Let’s keep on the suturing topic and talk technique!

Interrupted suture- most commonly used in ED to close percutaneous wound

• Wound edges must be everted
• Needle enters skin @ 90 degrees with the suture loop as wide as it is deep to the skin surface
• Try and get similar width and depth on both sides
• Placed close enough so you don’t have a gap in the wound edges (approx distance between sutures = distance from wound edge around .5-1 cm)
• For most traumatic Lacs we see start with a bite in the center suturing out (clean linear sharp cuts can start at the far edge but we dont usually see these

Dermal/buried suture- used to approximate dermis below the skin (reduces tension and closes deep tissue spaces making it easier to close percuteanously)

Absorbable sutures must be used and the knot (less than 3 ideally) buried so as not to inhibit healing. Avoid in highly contaminated wounds

Running suture: rapid percutaneous long wound closure ideal for long wounds with already goo edge approximation (distributes tension evenly along the length of the wound)

• Final bite made 90 degrees in direction of previous bite left as a loose loop to act as a free end for knot tying.
• Disadvantage is if the suture breaks the entire wound will open and you cannot remove just a few sutures at a time.

Vertical Mattress-  good for wounds under tension or whose edges tend to invert

• Far-Far suture acts as a deep/dermal stitch and near-near stitch acts to evert edges
  

  vertical mattress suture

Horizontal Mattress- also serves to evert wound edges and distribute tension good for pulling wound edges over larger distances or to as an initial suture to anchor two wound edges

• Also good for holding fragile skin together
  

  Horizontal mattress

Corner stitch- used to approximate angled skin flaps (avoids needing to put in multiple sutures to hold a corner down leaving the tip intact).

Corner stitch

sources: utdol.com; http://www.aafp.org/afp/2002/1215/p2231.html, Rich Wong and google of course!

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Monofilament v. multifilament (braided or twisted) -

• Monofilament – stronger, low tissue drag and harbor less infection. But DO NOT handle as easily and multifilament
• Multifilament- handles easily but promotes tissue infection and reactivity as it acts as a capillary allowing liquids an bacteria to travel along the strand easily
• Tensile strength- Higher number of zeros the smaller the size and less strong the suture is (general guide below:)’

5-0 to 6-0 : face, eyebrow, nose, lip, eyelid, ear, penis

4-0 to 5-0:  hand

3-0 to 5-0:  Scalp, torso, extremities, foot/sole

2-0 : Chest tube securing  (good luck finding it so we at Elmhurst use 5 Silk)

Absorbable:

• Fast-absorbing/plain/chromic Gut- strength retention 7 days and absorbs in 10-14 (chromic a little longer). Fast- absorbing less tensile strength than plain gut.

Fast-absorbing good for peds lacerations where removal might be difficult

• Vicryl- synthetic absorbable braided suture. 2 weeks of 65% tensile strength. Complete absorption 60-90 days

Great for buried suture to approximate wound edges and gain strength to keep wound closed; also great for nail bed closure

• Vicryl rapide- synthetic absorbable multifilament. 50% tensile strength at 5 days with 0% at 2 weeks. Absorption/falling off by 2 weeks.

Non-absorbable

• Nylon (Ethilon, Dermalon)- first synthetic suture/monofilament – high tensile strength (at 2 weeks), low $ and minimal tissue reactivity. Has poor memory so you need more knots to hold suture in place
• Prolene –synthetic/monofilament- similar to nylon in high tensile strength and low tissue reactivity. Plasticity noted allowing it to stretch and accommodate wound edema. Is slippery so requires extra throws to secure the knot.
• Silk- natural/braided – low tensile strength, evokes significant inflammatory response but with good knot security– rarely used cause we have nylon and prolene

Needles- 3 parts to a needle eye where the suture attaches; body where you hold on to; point tip to maximum cross section of body.

