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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.

Thursday, October 01, 2015

Part 2 of a Series


Our series on joint care has given you a basic overview on knee arthrocentesis. Typically, it is not necessary to have an orthopedic consultant come to the bedside in the emergency department to do this procedure. Arthrocentesis is a procedure you can do well and feel confident about your technique.


Take a moment to review our last blog post on knee pain before reading this post and watching the accompanying video. ( As always, review the anatomy; it plays a key part in successful bedside technique. Ultrasound-guided arthrocentesis is always a favored approach.


Although emergency physicians and advanced practitioners can complete this procedure at the bedside, we suggest contacting the  surgeon involved for post-op patients before starting arthrocentesis. Most surgeons (if in-house at the time) will want to see a hot post-op knee. The surgeon may want to complete the procedure herself or omit a procedure if she does not feel it is necessary. Surgeons also may have concerns about antibiotics use (or misuse) and follow-up care for their patients.


The Approach

n Identification of knee effusion on physical exam

n Identification of knee effusion on plain radiograph

n Localized anesthesia prior to arthrocentesis of the knee

n Arthrocentesis of the knee

n Send laboratory testing including (but not limited to) cell count with differential, crystal analysis, Gram staining, bacterial culture(s), and sensitivity analysis.



n Suspected or definitive infection overlying the joint


The Procedure

n Obtain the following materials:

o 27 g needle x1 (for local anesthetic)

o 10 mL syringe x1 (for local anesthetic)

o 20 mL syringes x3 (for aspiration)

o 18-20 g needle x1 (for aspiration)

o Sterile gloves

o Hemostat

o Antiseptic of choice

o Sterile perforated drape

o Three-way stopcock

o Sterile testing tubes and/or containers

o Bandages and/or dressings of choice

n Identify all landmarks.

o Landmarks include the medial edge of the surface of the patella or at the middle or superior aspect. Note: The medial approach is typically the first-line approach, although a lateral approach is also an option.

n Position the patient lying supine and extend the knee as far as possible, keeping in mind that flexing the knee to a 20- to30-degree angle may assist with quadriceps relaxation.

n Cleanse the patient’s skin with antiseptic. Recommendations include clorhexidine or Betadine. Remember, if you use Betadine, you should remove the excess using an alcohol swab prior to injection to prevent Betadine from going into the joint itself. Entrance of Betadine into the joint can cause inflammation and should be avoided.

n Apply a sterile fenestrated drape.

n Use a 27 g needle to create a small wheal of anesthetic to the appropriate area. You may use 1% or 2% lidocaine in combination with sodium bicarbonate, approximately a total of 10-15 mLs. The solution is 1:10 mL of bicarb and lidocaine.

n Hold the patella firmly with your non-dominant hand.

n After a wheal is created, position your dominant hand so that it is parallel to the stretcher. Inject the anesthetic slowly into the skin and along the entire track of the aspiration of the needle. Infiltrate the skin down to the area of the joint capsule. The injection track should be dispensed between the posterior portion of the patella and the intercondylar femoral notch.

n Use your non-dominant hand to milk the effusion from the suprapatellar pouch above the patella. This will force fluid into the joint. This will aid in fluid removal as you aspirate.

n Do not forget to aspirate as the needle is advanced.

n Use a large syringe (20 mL is suggested) because there may be a larger-than-expected effusion present. The knee can hold up to about 50-70 mL of fluid.

n Place all fluid into appropriate tubes, and send to the laboratory.

(Adapted from Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.)



n If this is your first time completing the procedure, consider using an ultrasound-guided technique to be certain you have the correct landmarks.

n If your first syringe is filled to its entirety, remove it and place a new empty syringe onto the needle. To do this, hold the needle that is in the joint with a hemostat to maintain the correct position. This also stabilizes the needle so you can remove the syringe.

n Another technique is to use a three-way stopcock applied to the needle to allow you to change the syringes without having to remove the needle.

n The procedure can be almost painless to the patient and you can limit his distress if anesthesia is appropriately used. Tense patients with tense muscles do not allow for solid technique, so be sure to aid in patient comfort. As always, we feel patient comfort is half the battle!

n Sedation is rarely required, but may be prudent in some patients. This is not routine practice.

n Always try to remove as much blood or fluid as possible. Large amounts of pus may clog the needle, and the joint may not be totally drained. If this occurs, inject a small portion of the aspirated fluid into the space from the syringe and attempt minor position changes. Do not forget to push down on the suprapatellar pouch.

n Do not completely withdraw and reinsert the needle. If positioning of the needle tip needs to be altered, advance or retract the needle a few millimeters, rotate the bevel or lessen the force of aspiration or injection.

n Avoid side-to-side movements of the needle. Keep the barrel of the syringe parallel to the stretcher.

n It is easier than you think to confuse your sharps after the procedure is completed. Do not accidently toss your sample into the sharps bin.

n Apply a clean, sterile dressing with an ACE bandage to the knee post arthrocentesis.


