PROCEDURES IN THE ED
| COMMON PROBLEMS IN THE ED —Joseph R. Lex, Jr, MD, Assistant Professor of Emergency Medicine, Temple University
School of Medicine, Philadelphia, PA
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| 10 most common problems: foreign body in eye; nose bleed; hit in mouth; cut hand; stray dog bite; broken bone;
stepped on nail; severe back pain; strep throat; bronchitis returned
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| Hand injuries: account for 1 in 20 emergency department (ED) visits; men more than women; 60% occur in 16 to 32 yr
age group; 60% lacerations; 10% fractures, most commonly distal phalanx of long finger; 5 studies confirm no improvement
in rate of hand infections with cephalexin, compared to placebo; appropriate cleaning of hand wound sufficient; antibiotic
use not beneficial; common practice to irrigate with 1% povidone/iodine (Betadine) solution (dilute 10%
concentrate), but this is still 100% cytotoxic, as is hydrogen peroxide; 0.001% povidone/iodine bactericidal, not cytotoxic;
do not soak wounds—soaking in water increases bacterial count; soaking in 1% povidone/iodine does not change
bacterial count; irrigation—no difference in infection rate between tap water irrigation and “sterile solutions”; stitches
not required—for lacerations 2 cm in length; study data show no difference in cosmesis or time to return to work; in
study, one sutured wound became infected, no unsutured wounds infected; savings in cost, pain, time, revisits to ED;
hand bites—referral bias; infected hands seen in ED from human, dog, and cat bites; infections polymicrobial (Pasteurella
multocida common in dog and cat bites); treat with cephalosporins
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| Foreign body in eye: history of pain, tearing, foreign body sensation; if light bothersome, patient has light sensitivity;
true, deep pain from light considered photophobia; caused by trauma or extended contact lens use; distinguish redness on
physical examination (bulbar vs palpebral conjunctiva); if palpebral, think conjunctivitis; visual acuity—normal with
simple foreign body; if not normal, consider deep, complex foreign body, perforation, or other cause; with fluorescein or
cobalt blue under Wood’s lamp, dye uptake shows corneal epithelial cells; have patient read Snellen chart through pinhole
device or hole poked in paper
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| Corneal abrasions: series of vertical abrasions indicative of foreign body embedded in upper lid; Sidell’s test (clear
stream through fluorescein) indicative of corneal perforation; pearls—topical anesthetic; cycloplegic 20 to 30 min before
examination; slit lamp, Wood’s lamp with fluorescein, or “poor man’s slit lamp” (have patient lie on back, focus
on fluorescent ceiling light so tube reflects on cornea, move head side to side); dendrite indicative of herpes infection;
remove contact lens before using fluorescein; common practice to have patients immunized with tetanus toxoid after
corneal abrasion, but no documented cases of tetanus from corneal abrasion; topical anesthesia—do not send patients
home with topical anesthetic (causes secondary keratitis; compromises healing); proparacaine not irritating, effective
in 20 sec, lasts 20 to 30 min, and costs $15 per bottle; tetracaine stings, takes longer to become effective, lasts few minutes
longer, costs same as proparacaine; irrigation—use neutral solution; if pH paper not available, use pH square
from urine dipstick; if Morgan lenses not available for rapid irrigation, use nasal prongs from oxygen tubing (drape
over bridge of nose, hook other end of tubing to intravenous [IV] bag); patching—4 of 6 studies show no difference
between patching and not patching; other 2 found patching made patient feel worse; no difference in complications; let
patient decide; antibiotics—data do not show antibiotics effective for simple corneal abrasions; most data show antibiotics
impede healing; if necessary, use least expensive (sulfacetamide); use antibiotic if contact lens caused scratch (often
become infected with Pseudomonas; treat with ciprofloxacin); avoid neomycin (causes severe contact dermatitis in
5% of population)
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 | Eye drops: nonsteroidal anti-inflammatory drug (NSAID) eye drops offer no provable benefit, and expensive; cycloplegics
paralyze ciliary muscle, relieve photophobia and pain; mydriatics cause pupil dilation; difficult to separate; color
code for drops (solution in vial with red cap dilates pupil, in green cap, shrinks pupil); iris color can affect response;
iris color sympathetically mediated; damage to sympathetic system before color fully developed can cause permanently
light blue iris; clinical studies of patients with corneal abrasions indicate no difference (in pain, healing, rate of
complications) between using simple lubrication, home atropine, NSAID drops, or home atropine plus NSAID drops;
half-life of most drops ≈20 min, so frequent application required (eg, herpes keratitis); drops washed out quickly; little
advantage to using ointment
