The Procedural Pause by James R. Roberts, MD,
& Martha Roberts, ACNP, PNP​

​Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, PNP, are the team behind The Procedural Pause.

The blog will focus on procedures that emergency physicians, 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.

This blog conveys personal opinions and experiences, and application of the information here remains the professional responsibility of the clinician. Tthis blog is not intended to dictate standard of care, but 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.

Please share your thoughts about the Roberts' posts.


Friday, August 31, 2018

Both-bone forearm fractures may make you feel a little nervous. A completely crooked forearm is definitely a disturbing sight. Both-bone forearm fractures (especially of the midshaft) typically require surgical intervention, but relocation of bony injuries, regardless of site or complexity, is an important and necessary skill you need to know. Plus, you will be required to assist with sedation, reduction, and splinting when the orthopedic team is involved.​

Correcting and stabilizing two bones (instead of one) may seem tricky, but we are going to help you do it right. This complex procedure should be done with orthopedic consultation whenever possible. If that isn't available and the patient requires transfer or faces a long wait, this is a good way to reduce and stabilize the injury.

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Creative Commons.

Why do we care about doing closed reductions for fractures if the really bad ones go to surgery anyway? And data suggest that minor pediatric bony injuries may not need reduction at all. (J Bone Joint Surg Am 2012;94[3]:246.) It's important to know why angulation, displacement, and degree of fracture may require quick reduction. Reduction allows patients to start healing faster, restores blood flow, and relieves pain. Avascular necrosis also can set in as early as six to eight hours post-injury in many long bone fractures, such as femur fractures. Reduction, even if closed is the only option, is key to avoiding long-term complications.

Both-bone fractures in pediatric patients require immediate closed reduction in the ED. Moderate sedation carries risks, but ketamine for sedation has been proven safe and effective during closed reduction. Reductions can be lengthy (bedside fluoroscopy, manipulation, splinting, etc.), and a longer acting agent with low respiratory compromise such as ketamine is a good choice. One study found that etomidate induces effective and adequate sedation in the pediatric emergency department for painful orthopedic procedures, but ketamine, which has longer action times, might be preferred for reductions because orthopedic procedures could be lengthy. No difference was seen in recovery time for these patients. (Pediatr Emerg Care 2016;32[12]:830.)

Ketamine is safe and cost-effective for treating displaced ulnar and radial fractures in pediatrics, with high parent satisfaction rates. (World J Orthop 2018;9[3]:50; You should adhere to your department's sedation policy and always use weight-dose ketamine for your patient. Premedicate patients with ondansetron before sedation; it significantly reduces vomiting associated with IV ketamine procedural sedation in children. (Ann Emerg Med 2008;52[1]:30.)

Ketamine has an onset of less than five minutes when administered IV or IM, with recovery averaging between 45 and 120 minutes. An intravenous dose of 1-1.5 mg/kg or an IM dose of 2-4 mg/kg will put the patient into a trance-like state with dissociative features. (Saudi J Anaesth 2011;5(4):395; These are very conservative doses, and sometimes more is required. You may increase the dosage depending on your experience with the drug and the patient's weight, response, and level of sedation.

The Approach

  • Closed reduction of both-bone forearm fractures in a pediatric patient using manual manipulation
  • Ketamine-induced moderate sedation and recovery
  • Application of reverse sugar-tong splint

The Pause

Consider using a sedation checklist before, during, and after administering sedatives. This list includes reminders such as checking Mallampati scores, setting up specific equipment, medication-dosing guidelines, and signed consent.

