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, March 31, 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.​

PP photo with video dislocation.JPG

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.​

PP-superglue.JPG


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.)​


Saturday, February 25, 2017

Watch Helen Karellas Bardis, NP, show off her pediatric pearl! This simple trick works well if you need to use ocular anesthetics for pediatric eye exams.

Add a few drops of the saline directly onto the fluorescein paper, and then suck the fluid back up into the saline dropper. This way, you don't have to put a piece of paper onto a child's eye. It is far less scary to have drops administered.

This trick also works with tetracaine/proparacaine for an all-in-one staining anesthetic.

Watch the video.

PP fluoro clinical pearl.JPG


Wednesday, February 1, 2017

What happens in Vegas … saves lives. You thought we were going to say "stays in Vegas," right? But this is one new invention that should travel far and wide. Taking in all the wonder that is the American College of Emergency Physicians Scientific Assembly, we found many new products that piqued our interest, but we kept coming back to the PerSys New Intraosseous (NIO). Fluid replacement and stabilization during a code means everything. The time it takes to achieve patient resuscitation takes not only skills but also the appropriate tools.

Overwhelming evidence shows how useful intraosseous (IO) devices are to intravenous access. EPs should use IO insertion when peripheral or central lines cannot be obtained. The NIO is a single-motion instrument used to obtain IO access on the fly. This device has made headway in the battlefield and among EMS providers.

The NIO is used to obtain access on adult and pediatric patients and has three needle sizes. A study by the New York Institute of Technology (NYIT) College of Osteopathic Medicine found a 98 percent success rate for first attempts at insertion in the proximal tibia and 91 percent in the humeral head. Additional studies by NYIT performed found zero occurrences of microfractures and an average procedure time of 18.3 seconds. The NIO is FDA-approved, Health Canada-certified, and has received a CE Marking.

PP-Nio.JPG

The thing we liked best about the NIO was that it was light and easy to use. Many of our ICU nurses carry the EZ-IO in fanny packs alongside their drugs. The drill is not that heavy, but it is still another thing someone has to carry around and clean. The NIO can be used once and thrown away. No drill or extra step is needed.

You simply place the NIO on one of the accepted sites, which include the proximal tibia, humeral head, and distal tibia. Then you turn the handle and the needle "pops" into place. As Dr. Roberts said, "It's easy, even for an old guy." Watch him in this step-by-step video.​

Contraindications of use include:

  • Skin infections at the insertion site
  • Bone disease
  • Bone fracture
  • Deformation of insertion site
  • Previous IO insertion attempts at the site
  • Previous orthopedic procedures at the insertion site
  • Tumor

We are curious about your favorite "new procedure toy" for the upcoming year. Let us know so we can learn more about it.

Disclaimer: No financial or material incentives were provided for this review. We just liked it.​


Tuesday, January 3, 2017

​When and where should you use prolene? What about nylon suture threads? We will end with the latest on antibiotic use in hand injuries.


Pediatric nail bed laceration and finger laceration. Tissue adhesives can be used in place of absorbable sutures for minor injuries to the nail bed.

Nylon vs. Prolene

How do we decide on which to use and where to use it? Prolene is a synthetic, monofilament, non-absorbable polypropylene thread. This material can be difficult to handle, and many practitioners avoid using it. Its fishing thread-like structure makes it stiff, and its knots tend to be loose, especially for larger threads.

Nylon is the go-to non-absorbable material we use for a plethora of superficial wounds because it is extremely easy to use. It is a silkier material that can come in various forms and thickness. Prolene may be a better choice for wound repair if you want to lessen the patient's pain and make your colleague's job easier, such as for eyebrow lacerations. This way, when the provider removes the sutures, the thread won't blend in like the nylon ones (making it hard to find). Don't use prolene anywhere else on the face because cosmetic healing can be compromised if the knots slip or move.

Where else can we use prolene? Have you ever tried to suture the scalp with prolene? We suggest giving it a whirl. Hand tying the knots (with surgeon knots) is easy and makes for a strong knot if it is too difficult to tighten them with your tools. Staples can be used in the scalp with ease, but sutures are less painful to remove and just as efficient. Often prolene is a good choice for bald patients. Staples can leave larger scars and prolene may allow for enhanced cosmetic results while still being extremely durable.