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| Nosebleeds: occur in young children and older adults; seasonal variation (more frequent in cold months); many drugs
predispose patients to nosebleeds; 98% should be treated by nonotolaryngologists; first apply constant pressure (speaker
uses 4 tongue depressors taped with two 1-inch adhesive strips at end; effect similar to clothespin); ice packs do not
work; err on side of caution, bring too much equipment; have patient hold emesis basin to catch clots; first have patient
blow nose to clear area; can use vasoconstrictor to reduce bleeding and local anesthetic; newer products effective; 2%
lidocaine, 1:1000 epinephrine and 2% tetracaine (LET) vasoconstrictor as effective as cocaine, less expensive, and has no
adrenergic surge; soak cotton ball in LET, wring out, gently insert with bayonet forceps, wait 10 to 15 min, then remove;
apply silver nitrate sticks if bleeding site obvious and bleeding has stopped (useless in active bleeding; random insertion
may cause perforation); bleeding site identified ≈10% of time; gently roll stick over area; avoid large area of eschar (can
cause necrosis and perforation); one half-inch wide Vaseline gauze effective; grasp gauze 6 in from end and insert (prevents
insertion into back of throat); leave 6 in exposed at other end; speaker has not had success with merocel sponges;
can try hemolyzing agents (eg, oxidized cellulose [Oxycel and Surgicel] self-absorbs in 2 to 3 days); balloon “savior” if
nothing else works; uncomfortable for patient, use procedural sedation; can cause bradycardia; ensure patient not bleeding
before discharge; have patient walk around ED at least twice to create stress; if possible have patient bend forward to
tie shoes; coagulation studies not indicated in ED; take good history (reveals whether patient on warfarin); prophylactic
antibiotics important because of risk for sinusitis and toxic shock syndrome; amoxicillin drug of choice; remove nonabsorbable
pack after 2 to 3 days; pitfalls—failure to apply pressure for adequate time; failure to pack nose properly; failure
to have patient perform “walkaround”; failure to prescribe antibiotics; failure to ensure patient not taking aspirin for
several days
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| Nose trauma: x-rays unnecessary; plastic surgeons and otolaryngologists wait until swelling has diminished; decide procedure
at that time; x-rays performed for medicolegal reasons; pitfalls—failure to identify and treat septal hematoma (results
in saddlenose deformity; drain hematoma by making curvilinear incision); failure to rule out cerebrospinal fluid
leak, especially in patient with persistent nasal drainage
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| SIMPLE PROCEDURES THAT CAN CHANGE YOUR PRACTICE —Gregory S. Johnston, MD, Assistant Professor of
Emergency Medicine, New York University School of Medicine, New York, NY
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Transthecal Digital Block
| Technique: inject into tendon sheath; lidocaine travels through sheath and diffuses into digital nerve; equivalent to performing
block on dorsal side of finger; procedure—povidone/iodine preparation; 1% lidocaine; look for distal palmar
crease; inject 2 to 3 mL lidocaine at 45° angle; sends anesthesia distally into sheath toward finger; use other hand to apply
proximal pressure on sheath to prevent backflow; use sterile technique and 25- to 30-gauge needle; resistance to injection
suggests needle tip on flexor tendon; pull back slightly and inject; wait 3 to 5 min; no complications reported in literature;
advantages—single injection; as effective as traditional block; small amount of anesthetic; no risk of hitting nerve;
disadvantage—slightly more painful; theoretic risk for infection (not documented); indications—lacerations; nailbed injuries;
foreign bodies; best for second to fifth fingers but also works for thumb; contraindications—infection; flexor tendon
synovitis
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| Literature: first described by Chiu (1990); 420 patients, no complications; Hill (1995)—162 patients, half received transthecal
block, half traditional block; both equally effective; minimal differences in pain during administration; Low
(1997)—20 volunteers, transthecal and subcutaneous single-injection digital block; slightly more pain during and 24 hr
following injections; small differences; suggested transthecal block possibly not as good as regular digital block; Cummings
(2004)—25 patients, mapped anesthesia using light-touch and pinprick sensation; found less dorsal anesthesia; not
necessarily relevant to clinical practice; Keramidas (2004)—50 patients, compared transthecal digital block with traditional
block; slightly more painful with injection and at 24 hr; Hart (2005)—transthecal digital block considered useful
technique
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Intra-articular Lidocaine for Shoulder Dislocation
| Technique: eliminates need for conscious sedation; procedure—sterile technique; cleanse shoulder and inject into joint
space (2 cm inferior to lateral edge of acromion) with 18- or 20-gauge needle; literature suggests first aspirating hemarthrosis
