Trick of the Trade: Reducing the metacarpal fracture

Metacarpal neck fracture reduction 

General principles of fracture reduction involve axially distracting or pulling on a fracture fragment and pushing the piece back into anatomical alignment. This can be seen in the video above (automatically starts at 2:25 for the actual procedure). What if this approach doesn't work? The fracture fragment remains immobile despite your best efforts.

Image from AO Foundation

Trick of the Trade:
Jahss reduction technique

This technique, also known as the 90-90 approach, involves flexing the patient's MCP and PIP 90 degrees. Dorsal force is applied to metacarpal head by through dorsal pressure on the proximal phalanx. The 90-90 positioning also stretches the collateral ligaments of the MCP joint, which further optimizes the reduction technique.

Although this cool animation below was intended for patient education, it nicely illustrates how the Jahss technique works.

See the Paucis Verbis card on Metacarpal Fractures.

Trick of the Trade: Ossification centers of the elbow

Fracture or a normal ossification center?

This is a common question heard when viewing an xray of a pediatric elbow. How do you remember the timing of normal ossification centers? FYI, the xray images above are normal and have no fractures.


Trick of the Trade:
The mnemonic CRITOE 1-3-5-7-9-11

• Age 1 year:    Capitellum
• Age 3 years:   Radial head
• Age 5 years:   Internal (medial) epicondyle
• Age 7 years:   Trochlea
• Age 9 years:   Olecranon
• Age 11 years: Extrenal (lateral) epicondyle

This great video is from a relatively new YouTube channel that I stumbled upon called "Radiology Channel", which is a Radiopaedia.org project featuring short polished presentations by Dr Andrew Dixon, Dr Frank Gaillard and Dr Jeremy Jones.

Trick of the Trade: Speed up ECG paper rate to differentiate tachycardias

Undifferentiated tachycardias, especially when the rate is extremely fast, make it difficult to see anything other than the QRS complexes! Is there a P or flutter wave?

Trick of the Trade:
Double the ECG paper speed to 50 mm/sec

Standard ECG machines run at 25 mm/sec. If you double the paper output speed, subtle ECG findings hidden in the tracings become more evident. Imagine the ECG tracing as a string and that you are pulling on both ends. Everything, including the QRS complex and intervals, gets wider.

What are your experiences with this?

Atrial flutter at 150 bpm:

• Standard rate 25 mm/sec 

• Faster rate 50 mm/sec (red arrows are flutter waves)

Thanks to Dr. Amal Mattu for sharing his ECGs with me from his University of Maryland ECG archives. If you haven't heard of this amazing ECG video series, you should definitely check it out.

Below is the video teaching this point within the topic of narrow-complex regular tachycardias. This trick is seen at the 15:00 minute mark.

For another example, check out Dr. John Larkin's blog ECG of the Week post on a pediatric SVT rhythm at 300 bpm with no P waves seen at 50 mm/sec.


Reference
Accardi AJ, Miller R, Holmes JF. Enhanced diagnosis of narrow complex tachycardias with increased electrocardiograph speed. J Emerg Med. 2002 Feb;22(2):123-6. Pubmed .

Gaspar JL, Body R. Best evidence topic report. Differential diagnosis of narrow complex tachycardias by increasing electrocardiograph speed. Emerg Med J. 2005 Oct;22(10):730-2. Pubmed Free PDF

Trick of the Trade: Ultrasound-guided supraclavicular central line

Subclavian central lines are commonly touted as the central line site least prone to infection and thrombosis. The problem is that they are traditionally performed without ultrasound guidance. They are done blindly because of the transducer's difficulty in getting a good view with the clavicle in the way.

Trick of the Trade:
Ultrasound-guided supraclavicular approach to subclavian line

What are the surface anatomy landmarks for the supraclavicular line?

• Identify the border of the clavicle and lateral margin of the clavicular belly of the sternocleidomastoid muscle. 
• Insert the needle there and aim for the contralateral nipple, aiming anteriorly 10-20 degrees to avoid puncturing the subclavian artery and lung.
• You are trying to cannulate the near the juncture of the IJ and subclavian veins. 

