3-5 mg/kg of Lidocaine s epi
5-7 mg/kg of Lido c epi
Lidocaine will last 20-30 min in infiltration and 30-120 minutes for blocks
1cc Bicarb for 9cc 1%, less for 2%
2-3 mg/kg of bupi s epi (1 cc/kg of .25%)
3-4 mg/kg of bupi c epi
Bupi will last ~4 times longer than lidocaine
Use 0.1 cc for 20 cc of Bupi
1 meq/cc Bicarb (Cardiac Syringe)=8.4%
To add epi to above:
Concentration should be 1:100,000=
For 50 cc vial, add 500 mcg or 0.5 cc of 1:1000
Lido and Bupi are amides (as are any with i in first part of name)
Multi-dose vials have a preservative which can be allergenic
Benzyl alcohol .9% with epi 1:100,000 is alternative in lido allergic (JEM 21:4)
Benadryl also works great, but you must dilute from vial which is 4% to 1%
Digital block using flexor tendon sheath
Insert into tendon at distal palmar crease without a syringe.
Flex and extend finger, should see needle swinging widely
Attach syringe and inject, if there is resistance withdraw slightly
You know that 1% lidocaine contains epinephrine at 1:100,000 (youve seen this on the bottle). You also have epi for sub-Q at 1:1000.
Hmm. What does 1:100,000 mean? 1:1000? For that matter what does 1% mean? Why didnt someone teach me this in medical school?
Dont panic, it is really easy. Start with the realization that percent (%) is equal to 1:100, just nobody writes it that way. Then realize that each of these ratios represents grams per cubic centimeters (or mls). So:
1% = 1:100 = 1 gram per 100 cc = 1000 mg/100cc = 10 mg/cc (standard lidocaine for infusion concentration)
1:1000 = 1 gram per 1000 cc = 1000 mg/1000 cc = 1 mg/cc (epi for sub-Q)
1:100,000 1 gram per 100,000 cc = 1000mg/100,000 cc = 0.01 mg/cc
You also note (with increasing excitement as you realize how simple this is!) that the bottle of 1% plain lido is a 30cc bottle.
So: 0.01 mg/cc times 30 cc equals 0.3 mg. Since you have epinephrine at 1 mg/cc, you can draw up 0.3 cc of this solution (use a tuberculin syringe) and add it to the lidocaine jar. Viola! You now have 1% lidocaine with epinephrine 1:100,000!! You are so slick.
Signs of systemic toxicity include: metallic taste, perioral numbness, ringing in ears, twitching of face, convulsions
Bier block procedure
Prior to the procedure, patients were given written information on the procedure, and informed consent was obtained. The technique of Bier block used at the WHCC is identical to that described in the emergency medicine literature,1 with the exception that the injured arm is simply elevated for 2 minutes before cuff inflation rather than exsanguinated. The insertion of an IV line in the unaffected arm was discretionary. The upper arm was wrapped with cast felt padding before the application of the pneumatic cuff, to reduce the risk of pinching or bruising. A 0.5% solution of lidocaine in a dose of 1.53 mg/kg was used, according to physician preference. Local anesthetic was slowly injected through an indwelling cannula and the patient was advised that the arm would tingle and feel warm (or cold) and that the skin would become mottled. The cannula was removed immediately after injection of the anesthetic, and bleeding was prevented by using a small (22-guage or smaller) catheter and by holding pressure on the site for several minutes after the cannula was removed. The risk of cuff leak was minimized by using an anesthetic injection site at least 10 cm distal to the cuff and inflating the cuff to at least 250 mm Hg, regardless of patient age. A second (distal) cuff was available, and was usually only employed if the procedure took longer than anticipated, resulting in discomfort at the proximal cuff site. The arm was typically anesthetized and appropriate for reduction at 1520 minutes post injection. The Bier block and reduction were performed by the attending primary care physician. Bier block guidelines at WHCC stipulate that the pneumatic cuff must be inflated to at least 100 mm Hg above the patient’s systolic pressure for a minimum of 30 minutes and no longer than 90 minutes. The cuff was deflated using a “deflation/re-inflation” technique to reduce the risk of a significant IV bolus of lidocaine reaching the central circulation, whereby for 3 cycles the cuff is deflated for 5 seconds and then re-inflated for 1 minute. In 2004 a mini-C-Arm (General Electric OEC) was obtained by WHCC. Post-reduction radiographs were routinely obtained, either before or after cuff deflation at the attending primary care physician’s discretion (depending on the confidence of reduction success).