if present; inject 20 mL of 1% lidocaine over 30 sec; wait 15 to 20 min before attempting reduction; indications—
anterior shoulder dislocations; no literature on posterior or inferior dislocations; contraindications—lidocaine allergy; cellulitis
over entry site; obese or muscular patients; advantages—simple; shortens ED visit; no sedation required; no recovery
period; does not limit other options (eg, conscious sedation); disadvantages—limits muscle relaxation (problematic in apprehensive
patient)
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| Literature: first described by Lippitt in 1991; Matthews (1995)—15 patients; better reduction in intra-articular lidocaine
group; Suder (1995)—66 patients; half received intra-articular injections and had good results; half received procedural
sedation (high complication rate); American Journal of Emergency Medicine (1999)—29 patients received intra-articular
lidocaine; longer period of dislocation period associated with less success with intra-articular lidocaine; Miller (2002)—
15 patients; big cost savings
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| PROCEDURAL SEDATION AND ANALGESIA —Luis M. Lovato, MD, Assistant Professor, the David Geffen School of
Medicine at the University of California, Los Angeles (UCLA), and Director of Critical Care, Department of Emergency
Medicine, Olive View/UCLA Medical Center, Los Angeles
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| Goals (American College of Emergency Physicians [ACEP]): sedate patient with or without analgesia; allow
patient to tolerate unpleasant procedure; maintain cardiorespiratory function; depress level of consciousness; maintain independent
airway control
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| Patient selection: based on American Society of Anesthesiologists (ASA) classification of physical status; P1 to P6;
P1—healthy, no medical problems; P2—inactive or mildly active hypertension; P3—hypertension, diabetes and coronary
artery disease (CAD), severe systemic disease; P4—patients with constant threat to life, eg, CAD patient with
active chest pain, acidotic diabetic patient; know when to call in consultant
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| Considerations: patient’s cardiorespiratory stability; length of procedure; previous adverse reactions; assessment of airway;
available alternatives (eg, digital block, regional block)
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| ACEP 2005 clinical policy: recommendation levels—(A) multiple randomized control trials; clinical certainty; (B)
strength of evidence suggests best choice; (C) slightly better than expert opinion; personnel—appropriately trained specialist;
patient assessment—history; allergies; airway; fasting—recent food intake not contraindication; equipment—
oxygen; equipment for advanced airway management; monitoring—close monitoring required; respiratory
assessment—check pulse oximetry if patient high-risk patient (may not be necessary); consider end-tidal CO2 monitoring
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| Speaker’s interpretation of ACEP policy: personnel—do not try procedural sedation and analgesia (PSA) if clinician
inexperienced; patient assessment—full history; assess airway; fasting—does not matter; equipment—always be
ready for complications; monitoring—monitor closely; respiratory assessment—preoxygenation (on nonrebreather
mask for 3 min) and pulse oximetry on all patients on deep sedation
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| Case 1 (wooden stick vs head): 2-yr-old with deep forehead laceration over eyebrow; no past medical history; no
known allergies; weight 15 kg; acting well; mild anxiety and agitation with staff; can “papoose” (restrain) child as reasonable
alternative; can use ketamine
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| Ketamine: class A; actions—sedative, hypnotic, amnestic, and analgesic properties; dosing—intravenous (IV) and intramuscular
(IM); reliable; onset/duration—IV onset 1 min, 15-min duration; IM onset 5 min, 30-min duration; side
effects—usually not problematic in children; nystagmus (warn parents) and vomiting; cardiovascular stimulation; hypersecretion;
emergence delirium; laryngospasm; can cause hypertension, cardiovascular stimulation, ischemia, and hallucinosis
in adults; do not use in large-size adults; contraindications—active respiratory infection; hallucinosis present;
infants <3 mo of age (laryngospasm likely); advantages—single agent; reliable effect; established safety record; note—
concurrent use of atropine in children <5 yr of age controversial
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| Case 2 (fever and agitation): complicated seizure, not regaining complete consciousness; 12 kg; requires computed
tomography and lumbar puncture
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| Medication choices: fentanyl and midazolam (Versed)—ACEP level B recommendation; titratable; mild, moderate, or
deep sedation; commonly available; established safety record; barbiturates—concerns of hypoxia, hypotension, prolonged
effect; overall very safe; use when concerned about increased intracranial pressure; propofol—ACEP level B;
