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.

Wednesday, March 1, 2017

A Rare Intervention for an Unusual Exposure

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.)​