If you just want to see the crux of the procedure, which uses the linear transducer to guide the long-axis needle insertion approach, start at 8:18.

Disclaimer: I do not have any commercial affiliations with Sonosite.

Reference
Patrick SP, Tijunelis MA, Johnson S, Herbert ME. Supraclavicular subclavian vein catheterization: the forgotten central line. West J Emerg Med. 2009 May;10(2):110-4. Free access to PDF

Trick of the Trade: Sterile cover for linear ultrasound probe

You decide to use ultrasonography to help you establish peripheral IV access for and obtain blood cultures from your patient. How can you ensure that you get a sterile sampling to avoid blood culture contamination? Do you need to open a full central-line ultrasound probe cover?

Trick of the Trade:
Use a sterile glove

Thanks to Dr. Haney Mallemat (Univ of Maryland, @CriticalCareNow) for the video and tip.

Trick of the Trade: Searching for Comments to a Published Article

One day back in 2005 during my PGY-1 pharmacy practice residency, I remember a conversation with my residency director. He was a Surgical/Trauma ICU pharmacist. There had been a recent article published (I think it may have been one linking 'tight' glucose control to decreased mortality in ICU patients). Funny how times change...

Anyway, he mentioned all of the 'discussion' surrounding the article in terms of comments submitted to the journal. It was my first introduction to the idea that published literature could be challenged through an avenue provided by the journal.

Just this past week during EM residency journal club, we were discussing the recent Etomidate/Sepsis Meta-Analysis published in Critical Care Medicine (more to come on that soon in another post). I mentioned to my group how one could search for submitted comments. Most seem surprised to learn this trick of the trade.

Medical Education Trick of the Trade: Look for comments at bottom of Pubmed citation

• Locate the article of interest on PubMed.
• At the bottom will be any comments submitted to and published by the journal.
• Click on the link and it will bring you to the comment.

Test out these "Comment In" links from the above example:

• Comment: frequency of medication errors with intravenous acetylcysteine for acetaminophen overdose. [Ann Pharmacother. 2009]
• Comment: Frequency of medication errors with intravenous acetylcysteine for acetaminophen overdose. [Ann Pharmacother. 2008]

Some comments are written to suggest solutions to a problem identified by the article (see above). Others are more contentious when controversial topics are published and/or subpar methods, statistics, results, or conclusions are reported (see below).

Links for the "Comment In" section:

• Safety of etomidate bolus administration in patients with septic shock. [CJEM. 2011]
• The safety of single-dose etomidate. [Intensive Care Med. 2010]
• Is etomidate really that bad in septic patients? [Intensive Care Med. 2010]

I highly recommend reading them. The tone is generally more pointed then the original article. Typically, the author(s) are given a chance to reply and those are also listed. It's a great learning exercise to read how other experts in the field critique a study and how the author responds.

Trick of the Trade: Persistent paracentesis leakage

Dr. Matt Borloz (Carilion Clinic) recently emailed me his recent trick in fixing a persistently leaking paracentesis site. Read about his experience:

A patient with advanced alcoholic cirrhosis with ascitic fluid leaking from a paracentesis puncture site from a procedure done 2 days prior.  Dermabond had initially been applied post-procedure, but it had come loose, and ascitic fluid had been saturating dressing after dressing. 

I initially tried a figure-eight stitch with no luck. In fact, this just made a couple more leaking holes. I had made the problem worse.  I followed this with another trial of Dermabond.  Now the problem was that the field just kept getting wet, and the Dermabond would not dry.  

Trick of the Trade:

1. Use a tissue adhesive to occlude the puncture site.
2. Apply high-flow oxygen via nasal cannula to dry the glue.

I hooked a nasal cannula up to oxygen and turned it all the way up to act as a concentrated stream of directed air. This both dried the ascitic fluid and hastened the solidification of the Dermabond.  I applied multiple layers. It worked great.  No more leak.