more incidence of hypoxia, hypotension; dosage unclear; etomidate—ACEP level C; no large-scale pediatric studies;
nonstandardized dosing; short acting; dose 15 mg in adults; onset <1 min; duration 10 min; reliable; minimal cardiovascular
depression; reduces intracranial pressure; no large studies; requires concurrent analgesic; fentanyl and
midazolam—ACEP level B; good combination (fentanyl [opiate] plus midazolam [sedative, hypnotic, amnestic]); quick
onset; ≈30-min duration; mild respiratory depression; mild hypotension; long titration to sedation; propofol—ACEP
level B; nonopiate, nonbarbiturate sedative hypnotic; no analgesia; sedation deep and sometimes general; antiemetic
and euphoric properties; initial dose 1 mg/kg bolus; titrate to effect with 0.5 mg/kg every 3 to 5 min; quick onset; 10-
min duration; decreased blood pressure; respiratory depression; reliable; no myoclonus; reduces intracranial pressure;
requires repeat dosing; pain with injection
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Suggested Reading
Burton JH et al: Propofol for emergency department procedural sedation and analgesia: a tale of three centers. Acad
Emerg Med 13:24, 2006; Chiu DT: Transthecal digital block: flexor tendon sheath used for anesthetic infusion. J Hand
Surg [Am] 15:471, 1990; Chudnofsky CR et al: A combination of midazolam and ketamine for procedural sedation and
analgesia in adult emergency department patients. Acad Emerg Med 7:228, 2000; Cummings AJ et al: Modified transthecal
digital block versus traditional digital block for anesthesia of the finger. J Hand Surg [Am] 29:44, 2004; Godwin SA
et al: Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med 45:177, 2005; Hart
RG et al: Transthecal digital block: an underutilized technique in the ED. Am J Emerg Med 23:340, 2005; Hill RG Jr et
al: Comparison of transthecal digital block and traditional digital block for anesthesia of the finger. Ann Emerg Med 25:604,
1995; Kosnik J et al: Anesthetic methods for reduction of acute shoulder dislocations: a prospective randomized study
comparing intraarticular lidocaine with intravenous analgesia and sedation. Am J Emerg Med 17:566, 1999; Low CK et
al: Comparison of transthecal and subcutaneous single-injection digital block techniques. J Hand Surg [Am] 22:901, 1997;
Matthews DE, Roberts T: Intraarticular lidocaine versus intravenous analgesic for reduction of acute anterior shoulder
dislocations. A prospective randomized study. Am J Sports Med 23:54, 1995; Miller SL et al: Comparison of intra-articular
lidocaine and intravenous sedation for reduction of shoulder dislocations: a randomized, prospective study. J Bone Joint
Surg Am 84-A:2135, 2002; Miner JR et al: Randomized clinical trial of etomidate versus propofol for procedural sedation
in the emergency department. Ann Emerg Med 49:15, 2007; Orlinsky M et al: Comparative study of intra-articular
lidocaine and intravenous meperidine/diazepam for shoulder dislocations. J Emerg Med 22:241, 2002; Roback MG et al:
Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: are they
related? Ann Emerg Med 44:454, 2004; Ruth WJ et al: Intravenous etomidate for procedural sedation in emergency department
patients. Acad Emerg Med 8:13, 2001; Willman EV, Andolfatto G: A prospective evaluation of "ketofol"
(ketamine/propofol combination) for procedural sedation and analgesia in the emergency department. Ann Emerg Med
49:23, 2007.
Educational Objectives
| The goal of this program is to improve the performance of simple procedures (including procedural sedation) in the emergency
department. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Discuss the role of irrigation, soaking, and prophylactic antibiotics in the patient with a simple hand wound.
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| 2. Summarize how to evaluate and treat a patient with an eye injury.
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| 3. Describe a rational approach to the patient with severe epistaxis (nosebleeds).
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| 4. Explain how to perform a transthecal digital block.
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| 5. Summarize the American College of Emergency Physicians policy on procedural sedation and analgesia.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts
were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial
interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. Lex addressed the 16th Annual Emergency Medicine Conference, held September 13-16, 2006, in Las Vegas, NV, and
sponsored by Kaiser Permanente. Dr. Johnston addressed Contemporary Concepts in Clinical Emergency Medicine, held
June 7-9, 2006, in New York, NY, and sponsored by the Department of Emergency Medicine, New York University School
of Medicine, Postgraduate Medical School. Dr. Lovato addressed Advances in Emergency Medicine and Primary Care,
held April 19-21, 2006, in Las Vegas, NV, and sponsored by the Olive View–UCLA Department of Emergency Medicine,
and the American College of Emergency Physicians, State Chapter of California. The Audio-Digest Foundation thanks the
speakers and the sponsors for their cooperation in the production of this program.
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