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.

Friday, December 1, 2017

​What do you do when something weird and wild comes into your emergency department? This month, we mean lacerations over tattoos or body piercings. Cosmetic repair of injuries involving tattoos and piercings are important to our patients. We should ensure proper wound closure while preserving the underlying body art.


Tattoos and piercings are ancient practices of body modification. This form of art appreciation continues to be a popular and important cosmetic alteration for many people. Body art ranges from ear piercings ($20-30 for earlobes) to extensive tattoos that cost thousands of dollars.

Many have sentimental value and special meaning to patients, and a laceration disrupting them can be upsetting for them. Scarring left behind from improper closure can cause the formation of keloids and discoloration on tattooed skin. Lacerations involving piercings, especially the ear and belly button, can cause severe skin stretching that needs plastic surgery repair if not closed appropriately.

The Approach

-Laceration repair of tattooed skin

-Combination of simple interrupted, mattress, and deep sutures

-Proper bandaging, wound care, and follow-up instructions

Watch a video of Ms. Roberts repairing a tattoo laceration with deep and simple interrupted sutures. Dissolvable sutures were applied on top of completed superficial sutures​.

The Pause

It is important to consider tattoo cosmetics during repair, but no skin art should take precedence over proper skin closure of an injured site. If the skin is mutilated or extensive skin surface is destroyed, closure and repair to control bleeding and promote healing are paramount and should be prioritized.

The Procedure

-Assure the patient that repair of the tattoo is a priority and that you will do your best to make it similar to the original. Be sure to remind them that there may be some scarring.

-Search for the right equipment, such as dissolvable and deep sutures, before starting your repair.

-Obtain a thread one size smaller than usual for skin repair involving tattoos. For example, if you are using 4.0 for a tattoo to the wrist or hand, consider using a 5.0 thread. This will aid in fewer scars and prevent skin complications during healing.

-Thread color may also be taken into consideration. For dark tattoos (such as ones with all black ink), consider contrasting thread color such as Prolene. This may be especially helpful for lining up the artwork during repair and for suture removal in the days to come.

-Clean the wound. Tattooed skin should be cleaned thoroughly to remove foreign bodies, dirt, or anything else that may cause an infection, which will worsen cosmetic outcomes, especially cellulitis or keloid formation.

-If the tattoo is on the hand, finger, or face, consider digital or nerve block. This will result in less swelling at the actual site, allowing for better approximation of the wound.

-During the repair, start in the center of the wound and work your way outward. If the skin is brought together corners first, it may misalign the tattoo or artwork.

-Consider using deep absorbable sutures in areas of tension and for deeper lacerations. Avoid deep sutures in the hand because they can cause increased risk of infection.

-Close areas of skin with tattoos with a mix of simple interrupted and mattress sutures depending on the depth and skin tension of the wound. This may take extra time and appreciation, but it will yield better cosmetic results.

-Approximate lettering (and other artwork) carefully, and use slight tenting of the skin during suture application to assist with wound healing.

-After you have completed the closure of certain areas of the tattooed skin, consider the double suture closure technique with dissolvable sutures. This is completed first by closing the wound completely with simple or interrupted sutures. After the skin is closed, the provider may complete additional dissolvable sutures on top of underlying sutures.

-Use splints to assist with wound healing.


-Do not be afraid to consult plastic surgery on difficult cases. These patients take pride in the cosmetic appearance of their art.

-Do not underestimate the healing power of dissolvable sutures for extremities.

-Avoid deep sutures in the hand.

-Consider prophylactic antibiotic use for patients with HIV or hepatitis if laceration is extensive or complicated. Otherwise, prophylactic antibiotics are not indicated.

-Do not use bacitracin or triple antibiotic cream for more than 24 hours on the wound. This can cause excessive moisture and poor healing, especially for tattoos involving red ink.