Prolene isn't always the first choice in terms of non-absorbable suture and can be more expensive than nylon. Some other disadvantages of prolene include brittleness, plastic-like feel, and being more difficult to use than nylon. Prolene, however, has its uses for eyebrow lacerations, scalp lacerations, and larger wounds. There is minimal tissue reactivity and durability when compared with nylon.

Nylon is the better choice as far as any finger laceration repair is concerned. The nail bed, however, should be handled differently. Finger lacerations can typically be repaired with 5.0 or 4.0 nylon sutures. Repair of small nail bed lacerations with absorbable sutures (unless partially amputated or brutally severed) is not indicated.

If the nail bed laceration is minor (or even moderate) and you can easily replace the nail over the wound, then do not suture the nail bed. Studies indicate nails can be tacked back down with tissue adhesives and heal in the same fashion with no difference in wound infection rates or complications as if sutures had been used. This practice has been in place for decades although many practitioners are still using sutures in the nail bed. (Plast Reconstr Surg 1999;103[7]:1983). Sutures in the nail bed can also increase infection rates and prolong recovery.


Dermabond, a type of tissue adhesive otherwise known as 2-octylcyanoacrylate.

A 2008 study from the University of Washington published in The Journal of Hand Surgery drew the same conclusions. (2008;33[2]:250.) Nail bed repair performed with Dermabond is "significantly faster than suture repair, and it provides similar cosmetic and functional results," and it is suggested in "the management of acute nail bed lacerations [as an] efficient and effective repair technique." Stop tediously sewing nail bed lacerations with a thin thread that only breaks and makes everyone's life more difficult. Consider tissue adhesive next time you see this injury.


Note the laceration on the side of the finger should be repaired with a 4.0 or 5.0 nylon suture thread. The minor lacerations under the nail can be covered with tissue adhesive, and the nail can be placed directly back onto the bed.

What about Infection Rates and Antibiotics?

Literature comparing wound healing rates of nylon and prolene threads is sparse. A 2003 study in The Journal of Oral Diseases assessed four different suture materials (catgut, silk, polypropylene, and Vicryl) in the soft tissues of 32 Sprague Dawley rats. (2003;9[6]:284.) The results demonstrated that Vicryl produced the mildest tissue reaction during early healing. It is well-known that absorbable sutures (like Vicryl) can be used on the face and reinforced with tissue adhesives and have similar healing rates as non-absorbable threads.

We highly recommend using Vicryl for facial wounds. "No difference in long-term cosmetic results of repairs with permanent or absorbable suture material" was seen in adults with clean wounds of the face or neck. (Arch Facial Plast Surg 2003;5[6]:488.) Many providers may agree they prefer absorbable sutures because they do not have to be removed, saving time and lessening the patient's anxiety and pain.


Vicryl can be used for many superficial and partial thickness wounds on the face. Patients do not have to follow up for suture removal because they are absorbable. Tension strength lasts up to seven days.

When are antibiotics indicated for hand injuries for infections? The bottom line is the hand does not like foreign materials. Hand injuries tend to get infected more often than other sites on the body because they are well-exposed, they have multiple areas of flexion and extension, and they have very little subcutaneous fat and overall space. ED providers should be wary of placing deep sutures in the hand in general. We suggest all tendon repairs be followed up with a hand specialist, and you will stay out of trouble deep down in the hand.

Normal, healthy children and adults do not need prophylactic antibiotics. You may have been taught that open fractures in the hand always need prophylactic antibiotics. A recent 2016 study published in The Journal of Hand Surgery completed a systematic review to determine whether prophylactic antibiotics reduce the risk of superficial infection and osteomyelitis following open distal phalanx fractures. (2016;41[4]:423.) A meta-analysis of four randomized controlled trials (353 fractures) were examined. There was no statistically significant difference between rates of superficial infection in the two groups.

These results fail to show any effect of prophylactic antibiotics on the rate of superficial infections following open distal phalanx fractures, and the authors suggested that treatment should focus on prompt irrigation and debridement rather than administration of prophylactic antibiotics.

If you still have doubts and your patient is immunocompromised or high-risk, IV Ancef or Cefazolin over 15 minutes prior to discharge (along with tetanus update) may be considered. Then, Keflex for five to seven days may be a useful adjunct. Clindamycin could be used as an alternative for patients with allergies. Prophylactic anything, however, may not make a darn bit of difference.

Watch Ms. Roberts repair a nail bed laceration in this video.​