POTD: Nasal Septal Hematomas

*Disclaimer: This POTD contains multiple images of the inner nares. Proceed at your own risk.*

The nasal septum is a combination of bony and cartilaginous structures that forms the midline of the nasal cavity. When the nose sustains trauma, blood can accumulate in the space between the septal cartilage and the perichondrium, a surrounding connective tissue layer. This collection of blood is known as a nasal septal hematoma.

Nasal septal hematomas are relatively rare, occurring in only about 1% of patients with nasal trauma. However, they are often overlooked. One study estimated that approximately 50% of nasal septal hematomas have a delayed diagnoses.

Prompt diagnosis is important because untreated nasal septal hematomas can cause irreversible nasal deformities. The perichondrium, the only blood supply for the nasal cartilage, becomes separated from the underlying cartilage when a hematoma forms. This condition makes the cartilage susceptible to avascular necrosis. Necrotic nasal cartilage can collapse and create a “saddle nose deformity.”

To avoid delayed diagnosis, providers should evaluate all trauma patients for the presence of a nasal septal hematoma. These patients typically complain of nasal obstruction (95%), pain (50%), and rhinorrhea (25%).

The best way to look for nasal septal hematomas is to examine the inner nares using an otoscope. If a hematoma is present, it will appear as a red, blue, or purple bulge extending from the septal mucosa. The hematoma will feel boggy (soft and watery) when palpated and will not shrink in size when vasoconstrictive agents like Afrin are administered. Since we are not ENTs, I have included some images below of normal nares, nares with nasal septal hematomas, and nares with other conditions that can mimic the appearance of a hematoma.

Normal Nares

Nasal Septal Hematoma

Nasal Spur (cartilaginous outgrowth, will be more firm than a hematoma)

Nasal Septal Deviation (septum is off center so looks like a protrusion) 

Nasal Polyp (soft grape like growth from the nasal mucosa, usually clear/white/yellow) 

Once a nasal septal hematoma is diagnosed, urgent drainage is necessary to prevent complications. To perform this procedure, you’ll need the following equipment: a light source (such as an otoscope or Schiller’s headlamp), lidocaine with epinephrine, pledgets (which can be found in the trauma bay), an empty 5 mL syringe attached to an 18G needle, a 11-blade scalpel, forceps, a 10 mL saline-filled syringe attached to an 18G angiocatheter, and two rhino rockets. Ideally, a nasal speculum would be used for better visualization, but I’ve never personally seen one at Maimo.

Here is a step-by-step guide:

1. Position the patient supine with their neck slightly extended.

2. Soak two pledgets (or rolled-up sterile gauze) in lidocaine with epinephrine. Insert one into each nostril and ensure they touch both sides of the nasal septum. Leave these in place for 5-10 minutes before removing them. Afterwards you may inject a small amount of local lidocaine at the anticipated incision site.

3. Insert the 18G needle into the hematoma and aspirate the blood using the 5ml syringe.

4. Use the scalpel to make a horizontal incision along the inferior border of the hematoma. Be careful not to cut the cartilaginous septum.

5. Evacuate the hematoma by using forceps to extract any clotted blood.

6. Irrigate the hematoma by inserting the 18G angiocatheter into the incision and flushing it with sterile saline.

7. Pack the nose with bilateral rhino rockets. You must pack both nares to keep the septum midline.

Once the hematoma has been evacuated, the patient can be discharged. They should be prescribed prophylactic antibiotics, typically Augmentin 875 mg PO BID for 7 days. They must follow up with an ENT specialist or return to the ED within 24-48 hours for nasal packing removal.

Sources:

https://www.ncbi.nlm.nih.gov/books/NBK470247/

https://www.tamingthesru.com/blog/masteringminorcare/nasalseptalhematoma?rq=minor%20care

https://wikem.org/wiki/Nasal_septal_hematoma

https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683&sectionid=45343819

POTD: Auricular Lacerations

The external ear, also known as the auricle or pinna, has unique anatomical features that influence wound management in this area. For today’s POTD, I’m going to review the anatomy of the outer ear and the management of auricular lacerations.

Anatomy

The term “outer ear” specifically refers to the auricle (or pinna) and the external auditory canal. The auricle can be divided into six sub-units: the helix, antihelix, conch, tragus, anti-tragus, and the lobule.

