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Volume 23 • Number 8
In This Issue
Lesson 15
Lesson 16
Tricks of the Trade for Lacerations . . . . . . . . . . . . . . . . . . . . . . . . Page 2
The Critical Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 9
The LLSA Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 10
The Drug Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 11
Feeding Tube Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 12
CME Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 18
The Critical ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 20
Contributors
2009
April
Erica Chiu Liang, MD, and Michelle Lin, MD, wrote “Tricks of the Trade for Lacerations.”
Dr. Liang is a senior emergency medicine resident at Stanford-Kaiser Emergency Medicine Residency
Program in Stanford, California. Dr. Lin is the associate program director at the UCSF-SFGH Emergency
Medicine Residency Program and an associate clinical professor of emergency medicine at the University of
California, San Francisco, San Francisco General Hospital.
Michael S. Beeson, MD, MBA, FACEP, reviewed “Tricks of the Trade for Lacerations.” Dr. Beeson is
program director for the Department of Emergency Medicine at Summa Health System in Akron, Ohio, and
professor of emergency medicine at Northeastern Ohio Universities College of Medicine, Rootstown, Ohio.
Nara Shin, MD, and Serge Hougeir, MD, MPH, wrote “Feeding Tube Complications.” Dr. Shin
is an assistant residency director and instructor at Thomas Jefferson University Hospital, Department of
Emergency Medicine, Philadelphia, Pennsylvania. Dr. Hougeir is an emergency medicine resident at Thomas
Jefferson University Hospital, Department of Emergency Medicine in Philadelphia.
Robert A. Rosen, MD, FACEP, reviewed “Feeding Tube Complications.” Dr. Rosen is medical director
of the emergency department at Culpeper Regional Hospital in Culpeper, Virginia.
Frank LoVecchio, DO, MPH, FACEP, reviewed the questions for these lessons. Dr. LoVecchio is
research director at the Maricopa Medical Center Emergency Medicine Program and medical director of the
Banner Poison Control Center, Phoenix, Arizona, and a professor at Midwestern University/Arizona College
of Osteopathic Medicine in Glendale, Arizona.
Louis G. Graff IV, MD, FACEP, is Editor-in-Chief of Critical Decisions. Dr. Graff is professor of
traumatology and emergency medicine at the University of Connecticut School of Medicine in Farmington,
Connecticut.
Contributor Disclosures
In accordance with ACCME Standards and ACEP policy, contributors to Critical Decisions in Emergency Medicine must
disclose the existence of significant financial interests in or relationships with manufacturers of commercial products that
might have a direct interest in the subject matter. Authors and editors of these Critical Decisions lessons reported no such
interests or relationships.
Method of Participation
This educational activity consists of two lessons with a posttest and should take approximately 5 hours to complete.
To complete this educational activity as designed, the participant should, in order, review the learning objectives, read the
lessons, and complete the online posttest. Participants may complete the posttest for this issue at any time up to 3 years
from the date of publication. No credit will be given after that date.
Accreditation Statement
The American College of Emergency Physicians (ACEP) is accredited by the Accreditation Council for Continuing
Medical Education (ACCME) to provide continuing medical education for physicians. ACEP designates this educational
activity for a maximum of 5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with
the extent of their participation in the activity. Approved by ACEP for 5 Category I credits. Approved by the American
Osteopathic Association for 5 hours of AOA Category 2-B credit (requires passing grade of 70% or better).
Target Audience
This educational activity has been developed for emergency physicians.
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Critical Decisions in Emergency Medicine
Tricks of the Trade for
Lacerations
Lesson 15
Erica Chiu Liang, MD, and Michelle Lin, MD
n Objectives
On completion of this lesson, you
should be able to:
1. Discuss several ways to achieve
hemostasis in lacerations.
2. Describe how tissue adhesives can
be used in the closure of simple
lacerations as an alternative to
suturing.
3. Explain several methods for repairing
scalp lacerations.
4. Describe ways to minimize
complications when using tissue
adhesives.
5. Describe an alternative method for
applying tubular gauze bandaging
for finger wounds.
n From the EM Model
Appendix 1. Procedures and skills
integral to the practice of
emergency medicine
Other techniques (Wound closure
techniques)
Laceration repair accounts for
just over 6 million emergency
department visits per year.1 This
figure does not include visits for
wounds such as abrasions, superficial
wounds, ulcers, and burns that
require only supportive care. A
“laceration” refers to a torn or jagged
wound, typically caused by trauma.
Principles important to wound
care in the emergency department
include restoring tissue integrity and
functionality, reducing infection risk,
and reestablishing cosmesis. Wound
care also has significant medicolegal
importance to emergency physicians,
because missed tendon or nerve
injury, retained foreign bodies, and
wound infection are common causes
of malpractice claims.2
Wound care in the emergency
department includes anesthesia,
irrigation, wound exploration,
closure, and after-care instructions.
Most trunk and extremity wounds
should be closed within 6 to 12 hours
of injury. Facial and scalp wounds
are best closed within 24 hours of
injury; because of the increased
vascularity of the scalp and overall
lower infection risk, a longer delay in
closure is allowed. Clean wounds left
open longer than these time frames,
contaminated wounds, and bite
wounds should be allowed to heal
by secondary intention or delayed
primary closure. Regardless of wound
closure method, patients should
always be warned of the possibility
of scarring and infection. Generally,
sutures placed in the face should be
removed in 3 to 5 days, scalp sutures
in 7 days, finger and hand sutures in
7 to 10 days, and sutures on lower
extremities, the trunk, and in high
tension areas in 10 to 14 days.
The choice of wound repair
technique should be influenced
by the shape and location of the
wound, age of the patient, and
adequacy of access to followup care.
In addition to standard sutures,
alternative approaches to laceration
repair include tissue adhesives, skin
staples, and tape closure. These
methods can be used alone or in
concert to maximize wound healing
and minimize complications such
as wound infection, dehiscence, and
scarring. Each method has its own
tricks of the trade for optimal use.
Case Presentations
n Case One
A 3-year-old girl ran into the
edge of a metal table in her home
and is brought to the emergency
department by her parents. According
to the parents, the event happened
approximately 1 hour prior to their
arrival at the hospital. The girl did
not sustain any loss of consciousness
but has been crying since the event.
The mother tried to clean the wound
with water but was unable to because
of the child’s screaming and crying.
The patient is currently sitting in her
father’s lap quietly, with a piece of
gauze over her wound, which is 3 cm
above her right eye. Vital signs are
stable. You remove the gauze, which
reveals a 2-cm linear laceration that
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Critical Decisions
• Which lacerations may be repaired using tissue
adhesive?
• Should tissue adhesives be used in repairing lacerations
with wound edge tension?
• What techniques can reduce the risk of inadvertently
applying tissue adhesive in unintended areas?
• How can emergency physicians reduce the risk of
missing a scalp laceration hidden within the hair?
is approximately 1 mm deep just
superior to her right eyebrow; there is
some oozing but no active bleeding.
n Case Two
A 30-year-old man is brought
to the emergency department by
ambulance after having a seizure
while in bed at a local shelter for
the homeless. The patient has a
known seizure disorder and is
known to be noncompliant with his
medications. On examination, he has
a normal sensorium and neurologic
examination. He admits to not
taking his seizure medications. He
has disheveled shoulder-length hair,
which now is coated with thick dry
blood mostly along his occiput. There
is no obvious active bleeding.
n Case Three
A 50-year-old woman presents
to the emergency department after
Table 1.
Contraindications to wound
closure with tissue adhesives
Deep lacerations
Poor hemostasis of wound
Uneven wound edges (jagged or
stellate-shaped lacerations)
Wound edges under tension
(hands, feet, or joints)
Wound involving mucosal
surface
Wound location in hair-bearing
areas
Wound location in highmoisture area (axilla or groin)
Wound longer than 6 cm
• Are there alternative techniques to conventional
stapling in the closure of scalp lacerations?
• How can hemostasis be achieved in bleeding finger and
toe lacerations in addition to applying direct pressure
over the wound?
• How can tubular gauze netting be applied to a finger
wound if the applicator is missing or unusable?
cutting her left index finger while
slicing a bagel approximately 2 hours
ago. She wrapped a piece of cloth
around the wound before arriving
for care. Results of a neurovascular
evaluation of the fingertip, performed
without unwrapping the bandage, are
within normal limits. There appears
to be no active bleeding through the
bandage.
CRITICAL DECISION
Which lacerations may be repaired
using tissue adhesive?
Closure of traumatic lacerations
in the emergency department
has traditionally been done using
conventional suturing techniques.
With the advent of tissue adhesives,
these products are increasingly
replacing suturing for closure of
simple, uncomplicated lacerations.
Multiple studies have shown that both
approaches have similar excellent
long-term cosmetic outcomes and low
wound infection rates.3 Additionally,
the use of tissue adhesive has several
advantages over suturing. Tissue
adhesive use is painless (avoids the
use of needles for local anesthesia and
suturing), faster and easier,4 and does
not require a followup appointment
for suture removal. Furthermore,
tissue adhesive repair of traumatic
wounds has been shown to be
more cost-effective for patients than
suturing.5
The US Food and Drug
Administration approved the tissue
adhesives 2-octylcyanoacrylate in
1998 and N-butyl-2-cyanoacrylate
in 2002 for use in wound repair.
Although relatively new in this
country, cyanoacrylate adhesives
have been used outside of the United
States since 1949 for such various
procedures as cartilage and bone
grafting, otolaryngologic ossicle
repair, corneal ulcer treatment, and
endoscopic sclerotherapy of gastric
variceal bleeding.
Cyanoacrylate tissue adhesives are
packaged in liquid monomer form,
which polymerizes into long chains
on contact with moisture, specifically
hydroxide anions. This bridge forms
a solid film within 1 to 2 minutes
that binds apposing wound edges
together, allowing for healing and
epithelialization of the wound. When
dry, tissue adhesives have a tensile
burst strength equivalent to 5-0
nonabsorbable sutures; the adhesive
will peel off after 7 to 10 days.
