- Hair Tourniquet Management
- Laceration Repair (Nail Bed)
- Laceration Repair (Tongue)
- Ring Removal
- Subcutaneous Abscess I&D
- Subcutaneous Extravasation/Infiltration Management
- Subungual Hematoma Evacuation
- Stapling (General)
- Suturing (General)
- Tissue Adhesives (General)
- Trigger Point Injections
Hair Tourniquet Management
Rapid Review
- Background
- Hair tourniquets occur when hair, thread, or other thin materials becomes tightly wrapped around an appendage (toe, wrist, penis, scrotum, tongue) and results in pain or injury. Can be removed using the unwrapping method, cutting method, or depilatory method
- Indications
- All cases of hair tourniquets should be managed
- Contraindications
- No contraindications.
- Complications
- Bleeding, infection. Incisional approach may damage underlying structures of affected site.
Pearls
- If skin is still intact, depilatory agents (ex. Nair) can be useful by dissolving the hair without having to risk injuring the surrounding soft tissue with needles or scalpels.
- A cutting needle (sharp edge on the concave side) can be a handy alternative to scalpels.
Laceration Repair (Nail Bed)
Rapid Review
- Background
- Nail bed lacerations commonly occur following compression/crush injuries to the digit and are typically repaired utilizing absorbable sutures or tissue adhesives.
- Indications
- Laceration of the nail bed
- Contraindications
- No absolute contraindications, though late repairs are often unsuccessful
- Complications
- Nonadherence, absent nail growth, infection, bleeding
Pearls
- Dermabond for nail bed laceration repair as been show to have similar function and cosmetic outcomes compared to traditional repair, while taking 1/3 of the time.
- Always use a finger tourniquet when possible to maintain a bloodless field.
Laceration Repair (Tongue)
Rapid Review
- Background
- Tongue lacerations can occur as the result of falls, blunt/penetrating, seizures, etc. Due to general blood supply, most tongue lacerations do not require repair unless they exhibit complex features.
- Indications
- Bisecting wounds, large flaps, U-shaped, gaping, or avulsion
- Contraindications
- Amputations or avulsions of more than 30% (requires flap procedure by specialist).
- Complications
- Infection, hemorrhage, airway compromise, disfigurement
Pearls
- To keep the tongue retracted during the procedure, have an assistant hold the tongue with gauze pads. If not feasible, you can throw a single 0-silk suture through the center of the anterior/midline portion of the tongue and use that to provide traction.
- Maintain a dry field by attaching suction tubing to compressed air and creating a mini “blow dryer”
Ring Removal
Rapid Review
- Background
- Ring removal can be accomplished using a manual ring cutter or by other means, such as the two rubber band technique, winding technique, compression technique, caterpillar technique, or twin threads technique.
- Indications
- Swelling or anticipated swelling in the ring finger from injury, infection, etc.
- Contraindications
- None
- Complications
- Digital nerve injury or injury to underlying tissue
Pearls
- Ring preserving techniques (rubber band technique, winding technique, compression technique, etc.) should be attempted prior to ring destruction techniques.
- An oxygen mask strap can be a useful (and perhaps more effective) alternative to suture threads for wrapping the finger.
Deep Dive
Subcutaneous Abscess I&D
Rapid Review
- Background
- Due to inability of antibiotics to penetrate the abscess cavity, subcutaneous abscess must be drained for complete resolution.
- Indications
- Abscess of the skin or superficial soft tissue
- Contraindications
- No absolute contraindications. Deep/large abscesses or abscesses in highly cosmetic areas may require operating room management.
- Complications
- Infection, damage to surrounding structures.
Pearls
- Point of care ultrasound can be useful in identifying the depth and extension of the abscess prior to incision.
- The loop drainage technique can be a useful, less-invasive alternative method to traditional incision & drainage.
Deep Dive
Subcutaneous Extravasation/Infiltration Management
Rapid Review
- Background
- Extravasation of certain IV fluids or medications can cause significant tissue injury or necrosis. Management includes cessation of fluid, aspiration of remaining drugs, injection of drug-specific antidote, and other conservative measures.
- Indications
- Extravasation of tissue-damaging solutions (sodium bicarb, dextrose, vasopressors, TPN)
- Contraindications
- None
- Complications
- N/A
Pearls
- Although your instincts will be to remove the IV catheter immediately following extravasation, it is important to leave it in place until aspiration can be attempted.
- There are specific antidotes that can be used depending on which medication was extravasated. Options include phentolamine (vasopressors), topical nitroglycerin (vasopressors, methylene blue), hyaluronidase (hyperosmolar agents such as mannitol, calcium, dextrose, benzodiazepines, or ampicillin)
Subungual Hematoma Evacuation
Rapid Review
- Background
- Also known as “nail bed trephination”. Involves draining blood from underneath the nail to relieve pain and discomfort
- Indications
- Painful subungual hematoma with nail edges intact
- Contraindications
- If the wound is not painful or is already spontaneously draining. Do not evacuate hematoma if nail removal is already indicated for complex nail bed lacerations. Do not use electrocautery tool on acrylic nails (may be flammable)
- Complications
- Injury to nail bed, infection, or incomplete drainage
Pearls
- Do not use a cautery device on artificial nails (may be flammable)
- Avoid advancing the needle/cauteryl too deep to prevent injury to the nail bed.
Stapling (General)
Rapid Review
Pearls
Deep Dive
Suturing (General)
Rapid Review
- Background
- Suturing lacerations helps facilitate biological healing by joining wound edges and minimizing scar formation. There are various techniques of suturing, depending on the size, shape, and depth of the wound.
- Indications
- Clean lacerations that have occurred within 24 hours and not at significant risk for infection.
- Contraindications
- Dirty wounds, body lacerations >12 hours old, face/scalp wounds > 24 hours old
- Complications
- Hematoma, infection, hypertrophic scarring, wound dehiscence
Pearls
- Irrigate and explore the wound thoroughly prior to closure to avoid missing any foreign bodies. Consider imaging if needed.
- Chances of a successful repair with good cosmesis are maximized when using the right type of suture, the right size, and the right technique.
Deep Dive
Tissue Adhesives (General)
Rapid Review
Pearls
Deep Dive
Trigger Point Injections
Rapid Review
- Background
- Injection of local anesthetic into myofascial trigger points (“knots”) for therapeutic relief. Common in masseter, levator scapulae, trapezius, and quadratus lumborum
- Indications
- Myofascial trigger points
- Contraindications
- Overlying infection, unclear anatomical landmarks, severe fibromyalgia
- Complications
- Vascular injury, allergic reaction to anesthetic, infection
Pearls
- Avoid causing a pneumothorax when treating trigger points on the thoracic region by pinching the affected tissue and pulling it away from the intercostal spaces prior to injection.
- Injecting sterile saline or simple dry needling may be just as effective as injecting local anesthetic