Tips of the Month: Smoking and Wound Healing

Did you know that smokers heal up to 50 percent slower than nonsmokers? All skin requires tissue oxygen, cell migration to wound sites, bacterial defense, and collagen synthesis to heal. (Br J Dermatol 2010;163[2]:257.) Anything that causes tissue hypoxia, such as smoking, can delay wound healing. (Arch Surg 1991;126[9]:1131.) Cigarettes also contain more than 4,000 toxic compounds that are generally unhealthy for the human body. Nicotine, carbon monoxide, and hydrogen cyanide are the most dangerous chemicals in cigarettes that disrupt healing in the body and cause chronic inflammation.

If your patient has a wound (tattoo or not), consider discussing smoking cessation with her. If she does have a tattoo and is a smoker, mention that the tattoo will not heal well or quickly if she continues to smoke.

Smoking cessation discussions during discharge are also a billable CPT code. In 2014, the Affordable Care Act began requiring insurance plans to cover many clinical preventive services. This includes tobacco use screening for all adults and adolescents, tobacco cessation counseling for tobacco users, and expanded counseling for pregnant women. ( Finally, the CPT codes used are time-based (greater than three minutes to 10 minutes [99406] and greater than 10 minutes [99407]). You must document the time spent counseling.

Keep in mind that ICD codes may vary based on presentation. CPT codes should be documented based on whether the patient is symptomatic or asymptomatic. If a patient is visiting your care area for a simple laceration and has no complaints related to smoking, be sure to follow appropriate CPT and ICD coding. But if the patient has a cough or other issues related to smoking and you provide cessation counseling, you may bill for symptomatic counseling.​

Wednesday, November 1, 2017

Welcome back to the weird and wild, "what do I do with that?" series! We want to take you back to the magical land of abscesses. This scalp abscess case study and Procedural Pause pearl will help you relieve significant pain and decrease the risk for skin infections and complications. This case made it to our weird and wild list for being rare and interesting.

Scalp abscesses and kerions can be tricky and complicated. At first glance, they can appear small and harmless. They are often underappreciated for this reason, but require immediate attention. There are several types of wound infections and rashes that occur on the scalp, including tinea capitus. Regardless of the underlying process or irritation, scalp abscesses must be drained and deloculated. Incision and drainage remains "an essential part of the treatment of bacterial abscesses," but "scalp abscesses are extremely rare unless there is immune deficiency or penetrating trauma and are usually associated with severe pain and constitutional upset," according to Nandwani, et al. (J Infect 1995;31[1]:79.)​

The scalp leaves very little room for swelling. When an abscess forms, it may cause significant pain and a lengthy abscess. These abscesses can form pockets across the scalp with varying levels of size, shape, and capsule size.

Posterior scalp laceration in a 29-year-old man with underlying seborrhea. The abscess has spread lengthwise and has caused mild hair loss to the area. Photo by Martha Roberts.

This particular fungal scalp abscess caused the patient significant pain and hair loss. Tinea capitus may also cause hair loss, and must be treated with appropriate referral to dermatology. Otherwise, kerion formation may become large and uncontrollable.

The Approach

Abscess incision and drainage

The Procedure

-Assess the area, and place the patient in a comfortable position.

-Have a second person ensure adequate airway if the patient is prone.

-Anesthetize the scalp with lidocaine and epinephrine to minimize bleeding.

-Use a small needle, such as a 27½ gauge, to inject the area. Multiple injections to encircle the abscess may be required.

-Do not use more than 1-2 mLs of anesthesia per 1-2 cm area of space. There is very little space in the scalp for the fluid to be distributed.

-The capsule is easier to remove in scalp abscesses because it is such a superficial entity. Be sure to remove if possible. It is often visualized with good lighting.

-Irrigate the area gently but copiously.

-Take note that Betadine cleansing liquid may be used to clean the skin. Injections of even half-diluted solution of Betadine and normal saline into the scalp may cause additional hair loss and irritation to the hair follicles. Be sure to use a very dilute solution if using Betadine.


-Know what you are dealing with: Is it a kerion caused by tinea capitus?