Trick of the Trade: Universal precautions for your iPad

iPads are increasingly being used in medical education in a variety of arenas, including the classroom, the bedside, and small group workshops.

I recently taught in a procedures lab with unembalmed cadavers at UCSF's new anatomy lab (on the 13th floor of the hospital with spectacular views of San Francisco and the Golden Gate Bridge). Everyone was gowned up from head to toe using universal precautions. But wait, what about my iPad? How can I use it to teach at the "bedside" about arthrocentesis?

Trick of the Trade:
Protect your iPad by wrapping in a ziplock bag

The iPad fits almost perfectly into a large-sized ziplock bag. I was surprised to find that the iPad still very easily sensed my gloved finger, allowing me to navigate through photos.

Top 10 medical photography tips for a camera phone

A picture is worth a thousand words. 

My corollary to this statement is that a poorly framed or blurry image significantly detracts from its impactfulness. Plus, it just looks unprofessional. I have had to either retake or Photoshop-edit several photos submitted for blog posts. There have been many amazing photos which I decided not to use because of image quality.

Dr. Jason Thurman, under the mentorship of Dr. Larry Stack (both at Vanderbilt University), recently shared his thoughts about medical photography. I approached him because he gave a wonderful SAEM lecture on this. Although his talk focused primarily on optimizing images using a SLR camera (nice review by Dr. Rob Cooney), there are many principles which hold true for camera phones. My point is that most clinicians don't have a SLR camera on shift. What we do have, however, are cameras on our iPhones or Androids. It's not ideal, but it's way better than any crayon-sketch I can do.

Below are some tips to make the best of camera-phone medical photography, which I adopted from Jason's teaching points. Note that if you want to take truly excellent medical photographs, you will need to make the investment for proper camera and lighting equipment.

1. Be sure the image is in focus!

• This seems obvious, but be sure the image of interest is crisp. The image above shows a blurry image because the camera focused on the background. Use the zoom feature of your image preview to double check. 
• Hold your camera very still while taking the photo.
• Don't hold the camera too close to the image. Camera phones have poor macro capability. It's better to move a few centimeters away and then later crop/zoom the image.

2. Manage distracting elements to make the image stand out

• Remove ECG leads, oxygen tubing, jewelry, if irrelevant.
• Brush aside hair.

So many things wrong with this photo that I'm embarrassed to share from my photo collection.
Background, offset lighting, distractors, oh my.

3. Control the background

• Your primary image should not be overshadowed by distracting backgrounds.
• Use a white, black, or blue background, ideally covering the entire frame of view. 
• Sterile towels are excellent.
• Be careful to get everything out of the frame of view (curtain, bedrail, etc)

4. Frame the image with a reference shot 

• Example: If you are taking an image of olecranon bursitis, first shoot the entire arm to show the location of the pathology and orient the viewer, then get a close up of the lesion you wish to show.

5. Manage the lighting 

• In the ideal world, an external flash provides the best lighting.
• Get creative with lights to make sure the pathology is illuminated as best as possible. This requires taking several photos with a light source being further or closer to the image to avoid whiting-out the image. Consider using the High Dynamic Range (HDR) setting for iPhones.
• Try to avoid using the camera phone flash.

6. Manage perspective distortion

• If you are shooting the face, take images straight on and perpendicular, do not take images at angles as this causes image distortion and poorly represents what you are trying to show) 

Ear foreign body

7. Provide a reference for scale

• You know what the image is, but think from the perspective of the viewer. How big exactly is that abscess? 
• Place a ruler or commonly identifiable object (eg. coin, pen) next to the object to give the viewer an idea of size.

8. Be your own worst critic

• NEVER be satisfied with a mediocre image. 
• Keep shooting until you get it right!

9. Avoid any patient identifier features, if possible. 

10. Be sure you have your patient's signed consent.

• I bundle my digital photos with a photo of the patient's signed consent form for tracking purposes as the last page.

