The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, PNP, 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.

Monday, July 3, 2017

​Simple ankle and wrist sprains and strains still need ACE wraps, Aircasts, Velcro wrist splints, or hard splints. Patients without fractures may still need assistive devices to help control their pain and place their injured extremity in a comfortable position while they heal. Hard splints (like Ortho-Glass) may be unnecessary. Appropriate splinting or hard casting, however, should be used to prevent further injury and decrease pain until follow-up. Strain, sprains, and even contusions do not need hard casting unless there is a high level of suspicion for missed injury, such as a Jones fracture, complicated avulsion injuries, or the nefarious scaphoid fracture.​

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Photo by Martha Roberts

One of the major problems we face is deciding on the right adjunctive therapy for our patients. Depending on the grade of sprain (table), patients may have greater pain or flexibility issues. More intense splinting and prolonged treatment may be indicated. Splinting items are also costly, so it's wise to be prudent with their use. Many devices do not take much time to apply, but it is still an extra step during a patient's visit.

Grading of Sprains

Grade 1Mild damage to a ligament or ligaments without instability of the affected joint.
Grade 2Partial tear to the ligament, in which it is stretched to the point that it becomes loose.
Grade 3Complete tear of a ligament, causing instability in the affected joint. Bruising may occur around the ankle.

Credit: Pain Medicine. Switzerland: Springer International Publishing; 2017.

Inappropriate application may lead to increased injury, such as the dreaded frozen shoulder, which is related to sling use. If a sling is applied and the injury is not a direct shoulder injury, you must instruct patients to do Codman's shoulder exercises to avoid secondary injuries.

ACE Wraps vs. Velcro Splinting

-ACE wraps are difficult to apply yourself for a wrist injury. Dorsal or circumferential Velcro wrists splints may be a better choice.

-ACE wraps assist with swelling and mildly restrict injuries. A Velcro wrist splint inhibits all flexion and extension of the wrist. Keep this in mind with strains and sprains because Velcro splints may not allow for full range of motion and cause muscle atrophy as the injury heals.

-Scaphoid fractures or suspected scaphoid fractures need a thumb spica hard splint. These areas of the scaphoid do not have good blood supply, have difficulty healing, need serial follow-up exams, splint changes, and sometimes OT/PT. A true Velcro thumb spica splint can be used in place of hard casting or Ortho-Glass for these injuries, but a simple dorsal Velcro wrist splint without thumb extension should never be used.

-Evidence Pearl: Grade 1 injuries typically only need two to three weeks of brace time to be fully healed, while grade 2 injuries may need up to six weeks. (Introduction to Splinting: A Clinical Reasoning & Problem-Solving Approach. St. Louis: Mosby Elsevier; 2008.) It is important to remind patients to limit their use of that wrist for up to that amount of time. Any worsening pain or delay in resolution should be seen by an orthopedist.​


Photo by Martha Roberts

ACE Wraps vs. Stirrup Splints

-Stirrup splints (or Aircasts) are meant to stabilize the ankle while the patient is standing. They are not to be worn while sleeping. It should be worn with a supportive shoe, and be sure to caution patients of secondary injury from the sides of the stirrup rubbing on their malleolus.

-An Aircast "boot" is not the same as a stirrup. Be wary of applying boots in the ED, and refer these patients to ortho if you think one is needed.

-ACE wraps should be used while sleeping during the first few days of ankle sprain injuries to help decrease pain and swelling.

-Just like Velcro wrist splints, stirrup Aircasts inhibit ankle rotation. It can cause muscle atrophy if full range of motion is limited.

-Any lower extremity device or cast decreases mobility. Consider patients with risk factors for PE or DVT by avoiding all unnecessary splints.

-Patients can wear ACE wraps under the Aircast (instead of a sock) for the first few days to assist with ankle swelling, but it is not necessary.

-Some patients prefer using the ACE wrap to a sock because it hurts more to put the sock on and off. Give them the option.

-Evidence Pearl: What is the most common sports injury? Lateral ligament ankle sprains. [HL1] The use of stirrup ankle braces to treat lateral ligament ankle sprains is encouraged. (Br J Sports Med 2005;39[2]:91.) The study reported decreased pain, swelling, ankle girth, and secondary injuries in men and women. The study showed significant improvement in ankle joint function at 10 days and one month compared with standard management with an elastic support bandage alone.​

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Photo by Martha Roberts

Crutches vs. Cane vs. Walkers

-A patient who can bear weight on an injury may use a cane or a walker.