Tissue adhesives are sterilely
packaged as single-use plastic vials,
each containing a 0.5-mL inner glass
ampule with a cotton-applicator tip.
When the inner glass is crushed
between the practitioner’s fingers, the
tissue adhesive liquid can be squeezed
through the cotton tip and should be
applied over the wound. To achieve
optimal wound closure and cosmesis,
the wound should be dry, bleeding
stopped, and the edges well apposed
before applying the tissue adhesive.
Contraindications to the use of
tissue adhesive are listed in Table
1. Suturing is indicated in these
scenarios. Although the marketing
insert for one of these products
mentions that wounds of 8 to 10 cm
may be closed with one vial (0.5 mL)
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Critical Decisions in Emergency Medicine
of the tissue adhesive, the authors
find that it is difficult to maintain
optimal wound edge apposition
during tissue adhesive application in
wounds longer than 6 cm.
Thus, wounds best suited to
closure with tissue adhesive are
linear, low-tension wounds located
away from moist surfaces of the
body. Thin skin flaps, especially, are
well-suited to tissue adhesive closure
because the skin may be too fragile
for sutures. Irregular and hightension wounds are at risk for wound
dehiscence.
CRITICAL DECISION
Should tissue adhesives be used in
repairing lacerations with wound
edge tension?
Lacerations whose edges are under
high tension when apposed should
not be repaired with tissue adhesives
because of the risk of wound
dehiscence. For wounds under mild
tension, however, tissue adhesives
may still be used if adjunctive
measures are taken to reduce wound
tension.
One adjunctive measure involves
the use of adhesive strips of tape.
For wounds under slight tension,
these strips should be applied
perpendicularly to the wound to
approximate the wound edges and
relieve some of the wound tension.
The tissue adhesive may then be
applied over the wound and tape. This
two-layered approach improves the
tensile strength of the wound repair,
compared to either method alone.
Furthermore, Chigira and Akimoto
advocate for a three-layered approach,
demonstrating that adding a pretreatment layer of tissue adhesive
before the tape and a second, posttape tissue adhesive layer adds even
more tensile strength to the repair6
(Figure 1).
A second option involves the
use of absorbable sutures under
the surface of the skin with tissue
adhesives. These sutures serve to
minimize wound tension so that
tissue adhesives can subsequently
easily maintain adequate wound
edge apposition. Similar to using
adhesive tape, strong fascial, dermal,
or subcuticular sutures can be placed
to minimize wound tension before
applying the tissue adhesive on
the skin surface. This two-layered
approach is more invasive than the
tape method, but provides more
tensile strength.
The third option involves
the use of absorbable sutures
on the surface of the skin with
tissue adhesives, specifically for
pediatric facial lacerations under
Figure 1.
The three-layered approach to closing a wound using
a tissue adhesive and adhesive tape. The first layer is
a pre-treatment layer of tissue adhesive, outlined by
the circle. The second layer comprises strips of tape.
The third layer is a wide area application of the tissue
adhesive on top of both the initial tissue adhesive layer
and the tape. Photo courtesy of Michelle Lin, MD.
mild wound tension. Luck et al
demonstrated equivalent cosmetic
outcomes, parental satisfaction, and
complication rates for pediatric facial
lacerations repaired with nylon versus
rapidly absorbing catgut sutures.
Patients with the absorbable sutures
were spared from having to return
for suture removal.7 It would seem
logical, then, that pediatric facial
lacerations under slight wound
tension might be repaired by a
combination of absorbable sutures
and tissue adhesives, although this
has not been studied. A few simple
interrupted absorbable sutures can
first be placed to decrease wound
tension and then the tissue adhesive
can be applied over both the wound
and sutures (Figure 2).
CRITICAL DECISION
What techniques can reduce the
risk of inadvertently applying tissue
adhesive in unintended areas?
A unique complication of tissue
adhesive use is the inadvertent
spillage or runoff of the liquid
adhesive to unintended areas such
as the eyelashes, which could result
in the upper and lower eyelids being
glued together. The decision to apply
tissue adhesives to wounds near
the eye should be made cautiously.
Figure 2.
The combined use of rapidly absorbable sutures and
tissue adhesive for wounds under slight tension. The
left photo shows a chin laceration under slight wound
tension. The right photo shows wound closure with two
absorbable sutures (arrows) with an overlying layer of
tissue adhesive. Photo courtesy of Jonathan Davis, MD.
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There have been anecdotal and
case reports of inadvertent tissue
runoff into unintended areas during
tissue adhesive application.8 Three
techniques are available to minimize
this complication.
The first technique relies on
gravity. Because the liquid tissue
adhesive will flow towards dependent
areas, position the laceration such
that it lies in a horizontal plane. This
prevents the tissue adhesive from
spilling into areas towards which the
laceration is tilted. For lacerations
near the eye, however, a slight tilt
away from the eye is desirable. This
can be achieved by reclining the
patient in a Trendelenburg position
for supraorbital lacerations and in
reverse Trendelenburg position for
infraorbital lacerations. Similarly
for lateral or medial lacerations, the
patient should be positioned such that
the tissue adhesive will flow away
from the eye.
The second technique takes
advantage of the fact that liquid tissue
adhesive will not penetrate petroleum
jelly and topical antibiotic ointments.
To prevent inadvertent application of
the tissue adhesive to undesired areas,
petroleum jelly or a topical antibiotic
ointment can be applied directly to
nearby high-risk areas. For lacerations
near the eye, for example, instruct
the patient to close the eye, and coat
the patient’s eyelids and eyelashes
with the jelly or ointment. Although
petroleum jelly and antibiotic
ointments serve as an effective barrier
for tissue adhesives, these products
can interfere with optimal tissue
adhesive polymerization and wound
closure if they accidentally contact
the wound closure area. Furthermore,
these topical preparations are slippery
and can prevent the practitioner
from maintaining good wound edge
approximation during closure.
A third technique eliminates
the need for any topical jelly or
ointments. This technique takes
advantage of the impermeability of
thin, transparent film dressings.
Start by cutting a circle out of the
transparent film dressing; the circle
should be the size of the anticipated
area of tissue adhesive application.
Discard the circle, and working with
the remaining film sheet, peel off
Figure 3.
The tape barrier technique to prevent inadvertent
application of tissue adhesive in undesired areas. The
transparent tape was darkened artificially for teaching
purposes. Photo courtesy of Hagop M. Afarian, MD
the adhesive backing and tape the
transparent film onto the skin, so that
the laceration is exposed and centered
in the hole. Only the portion of the
transparent film along the rim of the
hole needs to be securely affixed to
the skin to prevent inadvertent tissue
adhesive leakage between the film
and the skin. The tissue adhesive
should then be applied over the
laceration. Any runoff liquid will
spill harmlessly onto the transparent
film. Before the tissue adhesive liquid
completely polymerizes, gently peel
off the transparent film. This will
reveal a well-demarcated circular area
of tissue adhesive cleanly centered
over the laceration. This technique
can be used for tissue adhesive
repairs in any area but is especially
effective for lacerations near the eye
(Figure 3). This barrier technique was
contributed by Dr. Hagop Afarian
from the UCSF-Fresno Emergency
Medicine Residency Program.
Figure 4.
The hair apposition technique for scalp laceration repair.
Apposing hair bundles on either side of the laceration
should be twisted 360°. Secure the twisting point with
tissue adhesive. Repeat this process along the entire
laceration. Photo courtesy of Michelle Lin, MD
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Critical Decisions in Emergency Medicine
CRITICAL DECISION
How can emergency physicians
reduce the risk of missing a scalp
laceration hidden within the hair?
Because the scalp contains a
rich vascular supply throughout
the connective tissue layer, scalp
lacerations often bleed profusely and
stop after the application of direct
pressure. The remaining clotted
blood, matted within the hair, can
hinder a proper, careful examination
of the scalp.
Examination should first begin
by directly visualizing the scalp
under brightly lit conditions. It can
be helpful to have an assistant direct
the light source while the practitioner
uses both hands to search for scalp
injuries obscured by the hair. Shaving
the hair damages the hair follicles and
places the wound at increased risk for
infection.
Next, the scalp should be
examined by direct manual palpation.
Using a methodical approach, the
practitioner should run his or her
fingers along the entire scalp to
identify any irregularities in the
scalp surface such as lacerations
or hematomas. This approach is
especially helpful in examining the
posterior scalp in supine patients
who are unable to cooperate with the
examination (eg, intoxicated patients).
Care must be taken to search the
entire scalp for multiple injuries.
There is a natural bias for premature
closure, ie, the premature termination
of the search for all the findings after
detecting one finding. Emergency
physicians should maintain a high
Table 2.
Contraindications to scalp
laceration repair with the hair
apposition technique
degree of suspicion for multiple scalp
injuries.
CRITICAL DECISION
Are there alternative techniques to
conventional stapling in the closure
of scalp lacerations?
Lacerations of hair-bearing
areas of the scalp traditionally are
closed with staples, which produces
excellent cosmetic results compared
to suturing in both the pediatric
and adult populations.9 It is often
extremely difficult, however, to keep
a frightened child still for multiple,
sequential staple placements. For
small scalp lacerations that require
only two staples, a “double staple
gun” technique can be employed.
This requires two practitioners, each
with a staple gun. After appropriately
irrigating the wound and parting the
hair strands away from the laceration
edges, practitioners should position
their staple guns adjacent to each
other along the scalp laceration,
and both staples should be placed
simultaneously. This technique
eliminates the need to re-immobilize
the now even more frightened child.
Another technique for scalp
laceration closure involves the
incorporation of hair strands and
avoids the use of staples or sutures.
