All right, good morning, everybody. Welcome to our final day of presentations. I'd like to go ahead and introduce our first speaker, Dr. Patrick O'Malley. He's a board-certified emergency physician in Newberry, South Carolina. He attended East Carolina University Brody School of Medicine and completed his emergency medicine residency in Charlotte, North Carolina. He has worked in a variety of emergency departments and urgent care centers. His main clinical interests include laceration management. He is the creator of the laceration course, which you'll see, you may see the logo during this presentation. Outside of work, he enjoys spending time on the water with his wife and two children. He also enjoys cooking and making homemade bacon. Dr. O'Malley does have a disclosure in that he receives a royalty from Medicine and Rescue Essentials for medical devices. He also does consulting and medical review for EB Medicine. Hello, this is Patrick O'Malley. Welcome to the talk, Laceration Pearls and Tricks of the Trade. So my name is Patrick O'Malley. I'm a board-certified emergency physician. I've spent most of my life in the Southeast, trained, went to medical school at East Carolina University, did my emergency medicine residency in Charlotte at Carolina's Medical Center, and since then have been in South Carolina and have worked in a variety of small and large community emergency departments and some different urgent care settings as well. I'm active with the Urgent Care Association and have presented several times at their national conference. Most recently, just about two weeks ago, from the date of the presentation that you are seeing, and was recently elected to the College of Urgent Care Medicine Board of Directors. And I'm very excited to work in that capacity and help expand the reach of the specialty of urgent care medicine. So disclosures, I do receive a royalty from both Rescue Essentials and Medline Industries and also revenue from the sales of an online CME course. And so we're going to go ahead and jump in and get started here. So here are the objectives for today's talk. Now I know that some of you, the practice setting that you are in is different from what I have worked in, but I hope that some of this is going to be relevant and will be able to give you some good helpful hints and tips and tricks to better take care of patients with lacerations. So I want to help you abandon some bad practice habits, things that have been passed down to us over the years, throughout our training, debunk some myths, talk about some tools and products and devices to make your life a little bit easier. Just kind of some general pearls of wisdom and advanced techniques, things that I've picked up from working in the emergency department for a long time. And then lastly, we'll talk about some medical legal topics when it comes to patients with lacerations and other soft tissue injuries. And lastly, we'll have some evidence-based links throughout the course. And I'll talk with Rhonda and see if we might be able to get an email sent out with a list of hyperlinks that are discussed here in the talk today. And lastly, thank you for having me. I'm really honored to be included in this list of presenters. And yeah, I look forward to being a resource for you if possible. All right, so lacerations, why are we talking about it? Well, they're common. One of the most common things that we see in the emergency department, as well as in the urgent care setting, from a work-related injury perspective, they are very common. A lot of the patients that I see with lacerations come from the work site. So it is something that you all will be seeing if you haven't already. I'm sure that you have. So I'm sure that you are somewhat comfortable with lacerations already. But when patients get sent to the emergency department for simple lacerations, especially when it's being referred from urgent care, they're not happy about it. They often question why that injury could not have been handled in the urgent care setting. So that's kind of my mission in life with all of this stuff, is to educate people who are not working in the emergency department setting, and really try to help them gain that confidence and some of the knowledge base that they need to be able to handle these. Because most of the time, they can be managed outside of the emergency department. So we're going to go through some myths and bad practice habits. And some of these slides, for some reason, have a little bit of a mind of their own. So if it starts to advance automatically, you may catch me going back. So I apologize for that. So we're going to talk about sterile gloves, water, epinephrine in digits, betadine, chlorhexidine, antibiotics, and the importance of some irrigation. So first of all, sterile water. Why is this important? Why am I talking about this? Well, there is a belief amongst many that we have to be using sterile solutions for the irrigation of wounds. And that's just not the case. Tap water is completely safe and effective when it comes to the irrigation of wounds. Now, you have to think about it and the fact that a laceration is not, it's a dirty injury. You know, the skin was dirty when it got lacerated. And the object that caused the laceration is likely a dirty object. So it's not like we're in the operating room when you want to have sterile skin whenever you start a procedure. So the use of sterile water really doesn't do anything. It doesn't add anything to this. When you look at the outcomes, which is what we're trying to look at, would be infection. There's no difference when you compare wounds that have been irrigated with sterile water versus those that have been irrigated with tap water. What I try to do is anesthetize the area and then have the patient, if the area, if the wound and the patient are amenable to this, and have them sit at the sink or stand at the sink and just irrigate it out for a few minutes. Sterile saline is infinitely more expensive than tap water because tap water is free. It comes out of the tap and there's no, you know, cost associated with it per se. So, you know, cost savings, convenience, you don't have to go scrambling around and looking for bottles of water or bottles of sterile solution. And bottom line is that it's safe and effective with the main outcome of the procedure. The outcome of looking at infection rates. All right, so sterile gloves, very similar conversation here. You can safely use the box gloves, the clean gloves that come in a box, they're on the wall, they're on the countertop. Again, looking at infection rates, there is no difference when you compare sterile gloves to the clean gloves. So if there's no improvement in that desired outcome, which is infection, then why use them? Now, some people may want to use the sterile gloves because they fit better. Sure, by all means, if that's your main reason for wanting to use them, go for it. But there's a huge cost savings, $2.30 for a pair of sterile gloves versus $0.07 for a pair of the clean gloves that come out of the big box. So over time, that definitely adds up. Bottom line is that you can safely use the clean gloves when you are looking at the primary outcome of infection rates. Again, here's a link that you can take a look at, a couple of links, and I'll try to get Rhonda to send those out again. All right, another myth, epinephrine. You probably have heard this mantra, you can't use epinephrine in the fingers, nose, penis, and toes. Well, that myth has been debunked. Orthopedic surgeons, plastic surgeons routinely use epinephrine-containing solutions in hand and finger surgery. It provides a couple of things. One, it gives you longer action of anesthetic activity, and it also can help with control bleeding. Biggest caveats there would be in patients who you know have peripheral artery disease, Raynaud's disease, Raynaud's phenomenon, any type of vasospasm-type situations. But by and large, it is safe, it is effective. The reason that this myth came up was that back in the 20s and 30s, the anesthetic procaine was mixed with epinephrine, and that was used in a number of patients. They ended up having this digital necrosis, and what they found is that it was actually a preservative in the solution that caused the pH to go down close to one. I mean, they were injecting almost pure acid. So it wasn't the epinephrine involved. It was actually the pH of the anesthetic solution that caused the problem. So bottom line is that epinephrine is safe to use in digital blocks and for local infiltration of wounds in the hands. And it's also safe to use in the nose, penis, and toes. All right, so here we go. Another, not necessarily a myth, but more of a bad practice habit, and the next two slides talk about this. And a lot of it is the same. So for povidone iodine, or betadine as we commonly refer to it, and chlorhexidine, or hibiclens as they're commonly referred to, it's not uncommon to see a patient when I walk into a room at different places where I've worked, and if they've got a hand injury, it seems like you see it more often with this, and their hand will actually be soaking in a tub of betadine or dilute betadine and chlorhexidine. And bottom line is that there's no benefit. There's some reports, some statements, sometimes people will say that it's tissue toxic or tissue cidal. I haven't found anything overly convincing that the betadine is tissue toxic or tissue cidal. I think that if it were, if that were to be proven, that there would be big red label warnings, black box warnings all over the place. But the bottom line is that there's no benefit. Whenever they look at the use of povidone iodine or chlorhexidine compared to water alone for the cleansing and irrigation of wounds, there's no benefit when it comes to decreased infection rates. So if you do currently do this, you don't have to. If any of your staff are soaking wounds in betadine or chlorhexidine, you don't have to. Now, I sometimes see orthopedists come in and they will do this, and that's fine. If that's what they want to do, that's totally fine. But for my practice, it's something that I have abandoned. And I really try to encourage my nursing staff to avoid doing this just because more than anything, it's extra expense, it's extra steps, it's extra resources, and it doesn't improve the outcome. So that's something that you can take home with you. Same thing, your chlorhexidine we just talked about. I'm a big believer in just using wet gauze. Let that be used to loosen up the dried blood. And hydrogen peroxide, I do want to say that this is something that we should never be using when it comes to irrigation and cleansing. Hydrogen peroxide is known to be tissue toxic and tissue-cital, so we don't want to be using this. I always tell the stories of patients, whenever I'm giving this talk, is you see a patient that has a wound, they come in the emergency department oftentimes, and they'll just say, yeah, it's just not healing. It's just not getting any better. And you look at the wound, and it looks very shiny. The tissue is very glossy. And I'll just ask them, have you been putting hydrogen peroxide on it? It just has that very characteristic, classic appearance to it. So hydrogen peroxide should never be used in the acute setting for the cleansing and irrigation of wounds. It shouldn't be used long term. And try to encourage your patients to not use this to take care of their wounds. Antibiotics. This is a topic that could probably take up about a 30 to 45-minute discussion alone when it comes to antibiotics for lacerations. And I just want to kind of give you a couple of high-yield points here. One, in general, prophylaxis is not needed, for the most part, for a simple, uncomplicated laceration. The times that you would be using antibiotics are listed here. If there's an extended time period from the injury and to their presentation, and they're coming in, it may be 24 hours later. And if it's a larger wound that does need closure, those would be ones that you would want to start patients on antibiotics. Location. The hands and the lower extremities are more prone to developing infection. Comorbidities. The biggest one, of course, is going to be diabetes. Others would be patients who are on immunosuppressant medications, chronic renal disease, if they're on steroids, things like that. So those are the things, the comorbidities. If those start to stack up, you may want to consider putting your patient on some antibiotics. This study here, this first one, it shows that we do tend to over-prescribe antibiotics. And they actually took it a step further and looked at the issue of patient satisfaction. What they found is that patients don't have higher levels of satisfaction, whatever that is, when it's associated with the prescribing patterns of their treating physicians for lacerations. So animal bites are a different animal, so to speak. Sorry for the pun. Cat bites, yes, always. Cat bites are nasty. They are more prone to getting infected and can turn south very quickly. So you always want to start cat bites on antibiotics. We don't suture cat bites for that reason because they're so prone to becoming infected. Dog bites, if you are not suturing it, the main recommendation is to irrigate, irrigate, irrigate. And they're felt to not need antibiotics. Maybe a caveat would be with the hand, if they have some of those comorbidities listed earlier. But if you are suturing a dog bite, you definitely want to prescribe antibiotics for that. Irrigation, this is a subject that is near and dear to my heart. The biggest things with irrigation are pressure and volume. Now, the volume is an easier one to quantify. And in general, what we want to do is provide 50 to 100 cc per centimeter of laceration. So the math is simple. 