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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.

Tuesday, March 31, 2015

Part 2 in a Series

Abscess incision and drainage should be loved and adored by all emergency providers because another abscess is waiting just behind the curtain. This month we highlight general guidelines for abscess incision and drainage, and show how to treat one in the video below. We will follow up with some additional videos in the months to come focusing on scalp, vaginal, and facial abscesses. And, just when you think you have seen it all, we will reveal a few more surprises.

 

Axillary abscess from hidradenitis. Photo by Martha Roberts.

 

The Approach

n  Identification of an abscess appropriate for I&D.

n  If unsure, use ultrasound to identify fluid.

n  Consider the use of IV or PO pain medication.

n  Incision and drainage (I&D).

n  Packing application.

n  Follow up with packing removal and/or surgical follow-up.

 

The Procedure

n Consider premedicating the patient with oral Motrin, Percocet, or Vicodin, or IV medication if local infiltration is not sufficient.

n Obtain laceration tray or surgical kit for I&D.

n Put patient in comfortable position.

n Prep using sterile gloves to keep it a clean procedure, though it is not meant to be a sterile one.

n Anesthetize the skin with 1% lidocaine. Inject slowly.

n Make a horizontal incision using an 11 or 15 blade scalpel, utilizing the entire length of the abscess. Do not make just a small stab.

n Allow pus to discharge freely at first, and then assist with gentle expression of the opened cavity.

n Once the cavity is fully expressed, use forceps to delicately break up any of the capsule inside the abscess.

n Depending on the size of the abscess, rinse with gentle jet lavage: 30-50 mLs of sterile water. Four to five sterile flushes usually do the trick.

n Pack the abscess with ¼-inch or ½-inch packing gauze. Soak the gauze in Betadine prior to insertion to allow for pliability.

n Cover the abscess with sterile gauze and leave in place for 24-48 hours. Try to use as little tape on the skin as possible to avoid further discomfort.

n If there is an associated cellulitis, then antibiotics may be required. Antibiotics are usually not indicated. We will cover this in future blogs.

n When the patient returns, wash out the cavity gently. You do not have to anesthetize the patient for this procedure; just be kind to this sensitive area.

n Bonus: If the capsule floats right out, that’s a good sign! Look for a white coated gel-like discharge in sac formation. If the abscess capsule is obvious in the cavity, attempt to remove it.

n Do not be afraid to complete I&D a second time (in 24-48 hours) if the wound has not appropriately drained. This will require anesthetizing the area again.

 

Cautions

n Do not make the incision too small because it will not drain correctly. Be sure to make it the full length of the abscess. Bigger is better!

n Do not I&D a complicated abscess of the face, neck, or foot. You may consider getting ENT, plastics, or podiatry involved for these wounds because airway, scarring, and diabetes may not allow for standard and safe healing.

n If you see one abscess, there may be more. Discuss this with your patient. Consider surgical consult for pilonidal abscesses because they tend to recur. The entire cavity may need to be completely and surgically removed. Marsupialization is only beneficial for Bartholin cysts or abscesses.

 

Tip of the Week

Treating an abscess in a pregnant or post-partum woman? No big deal! You can do it using good judgment and proper follow-up. Stay tuned for future blogs and video workshops when we address vaginal abscesses during and after pregnancy.

 

Evidence-Based Practice Pearl

What about the immunocompromised patient? These patients make us a bit weak in the knees know. Leave it to the Canadians to help us piece together the literature. A large meta-analysis and database search by Korownyk and Allen suggests even patients who are immunocompromised do not necessarily need antibiotics. Incision and drainage is the treatment for almost all abscesses.

 

I&D under local anesthetic is “generally sufficient for abscess management” for patients who have no confounding risk factors, the authors write. They also note that “there is no compelling evidence for routine cultures or empiric treatment with antibiotics.” And as far as cultures go, level II evidence reveals “routine cultures do not change management or outcome for patients presenting with abscesses.” We hope that clears things up for some of you, including the abscess! (Can Fam Physician 2007;53[10]:1680; http://1.usa.gov/1vzP7rC.)

 

Watch a video of Ms. Roberts draining an axillary abscess.

 

 

We highly recommend reading more here:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231432/

 

Read more about all kinds of abscesses in our archive.

 

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Monday, March 02, 2015

This month we want to touch gently on treating pilonidal abscesses as we continue on our series on abscess incision and drainage. A pilonidal cyst or abscess is a fluid-filled pocket of dead skin cells, or pus. These pockets occur on the back over the tailbone, coccyx, or natal cleft. Pilonidal cysts often remain cysts and do not get infected. If the abscess is ignored or spreads (forms a fistula), then the practitioner should be concerned with a possible bacteremia or systemic infection. Infected pilonidal cysts are painful and sometimes dangerous.