A review (Emerg Med J 2013;30:214-217)
LET Application Instructions. Use 1-3 cc of LET (works best if blood and debris are removed from wound). Gel Apply to wound and wound edges with a cotton-tip applicator. The wound is NOT covered (as it is with solution). The LET is usually effective in 20 min, at which time skin around the wound appears blanched, due to the epinephrines effects. The gel should be removed prior to suturing. LET gel anesthesia lasts about 45-60 min after it is removed from the wound.
Solution Paint solution onto wound and wound edges with cotton-tip applicator. Then apply a cotton ball saturated with LET to the wound. Immunocompromised status The LET is usually effective in 20 min, at which time skin around the wound appears blanched, due to the epinephrines effects. *Source: Adapted from: Kennedy RM, Luhmann JD. The ouchless emergency department getting closer: Advances in decreasing distresss during painful procedures in the emergency department. Paediatr Clin North Am. 1999;46:1215. See Reference 224.
No Gloves Necessary
816 patients, no increased infection rate (Annals 2004, 43:3, p.362)
Restudy proving tap water is as good as sterile (Acad Emerg Med 2007;14:404)
To simplify glue administration, one
can draw up the glue into a 1 ml tuberculin syringe, after first puncturing
the vial with finger pressure, as if the vial were to be used. The needle of
the tuberculin syringe is passed through the cotton pledget at the tip of
the vial, and the purplish glue is drawn from vial to syringe. The vial and
needle are then discarded, and the needle replaced with a 24 gauge plastic
If gentle separation of the lashes is not possible, application of liberal mineral oil/petroleum jelly may allow for mechanical lysis of the adhesions within minutes. If this is still not successful, the application of mineral oil/petroleum jelly under pressure patching overnight will frequently allow for separation upon recheck the next day. Some recommend patches soaked in normal saline.
put tegaderm over eye
Tissue adhesives for wound closure often seem to intentionally make a bee-line straight for high-risk areas such as the eye. To avoid inadvertent application of the tissue adhesive, Dr. Hagop Afarian (UCSF-Fresno) utilizes a transparent tegaderm tape with an oval cut out of the center to provide a protective barrier. Immediately after application of the tissue adhesive, the tegaderm can be carefully peeled off to reveal a still-drying, well-circumscribed aliquot of glue over the wound. Be sure that the wound is dry, and the edges are well-apposed prior to tissue adhesive application.
Hair Apposition Technique
(Annals 2002 40:1)
Always place needle holder between two ends, wrap around towards other end, and then pull ends towards opposite sides
Can use dremmel multipro c high speed tungsten carbide cutting disc at maximum rpm with piece of splint under ring. (J. Emerg Med 20:3)
Stapling can be used for trunk and extremity wounds as well as scalp. (Annals EM 18:10, 1989. p. 1122 JB-P)
Consider taping alone or tape parallel to the wound edges and suture through the tape.
place fine mesh gauze
wrap in compressive dressing
bring back in 72 hours
Figure 3. Technique For Closing Avulsion Of Gingival Mucosal Tissue.
The technique to close this injury is shown. The sutures are brought around the teeth and through the avulsed tissue flap (insets).
Used with permission from: Trott A. Special Anatomic Sites. In: Weimer R, Cochran A, eds. Wounds and Lacerations: Emergency Care and Closure. St Louis, MO: Mosby-Year Book; 1991:172. Figure 1.
Technique For Closing Avulsion Of Gingival Mucosal Tissue When A Needle Cannot Be Passed Between The Teeth.
The technique of flossing the suture material through the teeth in cases in which the needle cannot be passed between the teeth because of tight interproximal contacts: A. Pass needle through facial tissue then floss through teeth. B. Pass needle through palatal tissue. C. Pass needle through palatal tissue again and floss through teeth. D. Tie suture on facial aspect.
