Eileen M. Handberg, PhD

• Associate Professor of Medicine
• Director, Clinical Programs
• Division of Cardiovascular Medicine
• University of Florida
• Gainesville, Florida

The emotional state of a patient on induction strongly correlates with the degree of distress on emergence and in the days immediately after the procedure symptoms jaundice effective retrovir 300 mg. Incorporating into the presedation preparation a discussion with the consultant about the sedation plan and the length of time required to safely prepare and sedate the patient can avoid the risks associated with hurried sedation treatment lupus discount 100 mg retrovir amex. Wait the appropriate time for the medications to produce the intended effect before adding more doses symptoms 3 weeks pregnant cheap retrovir 300mg online. When using opioids treatment head lice 100mg retrovir mastercard, administer doses in 2- to 3-minute increments and observe for side effects such as miosis medicine 773 quality retrovir 100mg, somnolence symptoms 7 days before period purchase cheap retrovir, decreased responsiveness to verbal stimuli, impaired speech, and diminished pain on questioning as appropriate initial end points. For sedative-hypnotics, use similar incremental dosing and end points such as ptosis (rather than miosis), somnolence, slurred speech, and alterations in gaze. New drug delivery systems, however, are expanding the effectiveness and ease of use of these routes of administration. The refinement of intranasal drug delivery has significantly increased the efficacy of this route of administration. Furthermore, new drug formulations with concentrations appropriate for intranasal administration are becoming available for study. With the exception of ketamine, agents administered intramuscularly have erratic absorption and a variable onset of action. Accordingly, prolonged preprocedural and postprocedural observation may be necessary. This gas can either be delivered by a demand-flow system using a handheld mask or be delivered to young children using a nose mask in a continuous-flow system under close clinician supervision. Significant forward flexion might cause airway obstruction if the child falls asleep on the way home. Time of onset from injection to the initial observed effect must be appreciated, especially when using drugs in combination, to avoid stacking of drug doses and oversedation. The correct agent (or combination of agents) and the route and timing of administration depend on the following factors: How long will the procedure last Does the patient require sedation only for a noninvasive diagnostic imaging study The true ceiling dose of an agent is the level that provides adequate pain relief or sedation without major cardiopulmonary side effects such as respiratory depression, apnea, bradycardia, hypotension, or allergic reactions. Relative contraindications include hemodynamic or respiratory compromise, altered sensorium, or an inability to monitor for adverse events. However, even in many of these circumstances, appropriate agents can be given to provide analgesia and sedation while minimizing the chance for further deterioration. Isadelayinwaitingfora sufficient fasting time worth the time lost in performing the procedure From Krauss B, Brustowicz R, editors: Pediatric procedural sedation and analgesia. Skilled practitioners can frequently combine a calm, reassuring bedside manner with distraction techniques, careful local or regional anesthesia, or both. Despite a cooperative patient, for some procedures it is impossible to achieve effective pain control with local or regional anesthesia. Young children requiring repair of lacerations are frequently terrified, and older children and adults may be highly anxious in anticipation of such repairs in sensitive or personal regions. Immobilization is most commonly an issue with young children and the mentally challenged. The benefits of reducing anxiety and controlling pain should be carefully weighed against the risk for respiratory depression and airway compromise. Such procedures can usually be managed with topical, local, or regional anesthesia. Midazolam can be titrated intravenously to a relatively deep level of sedation, although as discussed previously, the risk for adverse effects increases with the depth of sedation. Ketamine (typically with coadministered midazolam when used in adults) can also provide the profound analgesia and immobilization necessary to perform painful procedures. However, in adults there is a risk for unpleasant hallucinatory recovery reactions. Although the pharmacopoeia is large, clinicians should familiarize themselves with a few agents that are flexible enough to be used for the majority of procedures. In all cases it is assumed that practitioners are fully trained in the technique, appropriate personnel and monitoring are used as detailed in this chapter, and specific drug contraindications are absent. Occasionally, procedures in extremely uncooperative adults or the mentally challenged are best managed in the operating room with general anesthesia. In other cases, supplementing nonpharmacologic techniques with topical or local anesthesia and anxiolysis with oral midazolam may be sufficient to permit successful wound repair. Although oral administration is most popular and least invasive, the nasal or rectal routes can also be used depending on operator experience and preference. Young children with facial lacerations at night, after their normal bedtime, may require only topical anesthesia and a quiet room for 20 to 30 minutes to achieve a painless laceration repair while the child sleeps. This can further increase hunger and irritability, especially if the child waits 1 to 2 hours to be seen by a clinician. A child who was frightened and uncooperative in triage may be calm and compliant during a procedure. An extremely anxious parent or a parent who must take care of other siblings during the procedure will find it difficult to assist in distracting the child or otherwise helping the child cope with the procedure. Direct experience is not the only way to create anxious, frightened, and uncooperative patients, though. Images from television, stories from peers, or previous witness of a sibling being forcibly restrained for repair of a laceration can leave a powerful and lasting impression. This type of influence should be especially suspected in children whose anxiety seems out of proportion to the present situation. Children manifest anxiety in many different ways, and emergency clinicians must be facile at recognizing the varying expressions of anxiety, especially in young children. A child with a facial laceration quietly sitting on the stretcher during the initial examination will not necessarily be a calm and cooperative patient during repair of the laceration Inquiring into how a child behaves during routine primary care visits can yield important information on how the child reacts to stressful situations, how cooperative the child will be with the anticipated procedure, and whether pharmacologic management is needed. Children who cry but hold still when vaccinated may be more compliant than children who are described by their parents as being "afraid of doctors" or "wild" during visits to the primary care physician. Ketamine may be the best option in such children because dissociative sedation can consistently provide immobilization and analgesia while maintaining protective airway reflexes and