Tip of the Week

The string test is a bedside technique to determine if the synovial fluid is inflammatory or noninflammatory fluid. Noninflammatory fluid may result from a meniscal tear. To complete this test, place a generous amount of synovial fluid onto your gloved thumb. Touch the drop with your index finger and slowly separate your fingers. A string will be formed as the fluid is stretched and manipulated. A string of approximately 1-2 cm will be evident in a noninflammatory condition. No appreciable string will be formed in an inflammatory synovial fluid such as rheumatoid arthritis. (Clinical Procedures in Emergency Medicine.)



Watch the video here.


Evidence-Based Practice Pearl

The Scandinavians seem to be doing it right. The study reported “significantly less procedural pain, improved arthrocentesis success, greater synovial fluid yield, more complete joint decompression, and improved clinical outcomes.” (Scand J Rheumatol 2012;41[1]:66.) We also recommend reading our friend Dr. Todd Thomsen’s article, Arthrocentesis of the Knee. (New Engl J Med 2006;354e19;


Final Thoughts

Jim weighs in: “Once you learn the technique, the knee joint is quite easy to tap. Using suprapatellar pressure maximizes fluid in the knee joint itself.”


Martha weighs in: “I always provide a rolled towel under the patient’s knee to help with relaxation and comfort to aid in proper positioning.”


Next Month

Complications of knee arthrocentesis and other clinical pearls related to joints.


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Tuesday, September 01, 2015
Part 1 of a Series

How often do you come in contact with a patient whose chief complaint is knee pain? How often can you actually to do something about it? Collectively as emergency providers, we do not typically fix these types of injuries in the ED, and at times, it is not even certain if we actually diagnose knee pain properly. The truth of the matter is simply that we can diagnose it correctly, help our patients feel better, and give them some answers.


Frequently, traumatic knee pain can be diagnosed as a contusion, generalized strain, or sprain. Rest, ice, compression, elevation, and NSAIDS are often prescribed. If you are lucky, you may encounter the uncommon patellar tendon dislocation, and obtaining a radiograph for traumatic knee injuries may actually yield positive results. At least you can pop it back into place. (Read our previous blog post and watch our video on patellar dislocation at The differential diagnosis for knee pain, however, is endless. Here are a few for you to peruse.


Common Causes of Knee Pain 



Older Adults

Patellar subluxation

Patellofemoral pain syndrome (chondromalacia patella)


Tibial apophysitis (Osgood-Schlatter lesion)

Medial plica syndrome

Crystal-induced inflammatory arthropathy: gout, pseudogout

Jumper’s knee (patellar tendonitis)

Pes anserine bursitis

Popliteal cyst (Baker’s cyst)

Referred pain: slipped capital femoral epiphysis, hip fracture

Trauma: ligamentous sprains (anterior cruciate, medial collateral, lateral collateral), meniscal tear, fractures, muscle strains

Metastatic cancer

Osteochondritis dissecans

Inflammatory arthropathy: rheumatoid arthritis, Reiter’s syndrome, pigmented villonodular synovitis


Juvenile rheumatoid arthritis

Tendonitis (quadriceps, patellar tendon, etc.)


Trauma: ligamentous sprains (anterior cruciate, medial collateral, lateral collateral), meniscal tear, fractures including epiphyseal fracture, muscle strains

Septic arthritis




Stress fracture/stress reaction



Referred pain: neurogenic, hip and leg pathology



In the end, it seems as if we habitually slap a knee immobilizer or ACE bandage on knees, have the patients follow up with an orthopedic specialist, and hope for the best. Knee pain is such a frequent guest in our emergency department that we need to be prepared for its daily arrival. It is time to put an end to the pass off to orthopedics because the buck stops here and now in your ED. We are going to make you all experts by the end of this series on joint injuries and aspiration.


First, let’s discuss the statistics. Many different providers treat knee injuries, but the National Institutes of Health reported 6.6 million people visited the emergency department in the United States from 1999 to 2008 with the chief complaint of knee pain. This is an average rate of 2.29 knee injuries per 1,000 people. Although 42 percent of the knee injuries were diagnosed as a strain or sprain, contusion and abrasions (27%) followed behind. Knee lacerations and punctures (10%) proved to be a solid offender as well, while arthritis, tibial plateau fractures, and other various knee ailments brought up the rear. (Acad Emerg Med 2012;19[4]:378.)


Further statistics reveal knee pain also accounts for approximately “one third of musculoskeletal problems seen in primary care settings.” (Am Fam Physician 2003;68[5]:907.) That means many of these cases of knee pain are first seen by their primary care provider, then possibly by the emergency department, and finally by the orthopedist. That is three providers and an exorbitant amount of time, resources, and money.


