards to review and practice when you are concerned about a burn patient.
 
Do not forget to tell patients with minor burns to increase fluid intake and avoid dehydration. This should be standard practice for all your burn patients. Encourage a balanced, high-caloric diet free from saturated fats and with increased protein intake over the next 48-72 hours. Also discourage high sodium and sugar intake for the next week. As noted, multivitamin supplementation is still debatable for many ailments, but vitamin C is an organic and inexpensive holistic approach. Be sure to note that aloe and honey are acceptable and affordable forms of topical healing agents, but manufactured creams like Silvadene and bacitracin are still the go-to topical treatments.
 
Tip of the Week
Having a hard time getting the gauze to wrap around the thumb? Cut a hole in the middle of the gauze wrap, and let it slide over the thumb just like the way you would put a T-shirt on over your head. The gauze remains uninterrupted, and you can continue to wrap the extremity. This will help keep the dressing in place, and doesn’t allow the gauze to roll up over the thumb and expose open skin that could let in bacterial intruders that could cause infection.
 
Go Green
You opened a pack of sterile gauze, and only used one piece. Your instinct is to just throw away the rest because the patient is leaving and doesn’t need any more gauze for his wound care. Send the extra home with the patient! He can use the nonsterile part on the outer surface of the bulky dressing.

Friday, February 28, 2014
Hand burns from thermal injuries are common chief complaints in the emergency department. Sometimes, 2nd- and 3rd-degree burns may need immediate interventions and warrant special attention. These injuries are painful, and often have associated complications such as permanent scarring, cosmetic issues, prolonged pain, and even infection. ED providers can assist with the primary complications related to blistering of the hand or extremity. Careful follow-up and a detailed discharge plan produce better outcomes and minimize overall complications. Full body/surface burns or circumferential burns should always be seen and evaluated by a local burn center. Burns related to alkaline, gas, fire, poisons, and chemicals may require expert consultation and possible admission to the burn center.
 
The patient’s burn featured in the photos below occurred about 48 hours before ED arrival. The patient, a chef, accidentally placed his hand on a hot flat-plate grill while cooking in a restaurant. The initial burn surface was not swollen or raised, but it began to swell uncontrollably over 24 hours. The swelling fluid pocket produced significant pain and restriction of the first digit. The patient came to the ED hoping we could drain the site and preserve the soft tissue of his hands.


 
 
The American Society for Surgery of the Hand (ASSH) classifies burns into four categories: 1st degree: superficial, redness of skin without blisters; 2nd degree: partial thickness skin damage, blisters present; 3rd degree: full thickness skin damage, skin is white and leathery; and 4th degree: 3rd degree with damage to deeper structures like tendons, joints, and bone. (http://bit.ly/HandBurns.) Classification of burns is also based on three criteria: depth, percentage of total body surface area, and source of the injury (thermal, chemical, electrical, radiation). (Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th ed. Philadelphia: Saunders/Elsevier, 2014.) It is important to complete an accurate evaluation of every burn patient in case fluid resuscitation or transfer to a burn center is necessary. More information about how to categorize burns can be found on the American Burn Association website at www.ameriburn.org.
 
The initial ED management blisters from burns, however, is controversial. It likely doesn’t matter exactly what is done. Traditionally, large blisters are left intact to help with pain relief, and small or broken blisters are debrided when first seen. Blistered skin will eventually have to be removed, and skin grafting may be required. All burns are different in size and shape and healing times may vary, but smaller more manageable wounds are usually watched carefully and not aggressively debrided on initial presentation. The blister in this case, however, warranted drainage. The patient will need to follow up with a plastic surgeon or hand specialist within a day or two. Actual treatment is based on the severity of the burn, potential for complications, and availability of follow-up.
 
Needle aspiration of blisters should not be performed with overlying skin that has not been debrided for more than a few days because this increases the risk of infection (UpToDate [2014]. “Treatment of Minor Thermal Burns,” http://bit.ly/1powgJT.) Each hand only makes up 2.5 percent of total body surface area, but loss of function and pain from a burn is 100 percent maddening.
 
 

Aspiration of the blister two days after the ED presentation with the skin left intact. This flap of skin will need to be debrided in a few days.

