History

5 year female presents to your facility with chief complaint of “She was running and fell and hit her chin and now it’s bleeding”.  Your patient is normally healthy without any daily medications and an unremarkable medical history.

Presentation and Exam Findings

Your patient is upset.  She’s a kid and she’s crying.  Not just crying, she’s wailing.  You don’t want to judge her parents, but you already have.  So, her airway’s fine.  You notice her mom holding a washcloth over her chin.  You introduce yourself and ask permission to examine the child.  She looks up at her mom and says, “noooo”.  It is then that you notice a 3cm mildly gaping mildy bleeding laceration to the inferior midline chin.  Classic pediatric laceration.  You direct your penlight toward the child’s face and ask her to open wide.  She opens wide by saying, “nooooo”.  You somewhat fully assess her teeth and find that there are no observable tooth fractures, tongue, or buccal surface lacerations.  Her mother denies loss of consciousness following the fall, as well as vomiting.

Concerns and Approach Considerations

No concern for airway in this patient.  No concern for secondary other secondary injuries.  The patient is wailing and will very likely not be a candidate for active-distraction closure.  The laceration is large enough that closure will require some modest time and effort.  Glue is not the best option given the length and mildly gaping presentation of the laceration.  Closure could be attempted with a single steri-strip over the midline of the wound, effectively bisecting the wound and reducing the gape, then following with glue at the edges.  However, poor approximation is a risk with this approach.  The best approach for closure is suturing with initial application of a clear adhesive dressing over LET or EMLA cream and allowing it to sit for 20 minutes.  Then, revisit the patient and attempt distraction techniques to facilitate closure.  If distraction doesn’t work, moderate sedation is the best option to achieve a good cosmetic outcome.  You assess for medication allergies and find that the patient has no known medication allergies.  You discuss the risks and benefits of moderate sedation with the patient’s family, including the risk of respiratory distress and decompensation, and the benefit of maximum potential cosmetic outcome and decreased emotional trauma.  The family agrees to proceed with moderate sedation.  IM ketamine with a target dose of 4-5mg/kg is initiated along with the full spectrum of your facility’s moderate sedation protocol.  You are able to close the wound with good approximation, patient response, and eventual cosmetic outcome.  You remember that antibiotics aren’t indicated for this patient’s wound.

Consider the following questions:

T/F: When dealing with pediatric patients, it is very important to ask both the patient and their parents for permission to begin the exam.

The best way to initially anesthetize a pediatric wound is through which method?

History

28 year male patient presents with chief complaint of LEFT hand index finger laceration and “I was field dressing a deer and the knife slipped.”  Your patient has a baseline health status remarkable for chronic seasonal allergies and mild controlled IBS.  His last tetanus immunization was 2 years ago.

Presentation and Exam Findings

Your patient is appears relaxed and without distress of any kind.  His vital signs are within normal limits.  All systems are negative on physical exam with exception of 2cm laceration of LEFT index finger located at lateral distal interphalangeal joint (essentially on the side of the joint).  Physical exam of the affected finger, which includes a comparison exam of the contralateral finger, demonstrates no deficits in sensation, motor function and strength across the range of motion, or circulation.  There is a mild pulsatile flow of blood at the wound.

Concerns and Approach Considerations

Given laceration via sharp (and intact) metal object, foreign object is not a concern.  Physical exam reveals no cause for concern for injury to functional soft tissues beneath the skin.  Physical exam, by the way, was completed before analgesia was delivered.  The reason for this was so that sensation could be fully assessed.  After consideration, you decide the best way to anesthetize this wound is through digital block using 6mL of bupivacaine 0.5% delivered in the normal fashion for digital block.  Five minutes following digital block, you instruct the nursing staff to soak the patient’s finger in a solution of 50% chlorhexidine gluconate and 50% sterile water for 20 minutes.

Following the soak, you further inspect the patient’s wound and note the absence of foreign body, a 0.5cm depth, and mild gaping.  The laceration is linear in shape.  There’s still that mild pulsatile bleeding, though, so you unfold a piece of 4×4 gauze, gently twist it into a single length (like a thick string), and tie it with moderate pressure at the base of the affected finger.  The pulsatile bleeding slows down, then stops.

The wound is further irrigated and scrubbed.

Once you have verified appropriate analgesia, you close the finger with 4-0 non-absorbable suture in simple interrupted or running-locking fashion.  You remove the tied-off 4×4 and note that the wound is hemostatic.  You apply a ribbon of antibacterial ointment to the sutured wound, cover with a non-stick dressing, and then apply a padded aluminum splint.  You instruct the patient to wear the splint for as long as the sutures are in the finger.  The splint prevents the sutures from popping out.  Make sure your patient know this.