The hair apposition technique (or
HAT trick), first described in 2002,
has been found to be an acceptable
alternative to suturing with equivalent
cosmesis, lower pain scores, fewer
complications, a shorter procedure
time, and no need for followup
removal of the sutures.10 Ong et al
also showed that this technique is
more cost-effective for the patient,
because it requires less medical staff
time and less equipment, has lower
complication rates, and eliminates the
need for a followup visit for suture
removal.11
To perform the hair apposition
technique, 4 or 5 hair strands from
each side of the laceration are bundled
and brought together with one full
360° twist (Figure 4). A few drops
of a tissue adhesive applied to the
twisting point should secure the two
hair bundles and prevent unraveling.
This should be repeated down the
entire length of the laceration until
the wound is completely closed.
Contraindications to using this
approach are listed in Table 2.
The hair apposition technique
should be considered in simple scalp
lacerations, especially for pediatric
patients, for whom suture or staple
removal can be difficult, and for
adults who might not be reliable for
followup with their suture or staple
removal appointment.
CRITICAL DECISION
How can hemostasis be achieved
in bleeding finger and toe lacerations
in addition to applying direct pressure
over the wound?
Control of bleeding is crucial
prior to wound closure to allow
the practitioner to search for occult
foreign bodies and visualize exposed
Figure 5.
The glove ring tourniquet technique for achieving hemostasis of digital wounds.
A: Apply a glove finger, and cut a small hole at the finger tip. B: Rolling the
glove finger towards the finger base results in a ring-like tourniquet (arrow).
Photo courtesy of Michelle Lin, MD
A
B
Active bleeding from laceration
Grossly contaminated wounds
Hair strands shorter than 3 cm
Scalp lacerations longer than
10 cm
Significant wound tension
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underlying structures. Often the
direct application of pressure over the
wound is sufficient to stop bleeding.
For persistent bleeding of finger
and toe wounds, hemostasis can be
achieved by extrinsic compression of
the radial and ulnar digital arteries
supplying blood flow to the affected
digit.
To compress these two arteries, a
digital tourniquet can be fashioned
using a disposable medical glove.
After cutting a small-sized glove
finger away from the rest of the glove,
puncture a very small hole at the tip
of the glove finger. Apply this glove
finger onto one of your own fingers,
and roll the glove proximally towards
the base of your finger. This results
in a glove “ring” tourniquet (Figure
5). Remove this glove ring and roll it
onto the base of the patient’s bleeding
digit to compress the digital arteries.
Alternatively, the entire glove or glove
finger with a hole in the tip can be
applied directly to the patient’s hand
or finger before rolling the glove
finger proximally into a ring-like
tourniquet.
For bleeding wounds of a more
proximal extremity, a manual blood
pressure cuff can be applied to the
arm or leg to temporarily compress
arterial flow just proximal to the
injury. The brachial artery serves as
the sole vascular supply to the arms.
The anterior tibial, posterior tibial,
and peroneal arteries serve as the
vascular supply to the calf and foot.
Using a manual sphygmomanometer,
insufflate the cuff approximately
20 to 50 mm Hg above the level of
the patient’s systolic blood pressure.
Adequate cuff pressure is crucial.
Insufflating to a pressure between the
systolic and diastolic blood pressure
will cause the bleeding to increase
because venous outflow is blocked
while arterial inflow persists.
To avoid excessive bleeding in
the emergency department, the
practitioner should assume that all
wounds, despite being wrapped in a
dry bandage, will bleed significantly
when unwrapped. Application of
a loose blood pressure cuff to the
extremity before removing the
bandage will allow the practitioner to
immediately control brisk bleeding
should it occur.
CRITICAL DECISION
How can tubular gauze netting be
applied to a finger wound if the
applicator is missing or unusable?
There are a variety of techniques
in managing finger wounds, ranging
from the use of topical antibiotics
alone to applying loosely-wrapped,
bulky, circumferential gauze wrap.
Especially for wounds that will
benefit from immobilization of the
digit, another option is to apply
layered elastic tubular netting using
Figure 6.
Use of a pelvic speculum to apply an elastic tubular netting on a finger. A: Load
the tubular netting onto the pelvic speculum and open the blades. B: Apply
three to five layers of netting by moving from proximal to distal finger and distal
to proximal finger, remembering to rotate the netting 360° at the patient’s
fingertip with each layer applied. Cut two tails longitudinally with the remaining
netting, and secure the bandage at the patient’s wrist. Photo courtesy of
Michelle Lin, MD.
A
B
a small, rigid finger applicator.
Often, however, the applicator is
missing or is too small to apply over
an underlying gauze wrap. As an
alternative in these cases, a small
or medium plastic pelvic speculum
can function as a finger applicator.
After loading a long strip of tubular
netting onto the speculum, open the
apposing blades. Wrap three to five
layers of the netting over the patient’s
finger, rotating the netting 360°
whenever the netting reaches the
fingertip to help secure the netting.
Cut the remaining 6 to 8 inches of
netting in half longitudinally, and use
these ends to tie a knot at the wrist to
prevent the netting from accidentally
sliding off of the finger (Figure 6).
This technique was suggested by
Tina King, a nurse practitioner in
the emergency department at San
Francisco General Hospital. A video
demonstration of this procedure can
be found at www.emresidency.ucsf.
edu; under the “Resources” menu,
select “Educational Material.” Elastic
band netting should be avoided in
patients with any sensory loss in that
digit. A neuropathy or sensory nerve
injury could lead to digital necrosis.12
Case Resolutions
n Case One
After building trust with the
3-year-old girl, the emergency
physician gently examined the
laceration more closely and detected
no foreign bodies in the wound. The
wound was gently irrigated with
sterile normal saline. A transparent
film dressing with a circular hole cut
out of it was applied securely around
the wound to protect the eyebrow,
eyelashes, and eye from contact with
the tissue adhesive. With the patient
lying supine on top of her father, who
was also lying supine in the gurney
and hugging the patient tightly, the
tissue adhesive was applied carefully
over the well-apposed laceration.
Immediately after the tissue adhesive
was applied, the physician gently
removed the transparent tape to
reveal a well-demarcated, dry,
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Critical Decisions in Emergency Medicine
circular-shaped tissue adhesive film
over the laceration.
n Case Two
The patient’s hair was irrigated to
remove as much of the dry, clotted
Pearls
• Consider the patient’s
compliance with followup
wound care when deciding
among different laceration
repair techniques.
• Use petroleum-based products,
patient positioning, or a tape
barrier method to help keep
liquid tissue adhesive from
spilling into an undesired
area such as the eye.
• Check for occult scalp injuries
using direct visualization in
addition to manual palpation
of the entire scalp.
Pitfalls
• Do not assume that all wounds
that are wrapped with a dry
bandage will remain hemostatic
when unwrapped; be prepared
to achieve hemostasis quickly to
minimize blood loss and reduce
the risk to providers from an
accidental blood exposure.
• Avoid applying creams, gels,
or ointments to wounds
closed with tissue adhesives,
as these products can cause
the adhesive to dissolve
prematurely; be sure to inform
the patients of this as well.
• Do not repair a laceration until
there is adequate hemostasis.
A dry field is necessary to
adequately examine the wound
for occult foreign bodies.
• Avoid applying a circumferential
tubular gauze netting bandage
on a finger with signs of
sensory neuropathy because
of the risk of digital necrosis.
blood as possible. Afterward, his
tangled hair still prevented adequate
visualization of the scalp. By directly
palpating the scalp with her fingers in
a methodical process, the physician
found a small hematoma along the
right parietal scalp and a shallow,
4-cm occipital laceration. Because
the patient was known to have poor
compliance with medical advice
and had once been found to have
3-month-old staples still in his scalp
from a prior scalp laceration, the
hair apposition technique was used
instead of stapling to close the scalp
laceration. On discharge, the patient
still refused to take any seizure
medications and was discharged back
to his shelter bed.
n Case Three
After carefully unwrapping the
bandage on the patient’s index finger,
the emergency physician found a
2-cm laceration over the volar surface
of the middle and distal phalanx. The
wound immediately began to ooze
venous blood. A tourniquet was made
by cutting one finger from a rubber
glove. Rolling this “glove ring” onto
the base of the patient’s index finger
stopped the bleeding and allowed the
physician to examine the laceration
more closely. After establishing
that flexor tendon function and
the neurovascular structures were
intact, the wound was closed with
nonabsorbable simple interrupted
sutures. Once suturing was
completed, a topical antibiotic and dry
gauze were applied, and the “glove
ring” was removed. Using a pelvic
speculum, tubular gauze netting was
applied to keep the wound clean,
covered, and immobilized. The
patient was instructed to remove the
bandaging after 12 to 24 hours and
provided with the usual after-care
instructions.
Summary
Wound care and laceration
repair are common reasons for
emergency department visits in
the United States. Cyanoacrylate
tissue adhesives provide a useful
alternative to traditional suturing
methods with comparable cosmesis
and rates of wound infection. Benefits
include needle-free wound repair,
speed of application, less post-care
maintenance, and the ability to
be used in conjunction with other
methods to achieve enhanced tensile
strength. Because of the liquid nature
of cyanoacrylates, patient positioning
and the use of barrier methods are
important for reducing complications
when these products are used around
the eye.
Scalp lacerations are challenging,
with hair potentially obscuring
wounds and lacerations. Emergency
physicians should perform a
meticulous search for these injuries
by direct visualization and manual
palpation before wound closure. In
addition to traditional stapling and
suturing techniques, alternative
approaches are available and should
be considered based on the patient’s
age, the patient’s tolerance for pain,
the laceration characteristics, and
the patient’s reliability for followup.
These include the “double staple gun”
technique and the hair apposition
technique.
Extremity lacerations can also
be difficult to manage. Maintaining
hemostasis and achieving a bloodless
field for laceration visualization
and repair are essential. For distal
extremity lacerations, application
of a ring tourniquet fashioned from
a disposable medical glove will
compress the digital arteries and
allow for further exploration of the
wound and wound repair. For more
proximal arm and leg lacerations,
a blood pressure cuff applied
proximally to the wound and inflated
to 20 to 50 mm Hg above the patient’s
systolic blood pressure can be used to
compress arterial flow for exploration
and repair of the wound.
