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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.

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



§  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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Friday, December 05, 2014

We feel it is extremely important to highlight some golden rules and additional pearls after our recent lumbar puncture series. (Read the first two articles about positioning and technique at and These tips will help you ensure the best outcome for your patients.


Be Prepared

§  Be aware that patients will be anxious.

   Spend dedicated time reviewing the procedure and informed consent.

   Make sure that they feel only the lidocaine injection.

   Most patients will do better with Versed as long as there are no contraindications.

§  Be prepared for patients to vagal! It happens.

   Keep the patient on the monitor at all times.

§  Bring an extra kit, sterile gloves, 1% lidocaine, and a partner to help you.

   PA student, anyone?

§  Walk the sample to the lab.

   Do not send it in the tube system, and take it to the lab immediately.

   Do not refrigerate it if possible, and test the sample immediately.

§  Know what goes in each tube.

   Collect 1.5-2 mL of fluid in each tube. No more.

   Know which label goes on which tube!

   Replace the stylet before withdrawing the needle.


Let’s remind ourselves how and why we label CSF tubes 1-4:



The color of the CSF:


Martha weighs in: Versed is a helpful adjunct for the right patient (all of them). Don’t forget to monitor your patient and then, of course, chart your vital signs and procedure notes.


Jim weighs in: I’ll repeat that: Give them Versed. Just do it!


Setting up for a lumbar puncture: Be organized, be sterile, and bring extras.

Credit: Martha Roberts


Know Your Positioning

§  Maintain proper positioning during the procedure.

   Read up on positioning here:

§  Supine positioning post-LP:

   1 hour or 24 hours? It doesn’t matter!

§  New or worsening headache?

   Occurs in about one of every three patients.

   May have to do with needle size.

   Related to multiple attempts.


The Evidence-Based Practice: Perfect positioning is a must before, during, and after an LP. The question remains, is LP positioning post-procedure just as important? Rumor has it that patients should lay supine for at least one hour after you have obtained your samples, but have you ever thought of mentioning to your patient to try bed rest for 24 hours? What is the consensus? An older controlled study found that it doesn’t really matter what you do. (The Lancet 1981;2[8256]:1133.)


The study compared 100 neurological patients post-LP for onset of headache. The same needle size was used for each patient, and all patients were questioned about post-LP headache. Fifty of the 100 patients were kept ambulant, and the other 50 were given 24 hours of bed rest. The incidence of headache between the two groups was not significantly different. Another study proved post-LP headache was not associated with ambulation or bed rest up to six days post-procedure. (Neurology 1992;42[10]:1884.) The study also noted that CSF opening pressure, cells, and protein, patient's position during LP, the duration of recumbence following LP, and the amount of CSF removed at the time of LP did not influence the occurrence of headache.


Martha weighs in: Let them rest if they are going to go home, and give them a work note. If they want to get up and go to the bathroom instead of using the bedpan, go for it, unless, of course, they are altered!


Jim weighs in: Treatment of a post-LP headache can be managed (debatably) with IV fluids, oral hydration, rest, analgesia, and other treatment options, such as a blood patch.


Vital sign check. Always check in and notice subtle changes in vital signs. A fluid bolus for dehydrated or meningitis patients may help keep things normalized.

Credit: Martha Roberts


Know Your Complications

§  Headache: Who gets it?

   Thin people with less body fat.

   Pregnant women.

   The young (18-30).

   The very old (over 80).

§  Blood patch:

   You may need to seal off the entry site. Call anesthesia.

§  Questionable samples:

   Were you looking for xanthochromia and didn’t find any? If so, and you are still concerned for an SAH, get a CT angiogram and a neurology consult STAT!

   Did you obtain cultures, and they are pending? Do you have a high suspicion for bacterial meningitis? Treat and admit.