Points:

•  Cutting- 2 opposing cutting edges – ideal for skin sutures that must pass through dense irregular thick dermal tissue
• Conventional cutting- have a 3^rd cutting edge on the inside concave curvature of the needle (track faces wound edge so risk of cutting tissue)
• Reverse cutting- 3^rd cutting edge on the outer convex curvature decreasing tissue cutout. Used for thick skin like palms and soles.
• Blunt – dull point used for friable tissue (fascia)

Finally a quick literature review comparing Absorbable v. non-absorbable (limited literature on this, not much at all looking at adults/elderly)

• 1997 J Emerg Med (Shetty, Dicksheet, Scalea) 5 year retrospective study of hand lacerations repaired with 5-0 vicryl or nylon and no complications or infections reported in study group and scar was comparable at 6 months in both group
• 2004 – Academic Emergency Medicine ( Karounis, Gouin, Eisman, Chalut, Pelletier, Williams) Randomized clinical trial comparing peds traumatic lacerations closed with absorbable plain gut sutures v. nonabsorbable nylon found comparable cosmetic outcomes
• 2008- Pediatric emergency medicine (Luck, Flood, Eyal, Saludades, Hayes, Gaughan)-  Facial lacerations on pediatric population compared fast-absorbing cat gut v. nylon sutures – small study but showed no significant difference in scar appearance/parental satisfaction, infection rate, wound dehiscence or keloid formation.
• 2007 Pediatric Emergency Care (Al-Abdullah, Plint, Fergusson) meta analysis – lack of large/RCT evaluating absorbable v. nonabsorbable. However from the data reviewed appears non-absorbable sutures seem no better than absorbable in wound repair.

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47 y/o M BIBEMS altered mental status (wife called EMS from out of country because husband hasn’t been heard from in 2 days) no history available from patient.  ? short lasting tonic-clonic activity noted on arrival.

Vitals: 101.7  128  140/91 19  96%   FS 143

PE remarkable for an agitated male, AOx1 not following basic commands. Laceration to forehead, Pupils dilated but equal and reactive. Tachycardic but regular rate; Lungs CTAB. Abdomen with decreased bowel sounds but SNT. Skin hot and dry. Neuro exam non-focal

EKG ST @ 137; Qtc 475; incomplete RBBB

Initial labs remarkable for WBC 19 (89% PMN); Lactate 6.2. Foley placed 1200 cc urine voided with UA WNL. CXR and Head CT WNL

Just in time the cousin arrives with an empty bottle of Benadryl (just as the patient was being turned to set up for an LP!). This patient has an Anticholinergic picture of Bendaryl OD.

Anticholinergic OD: Red as beet; Dry as a bone; Hot as a hare; Blind as a bat; Mad as a Hatter (seizures as with this patient possible); Full as a flask . tachycardia (earliest sign of OD), decreased Bowel sounds

Rx: ABCs of course!!   Charcoal can be given within first 2 hours of ingestion if patient can tolerate it; Sodium Bicarb for QTc and QRS prolongation (given in this case in anticipation of continued absorption and lengthening of already prolonged QTc); Benzo’s for seizures and agitation, Physostigmine.

Physostigmine- once part of the “coma cocktail” for AMS now not often used.

A carbamate acetylcholinesterase inhibitor that binds reversibly to inhibit acetylcholinesterase increasing amounts of acetylcholine to overcome anticholinergic blockade.

Should not be given if TCA OD is suspected (more sedated than agitated anticholinergic picture) especially if patient has wide QRS cause can lead to asystole

Superior to Benzos for the AMS/agitation of anticholinergic OD

Can be used diagnostically if unclear picture as administration of physostigmine in AC OD should result in improvement of clinical picture. Repeat dosing can be done every 20-30 minutes for continued agitation/delirium.

Reminders for the oral boards:  altered patients need all 6 vitals HR, BP, RR, O2 Sat, Temp and FS. Always order Tylenol for patients with fevers and tetanus for patient with lacerations.

Thank you Raashee for interesting morning report!

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22 y/o F 35 weeks gestation being treated with magnesium sulfate for preeclampsia in your ED awaiting transfer to nearby hospital for definitive care. You go to re-evaluate the patient and find her somnolent, decreased respiratory drive and decreased deep tendon reflexes. After managing the airway what is the next step in management:

1. Dexamethasone
2. Lidocaine
3. Labetolol
4. Calcium gluconate
5. Atropine

(more…)

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Back to some more Board-Style questions:

56 y/o F with acute organophosphate overdose, severe bronchorrhea, bradycardia and coma. She is intubated for airway protection and atropine therapy initiated. After 10 mg Atropine her HR is 130, BP 160/90 and secretions are still copious. Which of the following is the most appropriate next step in management?