Bandaging of finger wounds can
be accomplished with elastic tubular
netting in order to keep the wound
dry, clean, covered, and immobilized.
A traditional finger applicator or,
alternatively, a disposable pelvic
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April 2009 • Volume 23 • Number 8
speculum can be used to apply and
secure the tubular netting.
Regardless of laceration repair
method, fundamental principles of
wound care should always apply;
tetanus status should be updated
as needed, thorough after-care
instructions provided, and followup
arranged if possible.
References
1.
Middleton K, Hing E, Xu J. National Hospital
Ambulatory Medical Care Survey: 2005 emergency
department summary. Adv Data. 2007;(386):1-34. (A
national report of trends for emergency departments
in the United States.)
2.
Henry GL. Specific high-risk medical-legal issues.
In: Henry GL, Sullivan DJ, eds. Emergency Medicine
Risk Management. Dallas, TX: American College of
Emergency Physicians; 1997:475-494. (A book on
high-risk conditions and scenarios in emergency
medicine.)
3.
Beam JW. Tissue adhesives for simple traumatic
lacerations. J Athl Train. 2008;43:222-224. (A
metaanalysis comparing tissue adhesives to
conventional suturing for traumatic lacerations.)
4.
Singer AJ, Quinn JV, Clark RE, et al. Closure of
lacerations and incisions with octylcyanoacrylate:
a multicenter randomized controlled trial. Surgery.
2002;131:270-276. (A study comparing tissue
adhesives and suturing.)
5.
Man SY, Wong EM, Ng YC, et al. Cost-consequence
analysis comparing 2-octyl cyanoacrylate tissue
adhesive and suture for closure of simple lacerations:
a randomized controlled trial. Ann Emerg Med. 2008
Apr 25 [e-pub ahead of print]. (A study showing the
cost savings for patients but not for the hospital with
tissue adhesive repair compared to suturing.)
6.
Chigira M, Akimoto M. Use of a skin adhesive
(octyl-2-cyanoacrylate) and the optimum reinforcing
combination for suturing wounds. Scand J Plast
Reconstr Surg Hand Surg. 2005;39:334-338. (A study
of the tensile strength of tissues adhesives with and
without the adjunctive use of skin closure tape using
pig skin.)
7.
8.
9.
Luck RP, Flood R, Eyal D, et al. Cosmetic outcomes of
absorbable versus nonabsorbable sutures in pediatric
facial lacerations. Pediatr Emerg Care.
2008;24:137-142. (A comparison study showing the
equivalency between absorbable and nonabsorbable
sutures in pediatric facial lacerations.)
Rouvelas H, Saffra N, Rosen M. Inadvertent
tarsorrhaphy secondary to Dermabond. Pediatr Emerg
Care. 2000;16:346. (A case report describing the
inadvertent gluing of the upper and lower eyelashes
together.)
Khan AN, Dayan PS, Miller S, et al. Cosmetic outcome
of scalp wound closure with staples in the pediatric
emergency department: a prospective, randomized
trial. Pediatr Emerg Care. 2002;18:171-173. (A
comparison study between stapling and suturing of
pediatric lacerations.)
A 71-year-old man with recent diagnosis of aplastic anemia presenting
with fevers to 38.9°C (102°F), leg weakness, and extreme leg pain.
Initially, the patient was thought to have neuropathic pain and
weakness, possibly indicating spinal pathology such as epidural
abscess. He rapidly developed crepitus of his legs. X-rays of the
patient’s legs were obtained, followed by noncontrast CT.
Air in soft tissues
of muscle planes
Air
Soft tissue
windows
Lung windows
This case demonstrates several important points:
•
Air is seen dissecting in muscle planes of the legs . On x-ray, air appears
black . Given the wide distribution of air, a focal abscess is unlikely, and
necrotizing fasciitis with gas-producing organisms should be suspected .
•
If the diagnosis is highly suspected and x-rays are nondiagnostic,
noncontrast CT is very sensitive for air . Air appears black on all CT window
settings and is particularly evident on lung windows, which make all
other tissues very white in appearance . However, do not delay surgical
consultation, antibiotic therapy, and surgical débridement to obtain
diagnostic imaging, once the diagnosis is suspected.
10. Hock MO, Ooi SB, Saw SM, et al. A randomized
controlled trial comparing the hair apposition
technique with tissue glue to standard suturing
in scalp lacerations (HAT study). Ann Emerg Med.
2002;40:19-26. (Introduces the hair apposition
technique for scalp laceration closure and compares its
cosmesis and complication rate to suturing.)
This patient was taken to the operating room and disarticulation of the hips
was performed . He died of septic shock hours later . Blood cultures grew
Clostridium perfringens—the feared gas gangrene organism of trench warfare
in World War I .
11. Ong ME, Coyle D, Lim SH, et al. Cost-effectiveness of
hair apposition technique compared with standard
suturing in scalp lacerations. Ann Emerg Med.
2005;46:237-242. (Analysis demonstrating patient
savings with the hair apposition technique over
suturing in scalp lacerations.)
Feature Editor: Joshua S. Broder, MD, FACEP
Images courtesy of Emergency Medicine Picture Archiving & Communication
System (www .empacs .org) .
12. Norris RL, Gilbert GH. Digital necrosis necessitating
amputation after tube gauze dressing application in
the ED. Am J Emerg Med. 2006;24:618-621.
9
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Critical Decisions in Emergency Medicine
The LLSA Literature Review
Highlights of the 2009 Reading List
From May 2008 through January 2009, “The LLSA Literature Review” summarized articles from ABEM’s “2009 Lifelong Learning and
Self-Assessment Reading List.” Highlights from 12 of those summaries were presented in the February 2009 and March 2009 issues
of Critical Decisions, and highlights from the remaining four summaries are presented below. Critical Decisions will begin publishing
summaries from the 2010 reading list in the May issue.
Missed and Delayed Diagnoses in the
Emergency Department: A Study of Closed
Malpractice Claims From 4 Liability Insurers
Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed
diagnoses in the emergency department: a study of closed malpractice
claims from 4 liability insurers. Ann Emerg Med. 2007;49(2):196-205.
Highlights
• The causes of missed diagnoses are complex and multifactorial.
• Analyzing the causes of specific instances provides
targets for prevention.
• Factors shown to predispose to error are “hand-offs/
signout,” inadequate supervision, and excessive workload.
Reviewed by Heidi E. Harbison, MD, and J. Stephen Bohan, MS, MD,
FACEP; Harvard Affiliated Emergency Medicine Residency; Brigham
and Women’s Hospital
Replacing Hindsight with Insight: Toward
Better Understanding of Diagnostic Failure
Wears RL, Nemeth CP. Replacing hindsight with insight: toward better
understanding of diagnostic failures. Ann Emerg Med.
2007;49(2):206-209.
Emergency Physicians and Disclosure of
Medical Errors
Moskop JC, Gelderman JM, Hobgood CD, et al. Emergency physicians
and disclosure of medical errors. Ann Emerg Med.
2006:48(5):523-531.
Highlights
• Medical errors are common, and stakeholders are increasingly aware of them.
• Under the principle of truthfulness, physicians should
disclose errors to their patients.
• Ideal error disclosure is prompt, clearly stated, and includes a sincere apology and an acknowledgement that
the error will be addressed and investigated.
• Emergency physicians work in an environment that creates both opportunity for medical errors and challenges
in recognizing and addressing them.
• Barriers to error disclosure exist at many levels, including the health care and legal systems and physician and
patient characteristics.
Reviewed by Christopher W. Baugh, MD, MBA, and J. Stephen Bohan,
MD, MS, FACEP; Harvard Affiliated Emergency Medicine Residency;
Brigham and Women’s Hospital
Highlights
• Errors are names given to actions after the act.
• Hindsight bias allows the reviewer to overestimate what
others knew who lacked this posthoc knowledge.
• Outcome bias results from assessing the process based
on the desirability of the outcome.
• Evaluation of actions must minimize the effects of
hindsight and outcome biases. Such methods are used
in other industries.
Reviewed by J. Stephen Bohan, MS, MD, FACEP; Harvard Affiliated
Emergency Medicine Residency; Brigham and Women’s Hospital
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April 2009 • Volume 23 • Number 8
The Drug Box
The LLSA Literature Review (Continued)
Lidocaine
Refusal of Care: The Physician-Patient
Relationship and Decisionmaking Capacity
Although lidocaine is well known as an antiarrhythmic,
this article focuses on its use as a local anesthetic. It is
one of the most commonly used anesthetics for repair
of lacerations, sometimes combined with epinephrine
for vasoconstrictive effects. As with any local anesthetic,
lidocaine can result in significant central nervous system
(CNS) and cardiovascular toxicity. Adverse reactions to
lidocaine are extremely rare when it is administered
correctly; most are the result of systemic exposure. It is
important to aspirate before administration to avoid
intravascular injection.
Simon JR. Refusal of care: the physician-patient relationship and
decisionmaking capacity. Ann Emerg Med. 2007;50(4):456-461.
Highlights
• Although refusal of care often becomes a question of
capacity, patients and provider benefit from a more nuanced approach to understanding each other’s thinking.
• Focus on enhancing the physician-patient relationship
with clear communication in lay terms and establishing
trust through attention, empathy, and patience.
• In negotiation, explore all reasonable options and attempt to break the plan down into steps.
• Capacity comprises three attributes, as follows:
– The possession of a set of values and goals
– The ability to communicate and to understand information
– The ability to reason and deliberate about one’s
choice
• Capacity is best assessed by a three-step process of
giving the information to the patient, listening to the
patient’s understanding of that information, and evaluating the patient’s reasoning and decision making.
• If a patient lacks capacity, seek information from advance directives or a surrogate decision maker.