 

 

A pilonidal abscess is lurking beneath the surface just above the natal cleft. It is much deeper than it actually appears when palpated. The scarring present is from prior I&Ds of the abscess. Photos by Martha Roberts.

 

Patients often present to the emergency department embarrassed and unsure of their diagnosis. They think they are doing something wrong, are unclean, or do not wash themselves well. This is not the case, and it is important to assure them they did not cause their ailment. Patients mainly complain of pain over their spine or above their buttock, redness or swelling over the area, discharge, and if infected, fever, nausea, or possible signs and symptoms of sepsis.

 

Many theories explain why some people develop pilonidal cysts or abscesses. Occasionally they occur due to ingrown hairs or infected hair follicles. Another theory is that pilonidal cysts appear after trauma to that region of the body. “[Many] soldiers developed pilonidal cysts that required a hospital stay” during World War II, and some physicians thought they formed because of the irritation from riding in bumpy Jeeps. The condition was actually called Jeep disease or Jeep seat. (Int J Res Med Sci 2014;2[2]:575.)

 

This retrospective study found that pilonidal cysts are most common between ages 20 and 30, and affect men more than women. The study also suggests it is more common in physically active age groups and does not show any preference to sedentary workers.

 

Note that incision and drainage is only completed on abscesses that do not involve the rectum or anus. If you are suspicious of a larger area of infection or fistula, order a CT of the abdomen and pelvis with IV contrast. Always discuss your patients with a colorectal specialist in-house (if you are lucky) or as an outpatient for close follow-up. Rechecking the wound and removing the packing yourself (or by the specialist) in 24-48 hours is ideal for the patient.

 

It’s time to stop packing pilonidal cysts. We challenge you to try a new approach if you have not already! Vessel loop drainage is used in place of packing sutures. Vessel loop is a plastic material used to circle around the abscess and keep it open to drain. It is especially useful for abscesses in the axilla, groin, and, of course, with pilonidal cysts. The Chinese have used a similar technique called suture-dragging therapy for more than 40 years. (Case Rep Surg 2014; Article ID 425497:1.)

 

Vessel loop is a modern-day take on this already successful technique. This technique is best described as taking the suture thread itself and forming a loop around the abscess or channel of the abscess. The track is kept open, and each day the patient moves the threading back and forth in the cavity to help express the leftover pus in the cavity. Occasionally, a wound vac is used over larger abscess cavities to help suck out the pus. This treatment can be used with or without marsupialization where the entire cavity or pocket is cut out and excised. The Chinese admit that the incidence of pilonidal sinus in China is low, but the misdiagnosis rate and recurrence rate are high.

 

Overall, they found that suture-dragging therapy was less invasive, and could speed up sacrum wound cavity healing. Countless research articles also found that positive and negative pressures accelerate healing by increasing local blood flow and the rate of granulation tissue formation.

 

Jim weighs in: “I’ve been doing this for years.”

 

Martha weighs in: “If I could just get my ED to stock it….”

 

Abscess drained using vessel loop drainage technique. Photos by Martha Roberts

 

Stay tuned for next month’s blog when we bring you some pretty ugly abscess I&D videos. We will walk you through the step-by-step process of draining these abscesses correctly.

 

What is your best tip for draining an abscess?

 

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Wednesday, February 18, 2015

This spring, more advanced providers will be graduating from nurse practitioner and physician assistant programs than ever before. With that in mind, we want to take a break from procedures and focus on transitioning to becoming a provider.

 

If it were easy, everyone would be doing it. Always let the patient be your guide when you work in the emergency department. Don’t get hung up on workplace drama or fear of making a mistake. No one is perfect, and it will take time to find your niche. It is up to you to do a good job and seize the day, each and every day from here on out. We only hope we can help you find success in your practice while having some fun along the way.

 

— Jim and Martha

 

By Martha Roberts, ACNP

 

One of the best days of my life (aside from my wedding and the birth of my daughter) was the day I graduated from my nurse practitioner program at Georgetown University. Soon to follow this incredible accomplishment was the day I passed my acute care board exam and received my license and DEA. At that time, I was pretty sure nothing could top those events in my scholarly journey, aside from maybe a future publication, crucial patient save, or fancy paid guest lecture. Needless to say, I was like a freight train — full speed ahead!