upper airway muscular tone. Do not attempt this procedure if the pulse oximeter, suction, oxygen, or bag-mask device is not working, the intravenous line is not secured, or the room is too small or not set up for procedural sedation and analgesia. Proceed slowly and patiently and allow the medication to take full effect before giving the next dose. An ageappropriate resuscitation cart with oral and nasal airways, endotracheal tubes, and a functioning laryngoscope must be nearby. Additionaldosesoffentanylor midazolam may be required if further pain or anxiety is noted based on the response and length of the procedure. Reversal agents should be considered if there is not a prompt response to assisted ventilation. The best choice is an agent whose pharmacologic properties are familiar to the operator, that is used frequently by the operator, is easily titratable, and has a short duration of action or is readily reversible. All drugs should be given in adequate doses because under-dosing of opioids or sedatives provides no useful purpose. Despite a wide margin of safety, chloral hydrate can cause airway obstruction and respiratory depression, especially at higher doses (75 to 100 mg/kg). When administered orally, the average time to peak sedation is approximately 30 minutes, with a recovery time of an additional 1 to 2 hours. When the benefits of using propofol outweigh the risks, administer lower doses more slowly. Patients should ideally have their volume status optimized before receiving propofol. When available, consider adding a separate emergency clinician who is solely dedicated to drug administration and patient monitoring. Because it is a halogenated hydrocarbon, overdoses of chloral hydrate can be arrhythmogenic and produce ventricular dysrhythmias. Benzodiazepines are a group of highly lipophilic agents that possess anxiolytic, amnestic, sedative, hypnotic, muscle relaxant, and anticonvulsant properties. They lack direct analgesic properties and thus are commonly coadministered with opioids. Caution must be exercised when using benzodiazepines and opioids together because the risk for hypoxia and apnea is significantly greater than when either is used alone. The time to peak effect for midazolam is approximately 2 to 3 minutes when given intravenously. Unlike diazepam, midazolam and lorazepam are water soluble, thus making parenteral administration less painful and mucosal absorption faster. On occasion, the patient may move or be moved into a position that is self-maintaining. Intubation is unnecessary, but occasional repositioning of the head may be needed for optimal airway patency. Consider encouraging adults and older children to "plan" specific, pleasant dream topics in advance of sedation (believed to decrease unpleasant recovery reactions). Emphasize, especially to school-aged children and teenagers, that ketamine delivers sufficient analgesia, so there will be no pain. Avoid ketamine in patients who are already hypertensive and in older adults with risk factors for coronary artery disease. More rapid administration produces high central nervous system levels and has been associated with respiratory depression or apnea. Blood pressure measurements after the initial value are generally unnecessary because ketamine stimulates catecholamine release and does not depress the cardiovascular system in healthy patients. Supplemental oxygen is not mandatory but may be used when capnography is used to monitor ventilation. Midazolam may be used for the same indications and in the same manner as in adults. Some children require larger doses than would be typical for adults on a milligram-per-kilogram basis,85 and paradoxical responses. Individual dosages may vary when used in combination with other agents, especially when benzodiazepines are combined with opioids. When administered by skilled practitioners using standard precautions (see Box 33. Deaths from undetected apnea have occurred,84 thus underscoring the critical role of continuous interactive and mechanical monitoring. Although hypotension can occur, it is rare when the agents are carefully titrated. One reason that midazolam is ideal for painful procedures is its significant amnesic effect. Even though patients appear to feel pain during the procedure, it is often not remembered. Pentobarbital is a barbiturate capable of profound sedation, hypnosis, amnesia, and anticonvulsant activity in a dose-dependent fashion. When carefully titrated intravenously, sedation is evident within 5 minutes with a duration of approximately 30 to 40 minutes. Like other barbiturates, pentobarbital can lead to respiratory depression and hypotension because it is a negative inotrope. Critics have cited the level of continuous vigilance required to achieve a desired effect while simultaneously avoiding significant cardiopulmonary depression because these agents can result in rapid swings in levels of consciousness. It can be cautiously combined with the short-acting narcotic fentanyl or with ketamine. The pain of a propofol injection can be minimized by choosing a large vein not on the dorsum of the hand and slowly injecting 2 to 3 mL of 2% lidocaine into the vein before injection of propofol. The half-life for blood-brain equilibration is approximately 1 to 3 minutes, and its clinical effects typically resolve within 5 to 7 minutes. Propofol exhibits inherent antiemetic and perhaps euphoric properties, and patient satisfaction is typically high. Propofol should be avoided in patients with known or suspected allergy to eggs or soy products. Transient apnea and respiratory depression can occur with propofol but typically resolve spontaneously before intervention is necessary. Etomidate may be somewhat less effective overall than propofol and, given its additional adverse effect of myoclonus, appears to be a less desirable choice than propofol for deep sedation. The safety and efficacy profile of etomidate appears to be similar to that in adults. The primary adverse effects of etomidate are respiratory depression, myoclonus, nausea, and vomiting. It consists of transient jerking or twitching movements that can be mistaken for seizure activity. Clinical recovery is rapid (15 minutes) as a result of rapid redistribution from the central nervous system to the periphery. The effects of fentanyl can be reversed immediately with naloxone should excessive sedation or respiratory depression occur. The longerduration opioids morphine and meperidine are preferred for nonprocedural or preprocedural pain control and are frequently given initially for acute analgesia followed by fentanyl to facilitate the needed procedure. Fentanyl is 100 times more potent than morphine and has no intrinsic anxiolytic or amnestic properties. This increase in potency and onset of action is in part related to its greater lipid solubility, which facilitates passage of the drug across the blood-brain barrier. The effects of fentanyl can be rapidly and completely reversed with opioid antagonists. Because the opioid effect is most pronounced on the central nervous system respiratory centers, apnea precedes loss of consciousness. If apnea should occur, verbal or tactile stimulation should be attempted before the administration of opioid antagonists. Because of its safe hemodynamic profile, fentanyl is an ideal analgesic agent for use in critically ill or injured patients. In addition, nausea and vomiting are rare in comparison to analgesia with morphine or meperidine.