The Procedure

  • Obtain all materials, including splinting items, medication, the airway cart, and other tools for sedation.
  • Make sure your signed consent is completed.
  • Complete a time out and tell the parents what you will do.
  • Start your sedation. Await three to five minutes for the ketamine to work.
  • Check your patient's sedation by carefully examining his eyes. He should have short, rapid beats and appear sedated.
  • You may see a rise in heart rate or blood pressure around the three- to five-minute mark.
  • The child may still be talking during your procedure, but it most likely will be unintelligible.
  • This next part will require two people and two sets of hands. Have both providers wrap their fingers under the forearm on the volar surface and stabilize your thumbs on the dorsal side over the injury. Apply firm, deep pressure using your thumbs on the forearm. Push using equal pressure on the ulnar and radius. Massage the bones into place. You may hear a click or pop and feel the bones come together.
  • Use bedside fluoroscopy to ensure proper reduction. You may also send the patient for formal x-rays post-splint application.
  • Splint the patient with a reverse sugar-tong splint using a distal-to-proximal wrapping technique with the ACE wrap. Be sure to keep the hand in slight flexion during the splint application.
  • Check the neurovascular status of the extremity.
  • Complete the sedation and recovery while monitoring for any abnormal events.
  • PO challenge all patients prior to discharge and ensure voiding occurs with witnessed ambulation to the bathroom. Document this in your chart.​


  • Watch for the common side effects of ketamine: psychological reactions, agitation, confusion, hallucinations, elevated blood pressure, tachycardia, tremors, laryngeal spasms, and vomiting.
  • The effect of ketamine on respiratory and circulatory systems is unique. It will usually stimulate rather than depress the circulatory system.
  • Ketamine can cause apnea, especially in higher doses, when combined with other sedative/analgesic agents or in critically ill patients.
  • There is an associated increased risk of adverse respiratory events with ketamine use in children under 3 months. This is "attributable to differences in airway anatomy and laryngeal excitability" seen in this age group, and "ketamine use for procedural sedation is relatively contraindicated in children less than 3 months of age and should be used with additional caution in children 3-12 months of age." (Saudi J Anaesth 2011;5(4):395;
  • Multiple studies have shown that using ketamine and propofol together for sedation is not necessary and heightens the risk of adverse events.

Photo Tip: Jim says check the edges of your fiberglass splinting material prior to application. Fold the edges into the padding to prevent any jagged edges.

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Pro Tip: We recently treated a child who broke both bones of his right arm and then broke both bones of his left arm three weeks later. That might raise your suspicion for child abuse, but also consider osteogenesis imperfecta. This rare genetic disease with dozens of subtypes and classifications may be seen in children. Look for a blue-colored sclera, short stature, loose joints, hearing loss, and severe dental disease.​

Monday, July 2, 2018

Some wrist fractures are straightforward, but some can be problematic. Your approach should always be a step-by-step process that progresses to more advanced aspects of a procedure such as hematoma blocks for wrist fractures.

Hematoma blocks can save the day in a busy ED and ease pain and set you up for a successful reduction. They may also negate the need for sedation, and are safe for adults and pediatric patients. Even if you must sedate a patient, hematoma blocks assist with pain control.

Hematoma blocks of the wrist utilize the fundamental process of nerve paralysis. Anesthetizing the nerves around an injury or fracture allows for successful manipulation of the bones. Displaced or angulated fractures often cause the blood to pool around the broken bones, forming a hematoma. The key is to locate the fracture and inject the needed anesthesia directly into that area.

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​Colles fracture. Photo by Martha Roberts.

The literature is clear when it comes to pain control and improved outcomes for hematoma blocks. We always worry that elderly patients will have a bad outcome, and they specifically benefit from choosing a hematoma block over sedation or surgery whenever possible. It is generally preferred to complete a hematoma block with immediate reduction for elderly patients in the emergency department.

A study of distal radius fractures in patients over 60 found that duration of manipulation, need for surgery, and discharge time were significantly lower in hematoma-blocked patients. (Anesth Pain Med 2016;7[1]:e40619.) This study found a "statistically significant difference during initial hours after fracture reduction and fixation so that pain intensity was less in elderly patients under hematoma block than patients who underwent general anesthesia in one and six hours after surgery." Most importantly, patients in the hematoma block group required less narcotic pain medication compared with the general surgery population.