-Jones fractures are non-weight-bearing injuries, and patients with these fractures need to be given crutches.

-Canes can be used instead of crutches depending on the grading and level of pain for ankle sprains or strains. (Table above.)

-Crutches should only be used for the first week (depending on severity of the injury) for acute ankle strains or sprains to avoid secondary axillary injuries.

-Walkers or canes can be given to adolescents, adults, and the elderly if their injuries are appropriate for use.

-Walkers are best suited for any individual who has balance or coordination issues, is elderly, and has difficulty with ambulation at baseline or for when crutches pose too much of a fall risk.

-Evidence Pearl: Some non-weight-bearing injuries include foot and ankle fractures, especially Jones and calcaneal fractures, Achilles tendon rupture, deltoid ligament tears, and tibial stress fractures. (Office Orthopedics for Primary Care: Diagnosis. Philadelphia: Saunders; 2006.)

Common Orthopedic Tips for Patients

-Patients with grade 1 ankle sprains who do not heal within three weeks or those with grade 2 or 3 sprains who do not heal within six weeks should be evaluated by an orthopedic surgeon. Complications include avulsion issues, ligament tears, underlying bone disease, osteoarthritis, osteomyelitis, effusion, and missed fracture. (Office Orthopedics for Primary Care: Diagnosis. Philadelphia: Saunders; 2006.)

-Most adjunctive pieces are needed for only one to two weeks, occasionally longer, depending on the severity of the injury. Patients should wear the assistive device for the first three to seven days, with periods of rest, ice, and compression, and elevation (RICE). Light stretching can be started in a few days, and they can resume normal activities (high-intensity sports or running) when fully healed. Consultation with an orthopedic surgeon may be necessary if patients are not better in two to three weeks.

-Patients can usually remove the splint or wrap to shower, but if it hurts and they have difficulty limiting use in the shower, they should cover it with a plastic bag and not get it wet.

Jim weighs in: Always give the name of a specific person in an orthopedic group to a patient for a referral, not just the group name. Tell them that Dr. Smith is someone at the National Orthopedic Clinic who people like, but everyone in the group is good if you can't get an appointment with Dr. Smith.

Tip of the Week: Instead of tearing the wrapper off an ACE bandage or trying to cut it open and compromising the band if you knick it, simply twist the ends of the wrapper like you're wringing out a towel. The plastic will pop right off.

Watch Ms. Roberts' video on back-to-basics essentials for ACE wrap and Aircast applications.​​​


Thursday, June 1, 2017

Check out this quick video by Martha Roberts, NP, and Carlynne DePolo, EMT, where they show you the basics of splinting in less than five minutes.

Future splinting segments will help you brush up on specialty splints and share pearls to make you a top performing clinician.

Not only will splinting your own patient save you door-to-disposition time, it also guarantees to make your patient happy. Plus, you can position your patients just right, the way you want them to stay, until their follow-up. Read more about splint and cast methods and indications: http://bit.ly/2pWOzhc​.

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Watch Ms. Roberts and Ms. DePolo talk about splinting basics.​


Monday, May 1, 2017

​One of the most important things you can do as a clinician is to fix a patient’s immediate problem. Mastering certain procedures like splinting allows us to provide immediate solutions to patient problems when they arise. We all want to be masters when it comes to splinting, and here is why.



EP splinting a complex distal radial fracture with the help of countertraction. stockinette, fiberglass splinting material, and ACE wrap are utilized.

One of the more common mistakes NPs, PAs, and even MDs make is avoiding splinting their own patients. This means they spend less time at the bedside. If you personally splint your patient, studies show that your added bedside experience may shorten your patient's length of stay and could produce higher patient satisfaction scores. (Am J Manag Care 2014;20[5]:393.) When you skip doing the splint, it can disrupt care and limit your interaction with the patient, which is disliked by patients. Splinting the patient yourself is a great way to expedite care, provide patient teaching, set the mold of the splint the way you want it, and connect with your patient. This is true in emergency care areas and primary care offices. Patients may expect similar interactions with caregivers in the ED as they do in the primary care environment, and the added time at the bedside increases their satisfaction. (Arch Intern Med 2001;161[11]:1437.)