-Use a Wood's lamp to examine the scalp and complete a special fungal culture (termed a mycological hair culture). Check with the lab to get the correct order.

-Do not close the abscess with sutures.

-Do not pack the abscess.

-Have the patient follow up in 24-48 hours for a wound check.

-Do not wait for the abscess cavity to heal before starting treatment for tinea capitus.

-Check the culture upon follow-up.

-Do not use a heavy amount of bacitracin because this will keep the scalp too moist and prevent quick healing. It is also not the treatment for tinea capitus.

-Tell the patient to avoid wearing hats for two weeks.

-Antibiotics for bacterial infections are rarely indicated unless additional cellulitis or a larger infection is present.

-Check for underlying lymphadenopathy and fever. Consider underlying immunocompromised disorders.

-Always ask about prior treatment.

Evidence-Based Practice Pearl: Tinea Capitus and Kerions

Regular skin abscesses should not be confused with kerions, which are managed differently. These boggy lesions occur on the scalp, and are caused by tinea capitus. This is the same organism that causes "ringworm." They are often present in children. Large kerions need to be drained under general anesthesia and managed by dermatology.

Currently, there is only one accepted treatment for tinea capitus, regardless of abscess formation. Abscesses that are related to kerions may be drained, but also need additional treatment by oral griseofulvin. Topical antifungals may also be used as well as a short course of oral steroids for severe inflammation. (BMJ 2000;320[7236]:696.) Be sure to complete a full ENT exam and to check for swollen lymph nodes and fever, which may mandate admission. Large kerions should be followed up with a dermatologist. You should start oral treatments for tinea capitus in the emergency department.​

Large kerions should be left alone and referred to dermatology. They often may reappear in a few months, and can be very troublesome for the patient. The 2000 British Medical Journal study above reviewed an ED case of an 11-year-old Caucasian boy with a kerion. The kerion was drained, and the patient received oral griseofulvin (15 mg/kg), flucloxacillin (500 mg four times a day), daily ketoconazole shampoo, and terbinafine cream (twice a day). The child had a full recovery, but it took three months. It is important to realize these abscesses may reaccumulate despite best treatments, even when followed by a dermatological team.

A large kerion on the scalp of a child. This kerion should be left alone and not drained in the emergency department. Instead, refer to dermatology. Credit: Grook Da Oger/Wikimedia Commons.

That paper also reported another case of a 10-year-old Asian boy with a month-long history of kerion who needed dermatological expertise due to its size and severity. Larger kerions with lymphadenopathy, significant swelling, fever, and failed prior treatments are not appropriate for drainage in the emergency department.

Tip of the Month

Consider creating an abscess checklist for your department. We really liked this one created by the medical students at Mount Sinai School of Medicine in 2012:

Watch a video showing Ms. Roberts draining a scalp abscess.​

​ PP-scalp video photo.jpg

Monday, October 2, 2017

​Emergency department providers welcome the weird, the wild, the wonderful, and the unexpected. Routine chest pain workups and negative abdominal CTs occasionally bore us. Last summer we had the pleasure of meeting a man who was a line cook at a local restaurant. He came via ambulance for a foreign body in his foot. What we saw was unanticipated—he arrived with half a wine glass lodged in the sole of his foot.​


The stemware was lodged in the patient's foot, going through his shoe and sock. Photos by Martha Roberts.

The patient was laughing and not in much pain. He said he had a high pain tolerance and could barely feel the glass at this point. The question remained: How do we remove this thing? Do we x-ray it first? Do we attempt to dislodge it in any way or secure it so it doesn't come out and then contact our surgical team? Because we could not see how far the glass went into the foot, we had no idea if it could potentially have passed through an artery or a bone. So we decided to x-ray it. Luckily, the patient was wearing slip-on plastic shoes that allowed us to image his foot without blocking much of our view.

When the films came back, we were relieved to see the glass had only partially penetrated the sole of his foot. We gently removed the shoe with the glass in place and quickly applied pressure to the area. We sent him back for repeat films after copiously irrigating the area and elevating it.

