Have you ever performed a lumbar puncture (LP) in a patient, only to have them return the next day for new debilitating headaches? It’s worse when sitting up, and much improved when laying down. You hate adding more problems for the patient, put you are certain that s/he now has a post-LP headache.
As great as tissue adhesives are in wound closure, they come with some risk. For instance, liquid adhesives, such as Dermabond, can “run” and contact undesired areas such as eyelid margins. Careful application of tissue adhesives is critical.
How can you minimize the amount of seepage of tissue adhesive to undesired areas?
Trick of the Trade
Create an impermeable tape barrier
I already mentioned this in an earlier post in July, but I now have more experience with this technique. Here are some recent photos of this trick in action.
- Cut out a circle from a transparent tape adhesive. In this case, I used a transparent Tegaderm which can be found with peripheral or central line IV kits.
- Adhere the tape to the patient’s skin primarily along the circular edge to prevent glue seepage under the tape. You don’t need to stick the ENTIRE transparent tape to the patient, unless you want to pull off some eyebrow and eyelid lashes!
- Apply the tissue adhesive glue over the wound while ensuring that the wound edges are closely approximated. Excess glue will run off onto the tape. You only need to wait a few seconds after glue application before peeling the tape off.
This idea was contributed by Dr. Hagop Afarian (UCSF-Fresno).
Thanks also to my Visual Aid Project photographer, Lourdes Adame, who photographed and consented the patient’s father for these photos. Her speaking fluent Spanish made them feel at ease and understand that we were photographing for educational purposes.
Often patients with scalp lacerations have clotted blood in their hair. While we can irrigate the wound itself (and unavoidably soaking the patient in cold irrigation fluid), a lot of blood remains stuck in their hair. It would be nice if we could completely wash out the blood. This would further allows us to detect occult scalp lacerations.
I got a nice email from Dr. John Fowler from Turkey who recently published a modified version of the Hair Apposition Technique (HAT) trick in the American Journal of Emergency Medicine in 2009.
Read more about the traditional HAT trick.
The HAT trick allows for scalp laceration closure by using scalp hair and tissue adhesive glue. Contraindications to this technique for wound closure include hair strands less than 3 cm, because it is difficult to manually manipulate short hair.
Remember back in the day when we made simple toys for pediatric patients to focus on during the physical exam? Remember the inflated medical glove +/- a face drawn on it?
I just encountered a FREE iPhone application (Eye Handbook), which has a lot of useful features. I currently only use the Pediatric Fixation animations. They can be found under the “Testing” section. Kids (and often adults too!) become mesmerized and distracted by the cartoon animations.
Over the years, I have been frustrated by how inelegant finger nailbed closure is. Nailbed lacerations are often sustained by a major crush injury, resulting in a stellate and irregular laceration pattern. This typically also requires the crushed fingernail to be removed. Cosmesis is never ideal because pieces of the nailbed are often missing, as seen in the photo above.
Occasionally, nailbed lacerations are caused by a cutting rather than a crush mechanism. In these cases, I use a different technique. I leave the fingernail on. In fact, I use the fingernail to help reapproximate the nailbed edges.
Testing lower extremity strength is a crucial part of the examination in patients with low back pain. In Emergency Departments, however, some patients provide a suboptimal effort because of general fatigue or malingering.
How can you differentiate whether asymmetric hip flexion weakness is from suboptimal effort or true weakness?