The Evidence-Based Practice: We already mentioned that post-LP headache might develop or worsen. The International Headache Society defines post-LP headaches as bilateral ones that “develop within seven days after a lumbar puncture and that disappear within 14 days. The headache worsens within 15 minutes of resuming an upright position and disappears or improves within 30 minutes of resuming the recumbent position.” (Cephalalgia 2004;24[Suppl 1]:9.) Patients need to know that they should come back to the ED if they still have a headache after 48 hours or develop any new symptoms such as vertigo, nausea, vomiting, vision changes, or confusion.


This is all great information to know, but what is the treatment for a post-LP headache? Your plan might be a bit different if your patient is being admitted. We know choice of analgesia could depend on your diagnosis. A blood patch may be an option for some patients. This is a procedure completed by anesthesia. It is created by adding the patient’s blood to the epidural space where the puncture was done. This blood clot stops the CSF from leaking and can help resolve symptoms. About 30 mL of blood from the patient’s vein is inserted into or around the space post-procedure. The patient then lays supine for one to two hours in-house and may be admitted. Decisions on this are made by anesthesia.


A blood patch can be done within the first 24 hours and is successful about 80-90 percent of the time. (Brit J Anesth 2003;91[5]:718.) Lastly, do you have a really convincing story but no xanthochromia? If you feel that the CT and the tap are wrong and your patient may still indeed have something bad, call neurology. You may have a mildly bloody tap (i.e., the cell count in tube #1 is 89 and in tube #4 is 29 with no xanthochromia). You may consider doing a CT angiogram to rule out aneurysm rupture or missed subarachnoid hemorrhage.


Martha weighs in: Why not just use a 20-22 g needle for your tap? Avoid numerous attempts and always keep the bevel up. This will allow you to separate the fibers within the space rather than rip them apart.


Jim weighs in: Interpreting the results of an LP can be difficult, and it’s always essential to be cautious of any blood in the sample, which can be a traumatic tap or bleeding from pathology.


Bonus Videos

Click here to watch this video of Dr. Susan Friedmann of Inova Fairfax Hospital ED in Falls Church, VA, creating a proper sterile clean field for an LP and draping the patient. It also shows proper lidocaine injection technique.


Click here to watch a video of Dr. Friedmann using 20 g needle during an LP for proper CSF removal.


May We Suggest Alternatives?

§  Obtain LP under fluoroscopy with a radiologist.


Patient being prepped for fluoroscopy (top left); sterile field created (top right); patient given lidocaine prior to procedure (bottom left), radiologist uses extension tubing to remove CSF (bottom right): this is a debatable practice; discuss with your facility.

Credit: Martha Roberts


The Evidence-Based Practice: You tried and your attending tried, but there is no CSF to send off for testing. Call your radiologist friend and do the LP under fluoro. The evidence shows that fluoroscopy-guided lumbar puncture with suspected SAH and negative CT findings “should reduce the frequency of false-positive diagnoses of acute SAH as well as the number of unnecessary angiograms for patients with suspected SAH but no underlying intracranial vascular malformation.” (AJNR Am J Neuroradiol 2001;22[3]:571.)


Martha weighs in: Make friends with your radiologist and walk your patient over. If you can, stay for the procedure. I know you are all busy, but watch one of these at least once!


Jim weighs in: Some LPs just can’t be accomplished in the ED. Limit your attempts to three.


Do you have golden rules about lumbar puncture to share? Please leave them in the comments section below.

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Monday, November 03, 2014

Part 2 of a Three-Part Mini-Series on Lumbar Puncture


This month we are back (no pun intended) with the second part of our mini-series focused on perfect patient positioning and lumbar puncture (LP). Part one can be found at


Now that you have the proper skills to position your patient for an LP, the procedure should be pretty simple, right? The answer is yes! We want you all to be experts. We know that you can and will master an LP after reading these short and sweet LP guidelines and clinical pearls.


Lumbar puncture in the emergency department.

Manual of Clinical Anesthesiology; Lippincott Williams & Wilkins, 2011.