 

As I finished my five-year journey as a registered nurse, I thought to myself: “I will be a nurse forever.” This was not an end to a career but the start of nursing voyage. Optimism was definitely one of my strongest qualities, but nothing could have ever prepared me for the hardships to follow. No one could have prepared me for what came next. The transition from RN to NP was not at all what I expected.

 

Fortunately for me (I once thought), the hospital I had worked for as an RN asked me to stay on as a midlevel provider. It was unexpected because I had already accepted a position far, far away! The current nurse practitioner pool in this country is competitive, growing, and constantly changing. There are so many exciting opportunities for new graduates. The midlevel role is becoming more important, as is our presence within all hospital care areas. I wanted to explore a new care area and a new hospital, but it seemed to make sense for my family and me to stay. I didn’t need to learn a new computer system or become familiar with a new place. The team I came from stood behind me 100 percent, and I was ready to make them proud. The proposed transition from RN to NP in my hospital seemed like a fuzzy, warm day in spring: easy, care-free, and budding with adventure. I was right about only one of those three things.

 

I forgot one oddity, that the age-old phrase from the more experienced nurses in our department was, “We eat our young.” I thought this would never happen to me; I had “fans!” I always felt my hospital would be different because I had friends and people I trusted to support me through my undertakings. I assumed they would be supportive and caring and hopefully a bit forgiving as I made mistakes and triumphs as a newly-minted provider. I envisioned days where we all would work as a team to help patients, and everything would move like clockwork. What was shocking was how unfriendly, unprofessional, and cruel the majority of my nursing colleagues were during my role change.

 

The day I arrived to the ED in my newly-ironed and embroidered white coat, I received a few heckling comments in a “loving way,” but they had jealous undertones. When I put in orders for the first time, my nursing pals scoffed at me, and said things like, “Are you sure you want that?” or “Don’t you mean x-ray, not CT?” It was beyond stressful. When I made a mistake, my fellow nursing friends relished in my shortcomings and made me feel like a complete amateur. Instead of being helpful, they were hurtful. They were quick to tell my higher-ups that I was a failure, and they rarely said, “Good job.”

 

It really did not matter what I did or how hard I worked. Each day was more difficult than the last. Instead of learning from my experiences, I questioned every decision and order. I didn’t sleep, I cried to my husband and boss, and thought to myself, “I am never going to be any good.” Peculiarly, this helped me learn, and it motivated me to go above and beyond what was traditionally expected. At times, it was painful and frustrating, but I knew the time would come when my nursing friends would say, “You passed the test; we trust you.” That day has yet to come.

 

While my “fans” found ways to make me feel like a flop, I used their evil for good. I helped publish a text, worked on various side projects, taught, and tutored while I wrote a monthly column. I made procedural movies and took out my frustration running laps around my alma mater. I spent time volunteering outside of work, helping others anonymously, and donated efforts to those who just appreciated a helping hand. I tried not to focus on criticism and instead to capitalize on accomplishments.

 

What I realized was the more the other providers, hospitalists, and attending physicians liked me, the more my nursing friends hated and disrespected my title. I would order a pelvic exam or lumbar puncture and ask for nursing assistance. The nurses would say, “You are being too needy” or “Come on, you can do that yourself, can’t you?” It was depressing and disheartening. My future seemed desolate and devoid of growth. Then, one of my most beloved attendings gave me some advice I will never forget. “You were a great nurse, but it’s time you start thinking like a provider and less like a nurse.” When he said this, I frowned because I felt like I was still a nurse! He went on to say, “You will always be a nurse at heart, but you need to embrace the cycle of change. No one will respect your evolution until you do.” Although I was still confused about how I would get my team to accept me, I pondered how I was going to change and evolve. From that point on, I started actually thinking like a provider.

 

A provider talks to her team and doesn’t just divvy out orders. I noted how nurses responded to certain providers I knew were well liked and avoided the behaviors of those they abhorred. I treated the patient as the number-one priority, and the arguments about care technique faded like ghosts. I paused and listened to my team in hopes they would see my growth and good intentions. I took it upon myself to grow each day by speaking less and listening more. I shook hands with my colleagues instead of forcefully instructing their hands.

 

What I have learned from my change is to practice free of judgment — judgment of myself, my abilities, and others. There will always be people, providers, patients, and personnel who wish to keep you from reaching your goals. You will be tested each shift. What you must discern is the fact from the fiction. Be the best provider you can be without seeming pompous. Be the fastest provider that you can be without being unsafe. Be the most effective provider you can be without being unforgiving. There will always be ups and downs in the emergency department, no matter your role. The true lesson to be learned is how you deal and react to the positive and negative results. Literally.