5 centimeter laceration should be getting 250 to 500 ml of water for irrigation. Now, the pressure part of it is a little bit more difficult because we obviously don't have some kind of a pressure gauge to evaluate how much pressure is being generated when we irrigate. But it is felt to be accepted that if you're using a syringe and a splash guard and you're putting moderate pressure on the plunger whenever you're irrigating, that that's enough to give you the desired pressure. Because what we're trying to do is we're trying to remove any contamination. We're trying to overcome the adhesive forces of the bacteria and the biofilm that's inside of a wind. I like to use a large syringe, a 60 cc syringe, just from an efficiency standpoint. If you're having to irrigate 500 ml, it's a lot easier to use a 60 cc syringe instead of a 20 just because of the number of pulls and pushes with the syringe. The other thing is that irrigating at the sink is felt to be effective as well, one from a pressure and from a volume standpoint. So sink is always good if the wind is amenable to being irrigated with tap water. All right, so that's some of the myths and bad practice habits. Now I'm going to talk about some products and some concepts that you should be familiar with, and we're going to run through all of these here. All right, trauma shears. If you've ever worked in an emergency department, you've probably seen or had some of these. Regardless, you can get them on Amazon or pretty much anywhere. They used to be given away by drug reps a long time ago in the good old days. But having a good pair of trauma shears, they don't have to be expensive. You can get some for $5 to $10. But they're really good just to be able to cut off clothing. You know, in your setting, in your environment, you may see a patient that comes to you with the omnipresent towel and duct tape. And when you're trying to get through duct tape and towels, they're covered with blood. Having a good pair of trauma shears is very helpful. Lighting. Depending on where you work, the quality of light that you have in order to see, evaluate, and treat wounds and do procedures in general may be highly variable. Having a good rechargeable LED headlamp is really just a nice thing to have. They're not expensive. Again, you can keep it in your bag, you can keep it at your desk, in a drawer. But I would recommend that you have one of these lights. Again, go to Amazon. They're all over the place. But they really are a good thing for you to have. Measuring tape or a ruler. These come as little paper ones. They come in, like, sometimes on the box of 4x4s. You may have a little ruler on there on cotton tip applicators. Or even if you wanted to just pick up a simple, you know, reusable, retractable tape measure that you can keep in your pocket or at your desk. And the reason that this is important is from the billing and coding aspect with lacerations. One of the main components from a billing and coding perspective is the length. So you have to have some way in order to measure the length of laceration. You may also, you know, for abscess and cellulitis. But having a tape measure is important. Finger tourniquets. I cannot overstate the importance of having a finger tourniquet device or technique that you should be familiar with. Something that you're comfortable with. Now, there are some commercially available finger tourniquets. And you can see one of them right here. The biggest thing is removing the tourniquet. So if you are using a tourniquet to help control bleeding in order to get a bloodless field so that you can better evaluate for the presence of foreign bodies, for the presence of tendon injuries. Being able to do this, you really do need to have a finger tourniquet. So either if it's commercially available. The larger picture here is the glove technique. And this is a simple one that you can do as well. So if you have a patient with a laceration on the finger, let's say it's the index finger. Essentially, all you're doing is you're putting a glove on. And it can be a clean glove or a sterile glove. Doesn't matter. And then what you're trying to do, what you end up doing is you just snip the end of the finger. And then you just basically roll this down all the way to the base of the finger. And it serves as a tourniquet. Not only do you have to remove it, but another thing is just the amount of pressure that these tourniquets can generate can be upwards of like 400 to 500 millimeters of mercury. I just want you to understand that you don't have to have massive amounts of pressure generated onto the finger in order for this to be effective. All you're trying to do is overcome the arterial pressure in a finger. You don't really need to wrench this thing down so tight that you end up causing ischemic injury to the nerve or the soft tissues of the finger. Finger tourniquets are important. Make sure you remove them and don't apply so much pressure that you end up causing nerve injury. Cyanoacrylate, aka glue, tissue adhesive, or Dermabond. There are a number of companies that make this, and it's really, really, really helpful. It really comes down to patient selection and wound selection. This cannot be used on wounds that are gaping open, that are actively bleeding, or are under a lot of tension. Small wounds, especially on the face, can be treated with tissue adhesive. Big thing is that you're not getting it into the eyes. You don't want it to leak down into the eyes and get the eyelids closed shut. What you can do, however, is put a Tegaderm over the eye. Almost is like a little eye shield with Tegaderm, if you are going to be working in that area. I've had a couple of patients recently who have had small periorbital lacerations, and they were very concerned about the scarring aspect of it. They insisted that I use Dermabond or tissue adhesive. All I did was just use that Tegaderm technique to help protect the eye and prevent the glue from running down in there. Now, it's also helpful for skin tears. You can combine it with stair strips. We'll talk a little bit more about that here shortly. Another good thing with the tissue adhesive is that it comes off on its own. It sloughs off over the course of the next five to 10 days, and so they don't have to come back in for a suture removal visit. All right, staplers. Again, this is another concept here. I'm sure you're all familiar with staplers. Staples are fast. They are very effective. Similar cosmetic outcome. They can be used pretty much anywhere except for the face, the hands, fingers, and feet. But staples do come in varying qualities. Now, you see two images right here. I don't even know what brand they are. I don't care. It doesn't matter. But there is a difference in quality. The picture that you see in the middle of the screen is more of your standard operating room surgical stapler. The one on the right is often referred to as a five-shot or a 10-shot stapler. I would encourage you to have some of the higher quality staplers, and the difference in price is negligible. I called my hospital, and the price that I was given for both of these was like $5.60 for the surgical stapler versus $3.50 for the smaller five-shot wobbly unstable stapler. If you do want to stock staples in your setting, I would encourage you to get some of the higher quality ones. But they're fantastic, especially for the scalp. All right. Steri-strips, again, are fantastic. They're a good thing for you to be able to close wounds, especially those that are not gaping open. You're not concerned about tension. Cosmetic outcome is very similar. You can combine these with sutures or glue, and they really are being advocated for more and more. Small lacerations, maybe these can get by without having sutures. But again, patient selection, as with the tissue adhesive, wounds with minimal tension, not gaping open. Now, the other thing is that you do have to have the benzoin, and that's that brown colored tissue adhesive that is needed for steri-strips to truly stick to the skin. If you are going to use steri-strips, make sure that you have benzoin. All right. That is section number 2. It looks like I'm around 22 minutes or so. I think we've got plenty of time to keep moving with some of these pearls tricks and advanced techniques. These are some of the fun ones. This is a lot of fun to talk about. All right. Ring removal. I wanted to put this first and foremost, you all are probably just as familiar, if not more familiar with finger injuries. It seems like that's a very, very, very common injury because people, well, they work with their hands, and the hands and fingers are a very common location for lacerations in the work setting. I put this in here because it's very, very important, and not only for you all to be aware of, but also for people who are working in the work environment, and maybe from an educational standpoint, whenever there are any finger injuries, I think it's something that needs to be relayed and communicated with people in the work setting, that if they do have an employee that has a finger or hand or upper extremity injury, one of the first things that needs to go through your mind is to look at the hands, and if there are any rings, they need to come off. For obvious reasons, if you have a laceration on a digit that has a ring on it, well, you need to get that off. But for anywhere on the extremity, swelling is often delayed a little bit, and if a ring is left on and the arm gets splinted and that ring is overlooked, you may end up having some issues with being able to get the ring off and some soft tissue injury, possibly even some digital necrosis there. So whenever you can try to get rings off, this commercially available device, I have no connection with the company. I do know the gentleman that owns it, but I have no financial ties to this company, is really a fascinating product called Ring Rescue. I've got a makeshift one that I keep in my bag. You can see it right up here. I just took like a preemie, a baby preemie, NICU blood pressure cuff, and tied off one of the tubes going in and then connected an IV adapter to it. Some IV tubing, and what you can do is basically wrap this little preemie baby cuff or the Ring Rescue onto the digit, inflate it, and that helps to remove some of the edema in the finger, and it does allow for the ring to be removed much more easily. You may have to end up cutting the ring. There are a lot of different devices that are available with that, but I would think that this would be something, either the preemie cuff or one of the commercially available devices for this, this may not be a bad thing for you to be aware of, because I imagine this is something that comes up quite frequently. All right, so knot tying. I put this in here because sometimes, even if you've been doing this, you feel very comfortable with suturing. This may be one of those things that you haven't really thought about in detail in a long time, so I'm bringing this up maybe for people who are new to suturing and managing lax, but even those of you who have been doing this for a long time, I just wanted to throw this out here as something that you can kind of refresh your memory on. All right, sorry, I'm trying to move this thing around so that we can still see what's important, but still see my face. All right, so the surgeon's knot. That's really the cornerstone here. So whenever you are tying an instrument tie, the first thing that you wanna do, your first throws of your needle or of the thread are two wraps around the needle driver, and then you grab the tail and you pull it across, and then that should come down nice and square over the laceration, kind of perpendicular to the laceration, and then your second throw, you're pulling the tail in the opposite direction, and what you're trying to do is get this back and forth kind of winding of the thread so that it goes like this, so that whenever you're tying your knot down, it looks like it does on the right where it says correct. So what that does is it allows you to have what is called a squared knot. Whenever we're tying knots and we're putting in stitches, we don't want the thread to unravel because if it unravels, then that means that the knot was not secure and it may lead to wound dehiscence, and that's not a good thing. So going back to the basics, it is important that you do your instrument tie properly. You wanna have at least three up to five throws that wraps around the needle driver and then pulling the tail in the opposite direction. You wanna do that in between three to five times, going in the opposite direction each time, and the next slide is just a little schematic here. So what I've done is on the left, you see the incorrect way. So if you're taking the thread and wrapping it around your needle driver and you pull the tail in the same direction each time, this is what it ends up looking like. You end up having space in between each of those throws and it doesn't come down nice and secure and it's prone to unraveling. On the right, you see the correct process being done. There's no space in between the individual throws and that's what you really need to strive for. So sorry for that basic review and return to what you may have learned many, many, many years ago, but I think it's always good to have a refresher on some of these things. All right, bleeding varicose veins or just small puncture wounds, something that you may not want to take out a whole laceration repair kit, but you can use a suture removal kit. And it's basically, we've probably all heard the term figure of eight, but the figure of eight stitch may not be something that you're familiar with. Essentially, it gets its name because it looks like the number eight just flipped on its side. And essentially what this is, is two passes of your needle side by side, starting and coming through kind of in the same orientation. And then you basically just tie it off across the middle. And this is a very useful thing. One for a bleeding varicose vein, you may have a patient who's in the work setting, their leg brushes up against something and they just get this little tiny, varicose vein, small pumping vein that comes in and you need to get