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.

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.

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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.


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.​

Thursday, December 1, 2016

How do you go about choosing your suture thread? Absorbable sutures may include polyglycolic acid, chromic catgut, or glycerol-impregnated catgut. Non-absorbable sutures are typically made of silk, Prolene, or nylon. Suture materials may be synthetic or natural, and they can be mono- or multifilament. Sutures may also be braided, unbraided, or coated. Sizes of suture materials also vary greatly. A 3.0-sized thread is a lot bigger than a 6.0-sized thread, for example.

Keep these key principles in mind: The time it takes for the thread to be absorbed is dependent on the tissue type and thickness, the size and type of the thread, the condition of the patient, and the absorption half-life of the product. Many online guides can help you learn more. Some sutures will be absorbed in five to seven days; some may take more than 200 days to disappear completely.

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Vicryl Rapide vs. Vicryl

Vicryl Rapide and Vicryl are absorbable sutures and are potential choices for repairing nail bed lacerations. Vicryl Rapide is a new and improved form of Vicryl, and may be more commonly used. Vicryl Rapide absorbs more quickly than other absorbable sutures, including Vicryl. Vicryl Rapide typically is completely absorbed after 42 days.

The most important thing to know is that after five days, Vicryl Rapide becomes 50 percent weaker than it was when you first put it in. No traction is left at all by day 14. Take this into consideration when you are assessing the wound. This is enough time for a pediatric finger laceration to heal if it is appropriately splinted and followed up.​

Polyglycolic acid derivatives such as Vicryl Rapide and Vicryl are far superior to non-absorbable sutures for wound healing, but problems still occur with their use, often because they are placed inappropriately or in areas with high tension.

Sample of Ethicon's 5.0 Vicryl Rapide polyglactin 910 undyed, braided, synthetic absorbable suture material.

A randomized prospective study in the Journal of Hand Surgery investigated Vicryl and Vicryl Rapide in 60 pediatric hand surgery cases. Thirty of the patients received Vicryl and the other 30 received Vicryl Rapide. The results showed that five "problems" occurred in the Vicryl treatment group and none in the Vicryl Rapide group (P=0.03).

All of the problems were related to the delayed absorption of the Vicryl suture material. The author concluded that Vicryl Rapide sutures are "more suitable than Vicryl ones in pediatric hand surgery." (2005;30[1]:90). Vicryl Rapide also has an antibiotic coating called triclosan. Studies are limited, but the coating has shown lower the rates of infection.

The major difference between Vicryl and Vicryl Rapide is in the composition and handling. Typical Vicryl is made up of a polyglycolic acid called polyglactin 370. Providers reported this coating made tying their knots more difficult, but it did decrease tension through the tissue and did less damage to the wound. The advantage of Vicryl Rapide is that it is a type of polyglcolic acid called polyglactin 910, which is not only easy to use but also easier to tie and secure. Its tension is better, and the absorption rates are relatively the same.

We will discuss suture materials in depth in future blogs, and talk about the differences between nylon and Prolene and when to use deep sutures for various parts of the body. The pediatric population requires strict guidelines and tension relief because of the difference in their skin composition, healing times, and body mechanics.

Tetanus Status: Pay Attention to These Kids!

When does a child first receive a tetanus shot? The American Academy of Pediatrics suggests the DTaP (diphtheria, tetanus, and pertussis) at ages 2, 4, and 6 months and again at 15 to 18 months. A DTaP booster is recommended for children ages 4 through 6 years old. Don't forget to administer appropriate boosters if your patient requires one. If parents are wary of receiving vaccines in the ED, they have 24 to 72 hours to discuss it with their pediatrician and have it still be effective.

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Recommended guidelines from the CDC on Td vaccine.

Next month: Antibiotics for open finger fractures (such as tuft fractures), using Dermabond vs. suturing for nail bed lacerations, and referrals and additional treatments for hand injury patients.

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

Tuesday, November 1, 2016

Our pediatric patient population is special, small humans with distinctive needs, medication doses, and unexpected challenges. The more you use the simple approach to pediatric emergency department procedures, the more you will experience faster, smoother, and better results.

You don't have to get fancy unless of course you have a Child Life Program in your department. The materials are simple and the skill is straightforward. Adding a sense of humor, learning the words to "Frozen," and laughing with your pediatric patient (whenever possible) will also help ease the tension.

A 4-year-old with pediatric nail bed laceration and partial nail bed avulsion.

Children, just like adults, don't like when you lie to them. It's important you give them just enough details to be able to complete your procedure. Be careful not to divulge too much scary information because it will just make treatment more difficult. Be aware of age-appropriate milestones and emotional development. Use suitable language to describe things to your patient, and involve the parent the entire time. Consider having mom or dad hold the gauze or a Band-Aid. Any complex or scary conversations should be held outside the room away from children's ears. Remember, don't use medications if they are not indicated and you can get through a procedure without them. Some kids are actually braver than you think. But do not hesitate to use light sedation if it will be safer for the patient, less stressful for the parent, and easier for you.