 
The Approach
• Wound care with simple hand washing and cleansing
• Gentle incision and drainage of the site
• Coverage of wound with ointment and bulky dressing
• Splint care and pain control
• Follow-up with plastic surgery or specialist in one to two days
 
The Procedure
• Medicate the patient appropriately with either PO or IV medications prior to starting any procedure after evaluating the initial burn. Burns are quite painful injuries.
• Instruct the patient to sit on a stretcher while you inspect the burn.
• Consider consulting a hand specialist prior to beginning. Typically, the ED provider can drain burns of this size and caliber (such as the one featured in this photo) at the bedside.
• Clean the area with Betadine or antiseptic. Gentle hand washing is also encouraged prior to treatment.
• Sterile gloves are not necessary, but they are not a bad idea.
• Use an 11-blade scalpel to make a 0.5-1 cm incision at the base of the burn. It is best to make the incision to an area of the burn where flexion or extension is at its least resistant. The incision was made at the base of palm, just distal to the wrist, in this case.
• Note: Local anesthesia is not typically indicated for the initial I&D of a burn. The patient’s skin is the most painful under the burn, and future pain is usually caused by drying or peeling/pruritus of the skin flap that remains over top of the burn. The drainage incision is also small and should not cause significant pain. Do not make a large incision if you are choosing to leave the skin flap in place.
 
 
• Slowly allow the fluid pocket to drain into a basin. Do not rush this evacuation. Gently massage the skin to evacuate the fluid. It may take two to five minutes to completely drain the area, depending on the size of the burn.
• We suggest initially leaving the deflated skin in place as a protective cover for the burn once the area is mostly drained and flattened. Complete debridement of the burn with removal of the skin is controversial, but all tissue must be removed eventually. (Roberts & Hedges, 2014.) Discuss your decisions with the patient based on your consult with plastic surgeon on call.
• Cover the area with ointment. Bacitracin and silver sulfadiazine (Silvadene) are fine choices. A thin, moderate layer is used. Silvadene has broad gram-positive and gram-negative antimicrobial spectrum coverage including B-hemolytic strep, Staphylococcus aureus and S. epidermidis. It may also cover pseudomonal infections, so it may be the better choice for diabetic patients or immunocompromised patients. (Roberts & Hedges, 2014.) Antibiotics are not initially given.
• Apply a bulky dressing and splint. Different variations of the thumb spica or radial gutter splint may be used best for palmar burns. Burns to the dorsal surface may do best with a volar splint.
• Give a supply of pain medication because the patient may experience increased pain from the site as the skin dries over the next 24-48 hours. Tell the patient to take pain medication half an hour before dressing changes. (Roberts & Hedges, 2014.) Pruritus is often a common complaint, and can be treated with over-the-counter Benadryl. Warn the patient to return to the ED for complications such as black or ecchymotic changes to the skin or even associated cellulitis or lymphangitis. Stress that the dressing should not be constricting and that the splint needs to be worn for proper healing.
 
Cautions
• Remind patients not to soak their hands in water or ice water. This causes further damage to the soft tissue. If the patient arrives at the ED with his hand soaking in a bucket, have him stop immediately.
• Take any jewelry or restrictive clothing off immediately. Rings and bracelets must come off with a ring or jewelry cutter if attempts by the patient fail.
• IV pain medication is often necessary so do not hesitate to medicate these patients quickly and appropriately.
• Cleaning the area with gentle soap and water is necessary to avoid infection.
• The patient should never scrub the area pre- or post-procedure because this will further damage the skin.
• Antibiotic ointments such as bacitracin or Silvadene are acceptable post-burn ointments. Patients should avoid holistic approaches like toothpaste, butter, herbs, or sprays because they can cause further damage to the soft tissue. (Medscape [2014]. “Emergent Management of Burns,”
http://bit.ly/1poP7nX.) Of note, Silvadene is contraindicated for term pregnancy and in newborns because of possible induction of kernicterus. (Roberts & Hedges, 2014.)
• Bulky dressings are helpful, but can often stick to the burn and cause more pain, especially with removal. Review wound care and approaches to dressing changes with the patient prior to leaving. Demonstrate how to apply appropriate layers of bacitracin or Silvadene with appropriate dressings prior to discharge. Gentle, cool water rinses can be used to help with dressing removal at home.
• Elevate the extremity while at home whenever possible (UpToDate.com, 2014.)
• 
Update tetanus as needed.
• You also should consider admission if you think a patient warrants PO antibiotics for potential or existing infection!
• Finally and most importantly, a circumferential burn of any limb can sometimes constrict it like a tourniquet. The constriction must be controlled or “released” with an escharotomy if this occurs. (American Society for Surgery of the Hand, 2014.)
 