Lidocaine
Mechanism of Action
Indications
Dosing
Side Effects
Reviewed by Benjamin A. White, MD, and J. Stephen Bohan, MD, MS,
FACEP; Harvard Affiliated Emergency Medicine Residency; Brigham
and Women’s Hospital
Estimated Cost to
Hospital
Contraindications /
precautions
a
Reversible nerve conduction
blockade by decrease in nerve
membrane permeability to sodium.
Local anesthetic
Antiarrhythmic (not covered in this
article)
Maximum dose: 4.5 mg/kg or 300
mg/procedure
If given with epinephrine, up to 7
mg/kg
Transient burning at injection site;
toxic CNS effects—nervousness,
perioral paresthesias, tinnitus,
tremor, dizziness, blurred vision,
seizures; cardiovascular effects
(typically occur after CNS symptoms
begin)—hypotension, bradycardia,
arrhythmias, cardiac arrest
$0.30 to $0.50 per 20-mL bottle of
1% or 2% lidocainea
Amide hypersensitivity; sulfite
hypersensitivity; severely
traumatized skin; hypotension,
hypovolemia, cardiac disease
Liver dysfunction increases risk of
toxicity
Pregnancy Class B
Cost data provided by Summa Health Systems
Feature Editor: Michael S. Beeson, MD, FACEP
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Critical Decisions in Emergency Medicine
Feeding Tube Complications
Lesson 16
Nara Shin, MD, and Serge Hougeir, MD, MPH
n Objectives
On completion of this lesson, you
should be able to:
1. Describe the different types of
enteral feeding tubes and their
components.
2. Recognize and manage common
complications of enteral feeding
tubes.
3. Demonstrate the steps for bedside
replacement of gastrostomy tubes.
4. Describe techniques to verify correct
feeding tube placement.
6. Discuss appropriate disposition and
consultation services for patients
with more serious complications of
enteral feeding tubes.
n From the EM Model
Appendix 1. Procedures and skills
integral to the practice of
emergency medicine
Other techniques
Feeding tubes are an
externalization of the gastrointestinal
tract whereby liquid nutritional
supplements and medications can be
delivered to a patient. The benefits
of enteral nutrition through feeding
tubes are well described and broadly
accepted. Gastrostomy tube placement
is very safe, with success rates
reported to be between 95% and 98%
regardless of the technique used, and
the procedure-related mortality rate is
less than 1%.1 It is no wonder that the
number of gastrostomy tubes placed
in the United States and United
Kingdom has increased annually,
and the list of clinical indications is
lengthening.
The problem, however, is that
feeding tubes have notoriously high
rates of long-term complications.
Admittedly, the vast majority of these
complications are not life-threatening,
but because of the sheer quantity, they
are costly, deplete medical resources,
and often require multiple evaluations
by health care personnel.
Increasingly these patients
are being referred to emergency
departments for evaluation and
treatment. Ackermann et al found
in 1998 that 6.8% of all visits by
nursing home patients to emergency
departments were for feeding
tube–related complications, making
these complications the sixth most
common chief complaint in this
population.2 In another study, 33
patients with dementia and who
were on enteral feeding logged 138
separate emergency department
visits specifically for feeding tube
complications over the study period of
20 months. One patient had a record
21 visits.3
As first-line caretakers of these
patients, it is crucial that emergency
physicians be familiar with the
different types of enteral feeding
tubes, the myriad complications
associated with them, and their
respective treatments.
Case Presentations
n Case One
A 78-year-old man with a history
of multiple strokes and dementia is
brought to the emergency department
by ambulance from a nursing home
because of abdominal pain. The
patient underwent a percutaneous
endoscopic gastrostomy (PEG) tube
placement for his dysphagia 5 days
earlier. He has been agitated, and
he pulled his PEG tube out the day
before presentation; a nurse at that
time inserted a Foley catheter into the
stoma and resumed enteral feeding.
The patient developed abdominal pain
over the course of the day and was
brought to the emergency department
for evaluation.
Physical examination reveals a
well-nourished and well-developed
man in mild distress, with
generalized abdominal pain. Vital
signs are normal and stable except for
tachycardia. Abdominal examination
reveals an unsecured Foley catheter
inserted in the upper abdominal area.
The abdomen is mildly distended,
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April 2009 • Volume 23 • Number 8
Critical Decisions
• Should a dislodged or accidentally removed feeding
tube be replaced in the emergency department?
• What is the proper way to replace a gastrostomy tube?
• How can correct placement of a feeding tube be
verified?
• How should a feeding tube be secured?
• What methods may be used to unclog a feeding tube?
• What complications involve the tube site?
has decreased bowel sounds, and is
diffusely tender to palpation.
Indications for Enteral
Nutrition
n Case Two
A 32-year-old man who is
quadriplegic from a gun shot wound
to the spine 6 years ago is brought
to the emergency department via
ambulance because his caretaker
has been unable to infuse enteral
feeds through the patient’s PEG tube.
The patient’s caretaker has tried,
without success, to flush the tube
with a 60 mL-syringe filled with
water. The examination reveals a
well-nourished man in no distress.
Vital signs are normal and stable. The
physical examination reveals a PEG
tube inserted in the midabdomen.
The abdominal examination is
unremarkable; bowel sounds are
normal, and no tenderness to
palpation, no rigidity, no distention,
and no masses are appreciated.
The use of enteral nutrition for
patients who have a functioning
gastrointestinal tract but are unable
to safely take nutrition by mouth for
a period of time is a widely accepted
means of preventing malnutrition.
More specifically, poor nutritional
status or significant weight loss, oral
intake less than 50% of energy needs,
the presence of catabolic disease
processes such as infections and
burns, and an inability to ingest foods
for longer than 7 days have been cited
as indications to begin supplemental
enteral feeding.4
Enteral nutrition is common
among patients with obstructing
malignancies, swallowing disorders,
head and spinal cord injury, and
stroke. For patients with severe
dementia and patients in a persistent
vegetative state, the ethical concerns
of enteral nutrition are considered
alongside the medical benefits.
Feeding tubes have been placed
in children with congenital heart
disease, cystic fibrosis, chronic
pulmonary disease, gastroesophageal
reflux disease, and failure to thrive.5
n Case Three
A 68-year-old woman with
squamous cell carcinoma of the
throat is brought in by her husband
because there has been increasing
leakage around her PEG stoma over
the past week. Her PEG tube was
inserted 8 months ago and has been
functioning normally. The patient’s
vital signs are stable, and she appears
comfortable. Her examination reveals
a PEG tube in the midabdomen,
with serosanguineous fluid and
granulation tissue around the PEG
stoma. No pus is expressed from
the site. The rest of the abdominal
examination reveals a soft, nontender,
nondistended abdomen, with active
bowel sounds.
Types of Feeding Tubes
Enteral feeding tubes come in
myriad shapes, sizes, lengths, and
materials. Nasogastric and orogastric
tubes are typically not used for longterm feeding and consequently are
rarely seen in the outpatient setting.
They are placed through a nare or the
mouth and end in the stomach. There
is no external bolster or internal
balloon, so they are externally affixed
with tape.
Gastrostomy tubes are placed
directly through the abdominal
wall into the stomach. They can be
placed a number of ways by different
specialists. PEG tubes have become
the most common type of enteral
feeding tube since their introduction
in 1980.6 It is estimated that 240,000
PEG procedures were performed in
2003, and the number of PEG tubes
has increased yearly.7 PEG tubes are
generally placed by gastroenterology
specialists using an endoscope to
guide placement of the tube through
the wall of the stomach. Tubes are
constructed with medical grade
silicone or polyurethane and come
in a variety of lengths and outer tube
diameters, measured in French units.
The four essential components of a
tube are the tube itself, an internal
retention bolster such as a balloon
or pigtail, an external bolster, and
at the distal external end, the ports.
One or multiple ports are designated
for infusion, and another port may
be present to inflate and deflate the
internal retention balloon. Tubes are
typically labeled with the commercial
brand name, caliber of the tube,
graduated centimeter markings, and a
radiopaque line along the length.
Gastrostomy tubes can also be
placed by interventional radiologists
using fluoroscopy or computed
tomography (CT) guidance. These
radiologically inserted gastrostomy
tubes are placed when the stomach is
punctured externally and the feeding
tube catheter is inserted using the
Seldinger technique. Alternatively,
a general surgeon may place a
gastrostomy tube using an open
surgical technique or laparoscopy.
Sometimes, the stomach must
be bypassed and the enteral feeds
delivered directly to the small
intestines. Jejunostomy tubes or
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Critical Decisions in Emergency Medicine
gastrostomy-jejunostomy tubes (G-J
tubes) are used in these cases. G-J
tubes have dual ports to access the
jejunum for feeding and the stomach
for either decompression or delivery
of medications. Jejunostomy and
G-J tubes can be placed by all three
previously described methods.
Complications
Most feeding tube complications
encountered in the emergency
department develop over time. The
frequency of certain complications
varies significantly depending on
the patient population studied
and the type and size of feeding
tube used. Patients with dementia
have the highest rates of accidental
extubation, followed by pediatric
patients.2,3,5 Jejunostomy tubes, which
are typically longer and of smaller
caliber, have more problems with
clogging. Ultimately, studies agree
that complications of all types of
feeding tubes are numerous and often
continual and repetitive.
In a 2007 prospective outpatient
study in which eight patients with
gastrostomy tubes were asked to
keep a daily journal over a 10-month
period, the most frequently reported
complications were related to the
tube site and included discharge
from the site, a tender stoma, and
problems arising from the growth
of granulation tissue.8 The most
common complications necessitating
intervention by medical personnel
were related to mechanical
dysfunction of the tube such as
clogging and accidental removal. On
average, there was one unscheduled
evaluation per patient for tube-related
complications every other month.