Understandably, you may not always have time to splint a patient yourself. If this is the case, it's important to rely on a team member well-versed in splinting techniques. If the splinting is done incorrectly, it can decrease your satisfaction scores, increase wait time, and impair treatment. Many technicians and nurses are able to apply appropriate splinting, but you as the clinician must always go back into the room and check the splint for accuracy and neurovascular status. Documentation of neurovascular status and splint check is also a billable procedure and recommended by the American Academy of Emergency Medicine. (Acad Emerg Med 2009;16[5]:423.)

The Basics

When you find yourself saying, "Splinting takes too long," we encourage you to attempt a few before coming to that conclusion. The average splint, when done properly, should only take about five minutes. Before you splint, you must know what type of splint is best for the patient's injury or problem.

Casting is a way to immobilize an area circumferentially, and is often reserved for outpatient orthopedic settings. The goals of ED splinting are to protect the injured area, limit the range of motion, and decrease pain, all while providing support and comfort to the patient. Splinting also allows room for swelling, which will occur during the initial healing process of the injury. Surgery, casting or booting, rehabilitation, and reevaluation all come later and should be followed by appropriate orthopedic referral. (Roberts and Hedges' Clinical Procedures in Emergency medicine. Philadelphia, PA: Elsevier Saunders; 2014.)

Complications of Splinting

Be aware of the potential complications of splinting and how to best approach patient concerns. If a patient returns with a splint that is causing more pain or impairs neurovascular status, simply remove and reapply the splint. Potential splinting issues are listed in the table. Keep in mind, all minor problems can turn to severe problems if left untreated.

MinorModerateSevere

Infection (mild)

Dermatitis

Joint stiffness

Pain

Heat injury

Skin breakdown

Burns

Pressure sores

Muscle atrophy

Chronic pain

 

Ischemia

Gangrene

Neurologic injury

Compartment syndrome

Splinting requires an understanding of the materials used during application. The most common splinting material used in the ED is a fiberglass padding that is moistened, applied, and set to dry. Plaster can also be used, but it's more difficult to work with and can be a lot messier. Plaster and fiberglass splints will be very hard once dried. All splinted extremities should be in a position of function, and a stockinette (or protective covering against the skin) should be used prior to covering with fiberglass. (Am Fam Physician 2009;80[5]:491.) This can help prevent minor, moderate, or even severe complications. The splint should have a padding folded over molded contours to provide a smooth edge, and the final splint should be wrapped with an elastic bandage in a "distal to proximal" direction. (Am Fam Physician 2009;80[5]:491.)


Photo of a thumb spica splint after application of a plaster splint in the emergency department. Notice the ring on the patient's middle finger; all jewelry should be removed before splinting and remain off during the healing process because of associated distal joint swelling. Photo courtesy of Larry Mellick, MD.

Managing Splint Application

Maintaining good anatomic fracture alignment throughout the splinting process is important to prevent the injury from getting worse. Stable fractures should be seen one to two weeks after splint application, although hand and forearm fractures are often reevaluated within the first week of injury. (Am Fam Physician 2009;80[5]:491.) Displaced and unstable fractures should be followed more closely, and if proper reduction cannot be achieved, orthopedic surgery consult or surgery may be indicated. (Hand Clin 2000;16[3]:323.)

Why Your Splints Matter

Patients are more likely to follow up with appropriate referrals when they leave your department with a splint. The type of bracing or splinting applied influenced the "no-show" rates for orthopedic follow-up, according to a 2014 study in The Journal of Bone and Joint Surgery. (2014;96[19]:1650.) Patients with splints that were easier to remove or were poorly applied were less likely to follow up with the orthopedic clinic. The better you apply the splint and the more time you spend with your patient, the more likely they are to receive proper follow-up care. The study found that assault victims had the highest no-show rate, and by anatomic region, patients with spine or back complaints had the highest no-show rate. "The easier it was to remove the splint, the worse the follow-up," the authors wrote, noting that patients who were morbidly obese and who currently used tobacco were also less likely to follow up. These factors may influence your disposition and management decisions for these patients.

Pearls

-Splinting should be completed after all radiographs and reductions.