that under control. Well, that's not something that needs to come to the emergency department. Yeah, this is something that can be done in the outpatient setting. And it basically just put in a figure of eight stitch around that area where it's bleeding, tie it off and it basically just kind of clamps it, kind of tamponades it off. Also good for other applications such as a patient who may have had a recent heart catheterization and they come in and they've got some bleeding from their groin. They may have had a piracentesis for removal of ascites and you can just put in a simple figure of eight suture and it can be with absorbable sutures so they don't have to come back. And then they can always follow up with their primary care physician. But a great little technique, the figure of eight stitch. All right, hairy areas. It's kind of hard to say fast, but I just wanted to bring up a couple of things right here. If you have a patient that does have a laceration such as the mustache, this was a work-related one, by the way. In the scalp, anywhere there's a lot of hair, I wanna encourage you to use a black colored suture. And that's because of ease of identification and removal whenever they have to come back in. I'm sorry, I think I misspoke there. You want to use a blue colored suture, not black, please, in the name of all things holy. Don't use black suture because it really does make it difficult to find the suture thread and identify it. And just, it's more difficult for your colleagues or nursing staff whenever they come back in. So try to use a blue colored suture whenever you're suturing in hairy areas. If it's in the scalp, really try to use staples. Using sutures in the scalp is just very, very difficult, not only for you, but also upon removal. So really try to use staples in the scalp if you can. And another, just a little helpful trick, if you are suturing in a hairy area, leave the tails of the suture long. Again, this is for ease of identification for suture removal. Scalp wound, here's another little trick that may be helpful. If you're in a pinch, if you don't have anesthetic, or the patient doesn't want to have staples put in, or they don't want to have the pain of injection of the anesthetic, you can do what's called the hair apposition technique. And it's basically, you kind of clean the area out, and then you're just taking several hairs on either side of the wound, as you can see in the diagram there. And you basically just kind of twist them around, pull them together, or pull them apart, pull them in opposite directions. And then you can take a little dollop of glue, and that will secure that twisted hair, and can serve as a, basically as a tissue adhesive. And the twisting around of the hairs brings the tissue together. So the hair apposition technique, that may be something that would be of benefit for you to be aware of, especially with children. I know that you aren't seeing a whole lot of children in your practice, but it is something that's advocated for with kids. All right, surgery lube-formatted hair. This is another one that may or may not be applicable to you, but I just learned about this a couple months ago. And if you have a patient who comes to you, and they've got a scalp laceration, it may have been bleeding for a little while, it's starting to clot off. And using just the little packets of KY or surgery lube, whatever you refer to it as, you can massage that into that clotted, matted hair and blood, and then irrigate it out. And it really does make a difference, makes it a lot easier to get that clotted blood out. All right, large volume irrigation. So this is something that you may or may not encounter or have the need or ability for, but just a couple of tricks. If you do have a wound, maybe you don't have access to a sink or they're, for whatever reason, we wanna try to prevent mess. Mess is not fun to deal with. We don't want the water from irrigation to get all over the patient's clothes. We don't want it to get all over the facility, stretcher, gurney, bed, table, chair, whatever it is. So what you can do is you can take, and the one on the right is probably gonna be more applicable, you can take a patient belongings bag or heck, even a trash can with a towel, a super absorbent pad, a Chucks pad, as they're often referred to, and put that inside the bag. And then whenever you're irrigating, it contains all of the irrigation fluid, and it may make things a little bit easier for you in terms of cleanup. Then you just toss the bag away. So yeah, just another little helpful hint. Now, if you do have wall-mounted suction at your disposal, that's another thing you can do is just take the suction catheter and put it in close proximity to where the irrigation fluid is going to be flowing towards and that just kind of sucks it off to the wall and out of your way. I think the bag technique is probably the most applicable and it really is easy to use. And it's nice just when you can kind of wrap that up and throw it away. All right, so here is one that I really want you to be aware of and try out. If you are going to be dealing with the evaluation of or management of a finger injury, it's called the intrathecal nerve block. And if you're not familiar with nerve blocks at all whatsoever, the premise is that you want to apply anesthetic to the nerves of the finger. So on both sides of the finger, we have a volar and a dorsal digital nerve and those run down the side of the finger and on both sides. So what I've done for as long as I can remember is kind of a two injection technique where you're basically just injecting on both the medial and the lateral aspects of the finger. And I put something up on some of my social media stuff and somebody said, hey, have you ever tried the intrathecal nerve block? It's just a single injection and I had not. So of course I'm on YouTube and I'm learning about it. And lo and behold, about 30 minutes later, I had a patient that came in with a finger laceration. So I was like, you know, getting all excited and wow, this is an opportunity to try it. So I did this for the first time and it's changed what I do. This is all I do now for digital blocks. The landmark is very simple. You're just looking at the volar palmar crease of the MCP joint. So I'm gonna hold my hand right up here and this is your landmark, that crease right there. So essentially all that you do is you take your needle with your anesthetic, which as we do know now can contain epinephrine. And then you're just essentially taking at a 45 degree angle, you inject right in the midline. Okay, at a 45 degree angle, you go down and you tap the bone, withdraw just a slight amount, aspirate, make sure that you're not in a blood vessel and you just deposit anywhere from two, three to four, I'd probably err a little bit on the higher side, four or five mLs of anesthetic. And then I just let that sit for a while. I'll go and I'll chart on that particular patient. I may go see another patient, just kind of check and see how the emergency department's going and then come back later, 10 minutes and the patient is usually ready for irrigation. Another thing you can do to save a little bit more time is say, look, after this is numb, if it gets numb, feel free to stand over at the sink and start washing it out. So intrathecal nerve block, great technique to have at your disposal. All right, fingertip abulsions. I know that you all see these a lot and there's a couple of little pointers here. So, we always wanna know, do you have to have imaging? Well, I mean, if it's a simple, straightforward, distal tip abulsion and there was no high risk features such as high energy, high mechanism of injury that would lead you to think that there was a fracture, if it's more, truly a laceration, a cut of the distal fingertip, no, you probably don't need to get imaging, but if there is any high energy associated with it, if it's a little bit more proximal, if there's a subungual hematoma, crush injury and things like that associated, yes, you might wanna get some x-rays. Digital blocks are very important, the use of finger tourniquets. On the next slide, we'll talk about this finger tourniquet technique. Now, if they have any intact tissue there, and you can still see like the little flap of skin, maybe it's still intact, you can do all those things with the digital block and the finger tourniquet, and then maybe just put in one or two sutures to attack that skin down so it can serve as kind of like a biological dressing. Now, the other thing that you can do is tissue adhesive and use that to cover that little flap of skin if it's still intact, great little techniques. And then after you get the bleeding controlled and whatnot, you can put a little bit of petroleum gauze, wrap it up and have them follow up with an orthopedist or a hand surgeon. Now, let's see, okay, yeah, so managing expectations, letting them know that it may continue to bleed, it may continue to ooze. The ones that really just make my skin crawl are the patients who are on anticoagulants, and you have these, because you know that it's frustrating for them because it continues to bleed, but really just giving them some reassurance that eventually it will in fact stop, but elevating, applying pressure. Uh, but this little technique right here, which is called the fingertip avulsion technique is really a good one for you to, uh, you know, you can just Google it, uh, follow this link here. Uh, but essentially what you're doing is you're applying a finger tourniquet to the, the affected finger. And then basically just soak that finger in lidocaine and epinephrine for about 10 minutes, and then, um, you know, dry it really, really well. And then, um, with the finger tourniquet still in place, apply several layers of tissue adhesive, the cyanoacrylate to that area, and it works amazingly well. I've done this several times. So the fingertip avulsion technique is the kind of the combination of the finger tourniquet, lidocaine and epinephrine soak, and then applying some tissue adhesive to that area. So that's a great technique for you to be familiar with. All right. Subungle hematomas. Um, I don't know if I can, I don't think I'm able to get on there. Um, the, the biggest thing, you know, is whenever you've got a, uh, hematoma under a fingernail, the technical term is subungle hematoma. Um, and you want to get those drained if it's sizable. I mean, if it's very, very small, you're probably fine leaving it alone, but if it's causing significant symptoms to the patient, and I've read different numbers. If it's greater than 40%, if it's greater than 50%, but you want to get those drained within 24 to 48 hours, uh, because it can cause some pressure injury to the nail bed. So how you do this is with an electro-cautery, and I would imagine that this would be another one of those things that you're, you may not be, you know, using those all the time, but it may not be a bad thing to have in your bag of tricks. Uh, so essentially you wipe down the affected nail with an alcohol swab, let it dry, and then you take your electro-cautery and you put a subuncle you put a single hole, uh, and you're going to get this small volcanic eruption of blood come out with almost immediate relief of pain from the patient. Um, I have, I was taught in a lot of the sources that I came across do recommend putting two holes in the nail. And the reason being, if there's only one, it may clot off and reaccumulate. So putting a second hole in there, the big thing I want you to, and this is from experience, um, is when you're putting that second hole in the nail, you don't want to keep pushing the electro-cautery looking for that same explosion and volcanic eruption of blood, because it's not going to be there. And eventually that, um, red hot, uh, electro-cautery mechanism is going to touch the nail bed and the patient is going to scream right, right at you. So, um, the second hole, you just need to make it, you don't need to keep pushing expecting that additional blood to come out. Uh, but these are, for me, these are fun to take care of because they almost get immediate, uh, sense of relief from the patient. So those are the big things, um, drain within 24 to 48 hours and put two holes in there and don't keep pushing on that second, uh, hole placement. All right. Combining steristrips and suture. This is fantastic. And I did this for the first time just a couple of months ago. And, um, essentially what you're doing is you're, you're utilizing steristrips to help bolster the skin, uh, to serve as an anchor for suture material to go through, if it's an area of very high tension or in a patient who has very thin skin. So I had a little teaser there that the slide advanced on itself. All right. So this is a patient that I took care of elderly. Um, and her leg got hit by a car door and you just had this snapping of the skin, almost like a burst injury. And, uh, you can see that there's quite a bit of distance between both the proximal and distal edges of that wound. And there was no way in the world I was going to be able to get this thing repaired, um, on its own. So I had read about this technique, but never had the chance to actually, uh, use it. So what I did is I, you know, anesthetized, irrigated, and then I used the benzoin and the steristrips to place along the margin of the wound. And then I just utilized a bunch of horizontal mattress sutures, which do allow you to, uh, place a lot more tension on the wound, uh, or on the, on the repair and just used a series of horizontal mattress sutures. I think there was seven horizontal mattress and then a single interrupted at the end and it really just came together beautifully. I talked to the orthopedist and he had never heard of this technique as well. So we both learned something. Um, but it ended up coming out just amazingly well, this was at two weeks, four weeks, and, uh, ironically, while I was, uh, putting some of these presentations stuff together, uh, the patient's