The Procedure

Known/unknown foreign body removal of the extremity.​

The Approach

-Approach the patient cautiously.

-Do not remove the object until baseline imaging has been obtained if bone, joint, or other injury is suspected. Secure object with tape, braces, or splints if needed to avoid unnecessary movement of the object, which can cause pain or excessive bleeding.

-If baseline imaging cannot be obtained prior to removal of the object, remove as much distracting clothing, devices, or small pieces of the foreign body (i.e. glass or wood) as possible.

-If it is possible to inject local areas with a numbing medication such as lidocaine or the longer-acting bupivacaine, complete injections prior to imaging or repositioning of the object.

-Prepare for complete removal of the object once imaging is obtained and you are able to judge the extent of the injury.

-Stabilize the affected area and gently remove the item. Avoid significant manipulation of the area.

-Apply immediate pressure to sites that are bleeding. If glass is embedded in the injury, use a soapy pressure flush of tap water during extraction to assist with the removal of debris and foreign objects.

-Copiously clean the area with additional soapy normal saline jet lavage to flush out any other foreign bodies as needed.

-Re-image the area (especially if glass shards or other radiopaque items are present) and bandage appropriately.

-Apply sutures to any sites that need repair.

-If fractures are present, splint the injury after your assessment, irrigation, and re-imaging have been completed.

-If foot or sole injuries are involved and sutures or retained foreign body is present, make them non-weight bearing for the entirety of healing.

-Update tetanus shot prior to discharge. 

Puncture wound caused by a wine glass in the foot. Irrigate, clean, close with loose sutures, and splint with non-weight bearing activities and crutches for 12-14 days. Photo by Martha Roberts.


-Unlike impalement injuries or foreign bodies to the face, neck, torso, and abdomen, foreign bodies in the extremities can usually be removed without surgical intervention. Detach the object if it is at all easy to remove without initially imaging the extremity.

-Puncture wounds should be closed cautiously and loosely to avoid infection. Provide proper antibiotic therapy for those at higher risk of infection, i.e., immunocompromised.

-Do not soak wounds in Betadine. This may cause necrosis and deterioration of tissues.

To Treat or Not to Treat

Puncture wounds rarely need antibiotic prophylaxis. It is OK to send patients home without antibiotic therapy if wounds are washed out and a retained foreign body is unlikely. You should consider the possibility of retained foreign body in patients with infected wounds and known puncture injuries. These patients should then be treated with appropriate antibiotic therapy. Consider Pseudomonas infections in patients with diabetes or those who are immunocompromised.

A retained foreign body is an issue with puncture wounds. One study found 15 percent of patients injured by broken glass have retained glass. (Am J Emerg Med 1998;16[7]:627.) Consult your surgical team if a retained foreign body has caused an abscess or concern for bacterial infection. Abscesses must be drained, and the retained object must be removed.

Tetanus prophylaxis is "necessary if there is no knowledge or documentation of tetanus immunization within 10 years, including tetanus immune globulin for the person with a dirty wound whose history of tetanus toxoid doses is unknown or incomplete." (Am Fam Physician 2007;76[5]:683.)

Puncture wounds and foreign bodies in the skin may first seem like minor injuries, but can cause big problems. Wounds with neglected foreign bodies are a common cause of malpractice claims. (Med Law 2004;23[3]:495.) Be thorough and irrigate one more time. And use tap water! Remember that tap water cleanses are considered level A evidence (consistent, good-quality, patient-oriented evidence), and may be used to clean wounds safely and effectively. (Am Fam Physician 2007;76[5]:683.)​

Friday, September 1, 2017

We use splints to help immobilize and stabilize injuries, but it's important to realize splinting also alleviates pain and edema and promotes healing until follow-up. If you are ever concerned that there is a fracture (even if it's not apparent on radiograph, i.e., navicular fractures), splint your patient before discharge. If you have the luxury of orthopedic consult in-house, talk to him before discharge.

