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.

Monday, April 30, 2018

​Some procedures are worth doing over and over because they are easy and fun. The bonus is they can improve outcomes for patients and prevent bouncebacks, costly follow-up exams, and prolonged pain and complications. This month we discuss the use of the ultrasound (US) water bath and bedside imaging for foreign bodies (FB). If you would like to see more about using ultrasound for FBs, see our previous blog post about wine glass in the foot. (http://bit.ly/2HSQLvZ.)​


Bedside US is an exquisite technique that can be used to examine and explore numerous parts of the body without using radiation. This procedure uses a simple technique, and can be mastered with just a little bit of practice. You can perform this procedure even if you are not formally trained in US technology. Patients with FBs in the hand or foot may benefit from this approach because retained FBs can cause infection, pain, keloids, granulomas, or other cosmetic issues. Early removal of foreign material is helpful in avoiding these complications.

Using a water bath "replaces the need for ultrasound gel or contact between the ultrasound transducer and the patient's skin," eliminating discomfort. (Am J Emerg Med 2004;22[7]:589.) This may make your patient more cooperative during the examination. The provider may also obtain superior images using this technique. (Am J Emerg Med 2004;22[7]:589.)​

US can be used on patients of all ages with a variety of retained FBs. Foreign bodies that have been in place from two weeks to 1.5 years can be removed using a US-guided technique, according to a small 2017 study in the Chinese Medical Journal. (2017;130[14]:1753.) The study looked at patients between 10 and 68 years old with FBs such as cactus needles, jujube thorn, metal, and glass and wood splinters. Some of these patients even had surgical procedures to look for the FB without success prior to US intervention. The FBs were successfully removed in 11 of the 12 patients under ultrasound guidance, and the procedure took 15 to 30 minutes in the study. Only one attempt failed to remove the FB, which was in a man with a wood thorn that had penetrated into the thenar muscles. The study concluded that US may be used at any time on any patient with any foreign body.


Watch a video of Dedrick Luikens, DO, of Southwestern Vermont Medical Center demonstrating how to use ultrasound-guided imaging in a patient with a foreign body in the hand.​

The literature surrounding the use of US in FB removal is not mixed. Alll of the multiple case studies and papers we reviewed said US is reliable and accurate. Sensitivities of up to 94% to 98% for ultrasound detection of radiolucent and radiopaque foreign bodies have been reported. (J Ultrasound Med 2009;28[9]:1245.) A 2010 study by Nienaber, et al., found that 29 of 30 foreign bodies—wood, glass, plastic, gravel, and metals—in experimental models of soft tissue were correctly identified, and the study yielded a sensitivity of 96.7%.(Emerg Med Australas 2010;22[1]:30.)

Finally, a paper from 2014 by Atkinson, et al., compared the accuracy of point-of-care US in detecting wood, metal, and plastic foreign bodies in an experimental model by emergency physicians and emergency nurse practitioners following a short training workshop. Sensitivities of between 83.3% (NPs) and 100% (EPs) were demonstrated. (Crit Ultrasound J 2014;6[1]:2.)

We expect to see improved US machines and more skilled providers at the bedside. Using this ultrasound-guided technique will only enhance the care and treatment of emergency department patients. We urge you to take a look at a paper published in Ultrasound that incorporated information from 12 fantastic studies on using US to look for FBs. (2015;23[3]:174.)​

The Approach

Using an ultrasound water bath to examine the hand to find, remove, or rule out foreign body.

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The Pause

  • Have you cleaned the hand yet? Why not use a basin to clean the wound and then directly image it in the same water bath?
  • Be sure the probe is clean from the tip to the cord before placing it in the water bath.
  • Be sure to document the procedure using the 10-step checklist in your EMR.