Knee pain can also be a source of significant “disability, restricting the ability to work or perform activities of daily living,” according to that same article. This means we need to really start paying closer attention to these patients.


The rate and pattern of knee injuries can vary by sex and age, so it’s important to know what to be concerned about depending on the chief complaint. Adolescent boys will often present with knee pain related to sports injuries. Those over 65 may present with arthritis. It’s very important to know the subtle differences between osteoarthritis and rheumatoid arthritis, which are two completely different ailments. The key is to understand knee pain. This enables clinicians to “better anticipate caseloads, allocate resources, and determine best practices for diagnosis and treatment of knee injuries in different age groups” in the emergency department, according to the Academic Emergency Medicine article.


This month, we are going to ease into our series on joint aspiration mindfully. Later, we will show you the proper procedure via video. This technique needs to be reserved for the correct patient because you do not want to tap every joint that looks irritated or is painful. Our initial portion of this series will begin by discussing traumatic knee injuries and related procedures.



Click here to watch the video.


You definitely need to keep the Ottawa Knee Rules in mind. (JAMA 1996;275[8]:611.) The question is, x-ray or don’t x-ray? These rules describe the criteria for knee trauma patients who may warrant knee imaging. The goal is to apply these rules to make your decision. If no criteria are met, imaging is not indicated.


Answering yes to one of these questions mandates imaging:

n Age 55 or over

n Isolated tenderness of the patella (no other bony tenderness)

n Tenderness at the fibular head

n Unable to flex knee to 90°

n Unable to bear weight both immediately and in the ED (4 steps; limping is OK)


Evidence-Based Practice

n Rules have been prospectively validated on multiple occasions in different populations and in children and adults.

n Numerous studies found sensitivities for the Ottawa knee rules of 98%-100% for clinically significant knee fractures. One study did find a sensitivity of just 86%.

n Specificities for the Ottawa knee rules typically range from 19% to 50%, though the rule is not designed/intended for specific diagnosis.

n When used appropriately, the amount of knee x-rays obtained can be reduced by around 20%-30%.

n The Ottawa knee rules are useful in ruling out fractures (high sensitivity) when negative, but poor for ruling in fractures (many false positives).


The creators of the rules at University of Ottawa offer these tips:

n Tenderness of patella is significant only if an isolated finding.

n Use only for injuries less than seven days old.

n Bearing weight counts even if the patient limps.


Precautions from the creators of the rules:

n Do not use on patients under 18.

n Clinical judgment should prevail if examination is unreliable because of intoxication, an uncooperative patient, distracting painful injuries, and diminished sensation in legs.

n Always provide written instructions.

n Encourage follow-up in five to seven days if pain and ability to walk is not better.


The Ottawa knee rules should be applied to all patients 2 and older with knee pain/tenderness in the setting of trauma.


Why Use It

n Patients without criteria for imaging by the Ottawa knee rules are highly unlikely to have a clinically significant fracture and do not need plain radiographs.

n Application of the Ottawa knee rules can reduce the number of unnecessary radiographs by 20-30 percent, which has proven to be cost-effective for patients without reducing quality of care.


Implementation of the Ottawa knee rules would be associated with meaningful reductions in societal health care costs in the United States and Canada without a reduction in quality of care.


Jim weighs in: Most ED patients expect an x-ray of a painful knee, especially if it was traumatized. Most clinicians can readily tell if an x-ray will be helpful, but meeting patient expectations is an important goal. If you are not going to order an x-ray, make sure the patient understands your reasoning and agrees with your tactics. Don’t fight with the patient about an x-ray. Decision rules and your exam are most important, but no exam takes the place of an x-ray to settle the issues in a borderline case. Finally, remember that a CT scan/MRI sees much more than a plain x-ray, so always keep open the possibility that one of these tests may be necessary if the pain, mechanism, and findings suggest an internal injury, symptoms continue, or x-rays are equivocal.


Stay tuned for next month’s Procedural Pause Blog, when we show you how to tap this knee! Can you tap it? Yes, you can.



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Monday, August 03, 2015

This blog teaches procedures, with its case studies and videos intended to help you perfect your technique and strengthen your confidence. This month we explore issues related to procedural patient impact. How will your intervention positively or negatively affect patient outcome? What happens when we decide to step in and complete a procedure?


A risk is always inherent when a provider undertakes a procedure, no matter how insignificant. Carefully, we weigh the pros and cons of the potential procedure with our patients. Will our intervention cause a positive effect or outcome? Our goals are to repair, resolve, or restore whatever may have gone wrong. That means there might be some sort of suffering along the way.


