A "HAT" Trick for Scalp Lacerations!

Welcome to a special short and sweet Christmas Eve edition of POTD!Here's a poem to get us all in the spirit:

Twas the night before Christmas, the ED was quiet, Not a creature was stirring, there wasn’t a riot. The patients slept soundly, so snug in their cots, With some having dreams of free vodka shots...

[Creative credit goes to http://brandtwriting.com/brandts-rants/twas/ where the rest of the poem can be found.]

Okay, down to business. Today we will be discussing some innovative tips/tricks for managing scalp lacerations. Sure, staples and LET are great. But what if you've run out of staple guns, or if it's a scared little kid whimpering in a corner? Is there a less traumatic option?

Hair Apposition Technique - who has heard of this, or better yet, used it on a patient? Apparently it's been around since 2002, but I only learned about this recently!

The Hair Apposition Technique, or HAT trick, creatively uses the patient's own hair essentially as sutures for approximating the scalp lac.

Let me explain the steps:

1. Irrigate your wound as usual, inspect for foreign bodies
2. Pull together 3-7 strands of hair on one side of the wound.
3. Do the same on the other side of the wound.
4. Twist these two hair bundles in 360-degree revolutions. Do not tie a knot
5. Secure the intertwined hair bundles by applying a few drops of Dermabond.
6. Repeat as needed to close the length of the laceration.

For us visual learners, here is an awesome 36 second long video: https://videos.files.wordpress.com/4H47OyPj/hair-apposition-web_hd.mp4

Patient with short hair? Don't worry, you can use the HAT trick, just need 2 pairs of clamps to gain the traction you need:

3 advantages over traditional staples/sutures: 1) Zero pain (especially useful in kids; just tell them you're braiding their hair!) 2) No need to anesthetize the wound (forget waiting for your nurses to first apply LET, then waiting more for it to kick in) 3) No need to return to ED for removal! The hair will unravel on its own after a week.

Bonus: a quick tip for keeping loose hairs out of your field of repair! Next time you're trying to staple Goldberg's latest scalp lac and his hair keeps falling into the lac, try applying petroleum-based ointment (or ultrasound jelly in a pinch) around the area to grease the strands down, then smooth them over to the sides of your field, like so:

This is a super easy/fast way that not only improves your visualization of the lac, but also helps you avoid trapping hair strands within the lac, which could cause wound dehiscense, a foreign body reaction, or a local cellulitis.

Happy lac repairs!

References: https://www.aliem.com/2014/03/trick-trade-parting-hair-scalp-laceration-repair/ https://lacerationrepair.com/techniques/alternative-wound-closure/hair-apposition-technique/

POTD- Foreign body aspiration

Did you know that over the holidays ER vists across the country >10 fold!

Most related to the decorations so be careful decorating your tree! Luckily most injuries are non-fatal!

With my massive family we've seen lacerations, sprains,  and most recently a pretty impressively crushed hand from a not so coordinated person carrying a heavybox, but we also had the scary moment when my 7mos old niece found her brothers toy on the ground and naturally put it in her mouth, she was fine with no ingestion or aspiration but just in case lets talk foreign body aspiration...

Normal presentations goes something like this... My child was playing on the floor and the next thing I know they were coughing and now they are making a funny noise and look like they are struggling to breath.

So what do you?

First  AIRWAY of course.  Does the child need immediate interventions? If so now is not the time to be a hero.. page ANESTHESIA and ENT fast! Try and maintain the child as calm as possible and in a position of comfort ( this may include keeping the kiddo head down!) Try and slip a pulse ox on and monitor but often less is more and letting the parent hold and comfort them can be better.

Get set up to intubate and have a surgical airway kit ready.

Intubating may involve pushing the object R mainstem so have all hands on deck.

For patients who are not in respiratorydistress, lets talk workup.

Starting with location.

• Laryngotracheal- uncommon but life threatening and often present in distress
  • Stridor, wheezes, dyspnea, hoarse voice
  • These kids need airway protection and STAT ENT and anesthesia consults!
  • Try is airway protection and RIGID BRONCH

• Large bronchi-
  • Cough, wheeze, hemoptysis, dyspnea, choking, SOB, decreased breath sounds
  • Will also need Rigid Bronch emergently!
• Lower airway- Little distress after the initial episode

What if you're not sure and just suspect a FBA? Follow this algorithm:

• Xrays should include inspiratory and expiratory films or Left decubitus in younger kids
• If you think its higher up inlay the neck ate PA and lateral views
• Xray findings of lower FB include:
  • Hyperinflated lung- lucency distal to obstruction
  • Atelectasis
  • Mediastinal shift away from the FB

Management:

• All children with high suspicion of FBA should be observed and schedule for a bronch
• Rigid> Flexible as it provides better visualization and access for removal of the FB
• Thoracotomy if bronchoscopy is unsuccessful

Complications:

• Atelectasis
• Pneumonia
• Bronchiectasis
• Abx should be started post procedure

Stay safe everyone and enjoy your holidays!

Alternative Headache Therapies

Hi everyone! For today's POTD, let's think outside the box when it comes to acute headache management in the ED. Headaches in general are one of the most common chief complaints we see in the ED. We have our tried-and-true drug cocktails -- an antidopaminergic drug (ex: reglan, phenergan, compazine), +/- benadryl, +/- toradol -- but what happens if those fail?

1) Other drug therapies: a) Sumatriptan 6 mg subcutaneously, or 10-20 mg intranasally [exercise caution in pts with cardiovascular disease] b) Dihydroergotamine 0.5-1 mg IM or IV [nausea is common; also exercise caution in pts with cardiovascular risk factors] c) Valproic acid: 300-1200 mg IV

2) Sphenopalatine ganglion block: Decent amount of anecdotal support for its efficacy (although no large studies yet), and very easy to do! - Soak long cotton-tipped applicators in your choice of local anesthetic - Insert nasally and apply firm pressure until you meet resistance at the posterior wall of the nasopharynx - Leave in place for 5-10 min; bask in the glory of your migraine-stopping powers https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/

3) Occipital nerve block: https://www.youtube.com/watch?v=JGLOaZpZwqU - Consider this for patients with primarily occipital distribution of their pain! - 1 mL of 0.5% bupivacaine injected over the greater and/or lesser occipital nerves (located along the imaginary line between the occipital protuberance and the mastoid process, as shown in this photo)

4) Cervical paraspinous nerve block: https://www.youtube.com/watch?v=oy1lggvxV9Y - Similar concept to the occipital nerve block; consider this for your cervicogenic headache patients - 1.5 mL of 0.5% bupivacaine injected approx 2-3 cm bilaterally to C6-C7, to a depth of 1-1.5 inches

References: https://www.aliem.com/2016/05/managing-migraine-headaches-complicated-patients/ http://www.emdocs.net/headache-management-best-current-evidence-ed/ http://rebelem.com/alternative-headache-therapies/ http://www.annemergmed.com/article/S0196-0644(16)30301-8/pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3737484/