Now, what about antibiotics?  The patient was field dressing a deer and we’re not sure if the wound was contaminated with feces.  One option is to prescribe prophylactic treatment with a short course (2 to 5) days of cephalexin PO QID.  A 2012 study showed that 2 days of prophylactic antibiotic coverage were at least as effective as 5 days in preventing wound infection.  A second option is to rely on the 20 minute soak and thorough irrigation and scrubbing as prophylaxis enough.

Consider the following questions:

Why is it important to conduct a physical exam of fingers, hands, toes, and feet prior to delivery of analgesia?

T/F: Extremity wounds should be soaked in a mixture of 50% sterile water and 50% surgical cleansing solution for 20 minutes prior to closure.

History

A 56 year female patient presents to your facility with chief complaint of “I was getting up from bed tonight and I slipped and fell into my night stand.”  She complains of LEFT ear laceration with bleeding.  Her baseline health status includes controlled hypertension, hypothyroidism, and insomnia controlled well with mirtazapine.  She denies loss of consciousness and vomiting.  She denies pain except at her ear.  Her tetanus status is unknown.

Presentation and Exam Findings

Your patient’s vital signs are normal and stable.  She appears well kept in a night robe stained only with blood.  Upon close visual examination of her LEFT ear, you note a laceration completely through the helix extending from the posterior contour midway through the body of the ear.  There is visible cartilage and the edges of the laceration are effectively unmacerated.

Concerns and Approach Considerations

You decide to anesthetize her ear through local infiltration of 1% plain lidocaine.  You achieve this using a 25 gauge needle inserted directly into the skin layer of the laceration circumferentially and with small amounts of infiltration per push.  After 2 minutes, she reports that her pain has diminished.  You begin cleaning and irrigating the ear with sterile water and chlorhexidine gluconate.  You gently scrub the anterior and posterior aspects of the wound.  After infiltration of the lidocaine, you notice that the bleeding has decreased.

For closure of the laceration, you decide to use a non-absorbable 5-0 nylon suture on an 11mm needle in simple interrupted fashion.  You first suture is on the posterior aspect of the ear, bisecting that section of the laceration.  Your second suture is on the outer contour of the ear and you notice that the interior cartilage is not allowing full re-approximation of the overlying skin.  Using iris scissors, you trim a small piece of interior cartilage away.  After re-placing the second suture, you note full approximation of the overlying skin.  Your third suture is on the anterior side of the ear, bisecting that section of laceration.  You continue closing the laceration in simple interrupted fashion, placing your sutures about 0.5cm apart.  The skin appears well approximated and fully covers underlying cartilage.

You apply a ribbon of antibacterial ointment circumferentially to the wound and then place gauze padding at the posterior and anterior aspects of the ear, which provide firm support.  A gauze turban is then wrapped around the patient’s head to encompass this gauze padding.  In this way, you address the potential for auricular hematoma.  You instruct a nurse to administer a tetanus booster (TD not Tdap), and you instruct the patient to keep the wound clean and dry, avoiding submersion, and to change the dressing over her ear once daily.  You note that antibiotics are not indicated for her wound.

Consider the following questions:

Why is it important in ear lacerations to ensure the underlying cartilage is fully covered by overlying skin?

Following closure of ear lacerations, what is the most important preventive measure that should be taken?

History

A pleasant 37 year female presents to your facility after having fallen on a walking track.  She reports, “I’ve been trying to lose weight and I was jogging and lost my footing and fell onto my knee.”  She complains of LEFT knee pain with obvious skin damage.  Her baseline health status is obese without complications.  She takes no daily medications with the exception of birth control.  She was brought to the exam room via wheelchair and was helped to the exam table by nursing staff.

Presentation and Exam Findings

Initial vital signs show mildly elevated blood pressure, but are otherwise within normal limits.  She reports her pain is 8 out of 10.  She denies pain anywhere except the LEFT knee.