granddaughter texted me this picture on the right. Uh, grandma was on her way to the emergency department for another laceration and she was asking if I was working that day and, uh, unfortunately I was not, but she sent me that picture of her leg and that just made me smile. Um, it came out fantastic, uh, cause this is a wound that otherwise may have ended up in the, um, you know, wound care clinic, um, maybe even a wound vac. So the fact that I was able to bring that together, uh, was really a big, um, a big win for, uh, for the patient in terms of her outcome and healing process. All right. So lip lacerations, this is another one that really, um, I think we've got a lot of fear about, but we shouldn't. And the, the take-home point with lip lacerations, the vermilion border is not some holy grail of a tissue that we are not capable of managing in the acute setting, um, I was just at this urgent care association meeting and I was told by several people that they have policies, uh, at their urgent cares where they're not allowed to touch vermilion border lacerations. So, um, that's, that that's a shame because when they come to the emergency department, it's, it's just a lowly ER doc like myself or a PA or a nurse practitioner who just happens to work in the emergency department, who's going to be repairing these. So the important thing is the approach and it's a stepwise approach. First, you align the vermilion border, then the muscular layer, the wet layer on the inside of the lip, the wet mucosa, and then the outer dry layer. And it's going to be with a combination of, uh, absorbable and non-absorbable sutures, buried sutures, and on the inside of the mouth or absorbable. And then the vermilion border and the dry mucosa is a non-absorbable. But these, you know, if it's, you know, some splayed open, gaping, flapping open, and you're really concerned about tissue loss and things like that, absolutely. But if it's a simple laceration that goes through the lip, there's no reason that we can't be, uh, repairing these outside of the emergency department. At least give it a shot. All right. So this is, uh, the same patient that I referenced earlier, uh, was struck in the face by a nail and just had this lip laceration, biggest thing is just aligning the vermilion border. And after that, everything else kind of comes together. And then you can see the orbicularis oris muscle was repaired with a single suture, and then this one didn't actually go inside the mouth, uh, but we just repaired the dry lip and then onto the face and it came together very well. All right. Another one that you may or may not see, uh, fishhook removal. And it looks like I've got about five or six more minutes. So I'm going to try to squeeze through the rest of this stuff. Fishhooks, um, yeah, this may be in fact a work-related injury, uh, depending on, on, on, on your location. Uh, biggest thing with fishhooks is to be familiar with the anatomy of a fishhook. The things that cause the problem are this barb, this, uh, this barb right here. Um, that's what keeps it from sliding out of the fish's mouth. And it keeps it from sliding out of Bob's hand when it gets stuck. So we want to get that barb out and visible so that we can either snip it, or we want to, uh, make an entry point along the shank of the hook so that you can easily remove it. Now, if the point and the barb are deeply, deeply, deeply embedded in the tissue, you're really going to have to try to back this thing out. And what I use is a 11 blade scalpel. And I just make an incision along the shank of the fishhook as it goes in. And then I'm just taking some pliers and trying to get it out. Now, if the point and the barb are in close proximity to the skin surface, you can use that same 11 blade scalpel, make a small stab incision for, uh, ease to kind of facilitate the, uh, the point and the barb coming out. And then you basically just snip it, uh, with some wire cutters. There are a dozen different techniques here. I would just encourage you to be familiar with them, a quick YouTube search, and you can find a handful of different things, but those are the ways that I approach fishhooks. All right. Tissue bridges and flaps. Um, again, this is, uh, some of the more complex injuries that you might see. Um, and I try to envision how the wound's going to come together and develop a plan or a strategy. And then, uh, you know, some of these may require some undermining and debridement, and you may end up using a combination of interrupted subcuticular and mattress techniques. Parallel lacerations. These are fun to put together. Um, you know, you, you probably not going to be seeing something, uh, with such a dramatic presentation there in the left lower corner, um, but you may get some small lacerations that are in fact, just in close proximity to each other and how I want you to, to visualize these is basically just having an extended, sorry about this slide thing. Um, having an extended or, you know, an extended horizontal mattress suture. And you're basically just going to be threading the needle and the thread through these tissue islands and tissue bridges, and then coming back through and then tying off on the same side that you started on. So as you can see, it's really just an extended horizontal mattress suture. And this is a great technique to be able to, uh, repair lacerations that are in close proximity, because we don't want to put a bunch of needle sticks and a lot of tension on these small, uh, tissue bridges or tissue islands right here that may end up causing some tissue injury. All right. So the Y shaped or V shaped or corner laceration, this too is a variation of the, uh, horizontal mattress suture sometimes referred to as a, uh, half buried suture, and you're basically just taking your suture needle and thread through the dermal layer of this little corner flap, and then coming back down, tying it off and bringing that tissue flap to kind of like that, that V, uh, like this right here, you're basically just kind of bringing that into close proximity and tying it off and it works really, really well. Uh, so the corner flap or the Y shaped wound, uh, corner mattress suture, uh, is, is an important technique. All right. So now lastly, we're going to speed through some medical legal considerations. Um, things that you really just want to keep in, you know, kind of keep in the back of your mind. Most of the medical legal issues that you're going to have with these types of injuries come from failure to diagnose and failure to treat. Uh, and the bottom line is that you can't find something if you don't look for it. Uh, associated fractures are a big issue. Uh, you really have to, you know, consider and respect and understand what the mechanism of injury is. You know, if they're cutting, uh, um, onions in the kitchen, not concerned about fracture, but if they're getting their finger caught in a wire or a door or some kind of a high injury mechanism, crush injury, if there's a presence of a subungal hematoma, you really do need to, to get the imaging. Being familiar with the definition of a, an open fracture, it doesn't have to be a bone sticking out of the skin. The official definition, according to the American Academy of Orthopedic Surgeons is, uh, an open wound in close proximity to a fracture. So it doesn't have to be a bone sticking out of the skin. Uh, they don't always require admission and antibiotics, I'm sorry. They don't always require admission and operating room. Uh, but it does require, and it warrants a discussion with your orthopedic colleagues and starting the patient on antibiotics, at least have that discussion and arrange for some followup. This foreign body is another huge thing. Not all foreign bodies show up on films. Glass is a huge one here. Uh, in my practice, whenever I see a patient that's been injured with glass, I always get the plain film just because you can't always see it and you need some additional eyes, uh, from, uh, from x-ray beams and radiologists to, uh, to help exclude foreign bodies. Uh, glass is just a bad one. Splinters and organic debris may not show up on, uh, plain film. So you may need some advanced imaging there. Um, when in doubt, order imaging. You know, you're not going to be blamed or get in trouble for ordering an x-ray, but you can certainly land yourself in hot water if you don't. And you over, you overlook a foreign body that ends up migrating. And that's the problem with, uh, with foreign bodies is they can move and end up causing more damage than just the initial injury. So whenever there are injuries in close proximity, there's a concern for foreign body in proximity to, um, you know, uh, significant structures, uh, uh, tendons. Uh, joint capsules, nerves, and blood vessels. You want to make sure that there is no foreign body. Uh, if it's something that you're not able to get yourself, uh, arranging follow-up with either a surgeon, a general surgeon, orthopedic surgeon, or even a podiatrist, if it's a foot, uh, foreign body, uh, but just make sure that you, um, you know, address that. And in your documentation that, uh, you know, foreign bodies were looked for, uh, and none were felt to be present. All right. So when to consult and when to transfer, um, you know, biggest things for me, I think, are, uh, and, and for you to take home whenever there's a concern for nerve, vascular, larger tendon, joint injury, uh, difficult to remove foreign bodies, um, high pressure injection injuries. I'm sure that y'all are much more aware of those and familiar with those. Uh, but those are a special, uh, breed of badness and, uh, high pressure injection injuries definitely need to be referred out and, uh, and, and managed, uh, likely in the operating room, anything that's out of your comfort zone. You know, I, I really try to get people to get out of their comfort zone, but if it's something that just, you know, gives you a bad feeling, uh, then that's something that needs to be sent out and, uh, and dealt with in a higher level of care. All right. So if you are transferring, you know, being in the emergency department, this is what I ask of you, uh, is to call and speak to me, uh, or whoever it is in the emergency department, um, just to make, and the biggest reason here is, um, not that we don't trust, trust you or whatever, but we want to make sure that we actually have the service that is needed. I work in a small community hospital and we don't always have, uh, you know, coverage by urologist, ear, nose, and throat, and some other things. We don't even have ophthalmology and we sure as heck don't have plastic surgery. So before a patient, you know, is sent to me, I want to make sure that we have the service that's needed. So that's the main thing, call and make sure that we have the service that, uh, that you feel the patient needs. And then lastly, don't promise what the patient or to the patient, what will or will not be done. Uh, cause sometimes things may change. We may get more information, uh, and it kind of paints us in a corner. All right. So follow up who, what, when, why, where, and how, uh, all those things need to be addressed verbally and with, uh, you know, written discharge instructions. All right. So that's it. I think I'm kind of right up around 50 minutes, 55 minutes. So here's my contact information. Uh, I'm passionate about this stuff. Please shoot me an email. If there's anything that I can do for you. Um, I I'd love to, uh, to be a resource for you. Uh, you can find me on LinkedIn and I would love to work with you. And again, thank you for the opportunity to, uh, to be here and share a little bit of my, uh, limited skillset with you. Um, and I hope y'all are having a good conference. Hello everyone. Uh, this is Patrick O'Malley again, and today we were going to go through, uh, a bunch of laceration case presentations. So for those of you who were, uh, who did not see the previous lecture that I'd done just a brief introduction, my name is Patrick O'Malley, I'm a board certified emergency physician. I went to medical school in North Carolina at East Carolina university. Uh, did residency in Charlotte at, uh, Carolina's medical center in emergency medicine. And I've been in South Carolina for about 15 years working in a variety of emergency department and urgent care settings. Um, I've been involved with the urgent care association, having presented at their national conference several times and was recently elected to the, uh, college of urgent care medicines board of directors. Uh, here's my contact information. I want to put this up front. I'm not sure how many of the cases I'm going to be able to get through. Um, so I just wanted to put this here. If there's anything that I can do to be of assistance, please don't hesitate to reach out. I'd love to work with you. You can find me on LinkedIn, but here's my email and phone number. All right. So here are my disclosures. I do get a royalty from rescue essentials and Medline, uh, and course revenue from my online course. And today with, with these case presentations, the objective is to And today with, with these case presentations, the objectives are to, to utilize those case presentations with real world examples, patients that I've taken care of in the emergency department to illustrate some important, uh, some important aspects of wound care, uh, to develop a methodical approach to every laceration encounter, uh, and really get into the medical decision-making process. Things that go through my head in the emergency department and share those with you. Uh, and then lastly, to develop good documentation practices from a billing and coding aspect, uh, and just from a, a charting standpoint in general things that you need to, uh, to look for. All right. So for the case studies, what I'm going to do for each of these is talk about the presentation, what the patient's coming in with, uh, how to, how I get prepared for the, uh, laceration repair, uh, certain aspects of the closure, the