After suturing a laceration in place, leave the suture tails 6-8 cm long.
Roll up a piece of gauze.
Place the gauze roll on top of the sutured laceration.
Secure the gauze using the long tails of the sutures.
After 1-2 days, the patient should cut the tied-over knots to remove the gauze. This allows the wound to be inspected and cleaned.
For step-by-step photos, check out Dr. Gemma Morabito et al's Medicinadurgenza website post. I have a question though:
I suture scalp lacerations only if the patient is balding or bald in the area. How would I bandage if you use staples instead of sutures for the scalp? I imagine my options:
Beanie hat approach
Hair braid dressing
Place 2-3 sutures to help close the laceration (interspersed amongst the staples) just to do a tie-over dressing
Don't bandage. Just cover up the staples with the overlying hair.
Thanks to Dr. Gemma Morabito (Rome, Italy) and Vincenzo Peloponneso (nurse in Cuneo, Italy) for the idea and images!
Ginzburg A, Mutalik S. Another method of tie-over dressing for surgical wounds of hair-bearing areas. Dermatol Surg. 1999 Nov; 25(11):893.
There are 2 flowcharts (above) that the AHA provides. They are conceptually complete, but I had a hard time implementing the steps in real-time.
So, I created my own. Thanks to Dan, who commented in my chat box that I should make an ACLS card.
Update 3/30/12: A reader (@drtompalfi) mentioned adding two other causes for potentially "reversible causes":
2 minutes of continuous, uninterrupted CPR is key before rechecking the rhythm.
Think about giving epinephrine every OTHER time you check the rhythm. This puts it at roughly a q4 minute dosing (recommended q3-5 minutes).
Don't delay CPR when you recognize a cardiac arrest. That means do this first, and then work on giving oxygen, placing the patient on various monitors, setting up the defibrillator, and establishing IV/IO access. Hence, the C-A-B mnemonic (Circulation before Airway)
Chest compressions should be "hard and fast" -- Depth of at least 2 inches and ≥ 100 compressions with a target pCO2 on the end-tidal capnography of ≥10 mm Hg.
Use your mobile phone's timer to help alert you every time when 2 minutes is up.
Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(18 Suppl 3):S729-67. Review. Erratum in: Circulation. 2011 Feb 15;123(6):e236. Pubmed .
Welcome the newest EM blog to the block: ED Trauma Critical Care. It's helmed by Dr. Amit Maini (St. Vincent's Hospital in Melbourne, Australia) and focuses on keeping us all up to date with the latest and greatest in trauma, resuscitation, and critical care.
Topics thus far:
IO vs IV access during out of hospital cardiac arrest, an RCT
Increased chest compression fraction on ROSC in nonVF cardiac arrest
Beware the pain in the neck...
Sedation in traumatic brain injury
Slightly funnier than placebo
Severe pneumonia and ARDS
Keep a lookout for many more great summaries and tips.
Relocation of a hip joint is often quite a sight to see in the ED. A commonly taught technique is the Allis maneuver (watch the first 45 seconds of the above video from the Medical College of Georgia). It has always seemed a bit precarious to me having someone stand on the patient's bed.
Trick of the Trade:
Captain Morgan technique
You can apply 3 forces of axial traction to the femur.
Position the patient: 90 degrees of hip and knee flexion
Step one foot up onto the gurney Captain-Morgan style (flamboyant cape optional).
Position your knee behind the patient's knee.
Ideally your foot should be resting on a hard surface like a backboard to allow your foot to push off of it.
Place one hand (A) under the patient's knee and the other (B) over the patient's ankle.
Use Hand A to lift up on the patient's femur.
Plantar-flex your ankle so that your propped knee can lift up on the patient's femur.
Very gently use Hand B to leverage-down on against the patient's tibia/fibula.
TIPS FOR SUCCESS
Pearls straight from "Captain" Hendey (Dr. Greg Hendey wrote the article):
Make sure to put the patient on a backboard and attach a strap over the pelvis to stabilize it to the board--this works far better than having some tech trying to lie across the patient, and it's better than tying a sheet around the gurney and the patient. It also provides a firm place to put your foot.