Concerns and Approach Considerations

Knowing that knees plus obesity plus falls can sometimes lead to injury to supportive soft tissues, you decide to get an initial LEFT knee series of radiographs.  While you’re waiting on the radiographs to be taken, you take the initiative to provide pain relief.  You ask her if she has any allergies and she responds, “no, but I had some dental work done one time and the dentist told me my body didn’t respond well to the numbing medicine.  They had to use a lot of it to get my mouth numb.”  On this queue, you decide to use 2% plain lidocaine, versus 1%, to achieve a stronger degree of analgesia.  You locally infiltrate the lidocaine into the knee laceration in the normal fashion, and you begin to see that the skin which overlies the patella presents as a flap laceration.  You’re glad, at this point, that you decided not to use lidocaine with epinephrine because epinephrine can cause moderate vasoconstriction in flaps that could delay or prevent healing.  The radiographs are completed and you note nothing remarkable.  Physical exam, including active and passive range of motion and assessment of pedal pulses, yields no deficits or remarkable findings.  There is no popliteal tenderness and popliteal pulses are present and equal bilaterally.

You decide to close the flap after irrigating with sterile water and scrubbing with a surgical cleanser, clearing debris from the wound, and ruling out foreign body.  You pull the flap down to assess for a natural re-approximation and notice that the flap does not want to stretch to the full extent of the underlying subcutaneous tissue.  It appears to have shrunk due to the elastic nature of skin.  You decide that your first suture should act as an anchor and you place it at the apex of the flap using the horizontal mattress technique.  This allows for good tissue apposition.  The remainder of your closure consists of a running suture technique on either side of the anchor suture.  All associated tissues appear vitalized and you are happy with the end result.  You place the patient in a knee immobilizer and instruct her to wear it while sutures are in place.

Consider the following questions:

Use of 2% lidocaine is an important step toward analgesia in some patients for what reason?

T/F: Anchor sutures are best used as substitutes for simple interrupted sutures; both techniques have the same indications for use.

History

An inebriated 43 year male presents to your facility after stumbling over some rocks.  With appreciation for his state, he is pleasant and regards you with a smile.  He is a poor historian and the mix of ethanol and urea peppering his bouquet provide you with an impetus to keep your interview short.  He complains of needing to use the bathroom.  His RIGHT foot is bleeding, however.  He was barefoot, after all, when he stumbled.  He cannot recall what tetanus is when you inquire about his immunization status.  He begins to vomit.

Presentation and Exam Findings

After clearing him from a brain bleed via emergent non-contrast CT, you get up close and personal with his RIGHT foot.  You ask the nurse to please bring some peppermint oil into the room (you ED folks know what I’m talking about).  The foot, you note, presents with a 1.5cm laceration between the great and 2^nd toes.  The wound is presently hemostatic and does not appear to penetrate too deeply.  Given your patient’s state, you increase the volume and decrease the speed of your voice and ask, “does this hurt”.  He asks, “what?”  You proceed to push and mash and poke and find no crepitus, normal passive range of motion of the toes, normal circulation, and a normal Babinski (in his state, this is a good way to elicit partial active range of motion).  Your physical exam includes the foot and ankle and distal lower extremity in a detailed way, as well as a cursory trauma exam for the rest of his body.  He has incurred no secondary injuries.  He is smiling at you again.  His vital signs are within normal limits.

Concerns and Approach Considerations

After updating his tetanus, you anesthetize the wound with 1% plain lidocaine.  This is easily done, as your patient is snoring.  You then decide a foot soak in 50% chlorhexidine gluconate and 50% sterile water is in order.  As it turns out, this causes more urea to be added to the bouquet about your patient.  But, he does keep his foot in the soak for 20 minutes.  Following the soak, you scrub the wound and find a chunk of glass that you extract with forceps.  No other shards are apparent, but you get a plain film foot series to assess for other foreign bodies.  You recall that glass is somewhat visible on plain radiographs.  Your assessment, as well as the assessment of the radiologist, is that no additional foreign bodies are present.  This is congruent with clinical presentation, so you re-scrub the wound and close with 4-0 nylon on an 11mm needle in simple interrupted fashion.  You’re using an 11mm needle because the contour of the wound between two toes makes using any larger needle almost impossible.  You close the wound and decide to throw in some thiamin IM for kicks and giggles.  Your patient is discharged wearing a post-op shoe after he is able to walk in a straight line.  Is there concern for infection in this patient?  Yes.  There is concern.  However that concern is based not on the location of the laceration (foot lacerations infrequently become infected) but on the hygiene patterns of the patient.  You could prescribe him a prophylactic antibiotic.  Whether he keeps up with his papers, remembers that he has a prescription, or even fills it is up to him.

Consider the following questions:

T/F: Glass is normally somewhat radiopaque on plain film radiographs.

Why is this patient discharged in a post-op shoe?