Flames are extinguished by smothering the fire with a blanket medicine evolution discount retrovir 300mg with visa, jacket symptoms 8 days after conception order 100 mg retrovir with amex, or equivalent item; by dousing the fire with water; or by using a chemical fire extinguisher medications54583 cheap 100 mg retrovir visa. Most chemical injuries are best treated by irrigating the affected area with copious quantities of clean water medications kosher for passover purchase generic retrovir. Patients with electrical injuries are removed from contact with the electrical source as soon as it is safe to do so medicine 72 hours purchase 100mg retrovir with amex. Cooling is most beneficial for small burns if started within 3 minutes of injury and possibly of additional benefit if continued for the first few hours after the burn medications 512 purchase retrovir 300mg on-line. Doing so has been shown to reduce pain significantly and can limit tissue damage by decreasing thromboxane production. Continue to frequently soak the gauze with cool saline or tap water drawn up in a syringe. Adding a few ice chips to the liquid is helpful, but do not cover the burn with ice. Narcotics are the best way to control pain in any burn, and should be used liberally. Sterile dressings are not required for field treatment; a moist towel or nonadherent sheet may be used. Nonmentholated shaving cream makes an excellent temporary covering for out-of-hospital use if a dressing is not available. Infuse half of the calculated 24-hour fluid needs in the first 8 hours following the burn. Initial Care of Major Burns Major burns require the specialized resources of a burn center. In such cases, emergency providers should initiate the resuscitation, consult the burn center for referral, and transfer the patient as soon as practically possible. Initial resuscitation should follow standardized trauma protocols, including a primary and secondary survey, and provide immediate interventions directed at airway management, breathing, and cardiovascular support, as needed. One need not use bolus fluid resuscitation as fluids are lost via capillary leak and via the raw skin, and significant fluid loss does not occur within the first hour. Historically, the Parkland or Brooke formulas have been used to estimate fluid needs. It should be noted that 24 hours starts at the time of the burn and not the time medical care begins. After the total amount is calculated, fluids should be administered as a constant infusion rather than by bolus administration. Half of the calculated fluid requirement should be given in the first 8 hours and the remaining half provided over the following 16 hours (Box 38. Lastly, these fluid quantities are guidelines and urine output monitoring will assist in adjusting the rate or volume to meet the target outputs of 0. The formulas estimate hourly fluid requirements and must be adjusted up or down to achieve a urine output of 0. Insertion of a Foley catheter is usually necessary to accurately measure hourly urine output. Patients exposed to carbon monoxide should have carboxyhemoglobin levels measured and empirically receive 100% oxygen. Once considered a traditional empirical treatment, there is no evidence-based proven benefit from hyperbaric oxygen therapy for carbon monoxide poisoning. The Cochrane review of published trials found conflicting, potentially biased, and generally weak evidence regarding the usefulness of hyperbaric oxygen for the prevention of neurologic injury. Per an evidencebased analysis, existing randomized trials do not establish whether the administration of hyperbaric oxygen to patients with carbon monoxide poisoning reduces the incidence of adverse neurologic outcomes. Because there may still be advocates of hyperbaric oxygen therapy, consultation with a local hyperbaric center is reasonable in certain cases, but it is not standard that this intervention be routinely implemented. Critically ill and pregnant patients are still often offered hyperbaric treatment, but controversy over the efficacy and safety persists even for these subgroups. Patients suspected of having been exposed to significant levels of cyanide and manifesting symptoms should receive hydroxocobalamin (Cyanokit [Meridian Medical Technologies, Inc. If not available, the Cyanide Antidote Package may be used despite lack of proven benefit of this traditional cyanide therapy. It is reasonable to empirically administer hydroxocobalamin or the sodium thiosulfate portion of the cyanide kit to burn victims in coma or to those exhibiting metabolic (lactic) acidosis after smoke exposure. The Baux Score was developed a half-century ago by Professor Serge Baux to estimate the mortality of burns. Burn patients have an impaired ability to regulate their core body temperature and will quickly become hypothermic if untreated. Core temperature should be measured frequently, and active and passive warming strategies should be implemented to prevent hypothermia from developing. In anticipation of Plot of the observed mortality versus the group midpoint computed within 10 groups of the revised Baux score. It is acceptable to add a few ice chips to the water, but packing the wound in ice must be avoided. All involved clothing and jewelry (such as rings), along with any gross debris, should be removed from the burned area. The burned area may be immersed immediately in room-temperature water or covered with gauze pads soaked in room-temperature water or saline. The gauze may be kept cool and moist to provide continued pain relief; the patient will let the clinician know when additional cooling is desired. Many clinicians use sterile saline for cooling, but it has no proven benefit over tap water, even when the skin is broken. As stated previously, immersion of burned tissue in ice or ice water should be avoided because ice immersion increases pain and risks frostbite injury or systemic hypothermia. With the exception of pain relief and removal of debris, the primary benefits of burn cooling are probably experienced only if the burn is cooled promptly, within the first 3 minutes after injury, thus making home care important. Nonimmunized patients should receive tetanus toxoid and immunization with subsequent boosters in accordance with current guidelines. Consider applying a layer of antibiotic cream or ointment such as 1% silver sulfadiazine (Silvadene [Pfizer Inc. If fingers and toes are involved, pad the web spaces and the digits individually and separate them with strips of gauze. Instruct the patient to elevate the affected limb to prevent swelling, which may cause delayed burn conversion or wound infection. Outpatient