You have already decided you will complete an LP. A few common reasons an LP may be indicated in the emergency department include:

n Headache with a fever (rule out meningitis or a central nervous system infection)

n Sudden “thunderclap” headache (rule out subarachnoid hemorrhage)

n Altered mental status

n Idiopathic intracranial hypertension


Always remember to consider the risks and benefits for any procedure and refer to the contraindications. Obtain informed consent before you perfectly position your patient and get sterile! Make sure you review the risks and benefits with each patient.




n Infection at the puncture site



n Thrombocytopenia (platelets <50,000)

n Coagulopathy

n Prior surgery at the puncture site (i.e., discectomy or fusion)

n Presence of increased ICP related to a space-occupying lesion (i.e., tumor, Aspergillus abscess, etc.)


List adapted with permission from Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014, pg. 1218.


The Approach

n Gather appropriate equipment, LP kit

n Patient positioning

n Identify appropriate landmarks

n Obtain opening pressure using a manometer (lateral decubitus position only)

n Lumbar puncture obtaining cerebral spinal fluid (CSF)

n Patient recovery


It is never a bad idea to buffer any lidocaine injection with bicarb. Try it.

Martha Roberts



Lumbar spinal puncture for CSF draw and spinal anesthesia illustrating location of CSF draw for LP specimen.

Grant's Dissector; Lippincott Williams & Wilkins, 2012.


The Procedure

n Obtain an LP kit and an extra Quincke spinal needle. Obtain a Sprotte needle if preferred. (NOTE: Most LP kits contain Quincke needle.)

n Grab an extra 1% lidocaine, a 10 mL syringe, antiseptic, and two pairs of sterile gloves.

n Position patient properly (read how to do that here:



The lateral recumbent positioning for lumbar puncture, top, compared with upright positioning, bottom.

Atlas of Primary Care Procedures; Lippincott Williams & Wilkins, 1994


n Give appropriate dosage of IV sedation such as midazolam (0.1-2.5 mg for patients 18-60) or fentanyl (0.5-1.5 mcg/kg for adults 18-20), if indicated. Sedation is recommended for all procedures because of test anxiety.

n Wash your hands, and identify your landmarks. Palpate the posterior superior iliac crests bilaterally and find the L4 spinous process, midline. Consider using ultrasonography. Mark with a pen.

n Don a sterile cap, a gown, gloves, and a mask.

n Open your LP kit and loosen the tops of all four of your sample tubes, but do not leave them open to air. Ask a partner/RN/tech to drop a sterile 10 mL syringe into the sterile field. LP kits usually only come with 3-5 mL syringes and not nearly enough lidocaine for appropriate anesthesia.

n Draw up your lidocaine into a syringe, and have it ready on the sidelines.

n Clean the patient’s back with antiseptic. Use extra if necessary. Clean using a circular motion from center extending outward in a large circle.

n Slide a sterile drape between the patient’s hip and the stretcher. This is the point at which many people tend to break the sterile field. If you do, simply put on a new set of sterile gloves.

n Use an additional drape with a hole over the site where you plan to insert the spinal needle.

n Warn patients of the needle stick.

n Infiltrate the skin over your landmark (between L4-L5 spinous process) with lidocaine injection. Start with a wheel under the skin using a 1.5-inch, 25-gauge needle and advance to subcutaneous tissue. A total of 5-10 mLs can be inserted. This is usually a painless procedure if you use enough lidocaine. It’s painful if you don’t.

n Wait one to two minutes. A common error is to fail to measure the opening pressure. Set up a stopcock and a manometer for opening pressure. (Note: Remember, this can only be obtained in lateral decubitus position, NOT sitting.) Ensure that the valve is working.

n Hold the selected spinal needle (3.5-inch, 20-gauge needle preferred) between your thumb and index finger of your non-dominant hand and insert perpendicularly into skin over the landmark by pressing the hub of the needle with your dominant thumb. (Pediatric LP to be covered later.)

n Slowly advance the needle below the L4 spinous process. Once you have infiltrated the subcutaneous tissue, aim the needle toward the umbilicus.

n Note: When you pass through the intra- and supra-spinal ligaments, you may feel a slight pop. If you feel bone (articular process), slowly remove the needle and ensure you are entering the midline of the spine. Re-angle your needle slightly to the left or right.

n Your goal is to reach the subarachnoid space.

n Attach the manometer, and obtain a pressure. The stopcock allows you to obtain the pressure and obtain CSF. Normal pressure is 7-20 cm/H20.

n Remove and replace the stylet at various stations (every few millimeters of advancements), entering the spinal column to check for CSF.

n Obtain desired CSF and replace the stylet before withdrawing the needle.

n Place bandage over infiltrated area and have patient lie supine for 30-60 minutes before sitting, standing, or walking to help avoid post-procedure spinal headache.