 

Do not make a decision based on emotion. Remember when in doubt, check a TSH. Use your brain and the skill set you have so dearly fostered to help guide you during your time of transition or when you are lost in translation. When your team asks you, “What will you do now?” Your answer should be something, even if you are unsure. There will always be that one person who will never like you and that one patient you can never fix. In turn, there will always be an opportunity to teach and a minute to stop and recalibrate. The true champion is the one who can recognize the difference between the two.

 

Finally, do not beat yourself up over policies, people, or patients you cannot change. Instead, improve on the things you know you can amend. Hindsight is 20/20. When you judge someone or something, you automatically assume someone else is wrong. Believe in yourself and your final decision.

 

One of the best days of my life was the day I quit my job at the place I felt safe. As it turned out, I wasn’t safe there at all. As difficult as it may be to make a transition to a place where no one knows your name or your practice style, you can always depend on yourself and your training. You cannot teach kindness or a gut feeling. The dose makes the poison, so keep your daily dose of self-inflicted poison light. Board exams are easy to pass when you are up against a pack of wolves. Take a breath in the stockroom, and remain par for the course. Keep your heart open, and I guarantee you that you will continue to find success.

 

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Thursday, February 12, 2015

Part 1 in a Series

 

We are pleased to bring you our first full-length tutorial on abscess drainage. Part 1 of this series focuses on set up and basics for all beginners.

 

It is important to note that you should practice on injection techniques and how to properly hold instruments before draining your first abscess. No one likes a shaky, unsure hand. We also believe in the “see one, do one, teach one” mentality. Be sure to check out the stockroom at your facility so you, too, can become familiar with all of the equipment used to drain an abscess properly.

 

Stay tuned for next month’s blog when we get down to draining the real thing. We have every abscess from the neck down!

 

Now, on with the show!

 

Click here to watch our video.

 

 

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Friday, December 26, 2014

Picture this: It’s Dec. 31 at 11:59 p.m. You’re spending your designated holiday working the overnight. You’re eating some leftover fruitcake in the nurse’s lounge, and you see the following complaint sign into triage: “Drunk/face pain.”

 

This could mean just about anything when ethanol is on board. You lift your head just slightly over the computer screen and see a young gentleman staggering in the hall. His chart is labeled “SLC” for “streamline care.” Everyone knows that intoxicated patients are never appropriate for your streamline care area, but you decide to take a chance, and hope this guy has something easy to fix.

 

 

Simple eyebrow laceration. Note misalignment of eyebrow.

Credit: Martha Roberts

 

This is something you can fix. There is no need to consult plastics or transfer this patient to another facility. You are actually pretty lucky because the laceration goes right though the eyebrow and spares the orbit and globe space. This patient also denies any other injury, and the bleeding is controlled. He is awake, alert, and — surprisingly — not rude! He is obviously intoxicated but behaving appropriately. It is important to take caution with inebriated patients because ethanol can mask pain and other complications. These patients need a full evaluation and often repeat questioning. You can be the judge on how far you want to work up this type of injury, but we can make a few suggestions.

 

The Approach

§  Local infiltration analgesia 1% lidocaine with epinephrine is best. There is no need for 2% lidocaine, and it is OK to use with epinephrine if you find bleeding is complicating things.

§  Image studies if indicated (CT head, orbits, face, cervical spine, etc.).

§  Wound care, copious irrigation (update tetanus).

§  Suture and repair (6.0 adorable Vicryl + 6.0 Prolene).

 

 

Local infiltration of lidocaine to injured area prepping for suture repair. Inject through the laceration edge, not the skin.

Credit: Martha Roberts

 

The Procedure

§  Proper questioning and full examination. Localize the acute injury and survey other possible injuries.

§  Order appropriate imaging based on exam and history.

§  Clean the area around the eyebrow laceration with 10% povidone-iodine or chlorhexidine gluconate. Do not allow this to enter the wound itself. (Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.)

§  Anesthetize the area. A local infiltration of 1%, not 2% lidocaine, is sufficient.

§  Allow just a few minutes for anesthesia to take effect, and test the area with a clean new needle to see if the patient experiences any pain.

§  Inspect the area with magnification to check for any foreign body. Gently rinsing the interior of the wound is required. Copious irrigation may cause more damage to the delicate facial tissues.

§  Use as little debridement as possible, but whatever is necessary.