Odom et al, in 2003, performed a
retrospective chart review to evaluate
the resource utilization of patients
with dementia who present to the
emergency department for feeding
tube problems.3 Ninety-one percent
of these emergency department visits
were for unintentional extubation;
94% of the tubes were replaced
at the bedside, and the remainder
were replaced endoscopically by
consultants. Another 6% had
clogged feeding tubes, and all
were successfully unclogged in the
emergency department. The authors
extrapolate that three additional
emergency department visits for
future tube complications would
result from each newly placed feeding
tube in a patient with dementia.
replacing a jejunostomy tube are the
same as for gastrostomy tubes except
that longer tubes (typically 20 cm)
are used. These tubes do not have an
internal retention device, so securing
the tube externally is imperative, as is
verifying proper tube location.
CRITICAL DECISION
Should a dislodged or accidentally
removed feeding tube be replaced
in the emergency department?
The physician should first ensure
that the feeding tube is a gastrostomy
tube and not another type of feeding
tube. The skin around the stoma
should be cleaned and sterilized
thoroughly. Anesthesia should not
be necessary, as the gastrostomy site
should not be tender; however, if the
patient’s stoma is painful, a topical
anesthetic such as lidocaine jelly may
be helpful. The replacement tube
should be the same size and type as
the original. If the size of the original
tube is unknown, a 16 F replacement
gastrostomy tube is appropriate. The
replacement tube should be liberally
coated with a water-soluble lubricant
and then advanced gently through
the tract with steady pressure. If
there is significant resistance through
the stoma, a smaller tube should be
tried.11 The tube should not be forced;
forcing the gastrostomy tube into
the tract can disrupt the fistula and
cause significant injury. After the tube
is inserted, gastric contents should
be aspirated to help confirm that
the tube ends in the stomach.12 The
internal retention balloon should be
filled according to the manufacturer’s
recommendation (typically 5 to 10
mL of water), and the external bolster
should be snuggly approximated to
the skin surface. The feeding tube
should not be used to instill feeds
until a confirmatory imaging test can
be performed.
If the appropriate equipment is
not available, any similarly sized tube
(Foley, red rubber, or even the same
gastrostomy tube) can be used as a
stent to keep the stoma open until
an appropriate feeding tube can be
placed.13
Accidentally removed gastrostomy
tubes should be replaced immediately
because the stoma and tract begin to
contract once the tube is removed.
If the gastrostomy tube was placed
within the previous 2 weeks, however,
the tract is still immature, and these
patients are at risk for peritonitis. For
these patients, the recommendations
are a 48-hour period of nasogastric
suction, intravenous antibiotics, and
a repeated PEG procedure in 7 to
10 days to give the initial tract time
to heal.9 For a gastrostomy tube to
be safely replaced at the bedside,
the gastrocutaneous fistula must be
mature to prevent disruption and
creation of a false passageway into
the peritoneum. The length of time
for fistula maturation is not exactly
known and depends on patient
characteristics of wound healing.
Fistula maturation is maximal at 6 to
8 weeks following placement, and a
2- to 4-week period is probably the
minimum healing time necessary to
prevent fistula disruption.10
There are no studies examining
the safety of bedside replacements
of jejunostomy tubes. Because of
the anatomic location and the long
lengths of jejunostomy and G-J
tubes, the correct placement of these
tubes can be more problematic. This
procedure can be easily achieved with
endoscopy or interventional radiology
and is best left to specialists. If,
however, bedside placement in the
emergency department is necessary,
the principles and processes for
CRITICAL DECISION
What is the proper way to replace a
gastrostomy tube?
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April 2009 • Volume 23 • Number 8
CRITICAL DECISION
How can correct placement of a
feeding tube be verified?
There are several case reports
of patients developing peritonitis
because of incorrect bedside
replacement of a feeding tube and
subsequent continued infusion
of nutritional feeds into the
peritoneum.13,14 In order to prevent
this, it is crucial to verify correct
placement of the tube before it is
used. Clinical signs that a gastrostomy
tube has been successfully placed
into the stomach—ease of tube
passage through the fistula, the lack
of resistance when insufflating the
retention balloon, auscultation of
borborygmi, and the return of gastric
fluid—are suggestive of correct
placement but are not consistently
reliable.
A contrast radiographic study
should be performed for verification
of tube placement. Water-soluble
contrast such as a diatrizoate
meglumine and diatrizoate sodium
solution (Gastrografin, MDGastroview) is injected into the lumen
of the feeding tube, and an upright
abdominal flat-plate radiograph is
taken. A correctly positioned tube
should instill contrast into the
stomach, thus outlining the gastric
rugae for easy visualization on the
radiograph. Any extravasation of
contrast into the peritoneum should
immediately result in discontinued
use of the tube. In addition to
verification of tube location, contrast
studies have aided in identification
of other potential complications of
feeding tubes such as gastric and
intestinal obstructions, fractured or
leaking catheters, intussusceptions,
and gastric perforations.15
Recently, two additional methods
of confirming tube location were
introduced. A prospective pilot study
showed six successful gastrostomy
tube replacements using bedside
ultrasonography guidance for catheter
re-insertion.16 Another study showed
successful use of air contrast to verify
tube placement.17 The authors injected
300 mL of air into PEGs replaced at
the bedside and took abdominal flatplate radiographs. The radiographs
revealed a distended stomach with
the PEG tube easily visualized in
the stomach. Although more studies
are needed to confirm the utility of
these methods, they may be useful
alternatives because ultrasonography
is readily available and radiation-free,
and air contrast is safer and cheaper.
CRITICAL DECISION
How should a feeding tube be
secured?
Once correct placement of a
feeding tube is confirmed, it must be
secured. The tube should be closefitting to avoid dislodgement but not
so tight that it causes undue pressure
and discomfort, which could lead to
future problems with tissue ulceration
or necrosis.
If commercially produced
clamping devices are not readily
available, several other techniques
can be effective in securing the tube.
Simple external fixation of the tube
can be achieved with a retention
silk suture to the skin that is then
wrapped snuggly around the tube.
Alternatively, an external bolster
can be created with a Foley tube.12
A 3- to 4-cm piece of tube is cut
from the middle of a Foley catheter.
This is made into a cross bar by
cutting 2 opposing side holes in the
center of the bar through which the
feeding tube is passed. The cross bar
ideally should be tight enough to
prevent slippage of the feeding tube
but still allow for passage of feeds.
Other suggested methods include
wrapping the tube around a gauze
roll and taping this to the abdomen
or wrapping latex tubing around the
base of the tube and securing it with
a tie.18,19
If a Foley catheter is used as
a temporary replacement tube, it
should be secured by an external
bolster in order to prevent migration
of the balloon. Several case reports
cite a migrated Foley balloon as the
cause of small bowel obstruction,
intussusception, enteroenteric fistula,
volvulus, intestinal perforation,
and pancreatitis.13,20-22 These
complications should be considered
when a Foley catheter has been used
to replace a feeding tube.
CRITICAL DECISION
What methods may be used to
unclog a feeding tube?
Another common complication
with feeding tubes is the inability
to infuse feeds because of a clogged
tube. All types of tubes are susceptible
to clogging with crushed medication,
inadequate flushing, and precipitation
of protein products in the nutritional
supplements. Feeding tubes that
are longer and smaller in caliber are
more inclined to clog, as are feeding
tubes that are used for continuous
slow infusion as opposed to bolus
feeds. Clogging can be minimized by
regularly flushing the tube with water
and by using liquid formulations of
medications.23
A clogged feeding tube can
generally be unblocked with
mechanical agitation using back and
forth infusion of a liquid product.
In a prospective study, carbonated
beverages (Dr. Pepper is a classic
favorite) were shown to be more
effective than water and less effective
than a pancreatic enzyme concentrate
(Viokase) mixed with bicarbonate.18
If patency is not achieved
with these measures, devices
such as an endoscopic retrograde
cholangiographic catheter or
endoscopic cytology brush can be
introduced into the feeding tube to
physically dislodge the clot.24 Such
methods are typically performed
by gastrointestinal or surgical
specialists. There are also a variety
of commercially available products
marketed for unclogging feeding
tubes such as long flexible plastic
probes with a screw and thread
design (Bionix DeClogger), small
4 F stiff catheters placed into the
lumen of the feeding tube to directly
access the clot (InTRO-ReDUCER by
Health Improvement Associates), and
15
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Critical Decisions in Emergency Medicine
Pearls
• Despite seemingly benign
presentations of feeding
tube complications, it is still
imperative to verify correct
tube location and function with
contrast plain film radiography.
• Infusion of carbonated
soda or pancreatic enzyme
concentrate mixed with
bicarbonate is effective at
unclogging feeding tubes.
• Educating the patient on
preventive maintenance such
as flushing the tube every 6
hours and securing the tube to
the appropriate tightness can
prevent future complications.
• Numbing the stoma with
lidocaine jelly could help
to lessen discomfort when
replacing a gastrostomy tube.
Pitfalls
• Replacing a feeding tube
at the bedside if the tract is
immature or less than 2 weeks
old can lead to disruption of
the fistula and intraperitoneal
placement of the tube.
• Infusing enteral feeds into a
newly placed or malfunctioning
tube without first verifying
correct tube position can lead to
peritonitis, abdominal distention,
and respiratory compromise.
• Failing to properly secure
a feeding tube with the
appropriate tension can
lead to many complications
and return visits to the
emergency department.
• Failing to recognize serious
emergent complications
from feeding tubes such as
necrotizing skin infection,
buried bumper syndrome,
peritonitis, intussusception,
and intestinal perforation can
result in significant morbidity.
different chemical formulations to
compose “clot busting” agents.
CRITICAL DECISION
What complications involve the tube
site?