Experienced providers often know exactly where to inject anesthesia for hematoma blocks. Ultrasound-guided injection techniques, however, prove to be more accurate. Using ultrasound to identify the hematoma and fracture before and during injection will improve technique when landmark localization is difficult. (J Emerg Med 2015;48[3]:310.).​

Hematoma blocks also work very well for wrist fractures in children. Not only do hematoma blocks provide adequate pain control, they also increase patient satisfaction and decrease length of stay and need for resources in the emergency department compared with the use of moderate or deep sedation. (J Hand Surg Am 2015;40[1]:57.)

​The Procedure
Hematoma block of the wrist for wrist fracture using a lidocaine injection.

The Approach

  • Review radiographs and locate the wrist fracture. Mark the area you plan to inject with a pen.
  • Have the patient supine on the stretcher. Dissuade the patient from watching you complete the setup and injection.
  • Wash the skin well with soap and water to remove any excess blood or debris.
  • Obtain cleaning solution such as alcohol, chlorhexidine, or Betadine, and clean the injection site.
  • Draw up 10 mL of 1% or 2% plain lidocaine into a 10mL syringe using an 18g needle.
  • Change the needle to one with a smaller gauge for injection (22-27g).
  • Begin by infiltrating a small wheel above the fracture site on the dorsal aspect of the wrist. Insert the needle at a 90- to 120-degree angle and slowly progress down to the hematoma, aspirating back until you see blood return to the syringe.
  • Advance the needle into the hematoma just a tiny bit further. Inject lidocaine into the hematoma and around the adjacent periosteum.
  • You may feel the needle drop into the space easily.
  • Remember to inject the lidocaine slowly. Fill the space with about 8-10 mL of lidocaine, and apply pressure to control any bleeding to the site.
  • No need to use an 18-gauge needle for this, and you should warn the patient that it will burn and that he will feel a lot of pressure. It is OK to take breaks during the injection and reassure the patient, instead of quickly injecting and unloading the lidocaine into the hematoma.

The Pause
Wait 15 minutes before manipulating the wrist to allow adequate anesthesia to take effect.​

wrist fracture.jpg
Watch a video showing a hematoma block for this wrist fracture that was reduced and splinted​. Photo by Martha Roberts.


  • Do not do a hematoma block for open fractures. These usually go to the operating room and need a washout.
  • Do not inject more than 10-15 mL of lidocaine into the fracture site. If you have used 15 mL of 2% lidocaine, that is 300 mg of lidocaine! You must consider toxicity, and don't forget about compartment syndrome with large amounts of fluid in this small space.
  • Do not repeat injections into the joint space.
  • Do not inject into the volar surface of the wrist.

Q & A with James R. Roberts, MD: Tips and Tricks about Hematoma Blocks

Q: What if the patient has a metal rod or partial prosthesis?

A: Avoid hematoma block for this patient, and consult an orthopedist because the risk for infection or complication is high.​

Q: What is the risk for infection from the injection?

A: Risk for infection is extremely low, and will not complicate this procedure.


Q: What if the patient has a history of carpal tunnel?

A: No big deal; it doesn't matter. Go ahead with the block.


Q: What if the patient is a diabetic or immunocompromised? Does he need antibiotics?

A: Probably not.


Q: What if the patient still has pain and is not anesthetized?

A: Give him an intravenous opioid like hydromorphone or morphine. Make sure you've waited a full 15 minutes or even 20. Don't be impatient.


Q: What if the patient is on anticoagulants?

A: It shouldn't really matter for the wrist or a hematoma block. Give strict return precautions.


Q: What if the patient has distal radius and ulnar fractures? Do I do two blocks?

A: Don't do two blocks! Generally, only one hematoma formed, and one block is enough.


Q: Can you do a hematoma block in a forearm fracture?

A: Sure, why not? Give it a try, and let us know how it goes.