Each age group should reach specific personality and emotional milestones, according to the American Academy of Pediatrics. All children are different, and this guideline may assist with decision-making.

The Pause

How old is your patient? What milestones has this child reached? Does the child seem responsive to treatment? Are there any emotional development delays? Discuss the procedure with the parent and determine the best plan. Discuss pros and cons of light sedation. Ask the parents how the child may handle shots and gore. Some children, even 4-year-olds, are actually quite brave and are willing to do the procedure without hassle. It may be helpful to review Erikson's States of Psychosocial Development before proceeding: Use your best judgment and then proceed with a set plan. Apply LMX 4% cream or EMLA cream to the base of the finger to make the digital block injection of anesthesia less painful.

The Approach

  • Identification of injury and the extent of the injury (Fracture? Multiple lacerations? Nail condition?).
  • Perform radiograph if indicated.
  • Determine plan (Sedation? Forms of anesthesia such as lidocaine?).
  • Inject a digital nerve block into the affected finger.
  • Clean and explore the wound.
  • Suture and repair the nail bed laceration(s).
  • Apply Dermabond or other adhesive glue to nail to secure it in place.
  • Repair any other lacerations.
  • Add dressing and splinting as indicated.
  • Determine if tetanus update is needed and discuss immunizations.
  • Give antibiotics if indicated.
  • Develop a follow-up plan

The Procedure

  • Assess the child's milestones and emotional development. Assess the wound and then discuss the plan with the parents. Include the child in the conversation only if appropriate.
  • Some parents prefer the use of a papoose or child procedure board that limits movement while you work. It is the right of the parent to refuse pain or anxiolytic medications for her child. You may want to at least offer ibuprofen or acetaminophen if the parents refuse sedation.
  • Apply topical LMX 4 % cream or EMLA cream to base of the finger. Cover it with Tegaderm or gauze to help with absorption.
AgentDuration Max Dose
LidocaineMedium (30-60 min)Without epinephrine: 4.5 mg/kg, not to exceed 300 mg
Lidocaine + EpinephrineLong (120-360 min)With epinephrine: 7 mg/kg, not to exceed 500 mg
BupivicaneLong (120-240 min)Without epinephrine: 2.5 mg/kg, not to exceed 175 mg total dose
Bupivicane + EpinephrineLong (180-420 min)With epinephrine: Not to exceed 225 mg total dose

  • Review your department's protocol and safety measures if you have chosen light sedation (i.e., anxiolytic +/- anesthesia, pain control) for your patient. I use intranasal Versed per our hospital protocol. All safety measures must be in place; it is your responsibility to review these guidelines.
  • All intranasal Versed doses are weight-based in kilograms. Determine the appropriate dose and administration per your protocol and current drug guidelines.
  • Set up the digital block once the child is calm, appropriately medicated, and ready for the procedure.
  • Allow at least 15-20 minutes for the anesthesia to take full effect after application.
  • Clean the wound with soap and water.
  • Complete the digital block using 1% buffered lidocaine. Massage the anesthesia into the base of the finger along the nerves.
  • Assess the wound and determine the degree of the laceration.
  • Repair the nail bed laceration with dissolvable sutures only. We suggest a 5.0 Vicryl Rapide. (More on suture types below).
  • You may decide to use a finger tourniquet to control the bleeding. A clean, dry field will allow you to place sutures more effectively. If a finger tourniquet is unavailable, you can use a rubber band over a piece of gauze around the base of the affected finger.
  • Replace the nail in the original position as best as possible. Use Dermabond or other skin adhesive to secure the nail in place directly over your applied nail bed sutures. The use of nondissolvable sutures through the nail and into the skin is a practice that is no longer needed. (See video.)
  • The nail not only is the best and most effective barrier over the injury but also allows the new nail to grow out straight. It is important to maintain the opening of the cuticle for at least one week to avoid scarring and a deformed nail. You can pack open the cuticle with a piece of gauze if the nail is not available. Other providers have used cut-out pieces of the suture packaging. The packaging is cut in the shape of the missing nail and inserted into the cuticle. This topic has not been researched thoroughly but may be of use in your practice. Providers may also use a folded piece of Steri-Strip as a fake nail to keep the cuticle open. Just make sure it is folded flat, and no sticky portions are open.
  • Speaking of Steri-Strips, use these to secure the nail if you think the adhesive needs added protection.
  • Dress the wound with a nonadherent dressing. Show parents how to care for the wound. It should be redressed twice a day.
  • Follow up with hand specialist in three to seven days.
  • Discuss tetanus, immunizations, and antibiotics with parents if there is an open fracture.

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

Next month, we will discuss antibiotics for open finger fractures (such as tuft fractures) and the use of Dermabond vs. suturing for nail bed lacerations. Then we will touch upon referrals and additional treatments for hand injury patients.