Find your landmarks by creating an imaginary line using this photo as a reference.

Martha Roberts




n Do not do this procedure without sedation, especially on those with altered mental status.

n Be generous with lidocaine administration.

n Be sure your needle is in midline and angled properly.

n Have an assistant help hold your manometer.

n Frequently check for spinal fluid once you are in the area by removing the stylet.

n Do not move the needle tip once you obtain CSF.


Tip of the Week

We all love to tape the lidocaine bottle to the stretcher post so we can draw up our own lidocaine without an assistant. We urge you, however, to grab a partner for this procedure. Your partner can provide an extra set of hands and patient comfort. It is vital to ensure that a nurse is close by to administer needed medications prior to the procedure. A difficult or altered patient is just too tricky to handle one-on-one, no matter how good you may be at LPs!


Evidence-Based Practice Pearl

A study in the New England Journal of Medicine discusses the use of head CTs in suspected meningitis patients. Clinical characteristics were identified in patients prior to receiving head CTs. If certain neurological characteristics were not present, the patients were unlikely to have an abnormal CT scan. The study concluded by stating that patients without specific neurologic abnormality characteristics at baseline (based on the Modified National Institutes of Health Stroke Scale) had a negative predictive value of 97%. The head CT was normal for 93 of 96 patients. Was it really necessary in absence of clinical abnormalities? Maybe not, but no one really wants to be that three percent. (N Engl J Med 2001;345[24]:1727.)


Stay tuned for our third and final edition of this mini-series next month, “How to Handle Lumbar Puncture Results.”


Do you have any tips that help make LPs easier? Share them in the comments section below.

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Wednesday, October 01, 2014
Part 1 of a Mini-Series on Lumbar Puncture
We love breaking down and simplifying complicated procedures so you can perform them easily and efficiently. The next few blog posts will focus on strengthening your practice.
We want to give appropriate and safe care. We also want to consider patient satisfaction, dignity, and comfort when we complete any procedure. This month, we are focusing on procedures that require perfect patient positioning. Half the battle of any procedure is setting up your stage to perform, no matter how complex or simple the task at hand may be. Successful procedures are all about positioning and patient comfort. The better the positioning, the better the procedure and overall outcome.
Positioning for lumbar puncture.
Oski’s Solution; Lippincott Williams & Wilkins, 2006.

Lumbar puncture anatomy review.
High-Yield Gross Anatomy; Lippincott Williams & Wilkins, 2010.
Consider the correct setup before you start a lumbar puncture. Is the patient young, thin, and tall with a fever? Or older and morbidly obese with altered mental status? Does he have some underlying condition like COPD or heart failure, which makes lying flat or even on his side almost impossible? Does the patient have a history of back surgery or infection that complicates the situation even more? Is he allergic to analgesics or lidocaine — or emergency providers? Next month’s blog will break down the actual steps you need to complete a successful LP, but this month just consider the setup.