Care of Minor Burns Minor burns are generally those that will heal spontaneously and do not require surgery or specialized wound care. These wounds are not associated with immunosuppression or hypermetabolism, nor are they highly susceptible to infection, a quality associated with larger burns. Many complications seen with minor burns are thought to result from overtreatment rather than undertreatment. Examples include the use of dry dressings that can adhere to newly forming skin and secondary infections from the overzealous use of topical or systemic antibiotics. The most important characteristic of a dressing is that it controls fluids within the wound. Burn dressings that keep the surface of the wound moist and avoid pooling of fluids will speed healing. The outer layer of dressing should be porous to permit evaporation of water from the absorbent dressing material. Cleanse the burned area gently with a clean cloth or gauze and a mild antibacterial wound cleaner such as chlorhexidine, and irrigate the wound with saline or water. There is no benefit to vigorously washing a minor wound with strong antiseptic preparations (such as povidone-iodine [Betadine, Purdue Products L. The wound can be washed two or three times per day, followed by reapplication of the topical agent. Biologic Dressings Burn Dressings Biologic dressings are natural tissues, including skin that consists of collagen sheets containing elastin and lipid. They are not routinely used in the emergency care of minor wounds and are primarily treatment options in burn centers. The benefits of biologic dressings include a reduction in surface bacterial colonization, diminished fluid and heat loss, avoidance of further wound contamination, and prevention of damage to newly developed granulation tissue. Examples of biologic dressings include cadaveric human skin and commercially available porcine xenograft or collagen sheets. Because these dressings are nonpermeable, problems with retention of wound exudates have occurred. For patients admitted or transferred to a burn center, simple gauze dressings are appropriate. Patients with serious hand burns should be admitted to the hospital, but minor burns can be treated in the outpatient setting. A, After the application of an antibiotic ointment or a dry, nonadherent dressing, separate the fingers with fluffs in the web spaces and B, enclose the entire hand in a position of function (here with the help of a roll of Kerlix). C, If the wrist is involved, a removable plaster splint may be applied over the dressing. D, the result of a minor burn involving the hand when the fingers were not wrapped individually. Initially, there were only a few blisters, but this patient now has second-degree skin loss because of an improper burn dressing that caused maceration of normal skin between the fingers. Not only were the fingers incorrectly wrapped together in one gauze wrap, but the first wound check was also incorrectly scheduled in 6 days, too long for the first wound inspection of a hand burn. Analgesia Specific Clinical Issues in Minor Burn Care Pain is a critical feature of any burn injury. Relief of pain by the appropriate and judicious use of narcotic analgesics is of the utmost importance in the initial care of all burn patients. Prehospital narcotics are very appropriate when standard contraindications do not exist. Parenteral narcotic analgesics have been erroneously relegated to pain control only for major burns, but it is suggested that narcotics be generously administered in the initial treatment of even minor painful burns. Regional or nerve block anesthesia is an excellent alternative when practical, and if feasible, nitrous oxide analgesia may be used. Oral opioids may be inadequate for the initial treatment of significant pain but can be used for continued outpatient analgesia. A properly designed dressing will do much toward preventing further discomfort after release home; however, home burn care and dressing changes may be quite painful. For this reason, an adequate supply of an oral opioid analgesic should be provided, and responsibility in analgesic use should be encouraged. Postburn pruritus is one of the most common and distressing complications of burn injury and is estimated to affect 87% of burns. Despite the limited literature on the treatment of postburn pruritus, available therapies include oral antihistamines, topical antihistamines, and topical moisturizers. The use of topical therapies should be withheld until sufficient wound healing has occurred. First, the increase in interstitial fluid increases the diffusion distance of oxygen from capillaries to cells and thereby increases hypoxia in an already ischemic wound. Second, the edema may produce untoward hemodynamic effects by a purely mechanical mechanism: compression of vessels in muscular compartments. Third, edema has been associated with the inactivation of streptococcicidal skin fatty acids, thus predisposing the patient to burn cellulitis. Most patients are unfamiliar with the medical definition of elevation and are not aware or convinced of its value. It is for this reason that lower extremity burns in general and foot burns in particular are prone to problems. Use of Topical Preparations and Antimicrobials Minor burns result in insignificant impairment of normal host immunologic defenses, and burn wound infection is not usually a significant problem. Topical antimicrobials are often used; however, some believe that these agents may actually impair wound healing. Most patients expect some type of topical concoction, so a discussion of their use-or nonuse-is prudent. Topical antimicrobials were designed for the prevention and care of burn wound sepsis or wound infection, primarily in hospitalized patients with major burns, and there is no convincing evidence that their use alters the course of firstdegree burns and superficial partial-thickness injuries. As noted, the burn dressing is the key factor in minimizing complications in all burns. Nonetheless, topical antimicrobials are often soothing to minor burns, and their daily use prompts the patient to look at the wound, assess healing, perform prescribed dressing changes, or otherwise become personally involved in the care. Keep in mind that if a topical antimicrobial is used, its effectiveness is decreased in the presence of proteinaceous exudate, thus necessitating regular dressing changes if the antimicrobial benefit of topical therapy is to be realized. In reality, once-daily dressing changes are most practical and are commonly prescribed, and no data indicate that this regimen is inferior to more frequent dressing changes.