Got another tip to add? Please comment.

Trick of the Trade: Avoiding a straight-needle needlestick injury

You are finishing up a successful subclavian line procedure. You insert the straight-needle suture needle through the skin to secure the line. When trying to pull it out, you accidentally poke yourself!

This is actually a common scenario for a needlestick injury. Although many central line kits now have curved suture needles, many still have straight needles. How can you avoid a needlestick?

Trick of the Trade:
Use a needle hub as a thimble-like protector

Safety technique for straight suture needle from Sinai EM Ultrasound on Vimeo.

Thanks to Dr. Bret Nelson (Mount Sinai) and SinaiEM.us for the video and great tip! Here's the link to the SinaiEM.us post as well.

Here's a variation on this trick by Dr. Haney Mallemat (@CriticalCareNow) and Ultrarounds.com.


Reference
Nelson BP. Making straight suture needles a little safer: a technique to keep fingers from harm's way. J Emerg Med. 2008 Feb; 34(2):195-7. Epub 2007 Oct 1. Pubmed

Trick of the Trade: High volume irrigation of abscesses

Large-sized abscess often have pus trapped in deep crevices and pockets. Irrigation can help express the pus. How can you set up a high-volume irrigation system?

Trick of the Trade:
Administer normal saline through a pressure IV bag and irrigate using an 18 gauge angiocatheter.

Thanks to Dr. Julian Villar (EM resident at UCSF-SFGH) for the idea and action photo! Read his insightful comments in the Comments section.

Editorial comments 11/7/12:

• Be aware that irrigation has not actually been shown to be necessary in incision and drainage procedures of abscess.
• Be sure that there is a large exit hole for the high-pressure irrigation or else you will be injecting into a closed system, potentially dissecting through surrounding tissue planes.

Trick of the Trade: IV ceftriaxone for gonorrhea

How many times have you given your patient IM ceftriaxone for that presumed gonococcal infection? ... still counting?

Many of us learned (or at least thought we learned) that ceftriaxone has to be administered IM to get the ‘depot’ effect.

Myth busted: There is no depot effect. IV and IM ceftriaxone have very similar pharmacokinetic profiles. Let me prove it to you, straight from the FDA-approved ceftriaxone package insert.

Time after dose administration (hrs) and Average plasma concentration (mcg/mL)

Dose/route	0.5 hr	1 hr	2 hr	4 hr	6 hr	8 hr	12 hr	16 hr	24 hr
0.5 g IV	82	59	48	37	29	23	15	10	5
0.5 g IM	22	33	38	35	30	26	16	unknown	5

• The plasma concentrations are almost identical after IM and IV administration through 24 hours.
• The volume of distribution is the same for both parenteral routes, too. This means that its penetration into the “affected area” is similar.
• For further proof, the CDC Guidelines recommend IV or IM ceftriaxone interchangeably for most gonococcal infections in infants and children.

Trick of the Trade: 
If the patient already has an IV line, give IV ceftriaxone instead of IM .

While most of the time patients with STD (or STI, if you prefer) complaints don’t have an IV line established, occasionally they do. My hospital stocks 1 gm and 2 gm premixed IV bags of ceftriaxone, so we just give 1 gm IV in these rare cases. But 250mg IV should be just fine.

Of course, the other way to avoid the painful injection is to mix the ceftriaxone with lidocaine... or avoid contracting gonorrhea altogether.


References:

Product Information: ROCEPHIN(R) IV, IM injection, ceftriaxone sodium IV, IM injection. Genentech USA, Inc. (per Manufacturer), South San Francisco, CA, 2010.

Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010;59(RR-12):1-110. [

PMID: 

21160459]. Free MMWR PDF download.

Trick of the Trade: Don't miss the pneumothorax in needle thoracostomy

A patient arrives in PEA arrest and you note that her left chest has no breath sounds or lung sliding on bedside ultrasound. You suspect a tension pneumothorax.