documentation, uh, we'll go through and look at very closely, uh, for most of these, I was able to get follow-up. There were several that I just wasn't able to. And then lastly, we'll have a brief discussion on each case. All right. So case number one, this was an elderly patient with a large pre-tibial laceration, uh, resulting from a car door hitting the, uh, the front of her shin. And as you can see here, this is a, it's about a 10 centimeter, eight to 10 centimeter laceration. And the things that kind of jump out at me, uh, initially upon seeing this are one, there's some associated ecchymosis, uh, the thin is very, uh, the skin is very thin, uh, you can see some wrinkling of the skin right here and with the wound at rest, you can see there's about a good, you know, centimeter, centimeter and a half, or if not more of separation of the wound edges. So this is going to be a wound, uh, that is going to be very difficult to pull together. So what types of things go through your mind? Obviously tetanus status, um, you know, is there going to be any need for imaging? Um, how am I going to get these wound edges to come together? Well, like we were talking about, how do you approach this? Uh, there were no associated injuries. It was not grossly contaminated. I'm not concerned about foreign bodies. So imaging is not going to be needed in a, in a pretty straightforward situation like this anesthesia. Um, you know, it's not hemorrhaging, uh, but I, I tend to prefer using lidocaine with epinephrine just because once you start putting the needle into the skin and irrigating and, and all that stuff, you can get some pretty significant, uh, oozing. Obviously if the patient's on anticoagulants, so, uh, you know, for, for wounds like this, if it's available, I'll choose lidocaine and epinephrine for that reason. Irrigation is very important. This type of injury, we're not gonna be able to, I was seeing this patient in kind of a fast track setting in the emergency department, and this is not going to be amenable to sticking the leg in the sink, but definitely want to use proper irrigation techniques, the right amount of volume, like we discussed in the previous lecture, 50 to 100 cc's per centimeter of laceration. And then for my supplies, I mean, this is kind of bread and butter, emergency medicine, single-use laceration kit. I'm going to grab probably two packs of non-absorbable suture with a large needle, a large gauge suture and thread, such as like a 30 proline with a 24 millimeter needle. And then I'm also going to grab some Steri-Strips, and you might wonder why I'm going to be grabbing Steri-Strips, but I'll show you here next. Okay, so for the closure for this one, this is a technique that I've seen over the years, but I've never really had the opportunity or I've never had the foresight to employ this technique. But essentially what you're doing, and this is a great technique for patients with thin skin or a large wound that is going to require some tension. So essentially what you're doing is you're using a benzoin, that brown adhesive, and painting it along the edges of the wound, and then applying Steri-Strips along the margins. And you can apply the Steri-Strips, and we talked about this in the previous lecture, along the margin or across the wound. And essentially what you're doing is you're trying to bolster the skin so that the tissue or the suture material does not tear through the skin. And it just gives it a little bit of extra strength. So what I did here is after irrigation, I applied the Steri-Strips, and then I placed, I think it was seven horizontal mattress sutures. And that's the equivalent of 14 interrupted sutures. So you can see in large wounds like this, how much of a time-saving that can be. And it gives the added benefit of that extra tension, essentially being able to pull a larger area of tissue together with the proximal end here of the suture. So the horizontal mattress technique is great for being able to apply a large amount of tension across a wound. And I think I had to end up here with a single interrupted suture, but this came together very, very, very nicely. And it's definitely something that I've used additionally since doing it this first time. All right, so the documentation for something like this, I'm not gonna read this word for word, you can sit there and read it. But documentation is very important for several reasons, and I'm not gonna go through this every single time. From a work-related injury standpoint, there may be workman's comp claims, you all know this stuff much better than I do, but it is important to document well for obvious reasons. And then from a billing and coding aspect, I have to be honest with you, I don't know how that affects you all in your line of work and whatnot. But from an emergency medicine standpoint, we get paid on the complexity of a wound. And there's a couple of main factors that go into determining complexity, and it's the length, it is the number of layers that are involved in a closure, presence of contamination, if you have to debride any tissue, layered closures, and then also location. So the big things are length, location, and complexity. And the complexity part really kind of goes into the number of layers that are involved, the debridement and removal of debris and contamination. And then I also like to put a little bit of the aftercare, what else did I do? Putting Bacitracin on a wound, I didn't have that in this one, but putting Bacitracin on the wound, being appropriately bandaged, placing the patient in a splint, any of these pre-tibial lacerations are under a lot of tension whenever a patient's bearing weight. So applying a long leg splint, knee immobilizer type thing, and some crutches, and then recommending orthopedic follow-up. All right, so this one really just made me feel good. The patient was there with her granddaughter, and we communicated over the subsequent weeks, and the granddaughter would send me pictures, also communicated with the orthopedic surgeon, who would send me a picture from time to time. But about a month and a half ago, when I was working on some of this stuff, the patient's granddaughter sent me a text. She was going to the emergency department with the grandmom, with the patient for another laceration, and she had reached out to me to see if I was gonna be working, and she sent me this six-month follow-up picture, which was really, I'm just tickled pink to see how well this came out. But this is a wound that otherwise would have ended up in a wound care clinic, maybe even needing a wound vac or something like that if we hadn't been able to get those wound edges together. All right, so discussion, need for imaging, we talked about it, not necessary in a straightforward case like this. Suture, you wanna use large gauge suture, non-absorbable. Biggest concerns would be just not being able to get the wound edges together and poor healing. Given the size, her age, lower extremity wounds do have an increased risk of infection. So I did cover her with some antibiotics, and I did go a step further in terms of connecting with and contacting and arranging close follow-up with the orthopedic surgeon. And I think those are all the things that could have gone wrong had I not done those steps. So this one came out well, I was happy with it, and hopefully that the steristrip tip may serve you in the future. All right, case two. So this was an elderly woman who fell. Now, I'm sure that most of your patients are not elderly women, but the similar type of mechanisms can be present, and you may see wounds like this. So she fell, striking her head against a fence post, and you see this large stellate flap laceration to the forehead. Obviously, tetanus, tetanus, tetanus is one of the main things that you want to address early on. And in looking at this wound, you can see this shiny white stuff. Well, that is the calvarium, that is the bone of the skull. So this was a pretty significant deep laceration that involved the galea, which is the thin layering over the skin, over the skull. And that's an important thing that we need to close to prevent the spread of a subgaleal infection. So what things are going through your mind? Obviously, tetanus we talked about. Is this patient going to need imaging? What types of closure techniques will you employ? What kind of suture material? Is this something that you can handle? Does this need plastic surgery? Not necessarily. So, again, how do you approach this? Well, it is trauma. So airway, breathing, circulation. One thing, whenever I see a wound like this, I always remember back to my trauma rotations and our trauma attendings would always just say, when you walk into a room and you see some ghastly, horrid injury, take a deep breath and check your own pulse before doing anything else. So always focus on the important things. The wound is stable. Make sure that the patient is. So we always want to assess the airway, the breathing, circulation, disability, exposure. Look for any other associated injuries. Imaging for this, just with her age, she was not on any anticoagulants, but just this type of mechanism with that significant of an injury. I got a head CT. Elderly patients are more prone to cervical spine injuries with head injuries. So I got a CT of the cervical spine. Fortunately, both of those were negative. Anesthesia, this could be done in two ways. One, you could do local anesthesia all the way around the margins of the wound, which is what I ended up doing, I think. The other option that you could have would be to do some facial nerve blocks, which would be the supraorbital nerves right above the eye, along the margin of the supraorbital rim. That would be another way to do it. Lidocaine with epinephrine. Again, I'm a big fan of that. So that's what I opted to use. Irrigation, definitely. You can see the gross contamination in here. If you scan in real closely, you can actually see some dirt in the skull. So this is a wound that definitely needs irrigation. I'll be using a single-use laceration kit, absorbable and some non-absorbable or some absorbable sutures for the galea repair, and some chucks pads for the irrigation to contain the mess associated with irrigation. All right, so the closure on this, believe it or not, it came together very easily. It was just time-consuming. So you do the galea repair with absorbable sutures such as Vicryl. And then the biggest thing is to use a corner flap technique. And I think we talked about this on the previous lecture. And basically what you're doing is this kind of like a modified, half-buried horizontal mattress suture. And you're entering the skin and then you're entering the little corner flaps in the dermal layer, and then bringing it back out close to where you started and tie it off in a horizontal mattress technique. And it's like a purse string. Like when you close a purse string, everything just kind of comes together very nicely. And you can use this regardless if it's three rays, four rays, or even more. And this technique really does work well. And then I finished it off with a combination of running and interrupted suture to close the remaining aspects of the wound. All right, so this is the documentation. Again, you can read this yourself. Contamination, the fact that there was gross contamination, that that was removed with irrigation and tissue forceps, the presence of a multi-layered closure with absorbable and non-absorbable sutures. And then the fact that it was post-treatment or post-repair, that it was covered with BASA trace and antibiotic ointment and a non-stick bandage. Again, all things that are important from billing and coding and from a just general documentation perspective. All right, follow up. This was like six months to a year later. I can't remember, but one of our case managers had seen this patient. She was in the hospital for something unrelated and her family member had actually said, if you could please take a picture of grandma's forehead and show it to the ER doctor. So she brought that back to me and I was really pleased at the six month follow-up. And this really goes to show that you have to give wounds time in order for them to truly declare themselves as to how they're going to come out. So I always tell patients, if you're not happy with the scar, you can always follow up with a plastic surgeon later on for scar revision or other treatment modalities. But you really do have to give it time. And this came out very well. All right, so discussion. This was a tough wound. It was very time-consuming, definitely need imaging, concern for infection with the gross contamination. So she was covered with some antibiotics. I did recommend close follow-up. I'm not sure if she actually did, assuming that she had come back in for suture removal. This was a couple of years ago. So I did not follow up with her on that perspective. What could I have done differently? I think that the main thing here is if you look at this, this was done with running sutures and running sutures are great for time savings, but they're not so good in case there are any complications. And this is definitely a wound that is prone to having some complication with wound dehiscence and infection. So the advantage of using interrupted sutures is that if there is an area of infection, you can cut out one or two sutures in that localized area. But with a running stitch, you have to remove the whole thing. I guess, theoretically, you could cut out a single area and maybe tie things off and be creative. But if I had the time, running a busy emergency department to be able to spend 45 minutes in a room is sometimes just not possible. And that's an indication for, if you are working alone or in whatever setting that you're in, if there are significant time constraints and you've got a large complex laceration, that is definitely a valid reason to sending a patient to a higher level of care where they may have more resources and not working single coverage. All