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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.

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Friday, November 9, 2018

Identifying and managing disease often requires the delicate and skillful use of temperamental emergency department machinery. The ability to apply these may appropriately help determine a difficult diagnosis.

Glaucoma, we all know, can cause blindness, and acute narrow angle glaucoma refers to the angles within the eye that are not as wide and open as normal. People with acute angle glaucoma have abnormal anatomy within the eye where the angle changes as the eye is dilated. This can cause blockages of fluid drainage from the anterior to posterior changes resulting in increased intraocular pressure. It ca lead to acute angle closure or crisis if the drainage canals become blocked in an eye with narrow angles. A sudden and rapid increase in the intraocular pressure can lead to a variety of symptoms and cause damage. Damage to the optic nerve can occur and cause permanent blindness if the pressure is high enough.

Patients presenting with potential acute angle closure or crisis should be treated without hesitation. Some patients may know their diagnosis, but many may not be aware of the risk. The proper use of the tonopen to measure ocular pressure is crucial to making this diagnosis. Providers must first recognize the classic signs and symptoms of angle closure. Patients often complain of a headache, unilateral eye pain, halos, painful vision, loss of vision, or nausea or vomiting. Patients may have decreased visual acuity or inability to read, an angry red eye, a dilated pupil, or a hazy cornea. Symptoms may mimic a migraine headache, but the astute provider will notice that the ocular symptoms are much more pronounced in angle closure. This is when the tonopen is put to use.

Most tonometry machines come with a user manual and an instructional video that are well worth the time to read and watch. Several types of tonopens are available: Some need to be calibrated, and some are ready to use. Use whichever is easiest for you to master.

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The tonopen is delicate and must be handled with care. It should be stored in a hard box with padding. Store it with a cover on the tip to protect it. Use a condom cover cardboard wrapping to cover the transducer while it is in the box. Be sure to use the right tip cover for your tonopen to ensure accurate readings. Photos by Martha Roberts.

The Procedure

  • Have the patient sit comfortably in a chair or on a stretcher. You can take a pressure with him lying flat, but it won't be accurate and is more difficult.
  • Consider managing the patient's pain first and adding an anxiolytic, such as morphine or valium, especially if the patient is very anxious or uncomfortable. This is painful.
  • Anesthetize the eye prior to taking the pressure. Use two to four drops of proparacaine hydrochloride ophthalmic solution 0.5%; that should be enough to anesthetize the eye surface for about five minutes, depending on how much your patient is crying. Have the patient hold a tissue against his cheek while you drop in the medication.
  • Tell the patient he will initially feel a burning sensation, then relief, and then more burning.
  • Always put the condom cover on the tonopen before using it.
  • Calibrate the pen if required after applying the condom cover.
  • Wait about 60-90 seconds before taking a pressure. If you wait for more than five minutes, the numbing agent will start to wear off.
  • Tap the transducer on the anesthetized cornea. The tonopen tip should be perpendicular to the cornea.
  • Use light, quick touches. You will hear the tonopen make a clicking sound to ensure it is reading the taps as it calculates the pressure.
  • Keep the transducer head as flat and direct on the cornea as possible. Do not press into the eye.
  • Do not hold the patient's eye in any way. You may rest your hand on his forehead or nasal bridge, but holding the eye will give you a false high reading. Don't pull down the lower lid or pull up on the upper lid if at all possible.
  • If you have to assist a patient with keeping his eye open, hold onto his eyelashes instead of the lids themselves.
  • You will have to touch the cornea 10 times. The machine takes an average of these 10 taps and displays the pressure as a single reading on the window.
  • The statistical calculator indicator is the small number (usually) on the window. It is usually in the 90 percent range on readings done correctly. If it is lower than that, consider rechecking the pressures.
  • It is suggested you check the pressure in both eyes and compare the values.
  • Some tonopens show the message "Or Err," and you should consider this a true concerning pressure that is very high. If you are using the pen correctly and receive this message, it is not because the pen is broken. It is more likely the patient has a severely high pressure and it cannot be measured.

Treatment While Awaiting Consult

Clinicians should provide immediate treatment to reduce intraocular pressure if an ophthalmologist is not available within an hour to confirm the diagnosis and the patient has a significant decline in vision (cannot read text or count fingers). Try to decrease the pressure by instilling cholinergic drops. This results in miosis.

Give one drop of timolol 0.5% to the affected eye, wait one minute, and then give one drop of apraclonidine 1% to the affected eye. Wait another minute, and then give one drop of pilocarpine 2% to the affected eye. Wait one more minute, and then give 500 mg IV acetazolamide (give by mouth if IV is unavailable). (UpToDate. 2018.)

  • Recheck the pressures every 30 minutes.
  • Systemic medications other than acetazolamide (such as IV mannitol) should be administered under the guidance of an ophthalmologist because angle closure should be confirmed before they are given.
  • Ophthalmologists will consider additional treatments like iridotomy to open the angles if pressures are higher than 40 mm Hg. This is a laser procedure and the preferred method of treatment. It can also be used as a preventive treatment for patients at high risk or with borderline pressures.
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"Or Err" means the pressure is extremely high. Don't be fooled by this reading. Photo by Martha Roberts.

Cautions

Several medications can increase intraocular pressure by narrowing the angle. Medications that block acetylcholine may increase the risk for narrow angle closure.

Medical Concern                Medications that May

or Diagnosis                       Increase Intraocular Pressure*

Anxiety, depression             SSRIs such as Prozac and Paxil; Vistaril

Nausea and vomiting          Phenergan

Muscle spasms                   Norflex, Artane, Cyclobenzaprine

Asthma, COPD                   Any steroid (prednisone, Decadron), Atrovent,

                                           or Spiriva

GERD                                 H2 blockers, Tagamet, Zantac, Detrol

Incontinence                       Detrol, Ditropan

Other                                  OTC decongestants, ephedrine, Benadryl,

                                           sulfa-based drugs (Bactrim, Topamax),

                                           many antipsychotics

*Incomplete list.

