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.

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. (

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.


-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.​


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.


-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.​

Friday, December 1, 2017

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


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

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

The Approach

-Laceration repair of tattooed skin

-Combination of simple interrupted, mattress, and deep sutures

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

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

The Pause

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

The Procedure

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

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

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

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

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

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

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

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

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

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

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

-Use splints to assist with wound healing.


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

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

-Avoid deep sutures in the hand.

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

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

Tips of the Month: Smoking and Wound Healing

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

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

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

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

Wednesday, November 1, 2017

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

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

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

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

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

The Approach

Abscess incision and drainage

The Procedure

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

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

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

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

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

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

-Irrigate the area gently but copiously.

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


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

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

-Do not close the abscess with sutures.

-Do not pack the abscess.

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

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

-Check the culture upon follow-up.

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

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

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

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

-Always ask about prior treatment.

Evidence-Based Practice Pearl: Tinea Capitus and Kerions

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

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

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

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

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

Tip of the Month

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

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

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