1. Stop Atropine, start Epinephrine
2. Stop Atropine, start Vasopressin
3. Stop Atropine, Start Pralidoxime
4. Continue Atropine therapy alone
5. Continue Atropine therapy and add Pralidoxime

(more…)

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32 F – presents with AMS. EMS reports neighbors smelled gas and called 911. They found patient unresponsive (? Sleeping) initially in the apt.  Patient doesn’t remember these events  but does recall that she is staying at a friends and had a few drinks earlier in the night mixed with 1 Xanax. nd isn’t sure how the gas got turned on. Vitals stable. Physical exam aside from being confused about events unremarkable.

Labs: alcohol (271), ASA (wnl), Tylenol (wnl)

Initial VBG: pH 7.34, PCO2 55, PO2 40 lactate 1.5

Carboxyhemoglobin 0.9

EKG- NSR 79, no STT changes. Incomplete RBBB. Flattening T waves laterally

(more…)

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78 yo f presents with generalized weakness. Patient denies any complaints per se and was brought in by family member after patient could not answer her door due to her weakness. Vital signs were stable. Physical exam was unremarkable and she had not other ROS complaints.

Initial venous blood gas revealed pH of 7.21, pco2 40, lactate 2.1 and glucose of 20.

Initial ER venous revealed Na of 140, K 5.1, Cl 109, CO2 23, Bun 19, Cr 1.1 and glu 20.

Patient has a non-anion gap acidosis. Helpful mnemonic for differential in this category is HARDUP.

• Hyperalimentation
• Acetazolamide or other carbonic anhydrase inhibitors
• Renal Tubular Acidosis
• Diarrhea
• Ureteroenteric fistula
• Pancreaticoduodenal fistula

Of these, RTA is most likely given her history and physical. Which RTA however?

(more…)

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23 year old male with HIV presents with 1 week of fever, cough with yellow sputum, malaise presents with worsening of symptoms. Patient has vital signs of T103, P110, BP135/89, sat 90% on RA. Physical exam reveals coarse rhonchi bilaterally. His initial pa02 is 78 mm Hg. Below is the chest x-ray.

What is the next initial management after starting IV TMP-SMX?

A. Corticosteroids

B. Intubate

C. Continue supportive care

D. Start antiretroviral therapy

(more…)

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It has been a long, eventful week in the wake of the tragedies in Boston and to honor those who were affected by the attacks, I would like those who are able, to have a moment of silence at 2:50 PM. 

To those further interested, below is the link to ‘The One Fund Boston’ to help those most affected by this tragedy. 

The One Fund Boston 2013

Please see below for today’s pearl.

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Good morning! Please see above for a response to last week’s tragedy.

44 yo female presenting with nausea, vomiting and abdominal pain. Patient is a chronic alcoholic with no other drug use admitted. Patient is tachycardic to 116 and hypotensive 90/68. She is alert and oriented x 3 but actively vomiting clear non-bilious and non-bloody vomit. She is tender in the epigastric and ruq. No tremors, jaundice or significant findings on exam. She has a Na 139, K 4.5, Cl 91, Co2 5, Bun 16, Cr 1.1. Her pH and lacate is 7.08 and 8.5, respectively, her urine dipstick contains ketones. There is no osmolality gap. What is your next best step in management after starting normal saline fluids?

A. CT scan of the abdomen

B. Thiamine and glucose infusion

C. Phosphate level

D. Abdominal x-ray

In this patient with a gap acidosis most likely relating to her chronic use of alcohol, the typical treatment of fluids and most importantly fluids with glucose and thiamine to help the nutrition depleted patient to improve their acid-base imbalance.

Alcoholic ketoacidosis usually develops in chronic alcoholics given their pan-nutritional deficiency status, causing the body to make ketones from the fasting state of alcohol only intake combined with low to none normal dietary food sources.

Patients, however, who develop marked hypophosphatemia are in significant risk for life-threatening sequelae including myocardial dysfunction or encephalopathy. Therefore, it is very important to ascertain the phosphate levels in such individuals to replet such a deficiency. Levels in a patient can be normal, but once treatment starts the insulin the body starts producing can drive extracellular phosphate intracellularly causing a drop in the level.

Although this occurs 12-36 hours after treatment, depending on where the level of phosphate is or how long the patient has been in the emergency department for, it is important to keep that in mind in the treatment of AKA.

Thanks to Dr. Hansen for his morning report.

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