The clinician should assume a comfortable standing or sitting position at one end of the long axis of the wound symptoms 8 weeks pregnant buy 300mg retrovir fast delivery. The skin surrounding the wound is prepared with a povidone-iodine solution and covered with sterile drapes medications pictures purchase 100 mg retrovir with amex. A clear plastic drape (Steri-Drape treatment neuroleptic malignant syndrome buy cheap retrovir 100 mg on-line, 3M Corporation) can be used to provide a sterile field and a limited view of the area surrounding the wound symptoms 5 weeks pregnant cramps purchase 300mg retrovir. Some surgeons do not drape the face but prefer to leave the facial structures and landmarks adjacent to the wound uncovered and within view 4d medications discount retrovir 300mg free shipping. If no drapes are used on the face medicine game discount retrovir 100mg on-line, the skin surrounding the wound should be widely cleansed and prepared. Closure Principles There is a tendency to overuse sutures for minor lacerations that will heal nicely with no intervention. A, the conventional cutting needle has two opposing cutting edges and a third edge on the inside curvature of the needle. The conventional cutting needle changes in cross section from a triangular cutting tip to a flattened body. B, the reverse cutting needle is used to cut through tough, difficult-to-penetrate tissue such as fascia and skin. It has two opposing cutting edges and a third cutting edge on the outer curvature of the needle. The reverse cutting needle is made with a triangular shape extending from the point to the swage area, with only the edges near the tip being sharpened. Use of a large Explore the wound to exclude the presence of foreign bodies, gross contamination, or injuries to deep structures. Place the first suture at the center of the wound so that it bisects the laceration into two equal segments. Place an additional three (single) throws and then cut the sutures while leaving 1- to 2-cm tails. Continue to place additional sutures by further bisecting each segment of the laceration. After the last stitch has been placed, cleanse the area and apply an appropriate dressing. Rotate the needle driver 90 degrees and grasp the short suture end on the opposite side of the laceration. Tighten only enough to approximate the skin edges; avoid overtightening, which may lead to tissue strangulation. To begin the second throw, again place the needle driver parallel to the laceration. Remember to place the needle driver parallel to the wound and pull the long suture end over the driver; this will ensure that all knots tied are square knots. Avoid cutting the ends too short, which may lead to knot unraveling or difficulty during suture removal. The scalpel is used to find an appropriate site; a natural plane often exists at the junction of the epidermis and dermis. A, this child sustained a superficial forehead laceration just through the epidermis. As the laceration was healing, it became red and more noticeable (as do all scars), but eventually faded. The best cosmetic result occurs when the long axis of a wound happens to be parallel to the direction of maximal skin tension; such alignment brings the edges of the wound together. Swelling after an injury creates additional tension within the circle of each suture. Tension can be reduced during wound closure in two ways: undermining of the wound edges and layered closure. The force required to reapproximate the edges of a wound correlates with the subsequent width of the scar. T undermine a wound, o the clinician frees a flap of tissue from its base at a distance from the edge of the wound approximately equal to the width of the gap that the laceration presents at its widest point. The depth of the incision can be modified, depending on the orientation of the laceration to skin tension lines and the laxity of skin in the area. The clinician can also accomplish this technique by spreading scissors in the appropriate tissue plane. Because undermining may harm the underlying blood supply, this technique should be reserved for relatively uncontaminated wounds when no other methods adequately relieve wound tension. Minimizing Tissue Trauma the importance of carefully handling tissue has been emphasized since the early days of surgery. When choosing suture size, the clinician should select the smallest size that will hold the tissues in place. Skin stitches should incorporate no more tissue than is needed to coapt the wound edges with little or no tension. Knots should be tied securely enough to approximate the edges of the wound without blanching or indenting the skin surface. Tie and bury the knot by pulling the sutures in the long axis of the wound as shown. Finally, layered closure provides support to the wound and considerably reduces tension at the skin surface. A "fat stitch" is not necessary because little support is provided by closure of the adipose layer and additional suture material may increase the possibility of infection. Layered closure is not recommended for wounds without tension, those with poor vascularity, and those with a moderate or high risk for infection. One approach is to close the length of this layer in segments by placing the first stitch in the middle of the wound and bisecting each subsequent segment until closure of the layer has been completed. Approximation of a lacerated muscle hastens healing and return of function to the muscle. A, In most situations, the needle should be loaded perpendicular to the needle driver. B, If the wound is narrow, the needle can be grasped at a slightly obtuse, 135-degree angle to the needle driver. Once the suture has been placed on one side of the wound, it can be pulled across the wound to the opposite side (or the edges of the wound pushed together) to determine the matching point on the opposite side. The needle should enter the dermis at the same depth as it exited from the opposite side, pass through the tissue, and exit at the bottom of the wound (or the base of the flap). The edges of the wound can be closely apposed by pulling the two tails of the suture in the same direction along the axis of the wound. Hand and instrument knot-tying techniques are described and illustrated in wound care texts. Slide the blade of the scissors down the tail of the suture until the knot is reached. This technique prevents the scissors from cutting the knot itself and leaves a 3-mm tail, which protects the knot from unraveling. The index finger is placed on the