The Procedure

  • Fill a basin with warm tap water.
  • Clean the extremity, if not already completed. Do not use a Betadine soak.
  • Engage the linear US probe on the machine.
  • Change the depth on the machine as needed.
  • Turn off the overhead lights in the room to assist some people with image identification.
  • Place the extremity in the water bath. The affected portion must be fully submerged.
  • Gently scan above the hand or finger where the foreign body may be located. Ask the patient to point with the other hand to the spot where they feel the most pain. Scan extensively above lacerations or puncture wounds.
  • You do not need to touch the skin with the probe while doing this exam. The water bath works the same way gel would work on the skin.
  • Once the foreign body is recognized, remove the hand and mark the area. Remove the object if indicated.
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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. (http://bit.ly/2CmxFLz.) 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

Cautions

-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.​

Wednesday, January 31, 2018

​A patient presented to the emergency department with a request to remove her back ring. Yes, that's right, her back ring. We were a bit confused at first by the piercing. The stud was placed in her back with no obvious way of removal. Our original thought was to send the patient to dermatology or even plastic surgery. The piercing certainly didn't qualify for emergency surgery or removal.​

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A 23-year-old woman with a back piercing in the left lower back. The underlying skin condition is not infectious. This is a classic example of tinea versicolor, and is not related to the piercing. It is a common fungal infection that causes small, discolored patches on the skin. Photo by Martha Roberts.

EMTALA only requires you to give patients a medical screening exam, and once deemed stable, they can be discharged appropriately. We are suggesting, however, that you consider completing certain nonemergent procedures in the ED if they are reasonable and will not cause harm. Providers often tell patients, "This is not an emergency," and "We don't do that here." This may be true in many respects for good reasons, but it doesn't mean you can't choose to do something you feel you're able to complete. A piercing removal is not always an emergency, but ED providers are capable of quickly removing them and fixing the patient's presenting problem.​

The Procedure

This technique is probably unknown to most providers. You must make a laceration to expose the underlying bar device used to keep it anchored, which we show in the video. You will need to:

-Anesthetize locally with 1% lidocaine with epinephrine.

-Make a small, horizontal incision.

-Remove the piercing with proper tools.

-Use Dermabond or other skin glue on the laceration site for closure.

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Make a small, horizontal incision to remove the piercing.

The Pause

Is there any potential risk or adverse event that may occur if you perform this procedure? Is it as straightforward as simple laceration repair or abscess drainage? You're the judge.​

Tip of the Week: Langer's Lines

These lines are also called cleavage lines, and refer to corresponding collagen fibers within the dermis of the skin. Knowing where these lines are is extremely important. The idea is that surgical cuts or incisions should be made in the same direction as (or parallel to) the Langer's lines. Perpendicular cuts may cause puckering, keloids, poor healing, increased rates of infection, and higher risk of scarring. The facial Langer's lines will change over time; all areas of the body may change secondary to body habitus or age.


Langer's lines are lines of tension on the body, which you should always consider when completing any laceration repair or when making an incision. The back has mostly horizontal resting tension lines. The closer you get to the buttock, the higher the risk of secondary infection. Also consider the risk of keloid formation. Of note, the facial relaxed tension lines are intricate and variable, which may change with age. Photo credit: The Family Practice Notebook. (http://bit.ly/2CVWJgI.)

Of course, nonemergent procedures may be referred to a specialist without immediate ED intervention. If your department is busy and filled with sick and critical patients, there may not be time for a procedure such as this one. But it is possible that this procedure would only take minutes, and your patient would be grateful. Determining what you can do for these patients requires patience and practice as well as compassion. Heavily weighing the pros and cons with the patient is pivotal.


The patient's back with skin glue after removal of the piercing and the piercing itself. Watch a video of Dr. Dedrick Luikens of Southwestern Vermont Medical Center removing it.​ Photos and video by Martha Roberts.

Cautions

-Explain the pros and cons of completing nonemergent procedures in the ED. Be sure to obtain proper consent and warn patients of poor cosmetic results. This is when they may opt to see plastic surgery or dermatology.

-You can still encourage follow-up with a specialist, even if you have completed the procedure. Simply explain to the patient that it may not be necessary unless the patient is at risk of infection or other adverse events.

