POTD: Trauma Tuesday - Nailed it!

For my final Trauma Tuesday POTD, I’m going to cover the topic of open nailbed lacerations.

What really matters most on initial inspection is any disruption to the proximal nail fold and lunula, which would suggest damage to the germinal matrix. Your fingernail grows from the germinal matrix, so if there is any disruption to that, the answer is easy. Stop and consult hand surgery. This patient is going to need a germinal matrix graft which is beyond our scope as ED docs.

If any of these other findings are also present, hand surgery consultation would also be indicated:

-              Infected wounds

-              Disruption of digital tendons

-              Displaced or unstable finger fractures that may require ORIF

-              Complicated digit dislocations

-              Fingertip amputations that include loss of nail and/or bone and fingertip pulp

However, if you note that the proximal nail fold and lunula look largely intact and all you have is a laceration to the nailbed + an avulsed nail, you can take care of that!

In an open nailbed laceration, you need to remove the nail and suture the nailbed. Controversy exists regarding replacing the nail. Nail splinting has been traditionally recommended to maintain the proximal nail fold during healing, prevent scarring and nail deformity, reduce infection, and decrease pain during dressing changes.

The most recent NINJA RCT in 2023 did not show difference in cosmetic appearance or infection rate at 7-10 days whether or not the nail was splinted in children, though these findings did not reach statistical significance.

Steps

Laceration repair:

1. Perform a digital block and have patient soak fingertip in saline while block is taking effect.

2. Placing a digital tourniquet may help minimize blood in field during repair.

3. Remove fingernail by gently separating the underlying adherent nail bed from nail.

   • Insert scissors or hemostat in closed position between nail and nail bed at distal tip and advance slowly in proximal direction.

   • Open and spread instrument while maintaining tips against undersurface of nail to avoid further injury to nail bed

4. Gently irrigate nail bed with 100-200 cc of NS.

5. Repair nailbed using 6-0 absorbables (chromic gut or vicryl rapid)

   • Direct needle from distal to proximal when passing needle to avoid tearing nailbed tissue.

   • Can alternatively use dermabond. In meta-analyses, using tissue adhesives was considered as effective as sutures for nailbed lac repair.

To splint with original nail:

1. Gently clean nail in dilute solution of povidone iodine and NS.

2. Place 3-4mm diameter hole in center of nail using sterile needle, scalpel, or cautery to allow drainage of any blood.

3. Replace nail beneath the proximal fold and secure in place with 2-3 drops of tissue adhesive. Can also suture nail in place (video below shows how you can do this).

4. If original nail can’t be used, place a nonadherent splint with single thickness of sterile gauze, silicon sheeting, or sterile foil from suture packet and hold in place with absorbable 4-0 sutures through lateral skin folds or skin glue.

Also repair any other lacerations outside of the nailbed (finger pad or folds) with 4-0 or 5-0 absorbable sutures.

Remove the tourniquet, apply a protective dressing, and you’re done!

Prior to discharge:

Update Tdap

Leave dressing in place until follow up visit with hand surgery within 7 days.

Most up to date guidelines suggest AGAINST routinely administering empiric abx, but consider using it in animal/human bites, excessive wound contamination, or patients with vascular insufficiency or immunocompromised states. Several randomized trials have not shown any benefit to giving abx. 

Make sure the patient understands that the nail is there to maintain patency of the proximal fold and that it will fall off within 1-3 weeks. A new nail will grow completely in 3-12 months. Despite our best efforts, scarring may still impact nail regrowth.

TL;DR: Check out below for an EMRAP video on nailbed laceration repair that basically sums this all up.

https://www.emrap.org/episode/nailbed/nailbed

References

https://www.uptodate.com/contents/evaluation-and-management-of-fingertip-injuries

https://www.emdocs.net/evidence-based-approach-to-nailbed-injuries-ed-presentations-evaluation-and-management/

https://www.aliem.com/trick-trade-nail-bed-repair-tissue-adhesive-glue/

https://first10em.com/the-ninja-trial-do-you-replace-the-fingernail-after-nail-bed-repair/

POTD: All About LVADs

Hey everyone,

Today’s POTD will be all about LVADs, something we encounter rarely, but vitally important to know about. Feel free to skip to the bottom for the TL;DR!

What are LVADs?

Left ventricular assistance devices (LVADs) were developed in 1960s as a bridge to cardiac transplant, but is now also used as destination therapy, meaning it is the patient’s final therapy for heart failure during their lifetime. They are typically powered by two batteries with a power base unit that can be plugged into the wall. Indicated for NYHA class 4 HF, ejection < 25%. Note the Heartmate II is the most common one in use today.

Components

Pump: takes blood from cannula in apex of LV and pumps it directly into aorta.

Driveline: percutaneous cable that exits the abdominal wall and connects pump to external components such as controller and battery.

Controller: external “box” containing computer for device. Monitors pump performance and has controls for settings/alarms/diagnostics. Will show pump speed and output. Listed here are the normal range of values.

• Pump Speed: 2200 – 2800 rpm (HeartWare VAD) and 8000 – 10000 rpm (HeartMate II VAD)

• Power: 4 – 6 Watts

• Flow: 4 – 6 L/min

• Pulsatility Index (PI): 1 – 10

Power supply: connected to batteries or power base station which plugs into wall

FOR EMS PROVIDERS: In an emergency, all efforts should be made to transport patients with LVADs to their respective LVAD center. If a patient is brought to a non-device center, it is crucial that EMS personnel make every effort to bring the patient’s peripheral equipment needed to support them until they can be transferred to an LVAD center.