Used with permission from: Trott A. Special Anatomic Sites. In: Weimer R, Cochran A, eds. Wounds and Lacerations: Emergency Care and Closure. St Louis, MO: Mosby-Year Book; 1991:172. Figure 2
Plastics Level Facial Closure
Academic Emergency Medicine Volume 11, Number 5 561-562, © 2004 Society for Academic Emergency Medicine Single- vs. Double-layer Closure for Facial Lacerations Adam J. Singer, Janet Gulla, Michele Hein, Scott Marchini, Stuart Chale and Balvantray P. Arora Stony Brook University: Stony Brook, NY ABSTRACT OBJECTIVE: To compare cosmetic outcome of facial lacerations closed with single or double layer of sutures. METHODS:DesignRCT. SettingUniversity-based ED, annual census 75,000. SubjectsED patients > 1 yr with non-gaping (width < 10 mm), linear, facial lacerations. InterventionsFollowing standard wound preparation, lacerations were randomized to closure with single layer of simple interrupted 6/0 polypropylene sutures or double layer of simple interrupted 6/0 polypropylene plus inverted deep dermal 5/0 polyglactin sutures. Masked OutcomesDuration of closure; 5-10-day wound infection rates; 90-day patient- and practitioner-assigned cosmetic scores (100-mm VAS from 0 [worst] to 100 [best]); percentage of wounds with optimal wound evaluation score (WES) of 6/6 at 90 days; and scar width at 90 days. Data AnalysisOutcomes were compared with chi-square and t-tests. A sample of 60 patients had 90% power to detect a 17-mm difference in cosmetic VAS scores. RESULTS: 60 patients were randomized to single- (30) or double (30)-layer closure. Mean age (SD) was 18.7 years (20.3); 15% were female. Mean (SD) laceration length and width were 2.5 (2.8) cm and 3.1 (1.9) mm, respectively. Groups were similar in baseline patient and wound characteristics. Length of single-layer closure was 6 minutes shorter (95% CI, 1-11 minutes) than double-layer closure. There were no infections in either group. 90-day follow-up rates were 89% and 97% for single- and double-layer closure groups, respectively. There were no between-group differences in patient (mean difference 1.4 mm [95% CI, 5.6 to 4.4]) or practitioner (mean difference 3.2 mm [95% CI, 3.2 to 9.6]) VAS scores. All patients in both groups received optimal WES scores of 6. Scar widths were similar at 90 days (mean difference 0.16 mm [95% CI, 0.4 to 0.15]). CONCLUSIONS: Single-layer closure of non-gaping facial lacerations is faster than double-layer closure. Cosmetic outcomes and scar widths are similar in sutured wounds whether or not deep dermal sutures are used.
Other clues for parotid injury include saliva leaking from the wound and/or blood seen coming from the duct opening (Stensons duct) inside the cheek at the level of the upper second molar. The three branches of the trigeminal nerve (supraorbital, infraorbital, and mental nerves) provide sensation to the face, and intact sensation on the face also should be documented. Facial nerve integrity can be established only by testing (and documenting) the function of all five branches. (See Facial Nerve Injury below.) In summary, if the patient can lift the forehead/brow, open/shut the eyes, move the lips in a smile or frown, and have contraction of the platysma when shrugging shoulders, the facial nerve is intact. Patients unable to cooperate with testing due to head injury or intoxication are likely to be admitted or observed until their mental status clears, but if discharged from the ED, one must remember to test and document nerve function before discharge. This easily can be overlooked when the patients stay extends beyond the first physicians shift.
Clues to diagnosis start with a high index of suspicion in any laceration between the tragus and the mid-cheek. Remember that one also should consider the diagnosis with fractures of the mandible or zygomatic arch.30
The next step is to thoroughly examine any wound on the cheek to see if the duct is visible in the wound. Then one should milk the parotid gland and look for blood at Stensons duct, located just inside the cheek at the level of the upper second molar.
Lacerations located lateral to a vertical line running through the lateral canthus of the eye and involving any of the branches of the facial nerve generally are considered for microscopic repair of the transected nerve tissue with 8.0 or 9.0 nylon epineural simple suture. Nerve injuries that result from lacerations medial to this line generally are not considered repairable, owing to the small caliber of the nerve. Figure 4. Facial Nerve and Parotid Gland: Note that the parotid duct lies roughly along a line drawn from the tragus to the mid upper lip. It enters the oral cavity along a line from the pupil to the mental nerve. The facial nerve divides into five main branches inside the parotid gland. Any laceration of the parotid gland or duct mandates an exam for facial nerve injury.
peridex 0.12 % 15 cc swish 30 sec and then spit
Use kling, then take two 10-15 cm pieces of umbical tape thread a piece at each ear with hemostat and then tie.
Trott 3rd Edition of Emergency Wound Care
Hemostasis-all bleeding but minor oozing should be controlled before wound repair
Anesthesia-a pain free repair is essential
Irrigation-Most important step for reducing infection
Exploration-in a bloodless field with good light/exposure
Remove devitalized or contaminated tissue-spare as much good skin as possible, but debride it all
Tissue preservation-Do not excise tissue, tack it down, it will allow the plastics folks to have a palette to work with later.