-Be wary of skin tags and growths that may need biopsy. If the lesion looks dangerous or infectious, treat the underlying issue and refer out.

-Do not spend too much time on nonemergent procedures. If it looks like it will take a while, is complicated, or can wait, refer the patient out.

-Specialists like referrals, and sometimes their input or consultation is best.​

Tuesday, January 2, 2018

​Some of our patients are total daredevils. This unique population keeps us on our toes. Our weird and wild series recently discussed laceration repair involving tattoos, but problematic piercings also present to the ED.​


Traditional through-and-through piercing of the tongue body without complication. Photo: Creative Commons.

An 18-year-old otherwise healthy woman presented to the emergency department with tongue swelling and mouth pain. Your first thought may be that this is an allergic reaction, but you quickly realize this is not the patient you expected. This patient just had her tongue pierced, and something has gone wrong.​

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Traditional tongue piercing involving the body of the tongue and accidental piercing of the frenulum linguae (left). Ventral tongue anatomy, right. Piercing involving the frenulum or areas of the ventral tongue surface and tongue floor can be complicated and dangerous. Photos: Creative Commons.

The patient was tripoding on the stretcher, while her friend soothingly patted her back. The patient's vitals were blood pressure of 140/90 mm Hg, heart rate of 120 bpm, respiratory rate of 30 bpm, temperature of 99.2°F, and oxygen saturation of 98% on room air. She was drooling, and there was scant blood in her sputum. She appeared anxious and teary, and could barely speak.

Her physical exam revealed an enlarged tongue with moderate bleeding around the piercing, some bruising to the site, a poorly visualized posterior pharynx, rhinorrhea, and tearing. The piercing had also gone through the frenulum on the ventral surface, which was causing her significant pain and limited range of motion of the tongue. The lips and buccal area were unaffected, and the rest of the ENT exam was otherwise normal. Her lungs were clear, and her heart rate was regular but tachycardic at 120 bpm. Her skin was warm and dry without any rashes, and the rest of her exam was otherwise unremarkable.

The patient mumbled her story as best as she can, revealing she had had her tongue pierced at a local shop the night before and went to bed feeling fine. Her friend said she woke up this morning with severe tongue swelling, difficulty breathing, and pain, so they came right to the emergency department. The patient had no known drug allergies or medical issues, did not take any medications, and this was her first piercing.

She stated that she had just started college in the area, and the place she went to was well-known. Her tongue was so swollen that you couldn't get a good look at the area where the small ball connects to the bar that keeps it stable.

The Approach

-Tongue piercing removal

-Bleeding control with potential use of TXA

-Decadron administration

-Monitoring and protection of airway

The Pause

Consider immediate intubation if the patient shows signs of respiratory depression, altered level of consciousness, oxygen saturation of <92%, or vomiting or bleeding to the point of choking. The best approach would be to use fiberoptic nasal intubation.​


This patient is a subject of blind nasal tracheal intubation because of the difficulty with obtaining an oral intubation. This technique is often used in patients with swelling of the upper airway to bypass the tongue and lips. Photo: James R. Roberts, MD.

The Procedure

-Have the patient sit comfortably. Apply nasal cannula to encourage her to breathe through her nose. It will also assist with comfort.

-Use suction to relieve drooling. Allow the patient to hold the suction wand; this will also assist with comfort and effectiveness.

-Have the patient open her mouth as wide as possible, and inject 1-2 mL of 1% lidocaine with epinephrine into the tongue directly around the site of the piercing. Do this on the ventral surface of the tongue so the swelling remains closer to the floor of the mouth.

-Hold pressure on the tongue for two to four minutes. This may help stop the bleeding.

-If the bleeding stops enough for good visualization of the ball attached to the bar of the tongue ring, grab it with small ring forceps.

-Once you have stabilized the ball portion, you can push the tongue down and hold the visible portion of the bar with needle nose forceps. Call your OR if you do not have this equipment readily available in your department. Also, consider your ENT, dental box (or build your own), or a laceration repair kit if in a hurry.