Or does it? There is a potential for any procedure to have a poor outcome. Our interventions are intended to help, not hurt the patient under our care.


Patient Impact: Pain Control

Pain control can make a major difference in every procedure, and is a best practice for our patient. Procedures can be completed more effectively and without distraction when a patient has less pain. And we are less likely to make a mistake, stop early, or prolong the procedure when we can perform without interruption. Pain control may even lead to better cosmetic outcomes because the patient is more relaxed, calm, and cooperative. Technique is only half the battle.


Vaginal Abscess I&D

It is impossible to maintain perfection 100 percent of the time. Poor patient compliance, financial hitches, unrealistic treatment times and department goals, lack of materials, and lack of follow-up, knowledge, and staff all contribute to poor patient outcomes. Procedural complications are not always simply chalked up to poor technique.


No one is perfect. Every day is a learning experience, and we do what we can with the resources we have. You will succeed by embracing basic concepts, using proper equipment, and not cutting corners. Part of that understanding is to use proper pain control, especially when draining a painful, sensitive vaginal abscess, as seen in this video:


Click here to watch the video on vaginal abscess.


During one incision and drainage of an abscess, the patient experienced horrific and traumatizing pain, and she returned two days later with a larger reaccumulated abscess, which had to be excised and drained for a second time. This was not happy news for the patient or the providers involved. The abscess may have reaccumulated despite our initial interventions. It may have returned, however, because it was not appropriately drained or treated the first time. Perhaps adequate drainage was limited because of pain. And she reported during a follow-up call one month later that she had painful and unsightly scar tissue.


Why did the patient have a poor outcome?

§ The patient’s pain was poorly managed during the procedure. It did not allow us to complete the procedure appropriately.

§ Our ED does not stock Word drainage catheters, which are best used for treating labial and Bartholin cysts/abscesses.

§ The nurse had to leave the room for a trauma, and we continued the procedure without pain medication.

§ Local anesthesia was not successfully achieved.

§ She had poor positioning during the procedure.

§ The patient was very fearful.

§ The patient was nauseated and vomited during the procedure, creating concern for aspiration and removing conscious sedation as an option.

§ The vaginal abscess was not completely drained because the patient was unable to tolerate additional procedure time secondary to lack of pain control.

§ The patient stated on the second visit that she felt abused by this procedure, which caused her significant stress. She stated that the physician never asked her if it was OK to discuss medical history in front of her abusive husband, and she had no chance to talk about more personal issues.

§ She felt we poorly explained the technique and rushed through it.

§ The provider performing the procedure answered her phone three times.

§ The patient spoke Spanish only, and though we used an interpreter, her discharge paperwork was in English.

§ The patient did not know how to take her own temperature and did not understand she should return for a fever of 104°F.

§ The pain medication and antibiotics made her vomit at home, so she never took the right doses.

§ The patient could not afford clindamycin anyway.


How do we fix these issues?

The majority of these issues are easy to resolve. This patient may have had a better outcome if the following issues were addressed:

§  You aren’t the boss, so you can’t fix staffing numbers, but don’t start any procedure unless you know you have the right people available to help you. Make the patient wait for an urgent procedure until you all can be ready to start without interruptions. Forget about your length of stay.

§  If the procedure is emergent, escalate this concern to the charge nurse or another provider and intervene early. You are in charge of the patient.

§  Always discuss a full history and perform a full physical before completing any procedure. This means if you are doing a procedural sedation, consider full cardiac and respiratory assessments. Call respiratory for a patient who might crump from COPD issues or orthopedics for an 86-year-old with afib and a dislocated hip. Maybe that one can be done in the OR.

§  Discuss all procedures (to your best ability depending on urgency) with the patient and a witness.

§  Have the patient sign and acknowledge the risks and benefits on a consent form. Don’t have her sign just for legal purposes. Have her sign so she understands what is going to happen.

§  Use an interpreter. Translate the paperwork into the patient’s language. We suggest Google Translate or another professional application your department allows.

§  Discuss pain control methods with the patient, and provide excellent pain management and local anesthesia.

§  Insert an IV for difficult procedures, such as labial or vaginal abscesses. Give patients adequate IV pain medication before the procedure and before local anesthetic infiltration.

§  Often forgotten, adding 1 ml of bicarbonate to 7-8 ml of lidocaine significantly reduces pain of lidocaine infiltration without compromising anesthetic effect.

§  Inject slowly and give enough lidocaine the first time to adequately block pain of the procedure. Consider a field block. It’s OK to use more lidocaine (generously through the incised skin edge) once the procedure causes pain.

§  PO challenge the patient before she is discharged. Consider an antiemetic.

§  Sit down and explain how the next 48 hours should look and feel for the patient.

§  Consider social work interventions for uninsured patients.