Tip of the Week
We know we said holistic approaches for burn treatments should be avoided, but aloe vera cream may be an inexpensive and useful treatment for smaller burns. Honey may also be used on the burn because it has been proven to provide antibacterial and anti-inflammatory properties. Oral corticosteroids, however, are not useful. There is “no role for topical steroids in the initial treatment of minor burns, as this may increase the risk of infection and impair healing.” (UpToDate, 2014 and Roberts & Hedges, 2014.)

Friday, January 31, 2014

Part 1 in a Series

Wound care and suture repair are two of the most frequently encountered issues in the emergency department. It is the midlevel provider’s job to be familiar with proper wound care and suturing techniques as well as quick and safe treatment of soft tissue skin injuries. You can use various suturing techniques and styles, but it is important to find a few that really work for you, often tailored to the area of injury.

This month, we are focusing on lacerations and puncture wounds to the soft tissue of the face. Future posts will touch on other suturing skills, with some great tips from our plastic surgery friends. More in-depth posts will include videos of nerve blocks to the face, which are incredibly useful for wound repair. We will also touch on nasal, buccal, and ear lacerations as well.

The face has a plentiful blood supply. Primary closure is important for facial lacerations to avoid unnecessary scaring. Sometimes, swelling or extensive facial tissue damage makes primary closure more difficult. Careful wound cleaning of facial lacerations is critical. The soft tissue of the face is not at high risk for infection, but removing foreign bodies and cleansing with antibacterial agents is paramount. All wounds should be cleaned well and closed within a four- to six-hour window. Wounds older than six hours or presenting the day after the injury can be repaired, but a plastics consult may be warranted. (Semers N. Practical Plastic Surgery for Nonsurgeons. Philadelphia: Authors Choice Press, 2007.)

Case Study
Mr. J fell down the stairs of one of Washington, DC’s busy Metro stations. He fell face first, and the frame of his glasses became embedded in his face. Mr. J could not remove them and neither could EMS personnel. The glasses were then tapped to his face to help keep them positioned without ripping his skin further until our providers in the emergency department could complete an evaluation.

The Approach
• Stabilization of foreign body to affected area
• Local anesthesia
• Careful removal of object
• Radiographs and/or CT as needed
• Wound care
• Suture and repair
• Plastics follow-up


The Procedure
• Consult your on-call plastic surgeon if you have any questionable areas of repair.
• Consider early pain management interventions for this procedure. Percocet or Vicodin are good PO choices. IV morphine or Dilaudid may be needed for more extensive injuries and pain. A small dose of Valium or Ativan may also help your patient relax after the emotional and physical pain these injuries can cause. Local anesthesia administered promptly will usually alleviate the need for additional pain control.
• Prep. Wash your hands. This is still the primary way to decrease infection rates for all procedures. It is a good idea to practice sterile technique for the majority of ED procedures. Sterile gloves have not proven to decrease infection rates, despite what your predecessors may have taught you. (Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition. Philadelphia: Saunders/Elsevier, 2014.) Masks and eye protection should always be donned.
• Anesthetize. Local anesthesia to the site of the laceration can be used before or after removal of the foreign body. Anesthesia may be considered when and if the foreign body is deeply lodged in the skin. The best choice of local anesthesia is buffered lidocaine with epinephrine. The only time lidocaine with epinephrine is contraindicated is when the wound is a flap, raised by the injury. (Semers, 2007.) Plain lidocaine is a better choice for facial flap injuries because you do not want to compromise circulation to the flap.
• Investigate. Inspect the area for any smaller foreign bodies once the larger objects have been removed. Complete removal of all debris, wood, dirt, and objects must be done. Also look for bone involvement. Obvious dead or dark tissue can be removed carefully.
• Clean. Jet lavage is the proper irrigation procedure to use, but excessive spraying can cause further tissue damage. Be gentle but thorough. A mixture of Betadine and normal saline is a good agent for cleansing.
• Note: Antibiotic solutions have not been defined as a standard practice.
• A 20-gauge angiocatheter used at the tip of the irrigation device is good for removing most debris. Copious normal saline or tap water can also be used. DO NOT put an irrigating catheter into a puncture wound; it disseminates foreign material and cause tissue swelling, but rarely provides wound irrigation. A hemostat spread open inside the tract helps to separate a small laceration to facilitate wound irrigation.
• Apply firm pressure with gauze for two to three minutes instead of countless dabs if you have significant bleeding from the injured area after irrigating.
• Inspect and examine the whole face, including an ocular exam if indicated. Tend to eye injuries first, such as a ruptured globe or lid laceration. Ear exams are also important because significant head trauma can cause injury to the middle ear. Check for the presence of a hemotympanum and Battle’s sign, which may indicate a basilar skull fracture. A ruptured TM can be a surgical emergency and cause facial paralysis if the facial nerve has been compromised. Consult ENT if you suspect this issue.
• Never put your finger into a wound to explore what’s inside! Use ONLY your forceps and tweezers and occasionally x-rays to explore ALL wounds.
• Cervical spine injuries may not be obvious because of distracting injuries. A complete CT of the cervical spine and a head CT should be done if the patient has a significant mechanism of injury to the face or neck such as a traumatic fall.
• Complete the necessary radiographs and/or CT imaging of affected areas (i.e., orbits, mandible, etc.).