You insert a standard 14g angiocather in the left 2nd intercostal space (ICS). You don't hear a rush of air. The patient's clinical condition deteriorates to impending asystole. How sure are you that your angiocatheter actually reached the pleural space?

Trick of the Trade #1:
If aiming for the mid-clavicular 2nd ICS, go more lateral than you think. The clavicle ends in the shoulder, not the lateral chest wall! (1)

• Ferrie et al study: Dots are where emergency physicians would have inserted an angiocatheter. Vertical line is the true mid-clavicular line.

Trick of the Trade #2: 
Insert angiocatheter at the 5th ICS along the mid-axillary line, similar to the location of a chest tube.

• Cadaver study by Inaba et al (2): Average chest wall thickness was 3.5 cm ± 0.9 cm at mid-axillary 5th ICS vs 4.5 cm ± 1.1 cm at mid-clavicular 2nd ICS
• Success needle thoracostomy placement was 100% (5th ICS) vs 58% (2nd ICS)
• Use at least a 5 cm angiocatheter.

Trick of the Trade #3:
Regardless of whether you use the mid-clavicular 2nd ICS or mid-axillary 5th ICS, use a longer angiocatheter than a traditional 3 cm IV angiocatheter. Otherwise it won't reach the pleural space!

• Example: Use the 6.3 cm angiocatheter often found in central line kits.
• The average chest wall thickness at the 2nd ICS in a retrospective study in Canada was (3):

Thanks to Dr. Scott Weingart (@emcrit). Listen to the podcast for more tips and suggestions on this topic at his EMCrit blog!

Reference

1. Ferrie EP, Collum N, McGovern S. The right place in the right space? Awareness of site for needle thoracocentesis. Emerg Med J. 2005 Nov;22(11):788-9. Pubmed. Free PDF article
2. Inaba K, Branco BC, Eckstein M, Shatz DV, Martin MJ, Green DJ, Noguchi TT, Demetriades D. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. J Trauma. 2011 Nov;71(5):1099-103; discussion 1103. Pubmed .
3. Zengerink I, Brink PR, Laupland KB, Raber EL, Zygun D, Kortbeek JB. Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? J Trauma. 2008 Jan;64(1):111-4. Pubmed .

Trick of the Trade: Safer guidewire disposal

Have you ever accidentally flicked a drop of blood while disposing a straight guidewire into a rectangular sharps bin? The bins just don't quite fit the wire easily. That's just an occupational exposure just waiting to happen to yourself.

Trick of the Trade:
Wrap guidewire around knuckles and dispose in reversed glove



Thanks to Dr. Rob Bryant (Utah Emergency Physicians) for the tip!

Trick of the Trade: A flexible pediatric ear curette

Image from univatty.blogspot.com

Having you had trouble seeing a pediatric patient's tympanic membrane because of impacted cerumen? Scared from that last time you used a rigid curette and caused bleeding in the ear canal? The parents   are worried that you hit the brain...

Trick of the Trade:
Make a customized, softer, flexible curette using a polyester-tipped applicator

The thin polyester-tipped applicators have a malleable and relatively soft handle. Fold the applicator in half and twist the apposing edges into a single curette instrument. You can shape the curette to adjust the angle to your patient's ear canal anatomy and adherent cerumen chunks.

Thanks to Dr. Aaron Kornblith (chief resident at UCSF-SFGH EM program).

Tricks of the Trade: Calcium gel for hydrofluoric acid burns

From AccessMedicine.com

A 41 y/o m presents to your ED after an occupational exposure to 30% hydrofluoric acid (HF). The thumb and index finger of his right hand were affected. Upon visual examination, the site of exposure looks relatively benign but the patient is complaining of extreme pain. Beyond giving opioids, what can you do?

Topical calcium gluconate is the treatment for minor to moderate cutaneous burns from HF.

It would be really nice if there were a commercially available calcium gluconate gel available. Wait, there is! But it's pretty expensive and most hospitals won't stock it. Generic versions of 2.5% calcium gluconate gel are also hard to come by.