Spinal puncture, position, and technique.
Neil O. Hardy, Westpoint, CT.
Indications for Lumbar Puncture
(See Cautions section below for contraindications.)

n Meningitis (CNS infection) with the exception of brain abscess or paramenigneal process
n Subarachnoid hemorrhage
n Syphilis
n Idiopathic intracranial hypertension
The Approach
n Excellent clinical assessment
n Assessing patient stature and mental status
n Obtain consent
n Gathering appropriate supplies for lumbar puncture
n Appropriate positioning and final setup and prep
The lateral recumbent positioning for lumbar puncture, top, compared with upright positioning, bottom.
Atlas of Primary Care Procedures; Lippincott Williams & Wilkins, 1994.

n Grab an LP kit. Get an extra kit and leave it outside the room (to avoid contamination if not used). You don’t want to leave the room once the procedure has started, so also grab an assistant.
n Additional bottle of Betadine or other cleansing solution.
n Extra 1% lidocaine (Kits usually only come with 3 mL vials, and you need 10 mLs.)
n Extra needle: one or two 3.5-inch, 20-gauge needle(s) for adults
n Pillow (Three blankets will also do.)
n Extra set of sterile gloves in your size.
n Versed or Fentanyl for sedation if appropriate.
Lumbar puncture supplies.
Visual Guide to Anesthesia Procedures; Lippincott Williams & Wilkins, 2011.
Lateral Recumbent Position or Side-Lying Position Positioning for Lumbar Puncture
n The patient should be fully undressed for this procedure and in a room on a flat and stable surface.
n Obtain consent. Review pros, cons, and risks vs. benefits prior to procedure with patient or medical beneficiary. Still complete consent with “emergent procedure” if indicated.
n Explain the procedure to the patient. Lessen fears by stating the numbing needle is small and should not be incredibly painful. They may feel pressure once the numbing medication is inserted, but should not feel pain.
n Note to the concerned patient, that removal of CSF from an LP is commonly regenerated within the subarachnoid space within one hour.
n State that the actual procedure itself is not long (5-10 minutes) and that the prepping usually takes longer. Make sure to mention you care about his comfort and safety.
n Assist the patient into a lateral recumbent position, with his back facing you.
n Place a pillow or a few blankets under his head and between his knees. The legs should be parallel.
n Let the patient get comfortable and settle in this position.
n Find your landmarks.
Lumbar puncture positioning, lateral recumbent position.
Lippincott's Nursing Procedures and Skills, 2007.
Finding Landmarks
n Find the highest points of the iliac crests visually and by palpation. Draw an imaginary line between them to the anatomic midline. This is the fourth lumbar vertebral body. L3-L5 can also be felt by palpation in a thin adult or pediatric patient.
n The correct level of entry of the spinal needle is “most easily determined with the patient sitting upright or standing,” and the spinal needle can be “safely inserted into the subarachnoid space at the L3/4 or L4/5 interspace, since this is well below the termination of the spinal cord.” (Lumbar puncture: Technique, indications, contraindications, and complications in adults. UptoDate; Sept. 18, 2013.)
Additional Pearls
n State one of these phrases to the patient: “Curl your back like a cat,” or “Get into the fetal position.”
n They should have neck, back, hips and legs in flexion.
n Set up your LP kit with the patient’s back facing you. Place it within close reach. There is no reason to set up the kit with the patient watching or before you have found your landmarks and feel confident you can complete the procedure.
n An assistant can help with positioning.
Sitting Upright Position for Lumbar Puncture
The steps for prepping this position are virtually the same as the lateral recumbent position. The difference is that this patient is sitting upright and hunched slightly forward. Have the patient place his head on his crossed arms over the mayo stand while he sits on the side of the stretcher. You must determine your landmarks before starting and prepping. Consider the following, however, before using an upright position.
n You cannot obtain the opening pressure in the upright position if you are concerned about increased ICP.
n Patients may become more nervous and uncooperative in this position.
n The upright position is more effective for obese patients.
n You need an assistant for this position and a stable patient.
n It is practical to give an anxious patient an appropriate dose of a benzodiazepine (IV or PO), but use caution in the upright position.