All of these structures, except the lobule, are composed of thick avascular cartilage that supports the ear’s shape and structure. This cartilage is surrounded by a poorly vascularized perichondrium, which is then covered by a tightly adherent connective tissue and skin layer.

Auricular Lacerations

When the ear sustains a laceration, it should be repaired using primary closure, similar to any other laceration. Simple lacerations (involving only the skin) or complex lacerations (exposing or extending through the cartilage layer) can be repaired by us ER doctors. However, for more advanced lacerations such as split earlobes, avulsions, or lacerations extending into the external auditory canal, an evaluation by an ENT or plastic surgeon is recommended.

Auricular Nerve Block

The ear is innervated by several nerves, including the auriculotemporal nerve, greater auricular nerve, lesser occipital nerve, and the vagus nerve. An auricular nerve block can be performed to anesthetize all areas of the ear except the conch (which is innervated by the vagus nerve).

• Draw up 10-20 ml of lidocaine without epi and attach a small 25g or 27g needle. (Remember the max dose of lido without epi is 7 mg/kg or 0.7 ml/kg)

• Enter skin at the point just below the ear, advance the needle posteriorly along the skin over the mastoid bone behind the ear, and inject 3-5 ml while withdrawing the needle

• Once the needle is close to the original puncture site, don’t remove it but redirect it anterior to the ear and inject another 3-5 ml while withdrawing the needle fully out of the skin

• Repeat the same process entering from above the ear.

• Enter skin at the point just above the ear, advance the needle posteriorly, inject 3-5 ml while withdrawing the needle, redirect the needle anteriorly and inject another 3-5 mL in front of the ear while withdrawing the needle.

Laceration Repair

Once the ear is anesthetized, irrigate the wound and assess for any exposed cartilage.

If there’s no exposed cartilage, repair the skin with 6-0 non-absorbable sutures using a standard simple interrupted technique.

If there’s exposed cartilage, you can still repair the wound with 5-0 or 6-0 non-absorbable sutures. However, you must ensure the skin is well-approximated and fully covers the cartilage. This might require the use of deep 5-0 absorbable sutures if the wound is full-thickness (through and through) or irregular.

Dressing

After the ear has been repaired, it is recommended to apply a bulky pressure dressing to avoid the dreaded cauliflower ear. Cauliflower ear is a deformity of the ear that arises when normal healthy ear cartilage is replaced by fibrocartilage. This occurs when the cartilage is left exposed or it suffers pressure necrosis from a hematoma forming between the skin and cartilage (as shown in the image below).

Head Wrap Technique: Apply petroleum gauze around the wound and pack it into the helix. Apply a generous amount of dry gauze anterior and posterior to the ear. Compress this dressing tightly to the head with kerlix gauze.  

Bolster Technique: Sandwich the wounded area between cotton rolls or small rolls of gauze, securing these in place by suturing them to the ear.

Ear Splint technique: Wet a small amount of plaster and coat it with a thin layer of cotton webril dressing to create a splint. Firmly press the splint in place against the ear with a wad of gauze. Cover the ear with several layers of gauze. Secure the splint to the head with a kerlix wrap around the head.
Review the steps here: https://www.aliem.com/trick-of-trade-splinting-ear/

Quick Caveat: Some argue that auricular hematomas are rare, and a pressure dressing can hinder wound healing through vascular compromise.

Antibiotics

As with any wound, ensure the patient’s tetanus status and administer an updated tetanus vaccine if necessary.

Historically, prophylactic antibiotics were commonly prescribed for ear lacerations. Evidence now suggests that they may not be universally required. The consensus among medical professionals, including UpToDate and multiple emergency medicine blogs, is that antibiotics (such as Augmentin or clindamycin) should be prescribed if the wound is visibly contaminated, if cartilage is exposed or requires repair, or if the patient is immunocompromised to increase their risk for infection.

Follow-Up

Technically speaking the best practice is to recommend the patient return in 24 hours to assess the wound for the development of an auricular hematoma. After this initial assessment, they should return in 4-5 days for suture removal.