-All jewelry should be removed, especially rings, as soon as possible after injury.

-Keep all patients in the ED until the splint is fully hardened.

-Teach patients the signs of ischemia, i.e., coloring, pain, numbness.

-Complete neurovascular checks before and after splinting.

-Splint in position of function (unless otherwise indicated).

-Do the splint yourself, whenever possible.

-Consult an orthopedic surgeon for all unstable or displaced fractures.

Patients will have less pain, fewer complications, and better outcomes when splints are applied appropriately and cautiously.​


Saturday, April 1, 2017

​Finger dislocations in general are relatively simple to identify and treat, but ligament, tendon, or volar plate injuries are often missed. Thumb dislocations can present with or without lacerations, and are often associated with ligamentous injuries. An injured thumb is almost always treated with splinting. Follow-up for these injuries is crucial. Radiographs are useful in locating the areas of injury and identifying avulsion fractures.


Thumb dislocation in a 24-year-old man 12 hours after injury.

Listen to the patient's story to identify the mechanism by which the injury occurred because mimicking this mechanism is typically the best way to relocate the joint. Patients typically do not need local anesthesia or digital block because relocation techniques are quick and can often be done while simply distracting the patient. Treatment is dependent on your skill level, comfort, and ability to recognize these injuries.

Keep in mind that the thumb contributes to 40 percent of hand function. Preservation of its ligament and tendon function is extremely important. Remember that the extensor or flexor pollicis longus and brevis tendons assist with thumb flexion/extension. If only one of these tendons is injured, the alternative extensor or flexor tendon will still allow the patient to extend or flex the thumb.

If the ulnar collateral ligament is injured, the patient will have a weak grip. This ligament connects the metacarpophalangeal (MCP) joints to the proximal phalanx of the thumb. These will also need close follow-up and splinting for several weeks.

All significant thumb injuries, even those with no obvious fracture or ligamentous disruption should be splinted for five to seven days. A thumb spica splint is the most common technique to immobilize the thumb.

Thumb Anatomy Review

-Flexion: Flexor pollicis longus and brevis as well as opponens pollicis and adductor pollicis

-Extension: Abductor pollicis longus and brevis as well as extensor pollicis longus and brevis

-Adduction: Adductor pollicis longus

-Abduction: Abductor pollicis longus and brevis as well as extensors​




A diagram demonstrating the hand's anatomy. (Source: CreativeCommons.org)

The Approach

-Digital blocks or local infiltration if indicated

-Pre-reduction radiographs are routine.

-Longitudinal traction method of joint reduction

-Laceration repair if indicated

-Immobilization with thumb spica splint

-Follow up with hand specialist within one week.

​ 

Thumb dislocation (metacarpal phalangeal joint) with radiograph evidence of fracture-dislocation of the left thumb.

The Procedure

-Order appropriate radiographs of the finger, not just of the hand, after examining the patient. Appropriate views include the AP, lateral, and oblique views. Lateral views of the finger allow the provider to see subtle dislocations or avulsion fractures.

-Digital blocks are not routine, but do one as needed or if the patient has a laceration, needs extensive wound care, or could benefit from a block. Note: Skin repairs are done after the dislocation is reduced.

-Longitudinal traction method of joint reduction is used to treat the injury.

-Distract the patient with conversation while holding the injured area. It helps to make eye contact.

-Mimic the path by which the initial injury occurred, slightly exaggerating the deformity that is present.

-Pull the finger forcefully and quickly in the opposite direction as you push the joint back into position.

-Complete a full range-of-motion exam and neurovascular check. Check stability.

-Perform appropriate splinting. Thumb spica is recommended for this injury.

-Orthopedic or hand specialist consultation is recommended within one week of the injury.

-Ask the patient about tetanus vaccination if there is a laceration or abrasion.

-Oral NSAIDs are appropriate treatment for pain and swelling.​

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Watch a video of Ms. Roberts sharing tips on how to treat a patient with thumb dislocation.

Wednesday, March 1, 2017

Children like to put things in their mouth, ears, nose, and eyes. A 9-year-old boy superglued his right eye shut and came to our pediatric emergency department. He thought the glue was an over-the-counter eye lubricant and filled his entire eye with the glue.​

Overdoses and poisonings are a dangerous threat to children. In fact, unintentional poison overdose or ingestion has continued to claim hundreds of children's lives. More than 300 children in the United States ages 0 to 19 are seen at EDs for poisoning and two of them die each day. (CDC. April 28, 2016; http://bit.ly/2kjVmhO.)