Common complications

Bleeding: most common reason for ED visit, most commonly in first month after implant. Tx with anticoagulant reversal, transfuse if needed. LVADs can cause acquired von Willebrand Disease, thought to be from the action of rotary or axial flow pump of the LVAD which causes high shear stress that may increase lysis of large vWF multimers.

Infection: from driveline and pocket, cover broadly with vanc/cefepime

Pump thrombosis: tx with heparin/antiplatelets or tPA in life-threatening situations. Pts will be on anticoagulation but pump thrombosis can still be common due to prosthetic material inflammatory reaction with blood and intrinsic endothelial activation in response to a continuous flow.

Arrhythmia: tx like you would in pt without LVAD either chemically or with electricity - place pads in anterior/posterior positioning

Suction event: when LV myocardium partially occludes the LVAD inflow cannula reducing inflow. Caused by low LV preload relative to pump speed. Tx by giving fluids, consider reducing LV speed in conjunction with LVAD team.

Cardiac tamponade: refer to LVAD center, pericardiocentesis discouraged b/c of low yield and potential for harm as the LVAD outflow graft may traverse typical course of needle.

Initial assessment FOCUSES ON CIRCULATION:

CONTACT THE LVAD TEAM: here at Maimo, the number is 35CHF

Note patients with LVADs will have NO PALPABLE PULSE and NO DISCERNIBLE HEART SOUNDS. Instead you will hear a continuous hum to confirm device is operating, though newest Heartmate 3 may have some interruptions to hum.

Measure the BP (must use doppler US and sphygmomanometer with doppler placed over brachial or radial artery).

1.        Cuff inflated until pulse no longer audible and then deflated.

2.        BP reading made when arterial flow audible again, giving single reading as MAP.

Goal MAP 70-80 and no more than 90 as this high afterload may compromise optimal function of LVAD. Should place A-line in hemodynamically unstable/hypotensive patients to more closely monitor BP.

Work-up will be the usual things you do for a cardiac patient: EKG, labs including trop, BNP, CXR. BEDSIDE ECHO AND COAGS/HEMOLYSIS LABS will be key because they can lead you down different diagnostic pathways.

Approach to conscious hypotensive patient with LVAD: check flow and power

Low flow vs high flow?

·      Low flow suggests hypovolemia

·      High flow state

o   Normal power or high power?

·      Normal power – distributive shock

·      High power – obstructive shock from thrombosis vs suction event vs cardiac tamponade

Differing schools of thought on CPR in LVAD:

Some argue you should analyze the LVAD first, others say you should begin CPR immediately if a patient comes in with circulatory collapse like you would any other patient.

If you were to analyze the LVAD first, then LOOK, LISTEN, FEEL:

Look at all connections

Listen for hum

Feel (hot control box usually means thrombosis or other obstruction)

Sometimes there is a hand pump attached to LVAD, but if pt unresponsive with MAP < 50 and etCO2 <20, or LVAD cannot be restarted, it is reasonable to proceed with CPR if you're in a setting without an LVAD team.

TL;DR of what to do when an LVAD patient arrives:

CONTACT THE LVAD TEAM through extension 35CHF here at Maimo.

1. Patients with LVADs may have no palpable pulse and that is normal! You should hear a continuous hum on auscultation to verify that it is working.

2. Look at all connections, listen for hum, analyze settings on the box.

3. Measure the BP with a cuff and doppler and aim for a MAP of 70-80, no more than 90. An A-line should be placed for close hemodynamic monitoring.

4. Do a bedside echo and get the usual labs but include hemolysis labs/coags.

5. In a hypotensive patient with an LVAD, low flow is from hypovolemic shock; high flow will either be distributive (normal power reading) or obstructive shock (high power reading).

6. Shocks are okay for the appropriate arrhythmias.

7. If a patient is in circulatory collapse and the LVAD is not working/can't be restarted/there is no handpump, it is reasonable to proceed with CPR if you're in a setting without an LVAD team, but follow your institutional recs. Note that here at Maimo, it is advised not to start compressions.

References

https://emcrit.org/emcrit/left-ventricular-assist-devices-lvads-2/

https://criticalcarenow.com/when-a-vad-goes-bad/

https://www.uptodate.com/contents/emergency-care-of-adults-with-mechanical-circulatory-support-devices

https://first10em.com/lvads/

https://rebelem.com/left-ventricular-assist-device/

https://www.emdocs.net/lvad-patients-what-you-need-to-know/

POTD: How to read a CT of the c-spine

Hello everyone,

I’m going to review the ABCS of reading a c-spine CT in today’s Trauma Tuesday. It’s something we order a lot of in the ED, so it’s good to have a standardized approach, just like we do with CXRs.

A = alignment: Best evaluated in the mid-sagittal view, evaluate the 4 smooth curves formed by the anterior and posterior surfaces of the vertebral bodies and the bases/tips of the spinous processes.

B = bones: In addition to looking at the vertebral bodies and spinous processes for breaks or loss of height, pay special attention to the arches/ring of C1 and the dens of C2.

C = cartilage: Assess the spaces between each vertebra, looking for widening, narrowing, or asymmetry.

S = soft tissue: Look at the pre-vertebral soft tissues in the mid-sagittal slice. Note that the soft tissue contour should parallel the vertebral bodies and is narrow from C1-C4.

There’s a couple of “spaces” to be aware of which I think is much easier to see rather than explain in written form so in the references below is a link to a short, helpful video that explains all this while showing you it at the same time!

References

https://www.youtube.com/watch?v=XY9xpI3EHec

https://coreem.net/core/the-abcs-of-reading-c-spine-cts/