POTD: Felon

POTD: Felon

• Subcutaneous pyogenic infection of the pulp space compartment of the distal finger

• Can often be confused with paronychia or herpetic whitlow (fingertip pain but should not cause taut erythema) which can sometimes present with volar erythema

• High risk to progress to osteomyelitis, Flexor Tenosynovitis!

Clinical Features:

• Erythematous, edematous, tense distal pulp space with significant pain and tenderness

• May see necrotic appearing tissue distally due to increased pressure in space 

Work Up:

• Usually diagnosed clinically

• XR: No foreign body, soft tissue swelling pulp of thumb

• US: Use the water bath technique to see a potential fluid collection

• Digital Nerve Block

• I & D is the cornerstone of management: 

• Apply a latex glove finger tourniquet

• If the felon is on patient’s index, middle or ring finger, make the incision of the ulnar aspect

• If the felon is on patient’s thumb or pinky, make the incision of the radial aspect

• Using your #11 blade start your incision 5mm distal to flexor DIP crease and end 5mm proximal to nail plate border. Digital arteries and nerves arborize near DIT. Avoid those!

• Blunt dissect and break any loculations until the abscess is decompressed

• Avoid the "fishmouth" incision. Potentially can cause an unstable finger pad, neuroma or loss of sensation

• Antibiotics: Cover for Staph (MRSA) and strep

Disposition: 

• Home with follow up in the hand clinic or ED in 1-2 days. 

Check out this video to see it done:  

• www.emrap.org/episode/felonincision/felonincision 

Stay well,

TR Adam

Hello, World!

How to Remove a Stuck Ring from a Finger

Today's post is short and sweet!

At one point or another in the ED you will encounter a case when a ring is stuck on a finger due to swelling (anasarca, envenomation, infection, burn, trauma, etc.). It is important to remove the ring so that the finger does not constrict blood flow distally and lead to ischemia.

An easy solution would be to cut the ring off, especially if it is made of a material that you could cut through. However, sometimes the patient would like to keep the ring and avoid damaging it.

In this scenario, you can use a string/rubber band/oxygen mask strap to help reduce the swelling and slide the ring off the finger.

This is done by wrapping the finger with the string starting around the distal end of the finger and moving proximally towards the ring.

Then tuck the string under the ring to the other side using either forceps, hemostat, or any probing device.

You could also hold the extremity above the level of the heart to increase venous return and help with reduction of swelling.

You then pull the string and the ring will slide off the finger while simultaneously unwrapping from around the finger.

If the patient is not able to tolerate the pain, you may perform a digital block prior to wrapping the string around in order to provide some anesthesia.

Video of how to perform this procedure: https://www.youtube.com/watch?v=onOnJOtE_X8

Procedural Sedation and Analgesia - Part 3

Welcome to the third and final post about PSA. Now you know what PSA is and which medications you will be using, so what’s next?

What else do I need to perform PSA?

Signed consent form (if non-emergent)

BVM

Oxygen source and delivery system

End tidal capnography

Vital signs monitor

Intubation equipment

Supraglottic airway

Airway adjuncts

PSA agent(s)

Paralytic (should you need to intubate)

Easily accessible reversal agent (if applicable)

At least 2 providers: One person must be dedicated to monitoring the PSA, watching the monitor and watching the patient to look for changes in respiration. This person should have an unobstructed view of the monitor, patient’s face and chest. Second person to perform whatever procedure you are doing the PSA for.

Here is a great checklist to go through before every PSA: https://emupdates.com/perm/PSAChecklistv2emupdates.com_screen.pdf

Additional notes/tips:

• Most important job of the EP performing the PSA is to watch the patient, especially changes in respiratory rate and depth

• Do not delay procedural sedation based on fasting time. There is no evidence to support that fasting for any duration reduces the risk of emesis or aspiration with PSA.

• If providing supplemental O2, be aware that this can delay recognition of respiratory suppression, especially if looking at the SpO2. It can take an additional 4-5 minutes for you to see a drop in the pulse oximetry reading while the patient is apneic.

• Capnography is a great adjunct to help you detect airway or respiratory compromise. Note the end-tidal CO2 prior to administering the sedative. If there is a significant consistent change in this number (>10mmHg) or if you notice that the waveform plateaus, begin addressing possible airway/respiratory compromise. Here is a great resource to practice interpreting capnography: https://www.medtronic.com/content/dam/covidien/library/us/en/product/capnography-monitoring/capnostream-tutorial-quiz/tutorial.html

• Do not discharge the patient until she has returned to her baseline mental status. Make sure to provide the proper discharge instructions. Adverse effects of sedation are rare once patients have returned to baseline mental status but they should be instructed to return to the ED if they begin experiencing difficulty breathing or vomiting.