side of the needle holder, where it guides placement of the needle. C, Hold the forceps in your nondominant hand as you would hold a pencil or a dart. Pull the suture across the wound to determine the correct level of dermal entry on the opposite side. Pass the needle downward through the dermis on the opposite side so that it exits at the bottom of the wound. B Start here If the wound has been undermined, the needle enters at the base of the flap and is passed upward through the dermis. C Pull the two tails of the suture in the same direction along the axis of the wound to appose the wound edges, and then tie the knot. Subcutaneous knots are "buried" at the bottom of the wound to prevent painful nodules beneath the epidermis and to keep the bulk of the foreign material away from the skin surface. Surface Closure the epidermis and the superficial layer of dermis are sutured in a single layer with nonabsorbable synthetic suture. If the edges of the wound are apposed after closure of the deeper layers, small 5-0 or 6-0 sutures can be used simply to match the epithelium on each side. Wounds with greater tension and separation should have skin stitches placed closer to each other and closer to the edge of the wound with consideration for an interrupted vertical mattress suture; layered closure is important in such wounds. When suturing the skin, right-handed operators should pass the needle from the right side of the wound to the left. The needle should be driven through tissue by flexing the wrist and supinating the forearm; the course taken by the needle should result in a curve identical to the curvature of the needle itself. The angle of exit for the needle should be the same as its angle of entrance so that an identical volume of tissue is contained within the stitch on each side of the wound. Once the needle exits the skin on the opposite side of the wound, regrasp it with the needle holder and advance it through the tissue; care should be taken to avoid crushing the point of the needle with the instrument. Forceps are designed for handling tissue and thus should not be used to grasp the needle tightly. Forceps can stabilize the needle by holding it within the tissue through which the needle has just passed. If the point of the needle becomes dull before all the attached thread has been used, the suture should be discarded. Complications Sutures act as foreign bodies in a wound, and any stitch may damage a blood vessel or strangulate tissue. Therefore, the clinician should use the smallest size and the least number of sutures that will adequately close the wound. Drive the needle tip downward and away from the cut edge into the subcutaneous layer. The needle tip is directed toward the opposite side at the same level by rolling the needle holder. This method incorporates more tissue within the stitch in the deeper layers of the wound than at the surface. As an alternative, if a small needle is used in thick skin or the distance across the wound is great, the needle can be removed from the first side, remounted on the needle holder, and advanced to the opposite side. The distance from each exit of the suture to the laceration is half the depth of the dermis. C, Correct number of stitches used for a wound under an average amount of tension. Rotate the wrist (pronate) so that the needle enters the skin perpendicularly, not at an angle, as the wrist supinates. If sutures are tied too tightly around the edges of the wound or if individual stitches are under excessive tension, blood supply to the wound may be compromised, thereby increasing the chance of infection. If the edges of a wound invert or if one edge rolls under the opposite side, a poorly formed, deep, noticeable scar will result. Excessive eversion that exposes the dermis on both sides will also result in a larger scar than if the edges of the skin are perfectly apposed, but inversion produces a more visible scar than eversion does. Because most scars undergo some flattening with contraction, optimal results are achieved when the epidermis is slightly everted without excessive suture tension. Wounds over mobile surfaces, such as the extensor surfaces of joints, should be everted. In other words, the stitch is wider at its deepest part and narrower at the surface. To accomplish eversion, lift and turn the edge of the wound outward with a skin hook or fine-toothed forceps before inserting the needle on each side. Eversion can also be achieved simply by pressing on the skin adjacent to the wound with closed forceps. Vertical mattress sutures are particularly effective in everting the edges of the wound, and they can be used exclusively or alternated with simple interrupted sutures. Although tying plus cutting each stitch is time-consuming, the advantage of this method is that if one stitch in the closure fails, the remaining stitches continue to hold the wound together. A continuous stitch is an effective method for closing relatively clean, low-risk wounds that are under little or no tension and are on flat, immobile skin surfaces. In a continuous, or "running," stitch, the loops are the exposed portions of a helical coil tied at each end of the wound. A continuous suture line can be placed more rapidly than a series of interrupted stitches. A continuous stitch has the additional advantages of strength (with tension being evenly distributed along its entire length), fewer knots (which are the weak points of stitches), and more effective hemostasis. Likewise, if infection develops and the incision must be opened at one point, cutting a single loop may allow the entire wound to fall open. A simple continuous stitch has a tendency to produce suture marks if used for the closure of large wounds and if left in place for more than 5 days. Among the variations of the continuous technique, the simple continuous stitch is the most useful to emergency clinicians. Place an interrupted stitch at one end of the wound and cut only the free tail of the suture. This technique allows the operator to see the needle path, thereby ensuring that the proper depth has been reached, and promotes eversion of the skin edges. B, "Tacking" type of vertical mattress suture extending into the deep fascia to obliterate dead space under the wound. The suture enters the base of the flap, is brought up into the dermis, and exits just proximal to the wound edge along the base of the flap to be tied and cut. After each passage of the needle, tighten the loop slightly, and hold the thread taut in your nondominant hand.