Trick of the Trade:
Make your own calcium gluconate gel.

What you'll need:

1. Calcium carbonate tablets (Tums^®), calcium gluconate powder, or solution
2. A water-soluble jelly (K-Y Jelly^® works great)

How to prepare: Mix any of the following with 5 ounces of K-Y Jelly^®:

• 10 g of calcium carbonate tablets, or
• 3.5 g calcium gluconate powder, or 
• 25 mL of calcium gluconate 10% solution

How to administer:

1. Thoroughly irrigate the area with water. 
2. Apply your concoction directly to the affected area. 
3. The best trick is to add the gel into a surgical glove and have the patient wear it for at least 30 minutes.

Don't expect your gel to look like one you could sell for profit. I'm a pharmacist with training in compounding and it still comes out pretty ugly (especially with Tums^®).

Other routes of calcium administration for topical burns include intradermal, intravenous, and intraarterial. An IV Bier block technique using 25 mL of 2.5% calcium gluconate has also showed some success.

Disposition

All patients with digital exposures should be observed over 4-6 hours. The pain usually recurs and you may need to reapply the gel (or maybe even try an alternative therapy). Make sure your patient has good discharge instructions and has access to specialized followup and wound care.



References

Anderson WJ, Anderson JR. Hydrofluoric acid burns of the hand: mechanism of injury and treatment. J Hand Surg. 1988;13:52-7. [PMID: 3351229]

Chick LR, Borah G. Calcium carbonate gel therapy for hydrofluoric acid burns of the hand. Plastic Reconstr Surg. 1990;86:935-9. [PMID: 2236319]

Bracken WM, Cuppage F, McLaury RL, et al. Comparative effectiveness of topical treatments for hydrofluoric acid burns. J Occup Med. 1985;27:733-9. [PMID: 4067676]

Upfal M, Doyle C. Medical management of hydrofluoric acid exposure. J Occup Med. 1990;32:726-31. [PMID: 2401930]

Burkhart KK, Brent J, Kirk MA, et al. Comparison of topical magnesium and calcium treatment for dermal hydrofluoric acid burns. Ann Emerg Med. 1994;24:9-13. [PMID: 8010555]

Kirkpatrick JJ, Burd DAR. An algorithmic approach to the treatment of hydrofluoric acid burns. Burns. 1995;21:495-9. [PMID: 8540974]

Su M. Chapter 105. Hydrofluoric Acid and Fluorides. In: Su M, ed. Goldfrank's Toxicologic Emergencies. 9th ed. New York: McGraw-Hill; 2011.

Trick of the Trade: "Pass the mayo" - getting off black tar

Industrial accidents sometimes involve hot coal tar stuck to a patient's skin. Coal tar is notoriously challenging to remove once it has cooled and adhered to the skin. The tradition teaching is to apply large quantities of petroleum jelly to the tar, let it sit for at least 60 minutes, and then diligently try to rub away the tar. Repeat as needed.

What if you don't have any petroleum jelly or petroleum-based products?

Trick of the Trade:
Use mayonnaise

Mayonnaise can apparently be used as an alternative, presumably because it is an oil-based product. There are no published reports in the medical literature, but there are more than several anecdotal reports of their effectiveness.

Anyone use this trick?

Thanks to Dr. Sally Graglia (UCSF-SFGH EM resident) for letting me know about this trick.


Reference
Food for Medical Emergencies on Life in the Fast Lane (see comments section)

Trick of the Trade: Oral naloxone for opioid-induced constipation

Opioids are amazingly effective for pain control. Patients on chronic opioids, however, often struggle with constipation. These patients may fail supportive treatment with enemas and laxatives.

Trick of the Trade:
Oral naloxone

Interestingly, there are minimal systemic effects with oral naloxone. So, constipation can be directly targeted without causing systemic opioid withdrawal. Published case series reports show a variable range of therapeutic doses, ranging from 0.1-20 mg of oral naloxone. One series quoted no effectiveness under 1.5 mg. Generally 2 mg PO is a good starting point. Then titrate up slowly to achieve the laxative effect to minimize any systemic absorption.