• Prep for your suture repair once the area is clean and dry. Suture choice: 6.0 or 7.0 nylon thread for soft tissue injuries of the face. Running sutures or simple interrupted are good choices for closure. Mattress suturing is NOT indicated for facial lacerations.
• Repair all flap injuries first.
• Note that sutures on the face are placed slightly closer together, approximately 3 mm apart. (Semers, 2007.)
• Cover closed lacerations with a thin layer of bacitracin or antibiotic ointment.
• Instruct the patient that suture removal must be done in five to seven days to avoid sutures scars.
• Leave the area open to the air or use a dressing. A gauze bandage is indicated if there is an extensive area of injury. Instruct the patient not to wash or disturb the repaired area for at least the first 24 hours (unless following up with plastic surgeon). Then, daily wound care using gentle cleansing of diluted antibacterial soap like Dove or Dial should be initiated. NO scrubbing.
• Note that covering the injury with gauze or a dressing not only serves as protection of the wound but aids patient comfort. They may also help stabilize the affected area if the patient is following up with plastics the following day. They also prevent the wound from drying out, which can cause the patient pain as it heals. Wound coverings also help absorb serosanguineous drainage. (Roberts & Hedges, 2013.)
• Tip: Consider Adaptic, Xeroform, or Aquaflo petrolatum gauze for better coverage.
• Do not use bacitracin after the first 24-48 hours because it keeps the area too moist, and can lead to further scarring or healing complications.
• Tell the patient to elevate his head when sleeping and to avoid heavy lifting, bending, or dangerous activities to minimize facial swelling. (Semers, 2007.)
• Small puncture wounds are best left unsutured. Even more irrigation is required if they are caused by a foreign body. Infection is common if foreign material is left deep within the puncture, but retained material cannot always be appreciated at the first visit. Be sure to warn the patient of this possibility! (We will discuss human, cat, and dog bite puncture wounds in future blog posts.)
• There are no universal standards or treatments for puncture wounds (Roberts & Hedges, 2013), and studies are limited. What is important is ample cleaning of the area. Probing or coring a puncture wound to the face is not suggested. Antibiotic use for puncture wounds to the face is not clearly defined in the literature. High-risk patients (immunocompromised or diabetic patients) may benefit from a short course of antibiotics, but this has yet to be proven.
• Update tetanus as needed.


Cautions
• Is there any pulsatile bleeding? Be sure to complete your vascular exam and address all issues.
• Is the patient a smoker? This will impair wound healing. Smoking cessation advice is always important in the ED.
• Did you ask the hard, personal questions about HIV, hepatitis, or other immunocompromised status? Always be sure to use universal precautions with all patients, but especially pay attention to those who are immunocompromised. Diabetic patients may also have wound healing issues.
• Was there an injury to the area involving the shoe, clothing, fabric, or other rubber? Bits of material may be imbedded in the wound. It may be required that a puncture in noncosmetic areas be widened into a linear laceration with a scalpel to adequately explore for and remove foreign material.
• Hydrogen peroxide is a very weak antibacterial agent. It is toxic to tissues and red cells. Don’t use it, and be sure to educate your patients on this concept as well.

Tip of the Week
This week we are giving a shout out to Medscape because we know you are all wondering about local anesthesia to the nose! Check out this excellent article by Medscape, and put all your fears to rest: http://bit.ly/1hIMU1K.

About the Author

James R. Roberts, MD & Martha Roberts, ACNP, CEN

James R. Roberts, MD, is the chairman of emergency medicine and the director of the division of toxicology at Mercy Catholic Medical Center, and a professor of emergency medicine and toxicology at the Drexel University College of Medicine, both in Philadelphia. He is also the chairman of the editorial board of Emergency Medicine News, and has written InFocus for more than 25 years.

Martha Roberts, ACNP, CEN, is an acute care nurse practitioner at Inova Fairfax Hospital Emergency Department in Falls Church, VA, and is Dr. Roberts’ daughter.

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