Not all toxic exposures are ingestions. Chemical burns from household cleaners, too much topical Bengay ("Looking Beyond the Obvious in Toxicology Patients," EMN 2017;39[2]:20; http://bit.ly/2kkVQm6), and even superglue can be dangerous.

Medication packaging and labeling and ongoing prevention and educational efforts are being made by pharmaceutical and consumer companies. One retrospective study found that the storage and packaging of medications might be the root of accidental overdose. (Clin Toxicol [Phila] 2013;51[10]:930.) Reengaging childproofing mechanisms and returning medicines to a secure location, high and out of sight, immediately after use may help children avoid toxic exposures.

Accidental exposure to superglue in the eye is a rare event. Typically, removal of the eyelashes is required, and corneal abrasions should be considered and treated. Do not hesitate to dislodge large areas of glue from the eye area, but do so with caution.

The Procedure
Removal of superglue from the orbital area, eyelashes, and face.

The Approach

- Identify the agent used.

- Contact poison control (if indicated).

- Gently irrigate the eye and surface area.

- Anesthetize the eye using ocular anesthetic drops.

- Trim and remove the eyelashes.

- Treat associated corneal abrasions.

- Follow up with an ophthalmologist.

The Procedure

-Immediately identify the agent in the patient's eye if possible.

-Begin irrigation immediately. Light sedation may be indicated depending on the age and ability of the patient. Intranasal midazolam 0.2-0.3 mg/kg (max of 5 mg) is appropriate.

-Consider ocular anesthetic such as tetracaine or proparacaine drops.

-Consider ibuprofen or acetaminophen before the procedure to assist with pain control once the anesthetic wears off.

-Obtain ice cold compresses and apply to the eye between irrigations. The polymerization is also temperature-dependent: Keep it in the freezer to maintain a more viscous form. The use of warm compresses is debatable, and studies are limited.

-NOTE: If the offending substance is severely alkaline, consider generous irrigation and call ophthalmology for consultation. These types of exposures can cause severe corneal burns. Superglue is not severely alkaline.

-Carefully use acetone pads to remove any superglue on the face. This can be very drying to the skin. Avoid the eye completely because this can cause increased insult and even blindness.

-Gently trim the eyelashes and remove all dried glue.

-Provide reassurance that the eyelashes will grow back. Note: Eyebrows do not always grow back.

-Provide a prescription for ophthalmic erythromycin 0.5% ointment or triple antibiotic ocular drops for three to five days.

-Encourage the child's parent to use propylene glycol (such as Systane) every hour for the next three to five days.

-The eye cells will slough off and eventually loosen the grip of the superglue. Losing your eyesight from glue exposure is rare. Complications from corneal abrasions are of greater concern.

-Follow-up should be arranged within 48 hours with an ophthalmologist.​

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The Pearls

-"Super Glue" or "Krazy Glue" was originally discovered by Harry Coover Jr, PhD. It is a methyl 2-cyanoacrylate, ethyl-2-cyanoacrylate, and is a fast-acting adhesive. It has minor toxicity when applied topically, but can last for weeks.

-Octyl cyanoacrylate was developed to address toxicity concerns and to reduce skin irritation and allergic response, although plain acetone can remove the glue.

-Other solvents include nitromethane, dimethyl sulfoxide, and methylene chloride, but may not be safe for use on skin and should be- discussed with the poison control center. (Otolaryngol Head Neck Surg 2005;133[5]:803).

-Using vegetable oil, sugar, or sandpaper can remove a good amount of cyanoacrylate from a user's fingertips.

-Never peel eyelids a part; cutting the lashes is the only acceptable way to separate the lids.

-Some patients may have symptoms of corneal abrasion or leftover glue in the eye area for one to two weeks.

-For other body exposures (buttocks, fingers, legs), paramedics have used WD40 to remove the glue.

-Eyelashes grow back in one to six months. Three case studies reported in the International Journal of Ophthalmology found that the eyelashes of all affected patients grew back without issues. (2012;5[5]:634.)​