Friday, June 1, 2018

What do you do for a nail from a nail gun in the hand? This procedure is simple, but you have to worry about the aftermath. Complicated issues may arise post-procedure in the days to weeks after extraction, including retained foreign bodies, infection, fractures, disability, pain, nerve damage, tendon rupture, and cosmetic concerns.

Removing the nail is only half the battle. Proper removal, treatment, and follow-up should be considered with all foreign bodies in the skin, especially the hand. Being prepared for the possible aftershocks will help your patient have a successful recovery.

Approximately 25,000 work‐related and consumer nail gun injuries are treated in the ED each year, according to The American Journal of Industrial Medicine. (2015;58[8]:880.) Patients with nail gun injuries will arrive at the ED with their hands raised in the air because any movement usually causes significant pain and immobilizing the area above the heart provides temporary relief. The nail should be removed as soon as possible if there is significant bleeding so that pressure can be applied, especially if a large vessel or artery is involved. You may consider immediately injecting the area around the nail with 1% lidocaine with epinephrine to help control the bleeding and pain.

The hand and fingers have thousands of nerve innervations, which are extremely sensitive. We suggest oral or IM analgesia, or even IV opioids, to relieve pain and anxiety. Getting pain medication on board early will not only make your patients feel better, it will also relax them for the procedure to come next. Do not be stingy when treating pain related to hand injuries.​

Once you have stabilized the hand, obtain x-rays to determine the extent of the injury, course and structure of the nail, and any radiopaque foreign bodies. Nails can penetrate bone and tendon or be lodged in soft tissue. Keep in mind that some nails are held together in a pack with small pieces of metal or glue that can remain in the skin after removal, making post-procedure imaging paramount.

Nails from a nail gun clip are held together with metal or glue that can be left inside a wound. Photo courtesy of Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care.

Be sure the area around the entry site is anesthetized. Distract the patient during the removal, and apply countertraction to the finger while attempting to keep the wrist and arm still. Pull the nail out of the hand or finger the same way it went in whenever possible, and don't push the nail through the hand in the direction of penetration. This will increase the chance of leaving behind rust, dirt, or debris and create unnecessary trauma. The nail head is always larger than the pointed portion, and could increase the size of the hole or cavity if pushed through.

Consider a more thorough cleaning if the nail is large and has left a significant path of destruction. Explore the entrance wound carefully, and remove any obvious foreign material. The literature is mixed when it comes to coring, carving, irrigating, and gauze clean-out. You may jet-irrigate puncture wounds that go through and through with a pressure-washing device or high-pressure tap water from the sink.​

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Jet lavage of the affected area.​

Never insert a catheter into a puncture wound that does not go through and through. This will push debris and foreign bodies deeper into the tissue. You may consider passing a strip of gauze through the injury once or twice in the direction of initial penetration. Simply pass a small hemostat through the puncture tract, grab the gauze (suggested: ¼-inch packing gauze), and pull the gauze through the puncture tract. Do not rock the gauze back and forth through the wound like dental floss. Always irrigate copiously. The primary cause of infection post-procedure is retained foreign body.

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Pass a small hemostat through the puncture wound and pull the gauze through. Photo courtesy of Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care.​

The literature is somewhat mixed about prophylactic oral antibiotics preventing infection. Many hand specialists will advise giving an IV dose of cefazolin 1 g or clindamycin 600-900 mg and updating the tetanus shot. Also place the patient on something to cover staph or strep, such as oral cephalexin, amoxicillin/clavulanate, or clindamycin. Discuss the case with your specialist. It appears that simple ED removal of the nail with local debridement and a short course of antibiotics are appropriate in most cases. Operative debridement may be necessary for intra-articular or neurovascular involvement or if the wound cannot be properly irrigated or cleaned, depending on the consultant's opinion. (Injury 2008;39[3]:357.) Occasionally, an immediate or next-day operating room wash-out by orthopedics or a hand specialist is suggested if the damage is severe or the wound is very dirty.

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Nail removed from a hand.