right, case three, our first work-related injury. So this was a 30-ish year old male who was removing a sheet of plywood from a truck and it had a small nail in it. It came down and the nail actually went through at the lateral aspect of the nose here all the way down through the lip. Fortunately, this did not extend all the way through the lip. This was not a flailed open gaping lip laceration that involved the inner lip or the wet mucosa. But the things that start going through my head, obviously, tetanus. All right, first and foremost, tetanus is up to date. And then imaging. Okay, what type of traumatic injury was this? Was this more of a shearing mechanism like a truly incisional injury? Was there any significant blunt trauma? Doing a good maxillofacial exam, making sure that the midface is stable, presence of any loss of consciousness. Was there any cervical spine tenderness with like a whiplash type injury? Any dental trauma? So those are the things that are going through my mind and will help guide me when it comes to making decisions on imaging. Fortunately, none of those things were present. This patient did not warrant any imaging and none was done. And so with lip lacerations, we'll talk about these here in much more detail. All right, so how do you approach this? Some of the things that we just discussed, there were no other associated injuries. Again, ABCDE of trauma, evaluate the entire patient, not just focused on the injury that you see. There was no need for imaging. Anesthesia for this, facial nerve block is the way to go. With the lip, your biggest thing is trying to bring that tissue back together with the vermilion border being the first step in that. If you put four or five cc's of anesthetic into those wound margins, you're really gonna distort the soft tissue. There's gonna be a lot of sub-tissue or subcutaneous edema, and that's gonna make it more difficult to bring together. So from an anesthesia standpoint, being familiar with and utilizing facial nerve blocks are paramount, they are so important. And for this would be an infraorbital nerve block, and you can feel on yourself, and I can imagine just all these people out virtually feeling their face right now for the infraorbital foramen, and that can be approached intraorally or externally. You just put a couple cc's of anesthetic right in that area, and that provides anesthesia from the lower eyelid all the way down through the upper lip. So that's what I opted for with this, and it worked great. Irrigation, definitely, just a dirty mechanism of injury with a nail, and then also involving the mouth, so you get that oral bacteria down in that area as well. So you definitely wanna irrigate well. One thing that I found for irrigating wounds around this area, if you're gonna be irrigating through a lip laceration, all that water can go into the mouth. So sometimes what I'll use is like a little suction, a Yankauer suction catheter, for the patient to hold in their mouth so that when the water goes inside their mouth, it just, it takes it away. Single-use laceration kit, we'll be using 6-0 proline or ethylene, a nylon non-absorbable suture for the external aspect, and then we'll be using some absorbable, and I think I used chromic gut or vicryl, I can't remember, for the repair of the orbicularis oris muscle. Anything inside the body is absorbable, outside the body, for the most part, will be non-absorbable, with some exceptions. So some 6-0 proline, and then some vicryl or chromic gut, or fast-absorbing plain gut, for the muscle repair and the inner wet mucosa repair. All right, so the closure for these, any lip lacerations involving the vermilion border, it is there, for some reason, the vermilion border has become kind of like a holy grail that we're not able to touch. And a lot of people, especially in the urgent care setting, I've learned a lot about this. Some urgent care companies actually have policies where they say you're not able to repair a lip laceration involving the vermilion border for some reason. And I think that's unfortunate. It's a disservice to our patients. And having them have to go to the emergency department for something like this, which is relatively simple, if you take the stepwise approach. So the first thing is to repair the vermilion border. And that's done with a single suture. And if you're having a hard time identifying exactly where the vermilion border is, or if your hands are a little bit shaking, you feel a bit nervous, what you can do is you can take a little marker, like a surgical pen, surgical marker, and actually just put a little dot along the vermilion border, and then use that as your landmark to bring it together. So once you put that first stitch in the vermilion border, it looks a lot less intimidating. The next step would be to put one or two or more sutures, however many are deemed appropriate, into the muscular layer. And that's just gonna be with your buried suture technique, where you enter the tissue deep and come out more proximal, and then tie your knot off and cut the knot, or cut the string close to the knot. Just one or two buried sutures to bring that lip muscle together. And then the next step, it was not seen or pictured on this one because it didn't extend into the wet mucosa, but the wet mucosa would be repaired next. And that too would be with your absorbable suture, followed lastly by the dry lip and the face, if the face is involved in that, is done with your non-absorbable suture. All right. So documentation, you can see here, you know, we want to mention, and I think I do in some of these, maybe not in all of them, that you do want to mention that verbal consent was obtained, who was repairing the laceration, you know, go through and explain the extent of any injury, what you had to do, including your anesthesia, talk about irrigation, if there was any debridement, you know, how you debrided the tissue, presence of gross contamination, and then kind of a stepwise approach here with the vermilion border, followed by the muscle repair, and then the external components covering with vasotracin. And again, this would be an intermediate complexity wound because it is a two-layer closure. All right, follow-up. This gentleman was from out of state and I tried and tried and tried, and unfortunately was not able to get any follow-up. I would have loved to have seen how this ended up turning out. So discussion on this, we talked about the imaging. it was not felt to be necessary because there was no other associated red flags or high-risk findings to warrant imaging. The vermilion border, it is just a stepwise approach. It's nothing to be overly fearful of. Now, if there's a vulse tissue, if it's going in multiple different directions and you just don't feel comfortable with it, absolutely. Send them over to the emergency department or to a higher level of care if you feel like it needs plastic surgery. These can be very time-consuming, so that is a definite concern. Concern for infection, again, just the fact that the mouth is involved, I tend to, I'm sure some antibiotic steward gurus may get on me from time to time, but just looking at the comorbidities, looking at the location, I tend to opt for antibiotics unless it's truly a low-risk injury. Close follow-up, this would be with ear, nose, and throat, plastic surgery, anybody in those realms, probably plastics or ENT would be good to follow up with. What could I have done differently on this one? Now, if I get in with a magnifying glass and I look at how I put in that initial vermilion border suture, to me, it just kind of felt like it was a little bit off, a little bit of Monday morning quarterbacking on myself. One important aspect of that is after you put in that initial vermilion border suture, if you're not happy with it, if it just doesn't line up like you want, take it out and do it again, and I feel like I should have gone back and done that when I looked at the images, putting the presentation together. So that is an important aspect of any suture repair, any laceration repair. If you're putting something together and the tissue planes aren't coming up, or you put a couple of sutures in and then you're coming up to a change in the orientation of the wound and the tissue just doesn't seem to be lining up, there's no harm in removing a suture or two or a staple or two and starting over, doing those sutures over. Sometimes these things are a work in progress. It is an art form. We are physicians and artists of sort, the art of medicine. And sometimes these things just, they require some real-time modification and change of plans. So I guess it can be akin to a pilot flying a plane, and sometimes you get a little bit of weather thrown at you and you have to divert course and change things up a little bit. There's no harm in doing that. All right, let's see here. Okay, so case number four. So again, this particular patient was not work-related, but there are plenty of Amazon and UPS drivers who are attacked by our furry little friends and do present to the emergency department, and I'm sure to you all as well, with some work-related animal bites, and especially dogs, I don't know how many attack cats there are out there chasing UPS drivers around, but animal bites are a common thing. And this particular patient was bitten on the hand, six hours prior to presentation by his own cat. So things going through your mind, tetanus, of course, rabies, was this a rabid cat? This particular cat, it was his own, he was up to date on all the shots, so that was not an issue. But things that are going through my mind are, first of all, it's a hand wound in an elderly person. So I'm thinking, what are the comorbidities, especially diabetes, peripheral vascular disease, immunosuppression with chronic steroids, anticoagulation, all of those things really do need to go through your mind and start helping to direct you along a certain pathway as to whether or not there's gonna be more of a significant workup needed. Now, if this was a 20-year-old with no comorbidities, would be much more, or would be much less concerned. But you can see, this is only six hours, and that's a pretty significant amount of erythema. There was definitely some appreciable swelling associated with this. So this is a guy where my radar is kind of going off here about whether or not he's gonna need admission, possibly surgical intervention. So how do you approach this? Some of the things that we've already discussed. Imaging, well, there was no associated injuries. Even with, I guess, probably more so with dogs, sometimes there's a large wound, and that has everybody's attention focused on it. But sometimes, was there a second dog? Were there any other injuries? So you really do wanna undress these patients and take a close look in residency on trauma rotations. Whenever there was a gunshot wound that would come in, our trauma attendings would always get on us about looking between the legs, looking in the axilla, those hidden areas that we tend to not look in. And man, I mean, you'd be surprised on occasion, some of the wounds and the injuries that would show up when you just look a little bit closer. So you always wanna look for any other associated injuries. Imaging on this, for cat bites and for dog bites, but especially cat bites. Those little teeth, they're sharp as heck, but they're also very thin, and they can break off. So it is recommended that you get an X-ray to look for any teeth fragments. There could be some foreign bodies associated with it as well. So on this X-ray right here, I'm not sure if I've got this later as well, but you can see these little black areas right here. Well, that's air, that's gas in the soft tissues, and that is not a good finding, and that was from this patient. So I see this, and my first thought is, okay, well, we're gonna be calling orthopedics. So I did, in fact, call orthopedics on this. So anesthesia not needed, irrigation not needed until I talked to the orthopedic surgeon, and we'll see what that plan is. So supplies for this one, not so much. The big thing here is going to be identification of need for a higher level of care, whether that being internal medicine for antibiotics or surgery for operative intervention. Closure, none. So that's pretty straightforward. In general, we do not close cat bites. Cat bites are nasty, and we don't suture them. Most cat bites are more of a puncture wound, and less so of a laceration or tearing mechanism. Dog bites, on the other hand, can be puncture wounds, but they also tend to be more crushing injuries. There is more laceration associated, kind of like a tearing mechanism. So closure for dog bites is a different animal. No pun intended, it's kind of a different situation, and it really depends. Dog bites, if they're large enough, and there's a cosmetic concern, yes, you can definitely close them, provide antibiotics. If they're small enough, they can heal by secondary intention. Just got to irrigate, irrigate, irrigate. All right, documentation for this, pretty straightforward from my perspective. It's basically bad wound, call orthopedics. So that's what I ended up doing. I do document here that there's evidence of gas in the soft tissue on plain films. Physical exam findings, you see the swelling, redness, and there was a palpable crepitance. So called orthopedics, and this is what we found here. So the patient went to the operating room, and on verbal report afterwards, I spoke to the orthopedic surgeon who was not overly thrilled about being called in. I think this was a Saturday evening, but he took the patient to the OR and he said, he told me, he said, yeah, I didn't find anything in there. Well, within six hours, I wouldn't expect there to be an actual abscess cavity. But the op note said left dorsal hand and deep wrist abscess, and the microbiology I followed up about a week later, did grow out Pasturella multicellar, which is a very common organism that is found in cat and dog bites. So the verbal