§  Use the right equipment.

§  Stockpile some discharge paperwork for common procedures or create a document on your computer that highlights your instructions. EPIC, for example, has information about cellulitis. Add some thoughtful additions and touches of your own, and save those as smart phrases. If you use paper charting, spend 10 minutes at home drafting a strong discharge packet. It will prevent patient bouncebacks and save an unbelievable amount of time.

§  Note that your involvement in your patient’s care does not stop at discharge. Make a follow-up call the next day for patients about whom you are particularly concerned. It takes almost no time at all to do, and your patients will be so thankful.



During a busy shift, it is easy to forget or forgo comfort measures or seize a patient teaching opportunity. Slow down! Pause for a minute to provide patients better pain management during uncomfortable and invasive procedures. Not only will it relax your patients, but their ensured and controlled comfort will make your job easier. It is the rare patient who will not benefit from pre-procedural IV opioid analgesia. Be generous!


Evidence-Based Practice Pearl

The most painful procedures for ED patients are nasogastric intubation, abscess incision and drainage, fracture reduction, and urethral catheterization, according to a study of more than 1,000 patients receiving the top 15 emergency department procedures. (Ann Emerg Med 1999;33[6]:652.) The study also showed that overall use of anesthetics before these procedures was low.


It is often noted that pediatric patients do not receive appropriate analgesia in the emergency department and as outpatients because of inadequate dosing. If you decide to give pain medication to pediatric patients, give them the proper dosage and discuss this with the parents.


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Wednesday, July 01, 2015

Most people will experience dental pain or a dental complication at some point in their lives. Dental pain is an incredibly common complaint by people of all ages, especially those who lack dental insurance and suitable hygiene habits. Sometimes, though, poor dentition or injury is simply a result of bad luck. Patients often present to the ED hoping to find a dentist and an answer to their problems.


Your first thought? “I am not a dentist. What am I going to do?” You’re right to an extent. We are not dentists, and often feel we have little to offer patients for acute issues that require equipment we don’t have and don’t know how to use. We certainly cannot assist with long-term tooth maintenance and treatment of chronic pain. As many of us know, pulling teeth in the ED is not something we do on demand and should not be expected to do.



Dental fracture, Ellis Type II, tooth #18, left, and common periodontal application kit and set up, right.


But we can do some procedures in the ED without a dentist being present or even consulted, and we can link the patient with some dental resources. There are many dental schools that accept patients for a marginal fee to improve their training skills. When it comes to educating your patients, suggest brushing twice a day, changing their toothbrush every six months, and having a dental cleaning at that time, too. In fact, we suggest you give out this information to all of your patients in the general discharge paperwork, even if they are not in your ED for dental pain. Give it to those especially on whom you complete smoking cessation instruction. Why not make it easy for them and their teeth? And while you are at it, ask them to tell their friends, too.


The best part about this particular procedure for dental fracture is that anyone can do it, and it only takes a few minutes. It is so simple that the actual procedure fit into a one-minute video.


The Approach

n Stabilization of fractured tooth (teeth)

n Dental block (if indicated) or topical pain medication for pain control

n Imaging (if indicated)

n Repair of lacerations (if indicated)

n Prepping the area of damage appropriately

n Mixing and application of bonding agent/periodontal dressing (calcium hydroxide or CaOH)

n Follow up with an oral surgeon and or dentist in 24 hours

n Pain control, antibiotics (if indicated)



Regular strength Coe-Pak periodontal bonding agent, left, includes the base and the catalyst, which are needed for activation of the base agent. A set of two cotton swabs with long plastic or wooden stems are needed for mixing and applying the agent, center. A general swirling motion is used to mix the agents together before application, right.


The Procedure

          n Have the patient lie on a stretcher at a 45-degree angle with excellent lighting.

          n Have the patient bite down on gauze if areas in the mouth are bleeding.

          n Depending on the type of fracture, complete appropriate dental block for pain relief. This is rarely needed, but it may be useful depending on patient’s comfort level and extent of dental injury.

          n Consider imaging if you are concerned about aspirated foreign body, facial fractures, or head injury.

          n Carefully examine the lips, especially those with lacerations. (The last fractured tooth I encountered ended up embedded in the patient’s upper lip, and it needed to be removed before suture repair.)

          n Examine and count all teeth, note them by number and approximation. Look for obvious fractures and then also consider micro-fractures from partially damaged fillings or teeth.

          n Note: Does your patient have a tongue ring? These can also cause dental trauma. Suggest to the patient that it be removed.

          n Prep the area of injury by having a partner set up dry wall suction and applying cotton gauze to the sides of the injured area. Note: The area must be dry or the periodontal bonding agent will not adhere correctly or safely.