Indications for Short Posterior Splint

-Fractures of the distal tibia and/or fibula

-Ankle dislocations

-Severe sprains

-Fractures of the talus

-Fractures of the calcaneus

-Foot fractures such as fractures of the fifth metatarsal

-Fractures of the cuboid, navicular, or cuneiform

Indications for Long Posterior Splint

-If you are discharging a patient, the only true indication for long leg posterior splints is for acute knee injuries and quadriceps tendon rupture. If a femur fracture or hip fracture is the concern, patients should be admitted for further workup and treatment by the orthopedic team in-house or by transfer.

-Temporary application of long posterior leg splinting can be used for distal femur fracture, proximal tibia/fibula fracture, or dislocations of the knee until the patent gets further evaluation from the orthopedic team.

-Associated tibial plateau fractures and patellar fractures

-If you are splinting for a knee injury, keep in mind the knee should be kept at 5-degree flexion and the foot in slight plantar flexion.

Other Indications

-Cellulitis (allows area to heal without movement, decreases pain)

-Deep lacerations across knee or ankle joints (reduces tension, prevents wound dehiscence)

-Tenosynovitis, strains, and sprains (prevents movement, decreases inflammation)

-Areas that are too large for knee or ankle immobilizers (i.e., Velcro knee sleeves or Aircasts)

All leg splints require close follow-up, potential casting, and repeat imaging. The patient must be referred to an orthopedic clinic within the next week and instructed on splint care, including neurovascular status checks. Patients discharged with a long leg posterior splint should be seen again the next day or within 72 hours.

Contraindications of Short and Long Posterior Leg Splints

-Neurovascular compromise

-Neuropathies originating from back injuries or diabetes

-Elderly patients

-Multiple trauma

-Open fractures

ACE vs. Knee Immobilizer vs. Splint

Knee injuries are extremely common in the emergency department. It may be difficult to tell which orthoses are appropriate for which patients. Typically, minor to moderate knee injuries do not require much intervention or surgery, and often heal in two to three weeks. Patients may need to avoid bearing weight, depending on the amount of laxity present in the extremity. It is virtually impossible to get a stat MRI for a knee injury in most EDs, so it is recommended that splinting and non-weight-bearing be completed prior to discharge. Quadriceps and patellar tendon ruptures must be completely immobilized and non-weight-bearing with an indication for immediate follow-up.

How do we know which splint is appropriate? Often patient comfort is the major determining factor. Elderly patients and those prone to DVT with clotting disorders or immobility should be splinted in the least invasive way. Splints should remain on during showers and kept covered. If a patient has a strain or sprain, the splint can be removed if the knee is kept in a neutral position. Far superior to ACE wraps and long leg posterior splints are padded Velcro knee immobilizers, which allow for easy reapplication.

The literature does not provide thorough evidence on whether ACE wraps or knee immobilizers are superior. The bottom line is ACE bandages provide minimal support of the knee. If you really want to achieve immobility, you must apply a long posterior splint or knee immobilizer that goes above and below the knee. The literature also says strains and sprain of the ankle do not benefit from immobilization and the splints are applied primarily for comfort.

Jim weighs in: Long leg posterior splints are bulky and uncomfortable for your patient. If your department does not stock Velcro knee immobilizers, consider investing in this commodity. Velcro splints are much better devices, and can be removed and reapplied by the patient. Lobby to get them in stock!

When in doubt, have an open and frank conversation with your patients about their at-home needs, and admit patients who simply cannot walk or care for themselves in their home.

Watch a lower leg splint being applied in this video.​​

Tuesday, August 1, 2017

Tennis elbow, also known as lateral epicondylitis, is a painful and persistent problem that can be transient or chronic. The syndrome is caused by overuse of the elbow, although not always caused by one too many games of tennis.​

Lateral epicondylitis is an inflammation of the tendons that join the forearm muscles to the outside of the elbow. Overused and abused tendons can be damaged or even destroyed. Performing the same repetitive motions over and over again can irritate and annoy the tendons, resulting in severe pain, tenderness, and even inability to use the affected extremity.