The Approach

Removal of a nail from the hand or finger.

The Pause

Ninety percent of puncture wounds do well, about 10 percent get gram-positive infections, and about one percent are disasters with osteomyelitis or retained foreign material. Involve the consultant when in doubt.

The Procedure

-Position the patient on a stretcher so he is comfortable.

-Premedicate the patient with analgesia.

-Consider IV access, depending on the extent of injury for potential medication administration (antibiotics, analgesics). Update the tetanus shot as needed.

-Clean the injection site with Betadine or alcohol wipes; do not soak the hand or finger.

-Anesthetize the area around the puncture site using 1% lidocaine. You may use lidocaine with epinephrine for extensive bleeding. Digital blocks may also be effective.

-Image using x-ray (several views) before and after nail removal.

-Use a hemostat to grab and remove the nail in one solid motion. Try not to wiggle the nail in the space. Do not push the nail through the skin.

-Copiously irrigate the area using jet lavage or high-pressure tap water flow.

-Consider pulling a piece of gauze through the area to remove leftover debris.


-Consider oral antibiotic choice. Oral antibiotics are a reasonable idea, but are not fully supported in the literature. Cephalexin or amoxicillin/clavulanate are good choices. PCN allergic? First, determine if the patient has a true allergy, and consider clindamycin if so.

-Typically, a retained foreign body is the cause of infection.

-Consider at-home pain control.

-Splint the area if indicated for comfort or fracture.

-Consider OR washout if the wound is very dirty or complicated.

-Tendon injury or rupture is possible. Be sure to check the patient's strength and mobility after foreign body removal.

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Monday, April 2, 2018

Compartment syndrome made it on our weird and wild list not only because it is uncommon but also because it is difficult to identify. It presents in strange ways, and is often missed the first time a patient seeks care. This rare but serious condition may result in permanent contractures or even loss of a limb. Complications from compartment syndrome escalate quickly if they're not treated promptly. Early recognition and treatment of this problem is imperative.

The increased pressure in the space around certain muscles that creates compartment syndrome can be caused by fractures, bleeding, recent surgeries, burns, rhabdomyolysis, existing contractures, contusions, crush injuries, or even prolonged compression of an extremity (i.e., splint). You may be surprised to know that infection, vigorous exercise, or even steroids may cause compartment syndrome. Extremities are not the only area at risk; the buttocks and abdomen—or any compartment—may develop this syndrome. (J Trauma 1997;42[1]:118.) Any time a part of the body has increased pressure around a muscle, it may swell and cut off the blood supply, causing tissue ischemia and cell death.

Patients with bleeding disorders or those on anticoagulants, especially the elderly, should always be considered high-risk. One case report described a young high school athlete with minor trauma eight days before he presented to the ED with the inability to contract his thigh muscles at the site of injury and pain that was disproportionate to his initial injury. (JBJS Case Connect 2018. doi: 10.2106/JBJS.CC.17.00123.). He was found to have compartment syndrome with undiagnosed coagulopathy. Patients, especially children, with diagnosed or suspected compartment syndrome should also be investigated for underlying coagulopathies.

Recognizing compartment syndrome includes noting severe, unprecedented pain in a limb that typically increases or is worse than expected given the history and physical findings. The area may appear swollen or pale, and the patient may complain of numbness or experience a cooling sensation. The first step in treating compartment syndrome is to remove the offending agent (i.e., splint or constrictive device). Determining the severity of the issue may involve using a manometer to measure the pressures in the affected area itself.

The American Academy of Orthopaedic Surgeons said identifying the issue is the most difficult part. ( Nonsurgical treatment may be used if the injury is identified early. Conservative therapies such as physical therapy, orthotics, anti-inflammatory medications, rest, and elevation may occasionally help. Surgery is usually indicated if the injury is severe or missed. The surgeon has to open the fascia to relieve the pressure so the muscles have room to swell. This can lead to infection, extended time in the hospital, sepsis, organ failure, life-long compilations, and even death.