          n Obtain bonding agents. There are many popular brands and agents (Coe-Pak, Reso-Pac, etc). We are specifically going to talk about Coe-Pak, which consists of a standard base and a catalyst.

          n Most bonding agents require mixing the agents in a 1:1 ratio, but products may have different mixing requirements. Find a product you like working with and try to stick with it.

          n Did you know that the majority of bonding agents come with a lined mixing packet card or pad? Place this card on a surface and use it to measure your bonding agents/materials before application. An injection gun is also a hot commodity, so hot that these items may be missing from your dental box. Just know they exist!

          n Place 1 cm of catalyst and 1 cm of base on the mixing card or other sterile mixing surface. We suggest opening a laceration tray to assist with this procedure because the hemostats may assist in application and sculpting later around the periapical areas. You can also use the instrument tray to mix your chosen product.

          n Use a swirling technique to mix the two agents if you have a small area to repair. A tongue blade may assist with this process. This is necessary to complete the chemical reaction and activation sequence of the agents. It takes about 30 seconds to mix most agents.

          n Some agents require a “balling up” type of application where a powder is used. These can be applied with your fingers rather easily. Remember to mix the catalyst and base well regardless of the type of bonding. If you are working with a larger area, combine the base and catalyst in a “balling up” process and then roll it out on the table into a tube-like structure (as thin as a pencil) for application.

          n Wait approximately five to 10 seconds before application. (Some products differ.)

          n Again please note: You may use either method: balling or direct application. We prefer balling the material before application, but direct application is also effective.

          n Retract the side of the mouth away from the injured area.

          n The now putty-like composite resin can be applied to the dental fracture itself over the natural surface of the tooth, regardless of depth of injury.

          n Shape and sculpt the periodontal bonding agent over the tooth/teeth. Create a flat surface (free of lumps and bumps) over the tooth and around the edges interproximally. Be sure the entire tooth is covered. This will allow for stronger hold and protection of the fractured tooth.

          n Consider using a small-nosed hemostat to shape the bonding around the injury. DO NOT use scalpels or needles to shape the mixture.

          n Most of the time, your fingers shape the area better than any tool. Use saliva from the patient’s mouth to keep it moist if it begins to dry out.

          n Wait approximately 60 seconds after applying, and then have the patient bite down (if able) to form a small indentation over the bonding. Be sure the bonding agent has had at least one minute to rest, or the patient may pull off the covering when the teeth meet the bonding.

          n Have the patient follow up with an oral surgeon or dentist within 24 hours.

          n Dental pain can be excruciating. We suggest prescribing the adult patient ibuprofen 600-800 mg tablets po q. 6-8 hours prn pain relief. NSAIDs will help treat inflammation and irritation to the gums. If you are feeling generous, Percocet or Vicodin will help the patient get at least one night’s rest. Prescribe narcotic pain medication at your discretion and in relation to the extent of patient injury, history, and presentation.

          n Suggest that the patient refrain from chewing food or gum on that side of the mouth. Encourage a soft diet.

          n Smoking cessation as needed.

          n Avoid brushing over the area with toothbrush, but the other teeth can be cleaned.


Dental fracture now dressed with periodontal dressing/bonding agent. It was later sculpted along the gum line for patient comfort and proper adherence.


The Pause

n Do not remix additional bonding agent with dirty hands/contaminated gloves after working inside the patient’s oral cavity. The bonding set usually can be used repeatedly, and it is completely acceptable to store and use the agents again. Do not throw it away after opening, but be sure to adhere to all expiration dates and product directions.

n What happens if the patient swallows any of the periodontal dressing? Most likely, nothing. Tell your patient that the mixture is nontoxic and safe. In fact, people can swallow parts of their braces or actual teeth without any complications. The parts simply pass through the GI system. Inhaling the dressing, however, can be life-threatening.



Watch application of Coe-Pak to a patient’s dental fracture.



n The area of injury needs to be dry before application of bonding agent.

n After mixing the bonding agent, wait 10-20 seconds before application. If you apply the mixture immediately, it will not be very easy to use. If you apply it too late, it will harden and not adhere to the tooth for very long. Do not use the cotton portion of the swab to apply the periodontal dressing. Use the stick portion of the swab for mixing and application.

n Homeopathic treatments using clove oil were popular for many years. Clove oil contains eugenol and can help with toothache or inflamed gingiva. Eugenol can cause nerve damage, and should only be used a few times or for one or two days. Most periodontal bonding agents today do not contain eugenol.

n Use bupivacaine 0.5% for dental blocks because it lasts longer for pain control.


Tip of the Month: Ellis Fractures

Ellis I: These crown fractures extend through the enamel only. These teeth are usually not tender and have no visible color change but have rough edges.