§  Use a 6.0 or 5.0 prolene suture to close the wound. Note: Subcutaneous sutures may be used. Prolene is the least secure when dealing with knot security, but it has the best tensile strength. It also has the least tissue reactivity (compared with nylon and silk) and handles well. (Roberts JR, Hedges JR, 2014.)

§  Prolene is the best choice for eyebrow laceration because it can be easily identified during suture removal from the eyebrow because of its bluish hue.

§  Your best choice here is simple interrupted. The first suture re-approximates the edges of the eyebrow. Deep lacerations may be best closed by also using subcutaneous sutures. The case above is borderline.

§  You may consider using skin glue if the laceration is superficial. The case above is too large and not appropriate for skin glue.

§  You can reinforce skin glue or sutures with Steri-Strips.

§  Have the patient keep the area uncovered!

§  Topical bacitracin has not been proven effective. It often keeps the area too moist and prevents proper wound healing, causing scarring.

§  Have the patient follow up in four or five days for suture removal.

§  Refer to plastics if needed.

 

Suture and repair eyebrow laceration with 6.0 prolene. Click here to watch a video of the eyebrow laceration repair.

Credit: Martha Roberts

 

Cautions

§  Does the patient also have a scalp laceration? Note that these can bleed freely without a pressure dressing and should be repaired rapidly. Using lidocaine with epinephrine decreases bleeding during repair of scalp and facial lacerations.

§  Keep good form when handling the forceps using the thenar grip technique and lift the skin gently, allowing for the best cosmetic results. The less insult to the skin after the initial trauma, the better.

§  Consider undermining to help relieve tension.

§  Consider the layered closure technique. This also creates less tension and better cosmetic results. (Roberts JR, Hedges JR, 2014.)

§  Do not tie the sutures too tightly. Instead, loosely apply the first throw and then reinforce the second, third, and fourth throws.

§   DO NOT grab too much tissue while suturing, crowd your sutures, space out your sutures, or stick the same area more than once.

§  Definitely consider ophthalmology or plastic surgery consult for this repair if the wound extends past the browline onto the eyelid. Most ED clinicians can repair these injuries, but a canaliculus injury should also be considered and discussed with appropriate consults if possible. (Roberts JR, Hedges JR, 2014.)

 

Evidence-Based Pearl: Closing Old Facial Wounds

A patient shows up in your emergency department with a facial and an eyebrow laceration. The original injury occurred “sometime yesterday.” Can you repair both or none? Do these wounds need antibiotics? The answer is: You can repair both, and you do not need antibiotics. How do we get away with this type of repair safely? For simple lacerations, anesthetize the area and simply trim away the edges of the old wound opening. Use a no. 15 blade, a 1 mm-deep incision with an undermining technique. (Roberts JR, Hedges JR, 2014.) As noted above, 5.0 and 6.0 (not 7.0) prolene is appropriate for the eyebrow, 6.0 nylon for the face.

 

Most lacerations heal without complications regardless of management. “Mismanagement may result in wound infections, prolonged convalescence, unsightly and dysfunctional scars, and, rarely, mortality,” according to a study in the Annals of Emergency Medicine. (1999;34[3]:356.) Simply put, avoid infection and anything that may cause an unpleasant scar. Going Green means keeping your body green.

 

Finally, if the patient is a smoker and is expressing cosmetic concerns, here is your chance to suggest smoking cessation. Cigarette smoking causes delayed wound healing. Nicotine is a vasoconstrictor that “reduces nutritional blood flow to the skin, resulting in tissue ischemia and impaired healing of injured tissue. Nicotine also increases platelet adhesiveness, “raising the risk of thrombotic microvascular occlusion and tissue ischemia.” (Am J Med 1992;93[1A]:22S.) These data have been around for decades.

 

Proliferation of “red blood cells, fibroblasts, and macrophages is reduced by nicotine,” the same study said. Carbon monoxide, which is also in cigarettes, interferes with oxygen transport. Statistically, smokers heal more slowly from all injuries and illnesses. The study also revealed that nonsmokers have a higher incidence of unsatisfactory healing after facelift surgery. Remind your patients who smoke and demand immediate resolution of their issues about the dangers of smoking in general.

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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 instructor of emergency nursing and the lead critical and acute care nurse practitioner in the Inova Mount Vernon Fairfax Hospital Emergency Department in Alexandria, VA, and is Dr. Roberts’ daughter. Ms. Roberts discloses that the views and opinions expressed here are not necessarily those of Inova Health System, and they may not be used for advertising or product endorsement purposes.

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