Upright sitting position for lumbar puncture with anatomy review.
Lippincott Concise Illustrated Anatomy, 2011.
Patient in appropriate upright sitting position.
Manual of Clinical Anesthesiology; Lippincott Williams & Wilkins, 2011.
n The opening “pop” you feel is the needle penetrating the surrounding ligaments.
n Never complete an LP with infection near the puncture site (i.e. cellulitis, open sore, wound, etc.)
n Completing an LP in a patient with a space-occupying lesion (i.e., abscess, tumor) causes risk for brain herniation.
n Relative contraindications include coagulopathy, increased ICP caused by space-occupying lesion, and severe thrombocytopenia.
n Thirty-one percent of adult patients have termination of the spinal cord at L2; the rest, above.
n Needle choice and bore size can influence the risk of a post-LP headache.
Become familiar with both types of spinal needles: standard point (triangle shape puncture (Quincke) vs. pencil point (Whitacre or Sprotte). The Whitacre needle has been associated with decreased risk of post-LP headache. (Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.)
n Note: Pediatric LP considerations will be covered in a future blog post.

The 22-gauge, 3.5-inch Quincke spinal needle is the most common one used by many practitioners for image-guided injection (22-gauge with black hub, 25-gauge with light blue hub; tip of 22-gauge needle is shown at various angles of rotation). The Quincke needle has a sharp bevel that advances easily through tissue planes. Most manufacturers produce a needle with a central stylette that has a small notch in the hub. The notch lies on the same side as the needle’s bevel face, and can be used to determine the direction of the bevel as the needle is advanced.
Atlas of Image-Guided Intervention in Regional Anesthesia and Pain Medicine; Lippincott Williams & Wilkins, 2011.
Procedural Pearl: What’s with the headache? Patients with idiopathic intracranial hypertension (IIH) will often have normal neuroimaging studies. The increased ICP may be ongoing and cause headaches worse with position changes, coughing, visual loss, chronic pain, or cranial nerve palsies. The only way to diagnose and relieve IIH is to complete an LP. The opening pressure, therefore, should be obtained with a manometer on every patient with a headache, altered mental status, or chronic headache receiving an LP in the ED. Normal pressures are between 7-20 cm H20. Any elevation should be alarming and noted to be abnormal. The concern for IIH would be if the opening pressure was 25-45 cm H20. (Roberts & Hedges, 2014).
Note on Local Anesthesia: A generous amount of 1% plain lidocaine can render the procedure almost totally painless. After a skin wheal, advance the long 25-gauge needle in the same direction and depth that the spinal needle will follow. Anesthetize deeply and widely using 5-6 mL of lidocaine. We’ll get into more of this next month.
Tip of the Week: This month’s tip of the week comes from Dr. Amie Woods at Inova Fairfax Emergency Department. Dr. Woods suggests using a bit more lidocaine to numb the area effectively before completing the actual LP. It is more comfortable for the patient and allows you to complete the LP with virtually no discomfort. She suggests drawing up an additional amount of 1% lidocaine in a 10 mL syringe, maintaining sterility.
Go Green: We know it’s not appropriate to save pieces of a kit used for a lumbar puncture, especially if the kit was taken into a room and used for a patient on isolation. This is why we suggest leaving the second kit just outside the door within reach, and having an assistant hand it to you if you need to start over.

Wednesday, September 03, 2014

As we approach the end of summer, we pay tribute to a special nerve block. This particular block is crucial for treating lower lip lacerations that may be related to slips and falls at the pool or skateboarding. We are going to ask you to go mental, as in blocking the mental nerve of the face.


The mental nerve is an extension of the inferior alveolar nerve, which branches primarily off the trigeminal nerve. It is a sensory nerve that provides sensation to the lower chin and lip. It does not supply sensory innervation to the lower teeth, although some patients report mild anesthesia to their teeth. Three branches come out of the foramen; two go to the skin of the chin and one to the lower lip.



Mental artery and nerve positions.


Head and neck regional anesthesia is useful for a variety of reasons. A single but precise nerve injection allows the practitioner to spread a large area of anesthesia to specific parts of the face for suture repair. The injured area may be delicate and sensitive, especially complicated injuries to the lip. Many facial nerve blocks are accomplished by using landmarks that are easily identifiable. Intraoral needle entry may help avoid additional trauma to the outside skin surface. A nerve block allows suture repair without distortion or swelling that can occur with local injection. Finally, the procedure itself commands straightforward knowledge of the anatomy and requires only a few simple supplies.