Ellis II: This is any fracture that involves enamel and the dentin layer. Teeth will be tender to the touch or air exposure. You may notice exposed dentin (yellow in color).

Ellis III: These fractures involving the enamel, dentin, and pulp layers, and will be exquisitely tender. You will see an area of pink pulp, redness, or blood toward the center of the tooth.


Reminder: Dental pulp may become infected easily. Pulpitis can occur after a dental fracture while patients are waiting to see a dentist or oral surgeon. Place the patient on antibiotics (typically penicillin VK 500 mg PO 4x/day for 10 days). If the patient is allergic, substitute clindamycin 450 mg PO 3x/day for 10 days. Other accepted antibiotics for potential or known infection include erythromycin, metronidazole, and amoxicillin-clavulanate.


Evidence-Based Practice Pearl

Did you do a good job? What did the dentists have to say? A small retrospective study of 25 ED providers found three ways that providers could approach dental fractures or avulsions. (Ann Emerg Med 2009;54[4]:585.) The periodontal pack took about four minutes to complete and was financially more appropriate. The study participants had no measurable or agreeable preference for a particular splinting or bandaging technique, but dentists preferred the use of reinforcement ribbon (96%) and light-cured composite (100%) when given the option. The only problem is that reinforcement ribbon and light-cured composite are difficult to obtain, stock, and use in the ED. It is also very costly and specialized, and those factors and the longer treatment time simply cannot be justified for use in the ED when CaOH bonding agents are just as effective. Although the specialist may prefer it, they may have to apply it.


The Language (NEW!)

Every specialty has some sort of new language with which you need to be familiar and use in documentation or description to your colleagues. If you are feeling adventurous and want to learn the dentistry lingo, here is a list of descriptive terminology used for differentiating tooth surfaces. Read our previous blog for more on tooth numbering and dental blocks. ( If you do consult the oral surgeon or dental consultant, he will want to know the number of the tooth and the location.


Terminology                                    Location

Facial                               Part of tooth that faces opening of mouth

Labial                               Facial surface of the incisors and canines

Buccal                              Facial surface of the premolars and molars

Oral                                 Area that faces the tongue or palate

Lingual                             Toward the tongue; the oral surface of the mandibular

and maxillary teeth

Palatal                              Toward the palate; the oral surface of the maxillary teeth

Approximal/interproximal     Contacting surfaces between two teeth

Mesial                              Interproximal surface facing anteriorly or closest

to the midline

Distal                               Interproximal surface facing posteriorly or away

from the midline

Occlusal                            Biting or chewing surface of the molars and premolars

Incisal                              Biting or chewing surface of the incisors and canines

Apical                               Toward the root of the tooth

Coronal                            Toward the crown or biting surface of the tooth


Source: Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th ed., Philadelphia: Saunders/Elsevier, 2014, pg. 1342.


If you want to hear some of the lingo, check out this very old video from the University of Michigan, free for public use and distribution for educational purposes. This classic video, although dated, uses principles we still use today. Watch here:


Final Thought

The American Heart Association published guidelines in Circulation about using antibiotics prior to dental procedures. They suggested that only those at greatest risk for bad outcomes from infective endocarditis should receive short-term preventive antibiotics before routine dental procedures. (2012;125[20]:2520.) This, of course, only applied to those who were waiting for a routine visit or procedure.


The literature found no compelling evidence that taking antibiotics prior to routine dental procedures prevents infective endocarditis in patients who are at risk of developing a heart infection because their hearts are already exposed to bacteria from the mouth, which can enter their bloodstream during basic daily activities such as brushing or flossing. Trauma, however, should always be considered as a possible increased risk of infection, and antibiotic use is best decided at time of presentation.


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Monday, June 01, 2015

Welcome to our new series, “Guts and Gore.” That title should serve as a warning that some of the videos we will use as teaching tools may be controversial and not for weak stomachs. We hope, however, that part of why you became an emergency provider was to handle sticky situations like the ones we will present. People like us have the ability to ignore blood and copious discharge, and instead focus on saving and improving the lives of our patients. Rarely are you thanked for this ability, and we hope this series on guts and gore will improve your technique, even when the going gets tough.


The Approach

n Proper identification of hematoma requiring drainage

n If unsure, use ultrasound-guided technique to identify fluid collection. Note: Much of the blood is a clot, with some free blood.

n Consider the use of IV or PO pain medication.

n Incision and drainage (I&D)

n Packing application

n Knowing the signs of compartment syndrome.

n Follow up with packing removal (if indicated) and/or surgical follow-up.