FYI, you need to use the IV preparation, because no PO formulation exists.

Alternatively per Bryan Hayes (@PharmERToxGuy), you can also use methylnaltrexone, which also is a mu-receptor antagonist. It is dosed 8-12 mg (0.15 mg/kg) subcutaneously.

Thanks to Dr. Graham Walker (Kaiser San Francisco) and Sarah Burkart (PA at Univ of Cincinnati) for sharing this great tip!


Reference
Holzer P. Non-analgesic effects of opioids: Management of opioid-induced constipation by peripheral opioid receptor antagonists: prevention or withdrawal? Curr Pharm Des. 2012 Jun 28. [Epub ahead of print] Pubmed

Leppert W. The role of opioid receptor antagonists in the treatment of opioid-induced constipation: a review. Adv Ther. 2010 Oct;27(10):714-30. Pubmed .

Meissner W, Schmidt U, Hartmann M, Kath R, Reinhart K. Oral naloxone reverses opioid-associated constipation. Pain. 2000 Jan;84(1):105-9. Pubmed .

Trick of the Trade: Alternative to Word catheter for Bartholin abscess

Word catheter

Bartholin abscesses are challenging to manage, partly because of Word catheter insertion. Sometimes, the space is not large enough (unable to fit the catheter) or too large (catheter falls out). How else can you "pack" the abscess space?

Trick of the Trade:
Jacobi rubber ring

This trick nicely piggy-backs with last week's Trick of the Trade on incision and loop drainage. Published in the American Journal of EM, Gennis et al present their successes with their 8-French rubber tube, threaded with suture material. Kushnir et al discuss their using butterfly tubing instead of a rubber tube to create a loop. Anyone have experience with these techniques (or a version of)?

Images from AJEM article

Thanks to Dr. Marianne Haughey (Jacobi Medical Center) for telling me about this.

Reference
Kushnir VA, Mosquera C. Novel technique for management of Bartholin gland cysts and abscesses. J Emerg Med. 2009 May;36(4):388-90. Pubmed .

Gennis P, Li SF, Provataris J, Shahabuddin S, Schachtel A, Lee E, Bobby P. Jacobi ring catheter treatment of Bartholin's abscesses. Am J Emerg Med. 2005 May;23(3):414-5. Pubmed .

Trick of the Trade: Incision and loop drainage of abscesses

From depts.washington.edu

Why are we still teaching the traditional incision and drainage approach to simple abscess drainage? They require frequent, painful packing changes to ensure persistent drainage of retained pus.

Loop Abscess Drainage from Rob from ercast on Vimeo.

Trick of the Trade:
Incision and loop drainage (I&LD) technique

As per usual, Dr. Rob Orman (ercast) beat me to this. He already reviewed the technique on his blog in 2010. This stems from a landmark article in the Journal of Pediatric Surgery, which involves creating a persistently draining fistula at two points by using a small vascular loop, tied into a non-tensile loop.

It makes sense to extrapolate and use this technique for both pediatric and adult patients with uncomplicated abscess, especially if the patients may not follow-up for packing changes as scheduled. The added benefit is that showering is encouraged to help encourage drainage without the risk of dislodging the secured loop.

Questions:
Does anyone have experience with this that they would like to share? Particularly, what if you don't have the skinny vascular loops in your Emergency Department?

What are the follow-up instructions?
Per the Tsoraides article:

• Take a bath/shower TWICE daily for the first 3 days.
• Remove the loop in 7-10 days (when the drainage stops and the overlying cellulitis resolves)

VessiLoop Presentation from V. Bonales, M.D.

Reference
Tsoraides SS, Pearl RH, Stanfill AB, Wallace LJ, Vegunta RK. Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children. J Pediatr Surg. 2010 Mar;45(3):606-9. Pubmed .