Several authors suggest that epinephrine-containing solutions can be safely injected into the fingers without adverse sequelae symptoms week by week cheap 100mg retrovir with visa. Current data support the use of epinephrine medications prescribed for adhd generic retrovir 300 mg overnight delivery, when correctly applied medicine 666 colds buy genuine retrovir on line, for the performance of digital blocks of the fingers and toes treatment integrity discount retrovir line. The use of phentolamine treatment writing purchase retrovir on line, which produces postsynaptic -adrenergic blockade medications with sulfa buy generic retrovir line, is recommended for clinically significant vasoconstrictor-induced tissue ischemia. This medication is usually given by local infiltration, in the area where epinephrine has been injected, at a dose of 0. If local infiltration is ineffective because of tension within a tissue compartment or if the area of vasoconstriction is large, give phentolamine by the intraarterial route. Patients may also demonstrate systemic reactions to hidden allergens that may mimic a systemic reaction, such as anaphylactic reactions to the latex in surgical gloves. High Blood Levels Systemic toxic reactions result from high blood levels of local anesthetic. Several factors are important in producing high blood levels, including the site and mode of administration, rate of administration, dose and concentration, addition of epinephrine, specific drug, clearance, maximum safe dosage, and inadvertent intravascular injection. Dose and Concentration the larger the total dose, the higher the peak blood level. It is uncertain whether increasing the concentration while maintaining the total dose by decreasing the volume affects the serum level. Addition of Epinephrine Epinephrine produces vasoconstriction and reduces systemic absorption, thereby resulting in lower peak blood levels. Occasionally, the apprehension, tachycardia, or palpitations induced by epinephrine can be incorrectly interpreted by both the clinician and patient as an "allergic" reaction. Site and Mode of Administration In comparing the routes of administration for a given dose, the intravascular route produces the highest levels, followed by topical mucosal application and then infiltration. The more vascular the site, the more systemic absorption that occurs and the higher the level obtained. The following blocks are arranged in decreasing order of systemic absorption: intercostal, caudal, epidural, brachial plexus, and subcutaneous. It follows that the site of administration is an important variable in determining the safe dose of an anesthetic. For example, 400 mg of lidocaine may produce a nontoxic blood level with subcutaneous abdominal wall infiltration but produce a toxic level when used for an intercostal nerve block. A single topical application leads to a higher level than a dose that is fractionated over time. Agents with high lipid solubility and lower protein binding (etidocaine > bupivacaine > lidocaine > mepivacaine) tend to become sequestered in tissue and have slower absorption and lower blood levels. Agents with a greater volume of distribution or faster clearance (etidocaine > lidocaine > mepivacaine > bupivacaine) also produce lower blood levels. Together, these effects produce margins of safety for each anesthetic, with etidocaine having the greatest safety margin, followed by bupivacaine, which is equal to or better than lidocaine. Esters are difficult to measure in blood because of their rapid hydrolysis by pseudocholinesterase. The liver metabolizes amides, with the clearance rate being a function of hepatic blood flow and the extraction capacity of the liver. Decreased hepatic blood flow, produced by norepinephrine, propranolol, or general anesthesia, slows clearance and potentially raises drug blood levels. Decreased drug extraction, associated with congestive heart failure, cirrhosis, or hypothermia, may produce a higher blood level. Hypovolemia, which decreases hepatic flow, does not raise blood levels because it causes an offsetting decrease in absorption. Decreased clearance of esters and an increased risk for toxicity occur in patients with either low levels or an atypical form of pseudocholinesterase. Low levels occur in various disease states, including severe liver disease and renal failure, and in pregnancy. Atypical pseudocholinesterase is an inherited trait, and its presence reduces the hydrolysis rate of procaine to a greater extent than low levels do. There are significant differences between pediatric and adult drug distribution and metabolism. Neonates exhibit both reduced levels of pseudocholinesterase and reduced hepatic metabolism, thus increasing the risk for toxicity. In older children, the effects of increased hepatic metabolism and a relatively larger volume of distribution increase their tolerance for higher doses. Because lidocaine is metabolized in the liver by cytochrome P-450 enzymes, drugs that inhibit these enzymes may slow lidocaine clearance and increase the risk for lidocaine toxicity. Although the effect of ciprofloxacin and erythromycin on infiltrated lidocaine has not been studied, these drugs decrease the metabolism of lidocaine and increase the concentration of its major metabolites when lidocaine is injected intravenously. The maximum safe dose of a drug may be defined as the dose that produces a blood level of the drug just below the toxic level (Table 29. One maximum dose of an anesthetic agent appropriate for all patients and all conditions cannot be stated. In an adult, peak blood levels do not correlate well with weight because the volume of drug distribution is relatively constant. Bupivacaine is not recommended for children younger than 12 years, although it is commonly used without adverse consequences. Furthermore, the dose should be modified according to the site and mode of administration. Maximum safe doses as stated on package inserts should be used only as guidelines because most of them are derived from animal experiments and are based on absorption data only. Levels vary with the site of administration, use of a vasoconstrictor, and to some extent, the health of the patient. To ascertain the strength of a solution in milligrams per milliliter, consider the following: A 1% solution is prepared by dissolving 1 g of drug in 100 mL of solution. Note: To calculate the strength from the percentage quickly, simply move the decimal point one place to the right, as follows: 0. For example: 1: 100,000 concentration of epinephrine = 1 g/100,000 mL = 1000 mg/100,000 mL = 1 mg /100 mL or 0. Drugs may be toxic even within the "safe range" when inadvertently injected intravenously. Inadvertent Intravascular Injection Most toxic reactions are caused by inadvertent intravascular injection of anesthetics whose doses were calculated for their intended extravascular sites. For example, lidocaine, 300 mg, is a safely infiltrated dose that would probably cause toxicity if directly injected into the bloodstream. Anesthetics that are injected intravascularly must pass through the lungs before they reach other organs. Intraarterial injections into subcutaneous end-arteries about the head or neck are capable of retrograde flow into the cerebral