History

An athletic 17 year male presents to your facility after working on his family farm and sustaining a laceration to his posterior LEFT distal lower extremity, right above the posterior heel.  His immunization status is current, and he does not take any daily medications.  He is a football player, and also runs on a cross country team.

Presentation and Exam Findings

This strapping lad’s vital signs are within normal limits.  He shows signs of obvious emotional distress.  His parents are with him in the exam room.  You introduce yourself and ask to examine the patient.  Upon examination you note a mostly hemostatic 3cm linear non-gaping laceration over the LEFT Achilles tendon.

Concerns and Approach Considerations

Your first thought is to anesthetize the wound.  You do this with 1% plain lidocaine, injected in the normal fashion.  Your next thought as about his Achilles tendon.  You ask him to turn over onto his belly slide down the exam table so that his feet are hanging off.  You instruct him to relax his legs.  You squeeze his RIGHT calf first, noting a brisk and strong plantar flexion response (his RIGHT foot pushes down like on a pedal).  You compare that response to his LEFT by squeezing that calf.  There is limited plantar flexion.  This is the Thompson test and your patient is positive on the LEFT.  His Achilles tendon is severed mostly or completely.  This prompts you to consult an orthopod.  They instruct you to cleanse the wound thoroughly and loosely suture it closed.  The also instruct you to give the patient 1 gram of an IV cephalosporin.  You note the time this consultation occurred, the orthopod’s name, and their instructions in the chart.  Then, you execute those instructions.  Using the simple interrupted technique, you tie your knots loosely, allowing about one half centimeter of space between the wound edges.  Your patient is admitted under the service of the orthopod and an MRI is performed the next day.  Surgical repair of the Achilles tendon is completed by the orthopod on day two.

Consider the following questions:

The Thompson test assesses integrity of which tendon?

Loose closure, as instructed by the orthopod in this case, means what?

History

A 3 year male presents to your facility with complaint from mother, “he fell against the coffee table and bumped his head. Does he need stitches?”  He has not vomited and is normally healthy.  His immunization status is current.

Presentation and Exam Findings

The child is smiling at his mother when you enter the exam room.  His smile quickly fades and he regards you with a weary stare.  You introduce yourself and ask permission to examine the patient from his mother.  She consents, and you then ask the patient if you can see his hurt spot.  You note neatly trimmed, close-cut hair and a 5mm superficial and very hemostatic laceration to his RIGHT lateral scalp.  You give the patient a good squeeze and poke over his neck, shoulders, back, chest, arms, and belly.  He laughs when you poke and squeeze his belly.  He does not appear to be injured anywhere else.

Concerns and Approach Considerations

Does this child’s wound need closure.  Very likely it does not.  A 5mm superficial laceration does not gape so scarring will be minimal.  Infection risk is also minimal.  The wound is not bleeding.  You discuss approaches with the mother which include a single staple (you spell this word out so your patient doesn’t hear an alarming word), a single suture, or doing nothing as the wound will most likely heal well on its own.  You explain that stapling or suturing will require injection of an anesthetic.  Even if you were to buffer the anesthetic with sodium bicarbonate in a 9:1 solution thus reducing the acidity of the 1% plain lidocaine, the child would still experience an emotionally traumatizing procedure.  You make sure the mother understands that infection risk is extremely low, and that scarring will be essentially equal among all approach options.  She decides to go with non-closure.  You gently clean the wound with sterile water and mildly scrub with chlorhexidine gluconate.  Then you apply a small ribbon of antibacterial ointment to the wound, smile, and tell the patient he did a great job.

Now, some in our field might protest and insist the wound needed closure.  They might even assert that distracting the child and inserting a single staple without anesthetizing the wound would be the best option.  I disagree.  Your job is to do what’s most right for the patient.  Not closing and allowing the wound to heal through secondary intention does no harm to the patient.  Emotionally traumatizing the patient, likely making staple or suture removal an even worse ordeal for a 5mm superficial laceration – that does not seem to be in the patient’s best interest.  Some might assert that gluing was a better option.  Perhaps, but scarring potential is equal with gluing versus secondary intention in a linear non-gaping small superficial laceration of the scalp.  I would always opt for non-closure in this case.  But the parents need to understand their options and the risks and benefits of each.

Consider the following questions:

T/F: Your number one job with any patient is to first do no harm.

Buffering lidocaine means doing what?

History

A 55 year female presents to your facility after having fallen at home.  She has arrived via EMS.  Their report includes a stable set of vital signs remarkable only for mild tachycardia (heart rate 111).  They report that the patient has vomited once while in route.  They have placed the patient in a c-collar.  You note that the patient is not on a spine immobilization board.  You recall that recent studies do not support their use when the mechanism of injury is a fall from standing height resulting in head trauma.  The patient’s baseline health status is remarkable for controlled hypertension and hypothyroidism.