The Procedure

n Obtain a marking pen, mask, sterile gloves, gown, suture kit (for use of tools only), gauze, ACE bandage wrap, ¼-inch packing, and 1% lidocaine with epinephrine.

n Always have the patient lay supine for any I&D procedure to avoid vagal response.

n Mark the area with a pen. Highlight the area that encompasses the hematoma. This area should be carefully watched for the next 24-48 hours if you are concerned about compartment syndrome.

n Call a procedural pause time out.

n Inject the skin over the most prominent area of the hematoma with 2-3 mLs of 1% lidocaine with epinephrine. Inject slowly and carefully.

n Use an 11 or 15 blade scalpel to make a 2-3 cm incision over the top of the hematoma where anesthesia was applied. Some hematomas (depending on size) will need a larger incision. Note: A small puncture is not large enough to drain clots.

n Allow the initial blood to ooze out slowly. Add gentle pressure to assist with the drainage and to expel any clots.

n Use your finger or hemostat to help drain the hematoma by inserting it into the cavity when the drainage begins to slow down.

n Once the hematoma has drained to at least half of its initial size, consider using ¼-inch packing to assist with further drainage. Packing is only used for very large hematomas or those with large incision marks.

n Gently clean the area with saline. Do not aggressively irrigate.

n Apply a dry compression dressing with several pieces of gauze.

n Wrap the extremity with an ACE bandage on top of the gauze.

n Give the patient a sling if the hematoma is on the wrist or arm. Provide crutches if the hematoma is on a thigh or lower leg to assist with non-weight bearing.

n Have the patient follow up with her primary care provider or the ED in 24-48 hours for wound recheck and packing removal (if used).

n If the patient is on blood thinners such as Coumadin, Xarelto, or Plavix, check back here next month when we will address how to treat these patients.


New! Tip of the Week

Is this an abscess or a hematoma? This month, we introduce a new Procedural Pause challenge. Think outside the box, and be prepared for red herrings. Misleading and distracting diagnoses present in your emergency department on a daily basis. Our hope is that you can recognize the decoy early and act accordingly. We ask you, is this a hematoma or is it something else?



Is it a hematoma or a contusion? Sometimes the only way to know is to open it up. Photos by Martha Roberts, ACNP, CEN


This patient’s left hip actually turned out to be a common contusion, or nefarious hematoma. The patient’s initial complaint was, “I hit my leg a week ago on the bed,” and noticed that the area became “red and irritated.” The patient said the area “turned colors” and “felt kind of squishy and soft.” She also said she had had abscesses before in her groin and on her leg that were MRSA-positive. Ultrasound revealed fluid under the skin. The pocket, however, was not uniform.


The area palpated felt soft and buoyant. The only way to determine if this patient had an abscess with cellulitis or a simple hematoma was to open and drain it. When we opened the area, it was filled with gross blood and clots. There was no abscess at all. From this experience, we learned that patients can (especially those with diabetes) form skin infections related to old contusions. The hematoma was successfully drained, and the patient was placed on prophylactic antibiotics for Pseudomonas coverage. A drain was placed because of the size of the cavity, and she followed up in 24 hours with her primary care provider.


Evidence-Based Practice Pearl

Hematomas are filled with clots. It is a common misconception to assume that large, raised hematomas are filled with unclotted blood that will deflate as soon as punctured. Quite the contrary. Subcutaneous hematomas often are filled with clots, and take several minutes of coaxing and poking to deflate. The incision needs to be large enough to pass larger clots, or the patient will not have relief. Irrigation of the site is also controversial, as is suction, so you try it and let us know how it works. One may also assume that the hematoma has been drained successfully once it no longer bleeds freely. This is not the case. Compartment syndrome may still be lurking.


Compartment syndrome may cause rhabdomyolysis, renal failure, and generalized muscle ischemia. Perioperative morbidity and mortality are high. Fasciotomies are not always the best way to treat these issues. We suggest initial I&D to avoid compartment syndrome and the potential for fasciotomy. The goal is to identify these issues early, so that the latter does not occur. Fasciotomies have been found to be associated with worse outcomes and higher morbidity and mortality. (World J Surg 2003;27[6]:744.) The lesson: Evacuate the hematoma early.


If you have learned anything as a practicing provider or even as a student, we hope it’s the art of misconception. Be sure to question clinical pictures that just don’t add up. Be wary of quickly assuming a diagnosis to be commonplace. Assertiveness is important, but exercising a prudent approach is paramount. When in doubt, take a second look, and you will be everyone’s champion. Most importantly, you will do what is best for your patient. At the end of the day, we all want to sleep at night.


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About the Author

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

James R. Roberts, MD, is the director of the division of toxicology at Mercy Catholic Medical Center, and a professor of emergency medicine 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 for Johns Hopkins Medicine at the Sibley Memorial Hospital in Washington, DC, an adjunct faculty associate and clinical instructor of nursing at the Malek School of Health Professions, Marymount University in Arlington, VA, and is Dr. Roberts’ daughter.

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