-Have an assistant hold suction to decrease secretion while you twist off the ball from the bar of the tongue ring. If it gets stuck, dry it off with gauze. You can also use the gauze to assist with traction holding the ball during removal.

-Hold pressure on the tongue for five minutes after removing the ball and bar. The patient may also assist with this pressure.

-If bleeding does not improve or you have difficulty removing or visualizing the ball on the tongue, consider applying a tranexamic acid (TXA) paste to the area to assist with oral bleeding control. (Ann Pharmacother 2006;40[12]:2205.)

-Make a paste or solution by combining two to three 650 mg tablets of TXA and 2-3 mLs of sterile water and apply directly on the site. You can also coat gauze with the paste and hold it on the tongue. Note: You are aiming for a paste or mixture that has 1,000-2,000 mg of the medication per dose to the oral area. Usually available options include 650 mg or 500 mg tablets or IV solution of 100 mg/mL of TXA.

-Give one IM dose of Decadron 10 mg to assist with the swelling to patients who weigh more than 50 kg. You may also consider IV steroids if the patient already has IV access or will be admitted. Note: Little evidence has been documented that IM Decadron has benefit in tongue swelling cases related to piercings, but we still feel this clinical decision based on our experience and follow-up is reasonable.

-IV antibiotics have not been shown to help in these immediate cases, but may be required if the tongue laceration does not improve within 24-48 hours.

-Cold, iced liquids advancing to purees for the next two days should be encouraged.

-Tetanus should be updated.

-Consider NS IV hydration 500-1,000 mL (depending on body weight) prior to discharge in anticipation of decreased oral intake.

Cautions

-Know your equipment and have it easily accessible.

-Consult ENT if the bleeding continues, and consider ordering a coagulation panel to reveal underlying clotting disorder.

-Admit patients who need to be observed without hesitation.

-Nasally intubate patients who cannot maintain their airway.

-Do not let a patient be discharged if she cannot swallow liquids!

-Consider observation in the ED post-Decadron administration.

-The TXA paste may be made by the pharmacist or by you in the ED. Note: The paste made from crushed pills is much less expensive than the IV form of the drug.

Evidence-based Practice Pearl: Topical TXA

What is TXA? Tranexamic acid is a "clot promoter" that can help prevent excessive blood loss. It can be used orally (650 mg tablet), IV (100 mg/mL), or in a topical paste solution. This medication has been making more of an appearance lately in cases related to trauma, vaginal bleeding, and epistaxis.​

TXA minimizes blood loss by "inhibiting lysine-binding sites on plasminogen, preventing its binding to lysine residues on fibrin." (J Trauma 2011;71[1 Suppl]:S9.) This "inhibits both plasminogen activity and plasmin activity, thus preventing clot break-down rather than promoting new clot formation." TXA also was shown to reduce bleeding and the need for blood transfusions in surgical patients. (Cochrane Database Syst Rev 2013;[7]:CD010562.) It was noted that the "risk of thromboembolic events was less certain."

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Photo: Creative Commons.

Dentists may use a 5% mouth rinse of TXA after tooth extractions or oral surgery to assist with bleeding complications. The pills can be crushed and applied topically or used in a rinse. (Ann Pharmacother 2006;40[12]:2205.) It can also be placed on gauze and applied directly on the area of bleeding. Topical treatment with oral or other solutions of TXA in nosebleeds also yields good results. (Am J Emerg Med 2013;31[9]:1389.) The medication is relatively safe with few complications and rare side effects.

TXA also has been shown to have good results when used in elective procedures such as rhinoplasty. A Journal of Craniofacial Surgery study that looked at using TXA before and during rhinoplasty concluded that the preoperative administration of 1g oral TXA significantly decreased the blood loss in patients undergoing rhinoplastic surgery without any significant adverse effects. (2016;27[1]:97.) Overall, TXA may be a useful adjunct for patients suffering from tongue bleeding or other ENT bleeding complications.​