It is difficult to diagnose compartment syndrome at first glance because swollen limbs may be mistaken for a simple contusion, uncomplicated fracture, cellulitis, or joint effusion. Compartment syndrome should always be on your differential, and the compartments should be measured and an orthopedic consult obtained if you're uncertain.

The Procedure

-Measuring compartments accurately with a manometer

The Approach

-Suspicion or identification of compartment syndrome

-Knowledge of the appropriate compartment pressures

-Use of a manometer to obtain limb pressures

-Immediate orthopedic surgeon consultation or transfer to a higher level of care

-Consider CK, PT, INR, PTT, CBC, and CMP lab testing


-Measuring the compartments should be done with caution.

-Pediatric patients can present with disproportionate symptoms.

-Note child or elder abuse.

-Beware of underlying coagulopathies or anticoagulant medications.

-This procedure should be as sterile as possible.

-A consent form should be used before completing this procedure.

-All areas of puncture need to be cleaned before and after the procedure and dressed appropriately.

-Practice using the manometer is paramount before using on a patient.

-Seek expert opinion if you obtain normal pressures and the diagnosis of compartment syndrome is still considered.

Step-by-Step Guide for Using a Manometer

-Obtain consent from the patient for compartment pressure measurement.

-Prep the manometer, and make sure it is in the off position.

-Connect the 3 mL saline syringe to the pressure transducer and needle device.

-Evacuate all of the air from the system into the needle.

-Load the device into the manometer and secure it. Close the lid. Turn it on.

-Clean the affected area well with soap and water if possible and with a Betadine or chlorhexidine solution. Do not soak the area.

-Position the device at a 45° angle for insertion.

-Press the zero button on the manometer.

-Insert a needle into the muscle beneath the fascia.

-Inject less than 1 mL of the saline into the compartment.

-Record the measurement.

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Watch a video of Adam Cohen, MD, performing this procedure.​​

Step-by-step instructions are also available in Clinical Procedures in Emergency Medicine and Acute Care, 7th Edition. (Philadelphia: Elsevier; 2018.)

Wednesday, February 28, 2018

Each month, we try to bring you a case that is laced with unexpected care techniques. Our hope is that our procedural pearls help enhance your practice. Procedures rarely change over time, but new techniques and equipment may help you tackle new challenges. Once you have mastered simple procedures like incision and drainage and suturing and splinting, you can move on to more advanced procedures.​

This month we dare you to think outside the box and combine all your skills to help this weird and wild patient. We've said it before, and we'll say it again: It may not be an emergency, but it's an emergency to your patient.

A keloid removed from the hand of a 40-year-old Caucasian man. Photo by M. Roberts.

This 40-year-old man of Irish descent has light skin and scars easily. He cut his hand several weeks earlier and ignored the need for suturing, causing the skin to form a large keloid. The original injury was a deep laceration that took a long time to heal by secondary intention. The result was significant pain and a cosmetic cruelty. It is unlikely that he will ever follow up with a specialist, and that is where you come into play.

The hand is a complex combination of skin, muscle, tendon, ligament, nail, joint, and bone. The thin surface makes it prone to infection and scarring. There is a reason plastic surgery specialists spend many years studying and perfecting the art of hand repair.

This is why your attention to hand injury cases, wound care, and healing is crucial. Proper referral is required if the procedure is too complex or potentially dangerous.

If you have not yet mastered the art of simple procedures, this case may be best suited for a seasoned professional. The concept is fundamental, however, and executed correctly can make a big difference for your patient. The procedure doesn't take more than five or 10 minutes, and really doesn't strain your overall work flow.​

We hope after watching this video, basic principles will be enforced, and you will be able to execute the procedure without fail. Upcoming Procedural Pause blog posts will touch on cosmetic injuries and your role as an emergency provider. Not everything you touch may turn into gold, but your patients will certainly think you're a queen (or king).


Watch a video of keloid removal.​