Make sure to tuck your knee tightly under the patient's knee so that when you lift up on your tiptoes, all the force is transmitted into lifting the patient's hip. If your leg is much shorter than your patient's leg, you may need to put a book under your foot to get your knee tucked under theirs.
Once you're lifting, keep a steady sustained force, just like any large joint reduction--no sudden jerky movements. Once you feel it start to move, don't stop--sometimes people stop lifting too soon when they feel movement, but before the reduction has occurred.
If it's not moving, try rocking back and forth, and twisting the leg (internal and external rotation at the hip) while you're lifting.
The provider does not use Hand A to lift up, although it seemed that he kind of wanted to. Note that he was stepping on the hard bed under the soft gurney mattress.
The provider shows you how you really need Hand A to help you to lift.
NPR interview with the article's author and my friend, Dr. Greg Hendey (UCSF-Fresno).
Today's Paucis Verbis card is a little different. This card focuses on helping you give talking points when giving feedback to a learner on shift. This could be a medical student or resident.
Dr. David Thompson (UCSF-San Francisco General Hospital) sent this great card to me and I thought it was too useful NOT to share. It's handy on shift, which ultimately is the purpose of these Paucis Verbis cards. These are useful especially for senior residents, who are supervising medical students and junior residents.
There have been several blog posts on giving effective feedback in the ED:
Print these cards and fill it out at the end of the shift. Give to the learner.
Pick 1-2 questions from the list below as launching points for your feedback discussion. You don't have to overwhelm the learner by answering everyone item below. Sometimes less is more to be effective.
From LifeInTheFastLane.com's illustrious Dr. Mike Cadogan. These were the slides from his Social Media in Medicine talk at the recent USC Essentials Conference. It's time more physicians get involved and join the conversations that are taking place on social media. Join now.
Hey look! I can say I've finally made it when I get a mention from Mike in his slides!
Scalp lacerations are one of the most common injuries which present to the Emergency Department. Applying a dry bandage over the staples or sutures can be a challenge because the tape just has nothing to adhere to.
We reviewed the use of tubular cotton gauze to create a beanie hat, but what should you do if you can't find any tubular gauze? Ever since I wrote about the beanie hat trick, people in the ED have been using the tubular gauze more and we're always out of stock whenever I look for it!
Trick of the Trade:
Use hair to create a "hair braid dressing"
This was actually published in the Neurosurgery literature in 2004, but I just heard of it from Dr. Gemma Morabito (Rome, Italy) of Medicinadurgenza website fame just this last month!
1. Apply gauze over wound by lifting overlying hair.
2. Criss-cross hair over gauze.
3. Using string or rubber bands, tie both hair braids to the hair underneath to securely "sandwich" the gauze.
4. Secure the two hair braids to the gauze with tape.
Yanaka K, Nose T. Braid dressing for hair-bearing scalp wound. Neurocrit Care. 2004;1(2):217-8. Pubmed .
What is your diagnostic approach to the acutely vertiginous patient?
The bottom-line question is:
Is the cause peripheral or central in etiology?
In this great 2011 systematic review article in CMAJ on Acute Vestibular Syndrome (AVS), the authors review how (un)predictive elements of the history and physical exam are. By definition of AVS, symptoms must be continuous for at least 24 hours and have no focal neurologic deficits.
Frighteningly, the authors report many of the signs and symptoms (type of dizziness, hearing loss, patterns of nystagmus, Hallpike-Dix) are not as predictive as we classically are taught!
The take home point is to learn and incorporate the 3-part HINTS exam into your diagnostic approach (see bottom box on card). It is reported to be as good as a diffusion-weighted MRI for diagnosing a posterior stroke. The steps are:
Do the horizontal head impulse test. (Normal = central cause)
Check for directionally-alternating nystagmus movement on left and right gaze.
Thanks to Dr. Brian Resler (UCSF-SFGH EM resident) for giving me the heads up about this at Followup Conference!
Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011 Jun 14;183(9):E571-92. Pubmed .