Many treatments are available for lateral epicondylitis, but steroid injections are the gold standard for chronic pain. Supportive treatments such as NSAIDs, RICE, heat, and physical therapy can also tackle the issue. Steroid injections with a long-acting corticosteroid (such as methylprednisolone) combined with 1-2% lidocaine can ease symptoms in two to four days, and can be completed in the emergency department.

PP steroids tennis elbow.jpg

Dr. James Roberts pointing at where the steroid injection is going to be placed.


Patients often complain of gradual, slowly increasing pain over their elbow and lateral forearm. They say it has been going on for about a month, but got worse over the past week. Usually no specific injury or insult occurred, but patients feel pain and burning on the outer part of the elbow. The pain has generally gotten so bad that it causes weakness in the grip strength of the hand. Occasionally, patients will say they have trouble shaking hands, and you can test this by extending your hand in introduction when you walk into the room. Patients often find it difficult to grab things off the shelf like a book or a plate in the cabinet.

Steroid Injections

Multiple trials and systematic reviews have found that steroid injection improves many short-term (six- to seven-week) outcome measures, but does not prevent recurrence. (Int J Clin Pract 2007;61[2]:240; Pain 2002;96[1-2]:23.) Steroid injection is reasonable for the quick treatment of severe symptoms and pain in the emergency department. The importance of physical therapy should be stressed, and the patient should follow up with an orthopedist. Splints should be encouraged. (J Orthop Sports Phys Ther 2009;39[6]:484.)

Patients should be instructed not to have repeat injections over a short period of time to avoid damaging the radial nerve. Some studies have shown that injections may lead to higher rates of pain recurrence. Patients who used the counterforce or sleeve splint had fewer repeat episodes of pain than the injection group. (Arch Phys Med Rehabil 2005;86[6]:1081.) It did, however, take longer to achieve the first pain-free period when splinting alone was used.

Another study of steroid injection involved an effective peppering technique where the painful tendon is injected approximately 40 to 50 times (as seen in our video). (Clin Orthop Relat Res 2002;398[5]:127.) The 120 patients in this study were randomly assigned to receive injections of 1 mL of triamcinolone, plus 1-2 mLs of lidocaine. Most patients "had excellent results at one year regardless of the medication or dose," suggesting that the technique played an important role.


What about splinting? Are we sending our first-time offenders or even repeat offenders home with a splint? Does it help? The effectiveness of orthoses or splints has been reported as positive, but comparisons of effectiveness among the many different types of orthoses are limited. Many providers (ED and ortho alike) have handed out counterforce braces (see image below) for lateral epicondylitis. They may provide benefit in the first six weeks post-injury, and may prevent recurrence. (Arch Phys Med Rehabil 2005;86[6]:1081.) These cuff-like braces are applied on the forearm about 6-10 cm distal to the elbow joint, and provide support to the elbow. They may even help remodel the muscles in the area, which can decrease pain and persistence.

A lateral counterforce brace, left, and a sleeve brace are used to treat tennis elbow.

Occasionally a full elbow sleeve brace can be used as an at-home splint. Regardless of what you use, studies show the counterforce brace and the sleeve result in an immediate increase in pain-free grip strength. No differences between the two orthoses were found, suggesting that either can be used. A wrist splint produces no immediate change in pain-free or maximum grip strength, indicating that it should not be used as a first-choice orthosis based on those outcome measures. (J Orthop Sports Phys Ther 2009;39[6]:484.)

A wrist splint is not as effective as counterforce and sleeve splints and is much more cumbersome.

Overall, 90 percent of your tennis elbow patients can be managed nonoperatively. (Am J Sports Med 2006;34[12]:1977.) The ED provider can provide fast and effective treatment for tennis elbow by giving an injection of steroids and lidocaine in-house and following up with an orthopedist in a week. A splint should be encouraged, specifically a counterforce or sleeve brace.

PP inject tennis elbow.jpg