circulation if the injection pressure exceeds arterial pressure. Because the blood volume in the brain is only approximately 30 mL at any given moment, even 1 mg of lidocaine injected into the carotid artery can theoretically produce toxic concentrations. Drowsiness, commonly seen with lower doses of lidocaine, is not associated with bupivacaine or etidocaine. These agents also slow electrical conduction and lead to reentry phenomena and various supraventricular and potentially lethal ventricular dysrhythmias, especially with bupivacaine and etidocaine. Prevention of Toxicity Knowledge of factors contributing to toxicity guides preventive measures. Avoid esters in patients with an atypical form or a quantitative deficiency of pseudocholinesterase. Pay attention to maximum safe dosages based on the site, technique, use of epinephrine, and patient status. Add epinephrine when possible to decrease the rate of drug absorption at vascular sites. Reduce the drug concentration by saline dilution to increase the volume for administration when a large area must be infiltrated. Treatment of Systemic Toxicity Local anesthetics should not be administered without the ability to recognize and treat a toxic reaction, including having all necessary equipment and drugs readily available and being knowledgeable in their use. Despite taking all possible precautions, toxic reactions still occur, and close observation of the patient allows early detection and treatment. Providing proper oxygenation and ventilation at the earliest sign of a reaction is the cornerstone of treatment. Intubation with high-flow oxygen and hyperventilation is performed for patients who cannot adequately ventilate. Seizures are generally self-limited but are treated if they persist or prevent adequate ventilation. Because respiratory depression secondary to toxicity may follow, low-dose lorazepam or an ultrashort-acting barbiturate (thiopental or sodium methohexital) is preferred. Intubate the patient to ensure an effective airway and prevent further lactic acidosis if the seizures persist. If toxicity is caused by an ester, especially if there is an associated pseudocholinesterase problem, succinylcholine will compete with the anesthetic for the pseudocholinesterase and may increase the toxicity of both compounds. It is now known that hypoxia may enhance anesthetic toxicity but is not the primary factor. Although studies of metabolic alkalosis have produced conflicting results, acidosis, particularly respiratory acidosis, can increase toxicity. The lower pH causes more of the drug to ionize, thereby furthering the block in the sodium channel and increasing the potential for toxicity. Acid-Base Status Protein Binding the concentration of unbound drug relates more closely to toxic effects than does the total drug concentration (bound plus unbound) as measured in the blood. Barbiturates were found to worsen anesthetic-induced apnea and cardiovascular depression. If two drugs are used at half strength, they produce the same degree of toxicity as though each were used alone at normal strength. As discussed previously, drugs that slow metabolism by inhibiting hepatic enzymes may increase the risk for toxicity. Although lidocaine (with diazepam pretreatment) has been shown to be effective for bupivacaineinduced ventricular dysrhythmias, strong theoretical and experimental evidence indicates that bretylium is more effective. High doses of atropine and epinephrine can be successful in correcting pulseless idioventricular rhythm. Intravenous Lipid Emulsion Animal studies, case reports/small series, and personal opinion have advocated the use of 20% lipid emulsion intravenously as a remarkable antidote to resuscitate bupivacaine- and mepivacaine-related cardiac arrest, a situation that is usually fatal (see lipidrescue. Picard135 considers lipid emulsion a "crucial antidote" that should be available when local anesthetics are used for peripheral nerve blocks. A large collaborative workgroup of leading toxicologists recommends Intralipid (Baxter) infusion during cardiac arrest associated with bupivacaine but strikes a neutral posture for cardiac arrest due to other local anesthetics. Lipid emulsion therapy in otherwise hopeless situations of cardiac arrest secondary to local anesthetic overdose is supported (Box 29. It appears prudent and intuitive to initiate this antidote before cardiac arrest when significant local anesthetic toxicity is identified. Allergic Reactions Allergenic Agents True allergic reactions are rare and account for only 1% to 2% of all adverse reactions, but they are important to recognize because of their serious potential. Patients may manifest an allergic response on first contact with a local anesthetic because of previous sensitization to these agents. Patients who are latex sensitive may have an allergic reaction incorrectly attributed to the local anesthetic. Cell-mediated delayed reactions manifesting as dermatitis are rare; it is immediate hypersensitivity that most concerns the emergency clinician. A spectrum of signs and symptoms may occur, from rhinitis and mild urticaria to bronchospasm, upper airway edema, or anaphylactic shock. The more frequent problem facing emergency clinicians is a patient who claims to have a past history of allergy to local anesthetics. Most patients assume that any adverse reaction to a local anesthetic procedure is an allergy. Because allergy is rarely the cause, a careful history and a review of previous records, if available, are crucial in evaluating these patients. Procaine is no longer used in dental practice, but it is the local anesthetic in intramuscular penicillin preparations (procaine penicillin g). Attempts to uncover the actual cause of the past reaction and the specific agent involved are often fruitless. Ask about the exact signs and symptoms, technique of administration, amount of drug used, and how the patient was treated. If an allergic reaction cannot be ruled out and the drug previously used is known, use an agent from the other class (whether amide or ester). If the wounds are extensive and the risk is acceptable, procedural sedation (see Chapter 33) or general anesthesia may be used. These methods may be useful, but the degree of anesthesia produced is frequently not sufficient. Antihistamines injected into a wound have been used successfully for many years and represent a good alternative. From Brent J: Poisoned patients are different-sometimes fat is a good thing, Crit Care Med 37:1157, 2009; and lipidrescue. Ketamine anesthesia may be a useful alternative in some situations and is commonly used in children. Dilute the standard 5% parenteral form to a 1% concentration for subcutaneous injection (1 mL of drug to 4 mL of saline). The duration of action of diphenhydramine is shorter than that of lidocaine but appears to be adequate for most procedures. The injection pain of diphenhydramine exceeds that of lidocaine but can be diminished by reducing the concentration to 0. At this lower concentration, the effectiveness of this agent on facial wounds is lost. This appears to be a useful alternative to diphenhydramine when lidocaine cannot be used but is of shorter duration than diphenhydramine.

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