 Sources:

https://accessmedicine.mhmedical.com/content.aspx?bookid=2969&sectionid=250461381

https://www.uptodate.com/contents/assessment-and-management-of-auricle-ear-lacerations

https://wikem.org/wiki/Ear_laceration

POTD: Insulin in the ER

Today’s POTD is brought to you by the fear and terror I feel every time I have to order insulin, so below I’m going to review the different types of insulin, when to use them, and importantly how to order them. 

Types of Insulin

There are four main classes of insulin: rapid-acting, short-acting, intermediate-acting, and long-acting. These classes are aptly named based on their onset time. Here is a summary of each class:

I know what you’re thinking – wow, that is a lot of options… which one do I chose?! How much do I give?! Do I give it subcutaneously or intravenously?! Well, luckily, the Maimo pharmacists simplified things for us by only having three types of insulin (lispro, glargine, and regular) and very thorough order sets. If you know your indication, SCM guides you through the rest.

Insulin administration comes in two flavors: subcutaneous and intravenous. Subcutaneous is the only dosage route for long-acting insulin but rapid and short-acting insulin can be given subcutaneous or intravenous. IV insulin should only be used when you are treating hyperkalemia, DKA or HHS. Otherwise, you should give insulin subq.

Dosage of insulin depends on the patient’s weight, blood glucose level, and insulin tolerance. This can be a lot to remember, so your best bet is to follow the order sets that I’ll go through next.

 Acute Hyperglycemia (without evidence of DKA or HHS) can be managed with subq lispro (as well as IV fluids and addressing the underlying cause). The amount of insulin you give depends on the patient’s current glucose level and their sensitivity or resistance to insulin. Be sure to ask what their home insulin regimen is before ordering. Then you can easily order through the “Insulin Subcutaneous Ordering” order set.

• Search for and open the order set “Insulin Subcutaneous Ordering”

• Select the patients feeding status – eating, tube feeding or NPO

• Scroll down to the “correction scale insulins” section and decide between very low dose, low dose, moderate dose, or high dose based on your patient’s home insulin regimen

  • Very low dose = for patients who are insulin naïve

  • Low dose = for patients who require less than 40 units per day

  • Moderate dose = for patients who require 40-80 units per day

  • High dose = for patients who require more than 80 units per day 

• Check the “insulin lispro correction scale injectable” under the appropriate dosing regimen. If you want to give a one-time dose in the ED double click the order to change the frequency from “3x/day, before meals” to “once” and make the start time “STAT”

DKA or HHS is treated with an IV infusion of regular insulin. We start the drip at 0.1 units/kg/hour and continue until the gap is closed. You may precede the drip with a bolus of IV lispro at 0.1 units/kg, but there is no evidence that giving a bolus is beneficial, and it can potentially cause hypoglycemia. Once the gap is closed, you can transition your patient to subq insulin by calculating the total amount of insulin administered IV and then give 50% of that total as subq glargine insulin.  (Of course, there are many other aspects of DKA/HHS management which could be a separate POTD; I’m just highlighting some key points here.)

• Search for and open the order set “ED DKA/HHS Ordering”

• Scroll down to “insulin” and check the “insulin 100 units in NS 100ml” infusion. You will need to double click the order to input a dose.

  • Of note, the dose is listed as units/hr and should be calculated as 0.1u/kg/hr. If your patient weighs 70kg, you would give 7 units per hour.

• If you want to bridge to subq insulin, go back to the same “ED DKA/HHA Ordering” but scroll down to “basal/long acting insulin”

• Select “insulin glargine (100 units/ml) basal." Double click the order to input a dose.

  • Remember the dose will be 50% of the total IV insulin given.

Hyperkalemia is treated with a rapid bolus of IV insulin intended to shift potassium into the cells. Be sure to give this insulin with dextrose to prevent hypoglycemia.

• Search for the “ED Hyperkalemia Order Set”

• Select “insulin lispro (100units/ml) injectable IV push”

  • This will default to a dose of 5 units. You can re-dose again if needed. 

Sources:

Our lovely ED Pharmacy team

https://www.uptodate.com/contents/general-principles-of-insulin-therapy-in-diabetes-mellitus?search=insulin&source=search_result&selectedTitle=2%7E150&usage_type=default&display_rank=1

https://rushem.org/2021/05/16/basic-management-of-diabetesnot-just-for-internists/

https://rebelem.com/benefit-initial-insulin-bolus-diabetic-ketoacidosis/