Tube site complications were the
most commonly logged problems
with enteral feeding in the outpatient
study where patients keep a journal.8
Complaints of leakage around the
stoma resulting in a painful and
raw tube site are frequent. There
are many potential causes, and
treatment is directed towards the
source problem. Risk factors thought
to increase the likelihood of leakage
include increased gastric secretion
and repetitive cleaning with hydrogen
peroxide. This can be minimized
by placing the patient on acid
suppressive therapy and cleaning the
site with water.7
The presence of cutaneous
infections and exophytic granulation
tissue growth can also cause leakage,
bleeding, and a painful tube site. Skin
infections are common complications
of PEG procedures and the incidence
ranges from 5% to 30% depending on
the study.7,8 Most of these infections
are minor. A careful examination of
the skin surrounding the stoma is
imperative. If local bacterial infection
is suspected, good wound care and
antibiotics are usually sufficient, and
surgical incision and drainage are
rarely required. Fungal infections
can be treated with topical antifungal
cream and by keeping the area dry.
Granulation tissue can be painful
and cause bleeding with little or no
trauma; use of silver nitrate sticks
can help prevent overgrowth of
granulation tissue.
Mechanical factors such as side
torsion of the tube with ulceration
on one side of the stoma, excessive
motion of the tube causing
enlargement of the stoma, and buried
bumper syndrome can lead to a
painful and leaky tube site. Buried
bumper syndrome occurs when the
internal bumper of the gastrostomy
tube slowly erodes into the gastric
and abdominal wall. The incidence of
buried bumper syndrome ranges from
1.5% to 22% in studies.25
Buried bumper syndrome can
present as an immobile tube or with
frequent leakage, skin infection,
or abdominal pain.26 Excessive
tension between the external and
internal bolster is primarily to
blame; additional precipitating
factors are a stiff internal bolster,
malnutrition, poor wound healing,
and significant weight gain. This
condition can progress to abscess
development, peritonitis, and, in
its most severe form, necrotizing
fasciitis. Consultation with the
service that inserted the tube is
necessary, because the feeding tube
will need to be removed and replaced.
Endoscopy can be needed to evaluate
the integrity of the internal gastric
mucosa. Ultimately, changing the
tube to a larger caliber tube, setting
the external bolster to obtain proper
tension and instructing the patient
to reset it to the same level after
cleaning, and affixing the external
tube so that it exits perpendicular to
the skin surface can improve comfort
and reduce leakage and the risk of
infection.
Case Resolutions
n Case One
The patient’s laboratory results
showed a WBC count of 20,000/mm.
An upright abdominal radiograph did
not show pneumoperitoneum. Watersoluble contrast, 30 mL, was infused
through the Foley catheter, and a
repeat abdominal radiograph showed
the dye freely entering the peritoneal
cavity. The patient underwent
exploratory laparotomy, and a large
amount of milky peritoneal fluid
was evacuated. The abdomen was
irrigated with saline, and a new
gastrostomy catheter was placed. A
sample of the peritoneal fluid revealed
no organism on Gram stain, and the
patient’s postoperative recovery was
unremarkable.
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April 2009 • Volume 23 • Number 8
n Case Two
Pancreatic enzyme concentrate
was not available from the hospital
pharmacy, so the emergency
physician obtained a carbonated
soda from the waiting room vending
machine. Twenty milliliters of the
soda was infused into the PEG
tube and met with resistance. Back
and forth infusion agitation was
performed manually for 2 minutes
and eventually cleared the blockage.
A radiograph with water-soluble
contrast confirmed correct position of
the PEG tube; the tube was secured
with a commercial clamping device,
and the patient was discharged home.
n Case Three
The patient’s CBC with differential
was normal. A contrast radiograph
of the abdomen was obtained to rule
out tube dislodgment, and correct
location of the tube was verified.
The stoma was cleaned and found
to have considerable granulation
tissue. Silver nitrate sticks were
used around the PEG tube site to
control the bleeding and reduce the
granulation. The tension between the
internal and external bolsters was
readjusted for a snug fit, and the tube
was secured with a clamping device.
The patient was discharged home
with instructions to followup with her
primary care physician.
Summary
Most feeding tube complications
seen in the emergency department
are not life threatening and can be
managed by emergency physicians
without specialist consultation.
Emergency physicians should
be proficient at managing these
complications and ensure that the
feeding tube is correctly positioned,
secured appropriately, and safe to
use. There is, however, the potential
for serious harm from feeding
tube complications, and prompt
identification of and consultation for
these life-threatening problems are
crucial.
References
1. Larson DE, Burton DD, Schroeder KW, et al.
Percutaneous endoscopic gastrostomy. Indications,
success, complications, and mortality in 314
consecutive patients. Gastroenterology.
1987;93:48-52.
2. Ackermann RJ, Kemle KA, Vogel RL, et al. Emergency
department use by nursing home residents. Ann
Emerg Med. 1998;31:749-757.
25. Mathus-Vliegen LM, Koning H. Percutaneous
endoscopic gastrostomy and gastrojejunostomy:
a critical reappraisal of patient selection, tube
function and the feasibility of nutritional support
during extended follow-up. Gastrointest Endosc.
1999;50:746-754.
25. Shallman RW, NorFleet RG, Hardache JM.
Percutaneous endoscopic gastrostomy feeding tube
migration and impaction in the abdominal wall.
Gastrointest Endosc. 1988;34:367-373.
3. Odom SR, Barone JE, Docimo S, et al. Emergency
department visits by demented patients with
malfunctioning feeding tubes. Surg Endosc.
2003;17:651-653.
4. Townsend C, Beauchamp RD, Ever M, et al. Sabiston
Textbook of Surgery. Philadelphia, PA: Saunders;
2008.
5. Fortunato JE, Darbari A, Mitchell SE, et al. The
limitations of gastro-jejunal (G-J) feeding tubes in
children: a 9-year pediatric hospital database analysis.
Am J Gastroenterol. 2005;100:186-189.
6. Gauderer MW, Ponsky JL, Izant RJ. Gastrostomy
without laparotomy: a percutaneous endoscopic
technique. J Pediatr Surg. 1980;15:872-875.
7. McClave SA, Chang WK. Complications of enteral
access. Gastrointestinal Endosc. 2003;58(5):739-751.
8. Crosby J, Duerksen DR. A prospective study of tubeand feeding-related complications in patients receiving
long-term home enteral nutrition. J Parenter Enteral
Nutr. 2007;31(4):274-277.
9. Galat SA, Gerig KD, Porter JA, et al. Management of
premature removal of the percutaneous gastrostomy.
Amer Surg. 1990;56:733-736.
10. Marshall JB, Bodnarchuk G, Barthel JS. Early accidental
dislodgement of PEG tubes. J Clin Gastroenterol.
1994;18(3):210-212.
11. Hooker E. Complications of gastrointestinal devices.
In: Tintinalli J, Kelen G, Stapczynski J, eds. Emergency
Medicine: A Comprehensive Study Guide, 6th ed. New
York, NY: McGraw-Hill; 2004:538-585.
12. Cosby K. Gastrostomy tube replacement. In: Reichman
E, Simon R. Emergency Medicine Procedures. New
York, NY: McGraw-Hill; 2003:456-466. (Gastrostomy
tube types and replacement methods.)
13. Shahbani DK, Goldberg R. Peritonitis after
gastrostomy tube replacement in the emergency
department. J Emerg Med. 2000;18(1):45-46.
14. Fox VL, Abel SD, Malas S, et al. Complications
following percutaneous endoscopic gastrostomy and
subsequent catheter replacement in children and
young adults. Gastrointest Endosc. 1997;45:64-71.
15. O’Keefe KP. Complications of percutaneous feeding
tubes. Emerg Med Clin North Am.
1994;12(3):815-826.
16. Wu TS, Rosenberg M, Huggins C. 2:10 Gastrostomy
tube replacement and confirmation under ultrasound
guidance. Ann Emerg Med. 2007;50:S66.
17. Burke DT, Hoberman CJ, Morse LR, et al. A new
procedure for gastrostomy tube replacement
verification: a case report. Arch Phys Med Rehabil.
2005;86:1484-1486.
18. Beck AR, Allen JE. An improved gastrostomy dressing.
Arch Surg. 1967;94:904.
19. Tuel SM, Wu Y. A method for stabilizing chronic
gastrostomy or jejunostomy tubes. Arch Phys Med
Rehabil. 1986;67:175-176.
20. Huff JP, Rosenblum J, Camara DS. Complications of
gastrostomy. South Med J. 1988;81:1050-1052.
21. O’Keefe KP, Dula DJ, Varano V. Duodenal obstruction
by a nondeflating Foley catheter gastrostomy tube.
Ann Emerg Med. 1990;19:1454-1457.
22. Tom W, Zachary K, Fruchter G, et al. Prolapse of
gastrostomy tube resulting in entero-enteric fistula
and intussusception. Ann Surg. 1988;54:245-247.
23. Pearce CB, Duncan HD. Enteral feeding. Nasogastric,
nasojejunual, percutaneous endoscopic gastrostomy,
or jejunostomy: its indications and limitations.
Postgrad Med J. 2002;78:198-204.
24. Marcaurd SP, Perkins AM. Clogging of feeding tubes. J
Parenter Enteral Nutr. 1988;12:403-405.
17
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Critical Decisions in Emergency Medicine
CME Questions
Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive CME certificates for up to 5
ACEP Category I credits, 5 AMA PRA Category I Credits™, and 5 AOA Category 2-B credits for answering the following
questions. To receive your certificate, go to www.acep.org/criticaldecisionstesting and submit your answers online. You
will immediately receive your score and printable CME certificate. You may submit the answers to these questions at any
time within 3 years of the publication date. You will be given appropriate credit for all tests you complete and submit
within this time. Answers to this month’s questions will be published in next month’s issue.
1. What triggers the polymerization process of
cyanoacrylate tissue adhesives?
A. contact with carbon dioxide
B. contact with the cotton in the tissue adhesive vials
C. contact with moisture
D. contact with RBCs
E. contact with WBCs
2. What will happen when tissue adhesive in liquid form is
applied on the skin and spills onto an area covered with
petroleum jelly?
