Commentaries

July 20, 2012

Submit!

Over the last few months, many readers have sent suggestions of various "tricks" that they have found useful. For this installment, I'd like to honor these folks by featuring two submissions, along with one I came up with on my own but has probably been discovered many times over.

Papoose for a Moose

Suturing facial lacerations on an uncooperative, robust toddler can be a nightmare for everyone involved. Procedural sedation and brutane (hands-on restraint) are always options, but they are personnel-heavy and can be very traumatic for patient, parent, and provider.

Many facilities have a "papoose board" or other commercial device for restraining pediatric patients. These items are effective but are eerily reminiscent of Hannibal Lecter's transport regalia in The Silence of the Lambs - and they aren't always available. If your department doesn't have a papoose board (or it's off at the laundry after a messy procedure), you can make your own version out of a pillowcase and a pediatric C-spine collar.

Photos courtesy Dr. Whit Fisher  Fig. 1. Cut a notch out of a pillowcase and slip it over the patient's head; then attach the C-spine collar.

Cut a notch out of a pillowcase. Slip it over the patient's head so that their head pokes through, and then attach the C-spine collar as you normally would (Fig. 1). The collar will keep your patient from moving her head in any plane and makes arching her back much more difficult. The pillowcase doesn't prevent movement of the arms, but it does make them much easier to control, especially if you wrap another sheet around the patient. On a purely anecdotal level, I've noticed that this arrangement seems to be less frightening to the patient than the papoose board, but perhaps I've just been lucky. Also, you could probably make a "sheet poncho" if you don't have pillowcases, but be sure to hide the truth from your hospital linen service.

Thud!

Don't make your pillowcase hole too small, and make sure the child can't make a break for it if you turn your back for a moment. Otherwise, he may run down the hallway with his arms pinned to his sides by the pillowcase, a surefire recipe for another facial injury.

Terri's Tense Tissue Technique

Our first submission is from Terri Zomerlei (a surgical PA-C/MD candidate at the Michigan State University College of Human Medicine, Grand Rapids), who suggested a method of securing dressings for sacral wounds using "Montgomery straps." I have slightly modified her technique for partial wound closures, and it worked very well for a recent case.

Fig. 2. A moped mishap resulted in this significant laceration.   Fig. 3A and 3B. The tab approach permits complete closure of the inferior flap and decreases the wound surface area.

A 61-year-old male presented to the department after a low-velocity moped injury with a significant laceration to the left anterior tibial region (Fig. 2). He was on vacation, and would be returning home after a long weekend. He had minimal pain and no signs or symptoms of compartment syndrome. Radiographs were negative for foreign body or fracture, and the area was liberally irrigated. There was notable traumatic induration of the area that placed additional tension on the wound. The patient made it adamantly clear that he would not accept admission under any circumstances.

Our general and orthopedic surgery consults recommended a partial closure, but expressed concern that trapping the wound margins between the suture and the anterior tibia would increase the risk of ischemia until the edema decreased. Remembering PA Zomerlei's suggestion, I made four tabs of silk tape, with one end doubled over on each tab. I then used generous amounts of tissue adhesive to glue the "sticky" portion of the tabs alongside the wound, with the doubled-over region just proximal to the wound border. I sutured through the tabs using a horizontal mattress technique with 3.0 nylon sutures (simple interrupted sutures don't maintain tension well enough). The end result was an improved approximation of the wound margins, permitting complete closure of the inferior flap and decreased wound surface area (Fig. 3A and 3B). The wound was dressed, and the patient went home with crutches and antibiotics, with instructions to elevate the leg and return in 24 hours. On the return visit, a significant reduction in wound edema and tension was noted, allowing additional closure.

The advantage of this technique is that all the tension from the sutures is distributed over the broader surface area of the tape tabs, decreasing the risk of acute ischemia posed by a tense, narrow suture pinning the wound margins against the tibia. There's also minimal discomfort, since you aren't sewing through any living tissue. The continual traction of the tabs helps the wound edges to approximate gradually as the edema resolves.

Twang!

There's always the risk that the tissue adhesive won't be strong enough and the tabs will pull off, so you need to be absolutely sure the patient has a wound check appointment scheduled for the very near future. For furry legs, you should shave the hair before you glue on the tabs. Make sure the patient knows that petrolatum-based ointments will dissolve the tissue adhesive, and that they understand and agree to follow explicit instructions regarding signs and symptoms of infection and ischemia. Depending on the location of the wound, some form of partial or complete immobilization (crutches, knee immobilizer, sling, splint, etc.) may be a good idea to keep the patient from putting additional strain on the lacerated area.

Sarah's Slice-the-Strangler Save

Hair tourniquets on fingers and toes can be a big challenge to unravel. Often several hairs are involved, so simply unwinding one does not mean you've solved the problem. Usually a deep furrow remains once a hair has been extricated from the digit, and it's very easy to miss a second, deeper tourniquet that's in exactly the same spot. Some sources recommend using a scalpel to be sure you've gone deep enough to sever any missed hairs, or a prolonged application of depilatory.

Dr. Sarah Morris, a recent graduate of the Emergency Medicine Residency program at the University of Virginia, Charlottesville, and now an attending at St. Luke's Hospital in New Bedford, Mass., has had success removing hair tourniquets with a curved suture needle with a cutting edge (PC-1). She noted:

Removing a tourniquet is essential, as unsuccessful reduction may need operative management and can result in significant complications including digital loss, flexion deformities, and amputations. Hair tourniquet removal can be very difficult as the hair eventually cuts through the edematous skin and becomes embedded in the subcutaneous tissue, making the hair invisible. It is not uncommon for a constricting fibrosis to remain after removal of the tourniquet. If the tourniquet appears to have been removed, close follow-up is needed to ensure a subcutaneous, invisible tourniquet is not present, as these have been known to cause bone erosion in the past (Ann. Plast. Surg. 2006;57:447-52).

Fig. 4. Run the cutting needle under the furrow and up through the dermis.

For her technique, you simply run the cutting needle under the furrow (perhaps after applying some EMLA for pain control) and bring it all the way through and up through the dermis just below the tourniquet depression (Fig. 4). This method leaves a small laceration, so proper wound care and follow-up is essential. If you're in a more humane mood, you could try to run the needle just under a visible hair tourniquet without injuring the skin, although this method might miss deeply embedded hairs.

Waaaaahhhh!

Remember to use a true cutting needle (where the sharp edge is on the concave aspect of the needle) and not a reverse-cutting needle (where the patient would get all of the pain and none of the benefit). 

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