report didn't really match up with the operative note, but bottom line is that this is a patient that needed consultation with orthopedics. So discussion on this, need for imaging? Yes. What type of suture? None. Definitely concerned for antibiotics. And I think right after I saw the patient, even before I called Ortho, I did give him a dose of Augmentin, which I probably should have given him something IV, just with the concern for him going to the operating room. Fortunately, that didn't slow anything down. If you do send a patient with a cat bite home, just make sure that they come back in 24 hours for a follow-up, just for a recheck. I think I'd seen somewhere here that it was like a third of cat bites that go to the emergency department end up getting admitted. Cat bites are bad. So what could I have done differently? Where could things have gone wrong? I don't think I did all that much here. The one thing that did come up in the discussion was that the patient told me that he had washed this wound out with hydrogen peroxide. Now, that makes me wonder if that gas that showed up on the plain film, was that partially due to the presence of the hydrogen peroxide that he used to wash it out? I have no idea. I don't know if the hydrogen peroxide, the gas from the hydrogen peroxide could have actually gotten down into the tissue like that. Regardless, I had physical exam findings that were concerning. I had plain films that showed gas, and you simply can't ignore those things. And you're always best to involve orthopedics in this discussion. And if they want to make a decision to not go the operative route, that's up to them, but you at least have to have those things in the back of your mind. All right, case number five. So this was a work-related injury. This was a 20-ish year old male who was working with some kind of a circular saw, kind of the bane of our existence. And I'm sure that the bane of your existence as well. Man, these things can be bad. So this was a gaping wound to the web space of the left hand. Web spaces are really difficult, and we'll talk about why. The biggest thing is just getting exposure and having an extra set of hands available to you to help with closure. So the things that are going through my mind here, one, of course, are tetanus. Sound like the teacher in Ferris Bueller's day off, tetanus, tetanus. So tetanus is very important. You can see the presence of some jagged edges here. Some of these tissue edges are a little bit thin. So am I gonna need to have some debridement here? It's not hemorrhaging. There wasn't a significant amount of blood loss. I think there was prior to him getting there, but these little arterioles and capillaries tend to vasoconstrict pretty well. Obviously, if he was on anticoagulants, that would be a much more complicated issue. I didn't see any obvious foreign bodies, but that's definitely a concern. So imaging is gonna be important, making sure that there is no fracture. I think that this was all in the soft tissues, but any significant hand injury like this, I think imaging is warranted. All right, so some of those things we just talked about. So there were no other associated injuries. This was an isolated injury. So no further imaging was warranted just at the hand. Anesthesia, this is gonna be local anesthetic with some lidocaine. And again, I'm just a big fan of epinephrine, especially on the hands, which we do know now from our previous talk that epinephrine in the hands and the fingers is completely safe. So anesthesia, irrigation, absolutely. After being anesthetized, this is an ideal wound that can be washed out at the sink for a few minutes. It provides enough pressure, and it definitely provides enough volume to adequately irrigate. Again, that little mantra of the pollution to solution is dilution. All right, so the supplies that I'm gonna need for this are gonna be our single-use laceration kit. I can pull the flap back, and it doesn't appear that there's any deeper structures, that it doesn't need a multi-layer repair, so I don't need any absorbable suture. However, I'll tell you something here in a second. So I'm gonna be using some, this is kind of gaping open, and I wanna be able to provide enough tensile strength to be able to bring those wound edges together. It's in an area that has a lot of mobility, and that's another thing that we can talk about as well, splinting for injuries like this. So single-use laceration kit, irrigation equipment, and a couple packs of large gauge suture material. All right, so the closure on this one, again, these can be a lot more time-consuming than you think. Some of these jagged tissue edges were debrided because that's devitalized tissue that's just not gonna do well, and it may serve as a nidus of infection, so you wanna kinda clean those little edges up with some sharp scissors. The little blue arrow right over here, what this is, this is pointing to a landmark. And sometimes with these, there's varying degrees of tension in this area, so when you get a laceration that opens things up, you may have a hard time figuring out exactly where tissue needs to be pulled together. So you can use these little palmer creases, sometimes wrinkles on the face, even tattoos can be used. You do wanna line up a tattoo properly if you have a laceration through it. But all I did right there was I used that little palmer crease as a landmark to start bringing the edges together. And once you bring one of those little areas together, a lot of the wound just kinda comes in place, and you can see how much better that looks after that first suture is placed. And then this was just a series of interrupted and horizontal mattress sutures. And you can see right here that with the horizontal mattress suture, you're able to bring those edges together. And there is a little bit of, see if I can demonstrate here on the camera, a little bit of eversion, which in theory is what is recommended to do. If you have tissue eversion, it means that you are taking the tension off of the wound margin, so to speak. And when tissue heals in a laceration, it contracts. So the theory is that if you have, if you offer a little bit of wound eversion in a repair, as it heals and contracts, it'll flatten out and have a better cosmetic outcome and functional outcome. So again, you can see on the dorsal aspect, there's several horizontal mattress sutures as well. And again, I think that's just a, it's a great technique for you to use on some of these wounds under tension that are gaping open. All right, and documentation, you can see all the same things here. The importance of the neurovascular exam, documenting that, making sure that all the radian, the radial, median, and ulnar nerves are all intact. Make sure that there's no involvement of the joint capsules, no tendon injuries, things like that. Yeah, so kind of the standard, you know, pretty detailed laceration repair note. And the fact that I recommend that he come back in seven days for suture removal, which unfortunately was not followed. This is a guy, when I spoke to him, super, super nice kid. And, you know, I reiterated to him several times how important it was that he come back in for suture removal or follow up with orthopedics. And at about 10 days, I looked him up and he hadn't come in. So I called, oh yeah, yeah, he said that he was gonna be coming in, you know, a week later, just out of curiosity, looked again, called, no answer, called again, no answer, no answer, no answer. Finally, at about four weeks, I was able to track him down through another family member who I got a number from on his medical record. And at four weeks, he still had not come in, which was really disappointing and sad. He said that he wasn't able to get a ride in. So that was a little bit of a disappointment. So as of four weeks, he still had those sutures in. And discussion on this, need for imaging, yes. Suture, we talked about, large gauge, large gauge needle and thread. Biggest concern is just, you know, making sure that there's no neurovascular injury, foreign bodies, deeper structure involvement with your joint capsules and tendons. Concern for infection, yes, on a wound like this. So we did place some antibiotics, follow up with orthopedics. So I think the biggest thing that I learned from with this is really having a straightforward, point blank discussion with the patient and say, look, you have to come back for suture removal. If you don't think that you're gonna be able to come back, then I'm gonna consider giving or putting in absorbable sutures in a wound like this. That's not the ideal choice, but it is a choice. And I think if, you know, just having in the back of our minds, if we're concerned about patients not following up and not following through and coming back in for suture removal, that's really important is, you know, if you don't have the sutures removed, they're gonna scab over, removal is gonna be much, much more difficult and may end up, you know, really causing some significant problems for this guy further down the road. Eventually the knots will unravel and they may work themselves out or he'll pull them out, but it's definitely something to have that discussion with. Now, another thing, and I did not do this with, actually, you know, I think I may have on second thought, but maybe I didn't. Regardless, having a splint applied for wounds like this, you know, in an area of high mobility, splinting is definitely something that is warranted, especially if it's over a joint, you know, on the fingers, or if it's, you know, a large laceration over the wrist, that's definitely something to consider is placing a splint just to provide that extra degree of immobility so that they don't move and risk opening up the wound, sutures popping out and wound dehiscence. So a couple of days of putting a splint on are definitely something to consider if the injury is in an area of high movement. All right, case number six. I'm gonna have to have a sip of coffee here. Excuse me. All right, case number six. So this was a work-related injury, and this was a young lady who was working at a local wire manufacturing facility. She came in with a fingertip laceration on the pad of the distal phalanx, caught in a wire at work. Now, I looked at the nail, and my first thought was, oh man, that looks like a subhungal hematoma. Well, on further evaluation with an alcohol pad, that all just rubbed off, and it was basically just dirt related to her work environment. So am I gonna need imaging for this? Well, that just kind of looks like a little laceration to the tip of the finger. So I'm not sure if I need to get an x-ray or not. Tetanus, yes. Does she have any other comorbidities? No, she did not. Young, healthy patient. Otherwise, so this seems to be a pretty straightforward issue or presentation. So how do we approach this? Well, that's where you have to understand, and I know that you all do much better than I do, the mechanism of injury in work-related environments. Having an understanding of the physics, the mechanics, the mechanisms of injury with high tension, anything that transmits a large amount of injury to soft tissue, anything that involves crushing mechanisms, things like that, those all warrant imaging. And what we found is that she did have a tuft fracture, a non-displaced tuft fracture. And you can see a little bit of some fracture line right down through here. So getting an x-ray in an injury like this is important. Again, no other associated injuries, of course. We always have ABCDs of trauma, no other associated injuries. So this was very much isolated. So we just got the x-ray of the finger and did find this fracture. Anesthesia, this is a digital block. You can see the finger tourniquet being applied afterwards. In the previous talk, whoops, this thing's got a mind of its own. In the previous discussion we talked about, I'm pretty sure we did about the intrathecal digital nerve block, those are huge. And I really do encourage you to try those out if you haven't already. Single injection to the volar MCP crease right here. And it's a good way to get anesthesia of the finger with minimal swelling and just a single needle stick. And then you can see she's standing at the sink. Again, this is a great way to irrigate wounds out with a large volume. The solution to pollution is dilution. So she stood at the sink for a few minutes. And then you can always, if you're concerned and you want to put a little bit more pressure in there, you can always use a syringe and splash guard and put a little bit more pressure in there. So supplies, finger tourniquet, as you can see. The biggest thing is make sure that you remove it. And the closure for this was pretty straightforward. It was just a couple of, it was like four horizontal, or I'm sorry, four interrupted sutures. And it came together well. Sometimes you'll see these like little tiny globules of fat. Sometimes those will stick out. And that may be associated with the edema that comes with irrigation. But if you have a couple of those little globules that are sticking out, always try to trim them before I start closing. If you bring the edges together and it's kind of, they get in the way, I just trim those with the scissors. Again, it's just something that may impede closure of those wound edges. This is a wound that's pretty difficult to get that desired wound eversion on, just because there's that associated soft tissue swelling in a very small space of the pad of the finger. But you do the best that you can and try to re-approximate it as best you can. All right, documentation. Sorry, this was just a screenshot or a picture of the screen. But again, we talk about the presence of the digital block, washing out at the tap water. I did apparently use a little bit of tap water syringe and splash guard, use of a finger tourniquet, what type of suture is used, and the fact that there was a fracture there and a splint. So the fact that there was some tissue debridement makes this an