A. an endothermic reaction will occur
B. an exothermic reaction will occur
C. the petroleum jelly will mix with the tissue adhesive
D. the petroleum jelly will not mix with the tissue adhesive
E. a precipitate will form
3. Of the following areas, where should tissue adhesives be
avoided?
A. external ear
B. fingers
C. forehead
D. mucosal surfaces
E. toes
4. To what pressure should a manual blood pressure cuff be
inflated to achieve hemostasis in an extremity?
A. about 20 to 50 mm Hg higher than the systolic blood
pressure
B. below the diastolic blood pressure
C. just above the diastolic blood pressures
D. midway between the diastolic and systolic blood pressures
E. two times the systolic blood pressure
5. In which patients or types of laceration should tubular
gauze bandaging be avoided in finger injuries?
A. all patients with diabetes
B. lacerations that were closed with high-tension sutures
C. lacerations with an underlying fracture
D. lacerations with an underlying tendon injury
E. patients with a sensory neuropathy in that digit
6. How many digital arteries provide blood flow to each
finger and toe?
A. 1
B. 2
C. 3
D. 4
E. 5
7. When positioning a patient, what position will most
increase the patient’s risk for tissue adhesives spilling into
the eye, when repairing a laceration just lateral to the
right eye?
A. left lateral decubitus position
B. reverse Trendelenburg position
C. right lateral decubitus position
D. sitting upright
E. Trendelenburg position
8. In the setting of hair that is matted down with dried blood
from a scalp injury, what strategy is best for identifying
scalp injuries, in addition to direct visualization?
A. irrigate the scalp and hair, and stop searching for lacerations if
there is no further active bleeding
B. manually palpate the scalp for injuries
C. obtain a head computed tomography scan
D. obtain a plain radiograph of the scalp
E. shave the hair to look for injuries
9. Assuming both procedures are indicated, which of the
following is true for scalp lacerations repaired with the
hair apposition technique, compared to suturing?
A. the hair apposition technique has a shorter procedure time
B. the hair apposition technique is more painful
C. the hair apposition technique requires more followup
appointments
D. the hair apposition technique results in better cosmesis
E. the hair apposition technique results in more complications
10. How many arteries provide vascular supply to the calf and
foot?
A. 1
B. 2
C. 3
D. 4
E. 5
11. Which statement is correct concerning replacement of an
accidentally removed PEG tube?
A. a catheter should be reinserted immediately unless the PEG
tube was initially placed within the previous 2 weeks
B. the PEG tube can only be reinserted within 48 hours after
extubation
C. the stoma needs to close before another PEG tube can be
placed
D. the tube has to be reinserted by a specialist
E. the tube needs to be reinserted immediately after extubation
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April 2009 • Volume 23 • Number 8
12. Radiographic verification of the location of a feeding tube
is best accomplished with which of the following?
A. contrast radiography
B. CT scan
C. MRI
D. ultrasonography
E. upright chest radiograph
13. Which of the following is most likely to result in feeding
tube clogging?
A. changing medication to liquid formulations
B. decreasing the length of the tube
C. frequent flushing with warm water
D. using continuous feeding instead of bolus feeding
E. using a larger caliber tube
18. Most of the complications from feeding tubes:
A. are not life threatening and can be managed by an emergency
physician
B. can be resolved by holding the enteral feeds
C. have a great potential for fatal complications and need
immediate surgical consultation
D. occur in the immediate postoperative period
E. require CT scan for diagnosis
19. Which of the following suggests incorrect replacement of
a feeding tube?
A. auscultation of borborygmi with air insufflation
B. contrast radiograph outlining the stomach rugae
C. immediate return of gastric contents with tube aspiration
D. lack of resistance when inserting the catheter
E. resistance when insufflating the internal retention balloon
14. Leakage around the stoma:
A. is a rare complication of PEG tubes
B. is best treated with a pressure dressing
C. is more common with silicone tubes
D. is usually treated aggressively with intravenous antibiotics and
a surgical consultation
E. requires a careful evaluation to rule out a serious
intraabdominal process, but is usually benign
20. What is the minimum length of time required for a
gastrocutaneous fistula to mature?
A. 24 hours
B. 1 week
C. 2 weeks
D. 4 months
E. 1 year
15. A rigid and painful abdomen in a patient with a newly
replaced feeding tube is treated by:
A. 24-hour observation
B. decreasing the volume of the enteral feeds
C. immediate surgical consultation and broad-spectrum
antibiotics
D. intravenous antibiotics and close followup
E. placement of a smaller feeding tube
16. What is the best management for a localized skin infection
without any abscess that is located around the stoma of a
feeding tube?
A. antibiotics, wound care, and possible admission
B. decreasing the infusion rate of the enteral feeds
C. replacement of the feeding tube
D. surgical consultation for incision and drainage
E. topical antifungal ointment
17. If significant resistance is met during the insertion of a
replacement PEG tube, the physician should try
A. an injection of lidocaine
B. more force
C. probing the stoma
D. a smaller caliber tube
E. a stiffer, larger tube
Answer key for March 2009, Volume 23, Number 7
1
D
2
D
3
B
4
D
5
D
6
A
7
D
8
C
9
B
10
E
11
A
12
B
13
B
14
C
15
E
16
D
17
C
18
E
19
B
20
C
The American College of Emergency Physicians makes every effort to ensure that contributors to College-sponsored publications are knowledgeable authorities in their fields. Readers are nevertheless advised that the statements
and opinions expressed in this series are provided as guidelines and should not be construed as College policy unless specifically cited as such. The College disclaims any liability or responsibility for the consequences of any
actions taken in reliance on those statements or opinions. The materials contained herein are not intended to establish policy, procedure, or a standard of care.
19
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NONPROFIT
U.S. POSTAGE
P A I D
DALLAS, TX
PERMIT NO. 1586
April 2009 • Volume 23 • Number 8
Critical Decisions in Emergency Medicine is the official
CME publication of the American College of Emergency
Physicians. Additional volumes are available to keep
emergency medicine professionals up-to-date on relevant
clinical issues.
Editor-in-Chief
Louis G. Graff IV, MD, FACEP
Professor of Traumatology and Emergency Medicine,
Professor of Clinical Medicine, University of
Connecticut School of Medicine; Farmington,
Connecticut
Section Editor
J. Stephen Bohan, MS, MD, FACEP
Executive Vice Chairman and Clinical Director,
Department of Emergency Medicine, Brigham &
Women’s Hospital; Instructor, Harvard Medical School,
Boston, Massachusetts
Feature Editors
Michael S. Beeson, MD, MBA, FACEP
Program Director, Department of Emergency Medicine, Summa Health System, Akron, Ohio; Professor,
Clinical Emergency Medicine, Northeastern Ohio
Universities College of Medicine, Rootstown, Ohio
The Critical ECG
A 43-year-old woman with high fever, productive cough, and vomiting for 1
week.
Joshua S. Broder, MD, FACEP
Assistant Clinical Professor of Surgery, Associate
Residency Program Director, Division of Emergency
Medicine, Duke University Medical Center, Durham,
North Carolina
Amal Mattu, MD, FACEP
Program Director, Emergency Medicine
Residency Training Program,
Co-Director, Emergency Medicine/Internal Medicine
Combined Residency Training Program, University of
Maryland School of Medicine, Baltimore, Maryland
Associate Editors
Daniel A. Handel, MD, MPH
Director of Clinical Operations, Department of Emergency
Medicine, Oregon Health & Science University, Portland,
Oregon
Frank LoVecchio, DO, MPH, FACEP
Research Director, Maricopa Medical Center Emergency
Medicine Program; Medical Director, Banner Poison
Control Center, Phoenix, Arizona; Professor, Midwestern
University/Arizona College of Osteopathic Medicine,
Glendale, Arizona.
Sharon E. Mace, MD, FACEP
Associate Professor, Department of Emergency
Medicine, Ohio State University School of Medicine;
Faculty, MetroHealth Medical Center/Cleveland Clinic
Foundation Emergency Medicine Residency Program;
Director, Pediatric Education/Quality Improvement
and Observation Unit, Cleveland Clinic Foundation,
Cleveland, Ohio
Robert A. Rosen, MD, FACEP
Medical Director, Culpeper Regional Hospital,
Culpeper, Virginia
George Sternbach, MD, FACEP
Sinus tachycardia, rate 168, previous inferior and anterolateral MI. The presence
of “camel hump” T waves (noted in the precordial leads) should always prompt
consideration of two possibilities:
• Fusion of T waves with U waves, consistent with hypokalemia
• Hidden (“buried”) P waves within the T wave
In this case, the abnormal appearance of the T waves was caused by the presence of
“buried” P waves. Sinus tachycardia in this patient was caused by a high fever and
severe dehydration due to pneumonia.
Feature Editor: Amal Mattu, MD, FACEP
From: Mattu A, Brady W. ECGs for the Emergency Physician. London: BMJ Publishing;
2003:99,140. Available at www.acep.org/bookstore. Reprinted with permission.
Clinical Professor of Surgery
(Emergency Medicine), Stanford University
Medical Center, Stanford, California
Editorial Staff
Mary Anne Mitchell, ELS
Managing Editor
Mike Goodwin
Creative Services Manager
Mary Hines
Editorial Assistant
Lilly E. Friend
CME and Subscriptions Coordinator
Marta Foster
Director and Senior Editor
Educational and Professional Publications
Critical Decisions in Emergency Medicine is a trademark
owned and published monthly by the American College
of Emergency Physicians, PO Box 619911, Dallas TX
75261-9911. Send address changes to Critical Decisions
in Emergency Medicine, PO Box 619911, Dallas TX
75261-9911, or to [email protected].
Copyright 2009 © by the American College of Emergency
Physicians. All rights reserved. No part of this publication
may be reproduced, stored, or transmitted in any form
or by any means, electronic or mechanical, including
storage and retrieval systems, without permission in
writing from the Publisher. Printed in the USA.
[email protected]
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