POTD: HEMATOMA BLOCK

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OVERVIEW

  • The hematoma block is local anesthesia delivered to the hematoma formation around a fracture site and done prior to reduction

  • Simple, fast, and does not require special equipment

  • Can be used for a variety of fractures (Colles’, ankle) and reductions

  • Has fallen out of favor due to rising popularity of procedural sedation

  • Does not increase the risk of infection

PROCEDURE

  1. Draw up 5 to 20 mLs of local anesthetic

  2. Find landmarks

  3. Clean area with chloraprep

  4. Insert the needle directly into the hematoma, withdrawing as you go

  5. Alternatively, use POCUS to identify the dark, anechoic hematoma

  6. Blood aspiration helps to confirm needle position

  7. Inject anesthetic, remembering not to exceed max dose

  8. Proceed with reduction after 5-10 min

CONTRAINDICATIONS

  • DO NOT perform procedure through a contaminated wound

  • DO NOT perform procedure on open fractures

TIPS and TRICKS

  • Use a combination of lidocaine and bupivicaine for rapid onset and longer acting anesthesia/analgesia

  • Note that after a few hours, hematomas can become unaspiratable

Sources:

  1. Tintinalli's Emergency Medicine, 9th Edition pp 247-248

  2. WikiEM: Hematoma Block

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POTD: DENTAL POSTEXTRACTION COMPLICATIONS

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If you’ve worked in our fast track area, you’re familiar with the variety of dental issues our patients come in with on a daily basis. Here, we discuss post-extraction complications — namely pain, dry socket, and bleeding.

POSTEXTRACTION PAIN

  • Pain and edema is common after extraction of third molars (wisdom teeth)

  • Peaks within the first 24-48 hours after extraction

  • Treatment: ice packs, elevation of HOB to 30 degrees, and NSAIDs

  • NSAIDS preferred over oral narcotics for pain

  • Progressively worsening trismus is worrisome for a post-op infection


POSTEXTRACTION ALVEOLAR OSTEITIS (DRY SOCKET)

  • Total or partial displacement of the clot from the socket, resulting in alveolar bone exposure

  • Can progress to osteomyelitis of the exposed bone

  • Commonly occurs on the second or third postoperative day

  • Associated with severe pain

  • Incidence: 1-5% of all extractions, but up to 30% in impacted wisdom tooth extraction

  • Risk factors: smoking, pre-existing periodontal disease, traumatic extraction, prior episodes

  • Treatment: Pain control with expectant management, gentle irrigation with warm saline or chlorhexidine 0.12% oral rinse to remove debris

  • Intrasocket placement of medications is controversial

  • Give antibiotics for suspected infections


POSTEXTRACTION BLEEDING

  • Soak a 2x2 gauze pad in TXA, apply to socket and ask patient to bite down (not chew!)

  • If this doesn’t work, can apply Surgicel into the socket to serve as a clot-forming matrix

  • Can use loose sutures to hold in place, or to loosely close gingiva over the socket

  • CAVEAT: Tight sutures may cause necrosis of the gingival flap

  • If this doesn’t work, may inject lidocaine with epi or use silver nitrate cautery

  • Still no luck? —> Consult w/ OMFS

Sources: Tintinalli’s Emergency Medicine, 9th Edition pp 1582-1583

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POTD: Revisiting the Resuscitative Hysterotomy

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Formerly known as the perimortem cesarean section, the resuscitative hysterotomy is performed in a pregnant patient of > 20 weeks gestation in cardiac arrest to improve the chances of ROSC.


Forget about the 4-Minute and 5-Minute rule!

  • Even in controlled simulations with obstetric teams, timing has been problematic.

  • While the procedure should be performed as quickly as possible to improve outcomes, there is generally no contraindication to performing the procedure beyond the 5 minute mark.

  • The procedure has benefited pregnant patients up to 15 minutes and fetuses up to 30 minutes after maternal cardiac arrest.


DO’s and DONT’s

  • DO assign team roles and prepare all equipment prior to patient arrival

  • DO start chest compressions immediately, establish an airway, and get IV access

  • DO give fluids

  • DO give blood in the setting of trauma

  • DO NOT stop to evaluate for fetal cardiac activity or tocometry

  • DO NOT prepare a sterile field (but be as clean as possible)

  • DO NOT wait for OB/GYN to arrive before starting the procedure

  • DO NOT transport the patient to another location


THE PROCEDURE

  1. Drench the abdomen in betadine and get ready to cut

  2. With a scalpel, make a vertical incision from the xiphoid process down to the pubic symphysis, cutting through the skin, fat, fascia, and peritoneum

  3. Avoid cutting the bladder — find it, and retract it

  4. Blunt dissect down to the uterus

  5. Make a vertical incision in the uterus large enough to fit 2 fingers in

  6. Once inside, lift the uterine wall with your fingers

  7. Use blunt scissors to divide the uterus between your fingers and extend the incision

  8. Deliver the fetus

  9. Double clamp the umbilical cord and cut BETWEEN the clamps

  10. Deliver the placenta

  11. Wipe the endometrial cavity clean with a clean, moist lap pad

  12. Pack the uterine cavity with sterile towels

  13. Continue resuscitation

WATCH EMCrit VIDEO of a LIVE SIMULATED RESUSCITATIVE HYSTEROTOMY
https://www.youtube.com/watch?v=IwDWv2iyAos

SOURCES

  1. Tintinalli’s Emergency Medicine, 9th Edition pp 646-647

  2. Rose, C.H. et al, Challenging the 4- to 5-minute Rule: From Perimortem Cesarean to Resuscitative Hysterotomy Obstetric Anesthesia Digest December 2016 - Volume 36 - Issue 4 - p 171

  3. WikiEM: Resuscitative Hysterotomy


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