topical epinephrine for wound hemostasis?

22 May

So your next patient has a good sized avulsion off the pad of his finger that’s still oozing despite his attempts at direct pressure.  

You also can’t find your Surgicel, and your patient hates needles.  You still have the lidocaine with epi in your pocket from when you thought you’d get to stitch something up, though.  Can we use this another way?

 

THE CONCEPT:

soak something (cotton ball/tip, gauze, etc) in epi, then mash it against the thing that’s bleeding

 

THE LOGIC:

epi (which also comes handily pre-mixed with lidocaine anesthetic in nice dilute doses) is a vasoconstrictor

-> better opportunity for platelets to not get swept away and form clot

dilute concentrations applied topically would seem to have less risk for harm than direct infiltration

 

SUPPORT?

quick Pubmed/internet biopsy is interesting, if with limited data:

one big review: 

  • delivery methods included epi + KY, epi-spray, sub-cut infiltration
  • epi achieved hemostasis faster than thrombin, saline, or mineral oil

 

other random discoveries:

  • lido + epi cotton balls shorted time to hemostasis in rabbit epistaxis
  • epi-soaked gauze reduced mean # of packings, cautery use, and procedure time in kids getting adenoidectomies
  • gauze-soaked epi used for tissue and gallbladder fossa hemostasis during a lap chole
  • suggested for hemostasis in circumcision (just don’t leave it on too long)
  • epi-soaked cotton products for dental procedures (just search the interweb “cotton epinephrine hemostasis”)

 

BOTTOM LINE:

mostly studied for ENT uses, but seems to help wound hemostasis

probably worth a shot.  keep it in your toolbox.

 

 

References: review articlerabbit epistaxisadenoidectomy; lap chole; circumcision; picture

quick exposure with trauma shears: cut & tear

19 May

something I learned by trial & error and watching others along the way, but nicely addressed in this EMT Spot blog post:

NOT ROCKET SCIENCE:

cut at the edges (hemmed areas like the cuffs, collar, waist, etc)

tear with your hands (most fabrics will tear along that line fairly well)

 

quicker than cutting down each entire sleeve/pant leg

– less likely to cut through cords/leads/IVs, since there’s less cutting

 

 

BONUS TIPS:

– to remove shoes, cut the laces, and/or cut down the sides

be careful when cutting near pockets (a cloud of white powder in the resus bay complicates things)

cut around penetrating trauma holes in clothing (may be useful evidence)

– if pt moveable (e.g. not immobilized), cut midline at collar in front and back, then pull from the sides.

 

REMINDER:

– once you’re done with the assessment, cover ’em back up 

 

There you go.

 

References: EMT spot blog + pictures

Isopropyl Alcohol (part 2) – Management

18 May

(check out the previous post for some initial isopropyl alcohol tidbits)

WHAT TO ORDER, WHAT TO LOOK FOR:

Tests to obtain — The following tests should be obtained in all poisoned patients:

  • POC glucose
  • Acetaminophen and salicylate levels, to rule out these common co-ingestions
  • Electrocardiogram (ECG), to rule out conduction system poisoning by drugs that affect the QRS or QTc intervals
  • Pregnancy test in women of childbearing age
  • Serum isopropyl alcohol and acetone levels (or serum osmolality, if direct serum drug levels are unavailable). 
  • Basic electrolytes, with calculation of anion gap
  • BUN and creatinine
  • Serum and urine ketones
  • Arterial or venous blood gas

 

Elevated Osmolar Gap. The absence of a high anion gap metabolic acidosis four to six hours post-ingestion enables the clinician to distinguish from other alcohols.

 

Serum concentrations of at least 100 mg/dL (17 mmol/L) are necessary to cause a decreased level of consciousness. 

Both isopropyl alcohol and acetone will raise the osmolal gap.

The plasma osmolal gap cannot distinguish among isopropyl alcohol, methanol, and ethylene glycol poisoning, and so cannot be used to exclude ingestion of these more toxic alcohols.

 Calculated Sosm   =   (2 x serum [Na])  +  [glucose]/18  + [BUN]/2.8

 

MANAGEMENT – ABC’s, then…

Decontamination — There is no role for gastrointestinal (GI) decontamination in most cases of isolated isopropyl alcohol intoxication. Its rapid absorption after oral ingestion and its low toxicity make such interventions unnecessary.

 

Alcohol dehydrogenase (ADH) inhibition — Since acetone (the primary metabolite) is less toxic than isopropyl alcohol (the parent alcohol), there is no indication for ADH inhibition with fomepizole or ethanol following isopropyl alcohol exposure

 

Disposition – Symptoms from isopropyl alcohol manifest quickly. Therefore, patients with unintentional ingestions can be discharged after two hours if they remain asymptomatic and isopropyl alcohol is known to be the only substance involved.

 

Submitted by Christina Brown.