  • Advanced age, female gender, hyperopia (farsightedness), and family history of angle closure and narrow angle glaucoma may increase the risk for closure.
  • Ocular and systemic steroids can increase intraocular pressure. Eye pressure should be checked in patients on long-term steroids and those who need steroids for more than 10 days.
  • Other reasons to check the intraocular pressure include trauma from blunt force or significant corneal abrasions.
  • Consider possible contraindications to medications for treating increased intraocular pressure (i.e., beta blocker contraindicated with severe bronchospasm, second- or third-degree atrioventricular block, uncompensated heart failure).
  • Consider higher doses of Zofran for nausea such as 8 mg. (UpToDate. 2018.) Do not give Phenergan if at all possible.
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Watch a video of Dr. Denis Dollard demonstrating how to use a tonopen.

Jim Weighs In

  • You should be checking pressures in any painful, angry red eye.
  • Put your tonopen back in the same spot every time.
  • Consult ophthalmology immediately if a patient has an elevated pressure. Very high ocular pressures are generally between 40 to 70 mm Hg (normal is approximately 8 to 21 mm Hg).

Martha Weighs In

  • Does your patient have a corneal abrasion? Give him one 5 mg tablet of PO diazepam to go. Let him get a restful night's sleep so the eye has adequate time to heal.
  • Never use the same condom twice and change it between eyes.
  • Never check someone's eyes without wearing gloves. You can transfer nasty germs into the eyes even after handwashing, so glove up.
  • The American Academy of Ophthalmology has some absolutely awesome information: https://www.aao.org.

Disclaimer: No financial compensation or other compensation was provided by Reichert in the making and publication of this blog.

Saturday, September 29, 2018

It's a good idea to find the ring cutter in your department before you need it. Know where it is, what the box looks like, and if it's electric or manual. Some departments may even keep it in the PIXIS or medication dispensary machine. You will also want to know where you keep your vice grips, wire cutters, and spreaders.

A patient with a hand injury must have his ring removed immediately. Lacerations, crush injuries, burns, degloving injuries, fractures, and even hand or finger contusions require prompt removal of any constrictive device. Swelling in the distal extremity can occur around the injury. The space in the hand, especially the joint space, is small and unforgiving. You must act fast and remove the ring because it can cause diminished blood flow, incarceration, or necrosis to digits rapidly.

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Using a manual ring cutter: Set up and act quickly. Photo by Martha Roberts.

Removing a ring from a finger can be tedious and troublesome. Occasionally, rings can be removed by using a lubricant such as petroleum jelly. Other rings may slip off if soaked in icy or soapy water. When those fail, the string method may work. (This technique will be discussed in a future post). For time's sake and to minimize trauma, a manual or electric ring cutter may be used to promptly and safely remove constricting metal, silver, and gold bands.

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Don't let this degloving injury scare you; this ring can be easily removed. You must anesthetize this finger before attempting removal because any contact with this area will be extremely painful. Photo by Martha Roberts.

What happens if your patient is wearing a Tungsten ring instead of a silver, gold, or metal one? Tungsten cannot be cut off or removed using a manual or electric ring cutter. You will need a Vise-Grip or some kind of locking pliers that can apply continuous and mounting pressure. These pliers crack off Tungsten rings instead of cutting. The cracking technique requires mounting pressure, and may need to be done several times before the Tungsten breaks. Simply place the Vise-Grip around the ring and squeeze. It will shatter. Check out this technique at http://bit.ly/2wdzeLq.

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Vice-Grip pliers are great for snapping off Tungsten rings. Photo by Creative Commons.

Sometimes you can get a ring cutter to gnaw off most of the ring, but that last little bit causes trouble. You can use a pair of mini wire cutters to snap through the last piece of the ring. Simply wedge the wire cutters into the space where you have been cutting and squeeze.

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Watch a video showing a ring removal with bonus footage of a degloving injury.

Ring Cutting Pearls

  • Anesthetizing the finger is necessary to allow proper placement of the ring cutter and to reduce anxiety and pain.
  • Electric or rotary ring cutters need a good, sharp blade. Swap out the blade if you aren't making progress.
  • A ring fully embedded in the skin cannot be removed without destroying it. Be sure to tell your patient that is going to happen.
  • Give your patient the pieces. Tungsten rings are usually guaranteed for life. The manufacturer will most likely replace it if it breaks (even on purpose).
  • If you're taking off a Tungsten, metal, silver, or gold ring, don't slide the pieces off the finger. Carefully peel back or pop off the layers of the ring or it will cut and damage the skin further.
  • Bee stings, animal bites, and even scratches to the hand or foot require immediate ring removal, even if swelling isn't initially present.
  • Double hemostats will also work if you don't have a spreader. See this demonstrated in the video.
  • Check with your maintenance department if you can't find the right tools. They will know exactly what you need.
  • Ring cutters are also useful for toe or penile rings.
  • Hand, finger, toe, and penile swelling aren't just related to trauma. Make sure you tell patients who are fluid overloaded, septic, and preparing for admission or surgery that they need to take off their rings as soon as possible.

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; http://bit.ly/2NcPSkZ.) 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; http://bit.ly/2NcgEd7.) 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.​

Cautions

  • 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; http://bit.ly/2NcgEd7.)
  • 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.

colles fracture.jpg
​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.​

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

Contraindications

  • 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.

Cautions

-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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