Closure Tension-wound edges should just barely touch. use undermining or deep stitches to avoid having to smash the edges against each other
Deep sutures-use as few as possible
tissue hadling-always be gentle
Wound infection-the most important dose of abx is the one given IV as soon as the patient arrives
Dressings-wounds heal best wet
Vicryl Rapide is irradiated polyglactin-910. Dissolves in 7 days; may be used for lac repair without stitch removal.
for delayed primary closure
give 4-5 days of antibiotics, then bring pt back, debride and close
can use chromic gut to close scalps, even better is vicryl rapide
erythema 5-10mm from abscess or wound edge is normal, beyond is cellulitis
DISCUSSION Cyanoacrylate adhesives were invented by Dr Harry Coover ofKodak Laboratories when he was trying to make clear plasticsuitable for gunsights.1 These were methyl-2-cyanoacrylate andwere found to be tremendously strong. These and similar short chain cyanoacrylates experienced commercial success and became generally known as “superglues”. In the 1950s and 60s, methyl-2-cyanoacrylateadhesive was used to bond skin and control bleeding in open wounds. Disposable cyanoacrylate sprays were used to control haemorrhage in the Vietnam War. However, it became apparentthat methyl-2-cyanoacrylate provokes acute and chronic tissuereaction. They also cause histotoxicity because of the exothermicnature of the polymerisation reaction of these short chain cyanoacrylates. Furthermore, they generate local high concentrations of breakdown products, which include formaldehyde and alkylcyanoacetate.2 As a result, compounds were developed that were more compatible with human tissue. These used monomers with longer alkyl chains, which owing to their slower degradation, cause less histotoxicity. These are used for wound closure and embolisation. They canalso be used as dressings for burns, minor cuts, abrasions andmouth ulcers. They have been shown to provide a waterproof antimicrobialbarrier and improve epithelialisation and wound healing.3
They are, therefore, quite different from superglues and muchmore expensive to produce.
Proper use of cyanoacrylate tissue adhesives for wound closure:
- 1 Wound should be in horizontal plane to prevent run-off.
- 2Wound should be clean and dry, haemostasis essential.
- 3 Woundedges opposed with only minimal tension.
- 4 Deep dermal suturesmay be necessary to take tension off woundedges.
- 5 Adhesiveapplied to opposed edges to act as bridge acrosswound.
- 6Do not get adhesive into wound.
- 7 Do not tell patient youare using superglue.
Go to source: Case of the month: Honey I glued the kids: tissue adhesives are not the same as “superglue” — Cascarini and Kumar 24 (3): 228 — Emergency Medicine Journal
Stopping the Bleeding (from James Adams Lecture)
From skin gelatin
Liquefies in 2-5 days in nose, rectum
Serves as a scaffold for coagulation
Oxidized Regenerated Cellulose
Johnson and Johnson
Binds platelets and chemically precipitates fibrin.
Cannot be mixed with thrombin
decellularized bovine source
Stimulates platelet adherence
Stops venous ooze
active part of the clotting cascade
Absorbed 90 days
Not likely to be useful for pumping arterial hemorrhage
Apply to the site of bleeding with pressure
Easily removed after hemostasis is achieved
When direct pressure does not work: Options
Bovine Thrombin, 5000u or 10,000 u
Cleaves fibrinogen to fibrin
Positive feedback to coagulation cascade
Mix powder with CaCl and spray
Can mix with gelfoam, not surgicel
Thrombin + Gelfoam + CaCL
Thrombin for cleavage/activation
Gelfoam as a matrix
Sucralfate for adherence
Mix and pack
FDA approved 1998
Concentrated fibrinogen with factor VIII
Thrombin and Calcium
Aprotinin to prevent clot dissolution
Takes time to prepare
Bovine Thrombin and CaCl
Human Fibrinogen and Factor VIII
Aprotinin for antifibrinolytic activity
Special heating and mixing
Applied through simultaneous spray or mist of the 2 syringes
1940s: fibrinogen (in cryoprecipitate) and thrombin were combined during surgical
1960s: concentrated fibrinogen developed
Good for diffuse oozing, needle punctures, lymphatic leaks, diffuse parenchymal organ
Used for hemostasis and adhesion
Liver and spleen lacerations
Dental extractions in hemophiliacs
Hemostasis at cannulation sites and vascular grafts.
Sealing dural leaks
Bone, lung, tissues
Superior Cluneal Nerve Block for Buttocks Abscess Drainage (J Emerg Med 2010;39(1):83)