Supplies for mental nerve block: gloves, 3 or 5 mL syringe, 25 or 27 gauge 1½-inch needle, topical anesthetic, and bupivacaine. Photo by Martha Roberts.


Injectable Sesorcaine (bupivicaine) and topical anesthetic (Benzocaine 20%). Photo by Martha Roberts.


The Approach

·         Identification of mental nerve and other facial landmarks

·         Topical anesthesia of mucosal entry point

·         Mental nerve block

·         Suture and repair as needed


The Procedure

·         Sit the patient upright at a 45- to 90-degree angle.

·         Place side rails up on stretcher so the patient can hold onto them as you inject. Patients have a tendency to grab or swat away your hand in response to the initial injection.

·         Identify your landmarks. Have your patient look forward and draw an imaginary line from the pupil down to the lower jaw. The mental nerve is midline to the pupil.

·         Place your pointer finger in the mouth along the gum in line with the pupil. Locate the foramen of the left or right side of the mental nerve. To do this, palpate 1 cm below the base of the second premolar (tooth #20 or #29, fifth tooth from the midline) between the lip and teeth. The foramen may be very difficult to palpate.



Photo courtesy of The Clinical Practice of Emergency Medicine, Lippincott Williams & Wilkins, 2001.


·         Generously squirt or squeeze topical anesthetic of your choice onto cotton-tipped applicators and place them on your landmark(s). The applicators are placed on the mucosa at the base of the space between the teeth and lip. Leave in the patient’s mouth for three to five minutes.

·         Draw up 3-5 mLs of bupivacaine into a 3 or 5 mL syringe. Obtain 25 or 27 gauge 1½-inch needle for injection.

·         Grab the lower lip with thumb and pointer finger with non-dominant hand and pull it gently outward, as if you are holding a large mouth bass.

·         Use your dominant hand to inject. Position your needle perpendicularly to the second molar, and insert the needle. Click here to watch a video of Dr. Roberts demonstrating how to do this step-by-step.

·         Insert needle and aspirate to ensure you are not injecting into an artery.

·         Inject 3-5 mLs of bupivacaine just above the foramen and remove the needle. Use a fan-like distribution of anesthetic about 1 cm to each side of the injection to ensure good anesthesia.

·         Massage area of injection on the outside of the face to help with distribution.

·         If the patient has an injury that crosses the midline, identify both landmarks and complete steps to both sides of the face.

·         Allow 3-5 minutes for full anesthesia to take effect.

·         Complete your suture and repair as needed.



Distribution of anesthesia from mental nerve block (top). Anatomy (center). Approach and positioning of injection (bottom). Photos used with permission from Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014, pg. 551.


The Cautions

·         Remember that the full length of the needle should never be fully inserted when using an intraoral approach for any nerve block.

·         Do not change the direction of the needle while it is inserted during injection. Pull back and change position.

·         Aspiration before injection is key.

·         Minimize pain by injecting anesthesia slowly.

·         Use a topical numbing agent whenever possible to minimize pain prior to injection. This block is nearly painless with proper topical anesthesia and a slow injection.

·         Always take into consideration that any injection to the face causes anxiety for the patient. Be sure to explain to the patient your procedure before injecting so that he remains still and comfortable while you work.


Tip of the Week

Next time you head to the dentist, why not ask for some one-on-one teaching? These guys are experts when it comes to facial anatomy and nerves. Although there is some mild anesthesia provided to the first and second premolars by blocking the mental nerve, you should note this is NOT the primary procedure for actual dental work or dental blocks. Please see our blog from March 2013 for more information about the inferior alveolar nerve block. (


(NEW!) Evidence-Based Practice Pearl

A randomized, controlled, double-blind study in the Journal of Endodontics by Whitworth et al. found the speed of injection reduces the pain of injection while performing a mental nerve block. About 50 percent of the tested patient population reported anesthesia to their first molars, bicuspids, and lateral incisors. For all your statistical nerds out there, the P value was <0.001.

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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