Presentation and Exam Findings

Initial in-facility vital signs parallel those obtained by EMS.  Upon entering the exam room, you note a well kept female who’s appearance matches her stated age.  She is without apparent distress.  You begin to interview her and note that her responses are somewhat slower than expected.  She is awake, alert, and oriented to person, place, time, and situation.  She complains of headache and posterior neck pain.  In an effort to clear her from the c-collar, and using NEXUS criteria, you ask a nurse to hold her head in place, instruct the patient not to move, and gently remove the strap of the c-collar.  You palpate her posterior neck to assess tenderness.  She reports midline tenderness near C3.  You replace the strap of the c-collar, ensuring it is appropriately fitted and applied.  You next go through a cursory trauma exam from head to toe.  You note a 6cm laceration to her LEFT forehead that extends into the scalp.  The trauma exam is otherwise negative.  Pupillary response and extraocular movements are intact and normal.

Concerns and Approach Considerations

Your next step is to order and obtain an emergent non-contrast head and neck CT (she’s already on the CT scanner, go ahead and order the neck as well).  She returns from the CT scanner and, while you’re waiting on imaging and the radiology report, you deliver analgesia through local infiltration at the site of her laceration with 1% lidocaine with epinephrine.  You continue speaking with her during this process, while you irrigate and scrub the wound.

You’re still waiting on the radiology report, so you decide to proceed with wound closure.  You close the wound in running-locking fashion using blue polypropelene suture, as the wound extends into the scalp and hairline.  Approximation is good and there is minimal maceration of the tissue.  The wound is hemostatic post-closure.  Following closure, you apply a ribbon of antibiotic ointment.  The radiology report is back, and you find that her head CT is negative for acute injury, while her neck CT is remarkable for non-displaced fracture of C2.  Your facility is not equipped for neurosurgical intervention, so you consult a provider at a larger hospital who accepts the patient for transfer.

Consider the following questions:

Lacerations that extend into the hairline, and that are sutured, are best closed with which of the following?

NEXUS criteria would not include which criterion?

History

A 34 year female presents to your facility with the chief complaint of LEFT buttock pain.  She reports, “I was dancing to a song in my living room.  I lost my balance and fell into the coffee table.  There was a lot of blood, so I came here.”  Her baseline health status is obese with mild controlled hypertension and uncomplicated diabetes mellitus type 2.  She is a non-smoker.  Her tetanus status is current.

Presentation and Exam Findings

The patient appears well kept.  Her intake weight is 310 pounds.  Initial vital signs are normal.  Because she is diabetic and presenting with acute trauma, you order a finger stick blood glucose which indicates her capillary blood glucose is 250.  Upon examination you note an 8cm linear and gaping laceration.  The wound is hemostatic.  There is profuse adipose tissue visible.  Physical exam rules out other injuries.

Concerns and Approach Considerations

Due to concern over retained foreign body, in this case glass, you order a soft-tissue plain film of the buttock.  While you’re waiting on the x-ray tech to come for the patient, you deliver analgesia to the patient through injection of 1% plain lidocaine in the normal fashion.  The plain films are obtained and you do not note any appearance of retained glass in the wound.  Following thorough irrigation with sterile water and scrubbing with a surgical cleanser, you begin closure.  You note the depth of this particular laceration and decide it is appropriate to start with a buried deep dermal suture into the subcutaneous tissue.  You achieve this using a simple interrupted or modified horizontal mattress technique with an absorbable suture on a 19mm needle.  You recall that deep lacerations need to be closed from the deepest layer to the outermost.  Non-closure of the deep layer could result in a void between the tissue where a hematoma could develop, delaying healing or contributing to a negative outcome.  After closure of the deep layer, you close the outer skin layer with an absorbable 4-0 suture on a 13mm to 19mm needle in the simple interrupted fashion.  You apply a ribbon of antibiotic ointment to the wound, and then cover with dressing.  You recall that the patient is diabetic and that diabetics fall into that category of having a generally poor immune response.  You discuss prophylactic antibiotics with the patient who is receptive.  You prescribe a five day course of a cephalosporin and give the patient clear instructions on visualizing her wound in a mirror daily, as well as the signs and symptoms of infection.

Consider the following questions:

T/F: Deep dermal suture material should consist of non-absorbable nylon.

Wound closure should begin at which the level?