intermediate complexity wound. All right, follow up. I followed up with her. This was probably about a month after the injury. It looked like it was healing nicely. And she was still out of her full work duty. She was working, but not in her normal capacity, pending orthopedic follow up. So that came out well. It looks like it's healing very nicely. And for me in the emergency department, we typically don't see our patients in follow up. But just with the work that I do from an educational standpoint, it's really taught me a lot to follow up with patients and get some follow up images. And I've really learned a lot from that. And I encourage you to do that. All right, so discussion here. The biggest things here, need for imaging, yes. Whenever there's a high mechanism of injury, a lot of energy associated with the injury, it is important to get imaging. Concern for infections, honestly, I can't remember if I provided her with antibiotics. This is probably a toss up. The fact that it was work related, there was some contamination in the area. There's a lot of dirt and debris on her fingers. I probably did. Following up with orthopedics, again, with this being a work related injury, she probably did follow up with OCMED. And I don't think there was a whole lot that I could have done differently. Things could have gone wrong. Missing, because this is an open fracture. The definition of an open fracture is a soft tissue injury, an opening in the skin in proximity to a fracture. It doesn't have to be a bone sticking out of the skin. There just has to be a fracture in close proximity to a soft tissue breaking the skin. Yeah, I think I said that right. There has to be an injury to the skin in proximity to a fracture. So that is the definition of an open fracture. And those do warrant antibiotics. So yes, I did provide antibiotics for this because it was an open fracture. I do know what I'm saying here. OK, all right, so this, let's see here. Yeah, so this is another web space injury, a tractor to the foot. Again, the difficulty here. And I'm going to wrap up this one. I'm going to make this one my last one. The web space, man, the web spaces are tough to deal with. And the biggest recommendation is having an assistant to be able to help with exposure. So this guy, unfortunately, was not wearing work boots. It seems like all of these really have something in common. And they're probably not wearing helmets or proper work attire. So how do you approach this? Again, this is going to be kind of the same type of scenario with the mechanism and going through a work boot. I did get an x-ray, which was negative. Anesthesia, local anesthesia, lidocaine with epinephrine. And you can see here with the blue arrow sign, you see these little white streaks. And that's what epinephrine looks like, lidocaine with epinephrine. So you get that vasoconstrictive effect. And you get the blanching of the skin. So that's another reason why I like to use epinephrine, because it tells you that the agent is in and that it's working whenever that vasoconstriction is present. All right, the closure on this one, this was a little bit more complex. And you can see the blown up image right here. This was just kind of some macerated damaged tissue with these little tissue islands that we talked about in the previous lecture. So what I did is I basically kind of integrated that parallel laceration repair technique with an extended horizontal mattress suture to bring this together. So this was kind of at an oblique angle. And I came in here under the tissue and just kind of threading it through using my tissue forceps to manipulate the tissue. And then come across and then back through. So this is kind of like threading the needle, so to speak, and really having to utilize my non-dominant hand with the forceps to get this to come together. But it did. It came together very well with a combination of horizontal mattress and interrupted sutures. So the documentation, pretty straightforward, just the fact that it was how it was repaired. Follow up, this is another one. Man, these ER patients are difficult to get in touch with. Finally tracked this guy down about six months after this repair when I was putting this talk together because I really wanted to have the follow up images. And he sent me these pictures. Yeah, you can definitely see the hyperpigmentation associated, which is always interesting to see how different patients heal. But this came together pretty well. He said that he still has some occasional discomfort when he's on his feet all day. So I just encouraged him to follow up with orthopedics or podiatry for evaluation, consideration of some orthotics or some other therapy. And then lastly, discussion on this one. Need for imaging, yes. Tractor going through boot, through sock, into the soft tissue causing pretty significant damage. I felt that imaging was warranted. Suture was going to be your non-absorbable. There was no deep suture needed, so no non-absorbable or no absorbable sutures needed. Biggest concerns, concern for soft tissue injury, foreign bodies and fracture. Definite concern for infection, so this patient was given antibiotics. Following up, recommending that they follow up with podiatry or orthopedics. And I don't think that there was a whole lot that I could have done differently on this. I think it came together well. Not providing antibiotics, not getting imaging. I think those are the situations where you may end up going wrong. So I am right at 55 minutes, so I'm gonna wrap up here. Again, my contact information was at the beginning of the presentation. I hope you can see my enthusiasm and my passion and joy of talking about this stuff. So again, if there's anything that I can do for you, please don't hesitate to reach out. I'd love to connect with other physicians, especially those in other fields that I'm not overly familiar with. So I'd love to learn more about the occupational health and preventive medicine arena, how you all manage lacerations. Please reach out to me. I'd love to work with you, love to connect. Find me on LinkedIn and let me know if there's anything I can do to help. Thank you for letting me be here and sharing a little bit with you. I hope you found it helpful and thank you again. Thank you for the presentation and also for the excitement of medicine that we could send your presentation. Removal, this is a very simple thing, but removal of the finger tourniquet. I would think that would be difficult because you've got it tight enough to tourniquet. I think it would be hard to get under either the glove or the tourniquet to cut it off. Yeah, that's a good question. The ones that are commercially available oftentimes have like a little piece of just nylon thread, almost like fishing line, or some other mechanism that you can raise it up a little bit and then just snip it with the sutures that come in the laceration kit. Same thing for the glove. If you're using the glove tourniquet technique, you could just take the hemostats and kind of lift that up a little bit, lift the tourniquet aspect, and then just cut it to loosen it and then just slide it off. Okay, great. Thanks a lot. Absolutely. Thank you. Other questions for Dr. O'Malley? Yes. Okay, we got one more coming up from our live audience. All right. Hi, Dr. O'Malley, Murray Berkowitz here. And I appreciate your contributions to our efforts here and certainly when you spoke earlier about removing the rings. One question, a lot of the guys in particular with wedding rings are going and opting for the titanium these days in the younger crowd. And what do you do when it's already beginning to be difficult to get that off because of the swelling? Man, that is a great question. And those are the ones that really just make life difficult for everybody, especially the patient. The titanium rings are incredibly difficult to get off. If they come into the emergency department and it's already an hour or two hours after their injury and there's some swelling, I try to use the ice elevation, that little premature, the preemie blood pressure cuff. I've used several times and that really does work well. I know that this is a CME talk. So I have no relationship at all whatsoever with that company Ring Rescue, but I would encourage all of you to go and take a look at their product. I do know the gentleman that created that, but again, I have no financial ties. So I do feel comfortable mentioning that. But Ring Rescue, the product that they have, I think is really a, it's a must-have product for the occupational health audience. And they actually have developed their own ring cutter, which senses the amount of tension going up against the ring. And it also detects how much heat is being generated. So check out Ring Rescue. I think that that's going to be an important thing for y'all to be aware of. Great, thanks very much. Appreciate the Q&A. Absolutely. But it oftentimes ends up being a phone call to orthopedics and a trip to the OR if it's that tight and if it's titanium. Dr. O'Malley, I recently had a little mucosale removed from my inner lip, and I found the aftercare instructions very interesting. It said to wash out with soap and water at least daily, apply Vaseline and keep a Band-Aid on it, which was kind of difficult because it was inside my mouth. But it also talked about the fact that the current teaching is not to allow wounds to scab, but to keep them basically moist and wet because the epithelial layer will grow quicker, which kind of goes against my training as a combat medic in terms of it's wet, make it dry. Don't use a lot of ointments because they end up being, after the nosocomial properties wear off, they end up being a harbinger of bacteria. So what is your thoughts and recommendations at this new guidance in terms of to scab or not to scab? Well, one, don't put Band-Aids inside your mouth. That's number one. That's an even more problem. They give you the same aftercare instructions where I'll put a Band-Aid. Yeah, for everything. Stuff like that. Exactly. The band-aids are in my mouth. The pitfalls of electronic medical records. Yeah, so on the body, whenever there's a wound, in researching the course that I put together, I did find contradictory recommendations with this. And I don't think, to the best of my recollection, there are not any randomly controlled trials looking at both. But it seems like the consensus leans more towards, at least for the first several days after an injury, after a laceration repair, is to put some kind of an ointment. And either if that's just Vaseline, if it's vitamin A and D ointment, or if it is vasotracing, some kind of an antimicrobial preparation. I think that there's something to the, preventing the wound from scabbing up and being completely dry. And that moisture that is provided with the petroleum-based product does allow maybe a little bit more movement and expansion and just prevents the contraction associated with the scab. That's kind of how I look at it. I just had a mole shaved off recently myself and the dermatologist put some Vaseline on it and then covered it with a Band-Aid. So, at the end of the day, all these wounds heal. Is there gonna be that much of a significant difference between letting it dry to air without any petroleum product or to put something on there? I think most of them end up doing about the same. I tend to put something on it just because that's what I've read and that's how I was trained. So, I tend to put the ointment on there. If you don't, I think it's gonna end up doing just fine as well, but I tend to do it. Thank you. I think we have time for one more question if anybody has one. I do. Right, go ahead. This is Steve Evans. Outside of Philadelphia. Do you have any experience using Steri-Strips on linear finger lacerations to, you know, in an optimist setting, we sometimes wanna try to avoid suturing and try to help a company out by avoiding a recordable injury. Have you had any experience or success with that? You definitely can use Steri-Strips and they're being advocated for more and more. I've spoken to several of my emergency medicine academic friends who say that they, you know, they're using them more and more. And I think that it's very reasonable to at least give it a shot. You know, and I understand that situation, you wanna try to help the company, but you wanna do what's best for the patient. The biggest things with, yeah, with Steri-Strips are, you know, I think it's fine to use on the fingers, but you, it's, you know, if it's gaping open or if it's right over the joint space, I would just be mindful. I think I did come across a study recently showing that wounds less than two centimeters on the hand, on the fingers, really don't need to be sutured. So, you know, two centimeters, that's almost an inch. So that's a pretty big thing. So I think that, you know, maybe combine, if you do use the Steri-Strips, I would just recommend that you use the Benzaline. Another thing that you can do is combining Steri-Strips with Dermabond, and that can give you some extra tension there, some extra strength. So if you did choose to do that, I would make sure that you're using some Dermabond with it as well, just to give it the best chance to stay closed. Thank you. Absolutely. No, and if you do do that, if you do do that, take a picture of it and send it to me. I'd love to see how it comes out. Dr. O'Malley, thank you very much. We'll probably be in touch with you to do either a full laceration course at a future conference. Absolutely, I'd love to. We may ask you to do a modified one, but anyway, I'll be in touch soon. I promise. Awesome. Thank you all so much. I really appreciate the opportunity. Bless.

laceration management

emergency physician

best practices

tap water irrigation

clean box gloves

epinephrine safety

trauma shears

LED headlamps

cyanoacrylate tissue adhesive

finger tourniquets

wound evaluation

antibiotic use

medical legal considerations

wound closure methods

patient care