 

References: uptodate.com; Trullas JC, Aguilo S, Castro P, Nogue S. Life-threatening isopropyl alcohol intoxication: is hemodialysis really necessary? Vet Hum Toxicol 2004; 46:282.; Stremski E, Hennes H. Accidental isopropanol ingestion in children. Pediatr Emerg Care 2000; 16:238.;  Bekka R, Borron SW, Astier A, et al. Treatment of methanol and isopropanol poisoning with intravenous fomepizole. J Toxicol Clin Toxicol 2001; 39:59.;  Su M, Hoffman RS, Nelson LS. Error in an emergency medicine textbook: isopropyl alcohol toxicity. Acad Emerg Med 2002; 9:175.; picture

Isopropyl Alcohol (part 1) – Recognition

15 May

ISOPROPYL ALCOHOL – Central nervous system (CNS) inebriant and depressant.  Toxicity and treatment resemble that of ethanol.

 

EPIDEMIOLOGY – Fatality from isolated isopropyl alcohol toxicity is rare, but can result from injury due to inebriant effects, untreated coma with airway compromise, or rarely, cardiovascular depression and shock following massive ingestion. 

 

PHARMACOLOGY AND TOXICOLOGY — a CNS depressant whose toxicity closely resembles that of ethanol, with which it shares strong structural similarity.  

In untreated animals, the median lethal dose lies between 4 and 8 g/kg.

Isopropyl alcohol does NOT cause an elevated anion gap acidosis, unlike the toxic alcohols methanol and ethylene glycol.  Why?  Because Ketones cannot be oxidized to carboxylic acids.

Isopropyl alcohol is metabolized by the alcohol dehydrogenase family of enzymes to acetone. 

Following ingestion, the elimination of acetone is slower than its formation, and this metabolic end-product accumulates.  Acetone itself is a mild CNS depressant and may exacerbate the CNS depression caused by isopropyl alcohol.  It is also responsible for the marked ketosis that is present in most isopropyl alcohol ingestions.

 

KINETICS – Peak serum concentration and clinical effects occur approximately one to two hours after ingestion.

 

CLINICAL FEATURES OF OVERDOSE

Symptoms – nausea, vomiting, and abdominal pain.

Signs – CNS Depressive effects peak within the first hour after ingestion.  Can cause an alteration in mental status similar to that seen in ethanol intoxication.

A fruity breath odor is often perceptible, suggesting acetone accumulation.

Following massive ingestion, signs of shock may be present, as may hematemesis (gastric irritant), pulmonary edema, and hemorrhagic tracheobronchitis.

 

Submitted by Christina Brown.
References: uptodate.com; Trullas JC, Aguilo S, Castro P, Nogue S. Life-threatening isopropyl alcohol intoxication: is hemodialysis really necessary? Vet Hum Toxicol 2004; 46:282. Stremski E, Hennes H. Accidental isopropanol ingestion in children. Pediatr Emerg Care 2000; 16:238. Bekka R, Borron SW, Astier A, et al. Treatment of methanol and isopropanol poisoning with intravenous fomepizole. J Toxicol Clin Toxicol 2001; 39:59.  Su M, Hoffman RS, Nelson LS. Error in an emergency medicine textbook: isopropyl alcohol toxicity. Acad Emerg Med 2002; 9:175.; picture

dermabond over steri-strips?

12 May

quick tip for laceration repair:

first apply steri-strips to approximate the wound,

then dermabond overtop the steri-strips for added strength for the closure.

 

bonus tip from personal experience: dermabond the ends of the steri-strips as well (had one drunk patient pick at the edges of the strips, which made it easier to lift-off the dermabond as well).

 

makes sense in theory (others have sutured over the steri-strips), found others who’ve tried this on a couple blogs, but otherwise the internet and PubMed are relatively bare on this potential technique

 

if you have any personal experience, or know of any sources for this use, please hit us up in the comments section.   Thanks!

 

References: blog post 1, 2, picture

visual aid: soft-tissue ultrasound

7 May

(apologies for the layoff between posts; busy time lately, but should be back into a rhythm)

some nice images via this April E-Med Journal article (for when you next need to determine if there’s something there to I & D):

Arrows (top to bottom) indicate: epidermis, subcutaneous tissue, muscle, bone

 

to help differentiate the sometimes difficult to distinguish (left to right): cellulitis, abscess, lymph node

 

References: emed journal article + pictures

strength in numbers: dizziness

23 Apr

Cribbed from this March ACEP Now article:

 

DIZZINESS/VERTIGO: numbers to consider

clinical factors associated with stroke in vertiginous patients

  • gait instability: Odds Ratio (OR) 9.3
  • subtle neurological findings: OR 8.7

 

predictors for serious neurological disease with complaint of dizziness, vertigo, or imbalance

  • Focal neurological abnormalities: OR 5.9
  • 60 years of age or older: OR 5.7
  • Imbalance: OR 5.9
  • Isolated dizziness: OR 0.20  (i.e. 80% less likely to be experiencing a serious neurological cause)

 

Study of 1681 pts w/dizziness:

  • CTs obtained in 48%
  • MRI’s in 5%

 

  • cost associated with identifying one abnormal CT: $165k
  • cost associated with identifying one abnormal MRI: $22k
  • all patients with positive CT or MRI had headache, neuro findings on exam, or optho complaints

 

5-SECOND TAKEAWAY:

  • don’t skimp on the neuro exam
  • walk (gait test) your dizzy patients

 

References: ACEP Now Article; picture

Follow

Get every new post delivered to your Inbox.

Join 41 other followers