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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. 2009-CDEM-April.indd 1 3/12/09 7:59:32 AM 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 2 2009-CDEM-April.indd 2 3/12/09 7:59:32 AM April 2009 • Volume 23 • Number 8 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) 3 2009-CDEM-April.indd 3 3/12/09 7:59:32 AM 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. 4 2009-CDEM-April.indd 4 3/12/09 7:59:32 AM April 2009 • Volume 23 • Number 8 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 5 2009-CDEM-April.indd 5 3/12/09 7:59:32 AM 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 6 2009-CDEM-April.indd 6 3/12/09 7:59:33 AM April 2009 • Volume 23 • Number 8 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, 7 2009-CDEM-April.indd 7 3/12/09 7:59:33 AM 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 8 2009-CDEM-April.indd 8 3/12/09 7:59:33 AM 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 2009-CDEM-April.indd 9 3/12/09 7:59:34 AM 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 10 2009-CDEM-April.indd 10 3/12/09 7:59:34 AM 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 11 2009-CDEM-April.indd 11 3/12/09 7:59:34 AM 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, 12 2009-CDEM-April.indd 12 3/12/09 7:59:34 AM 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 13 2009-CDEM-April.indd 13 3/12/09 7:59:34 AM 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? 14 2009-CDEM-April.indd 14 3/12/09 7:59:34 AM 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 2009-CDEM-April.indd 15 3/12/09 7:59:35 AM 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. 16 2009-CDEM-April.indd 16 3/12/09 7:59:35 AM 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 2009-CDEM-April.indd 17 3/12/09 7:59:35 AM 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 18 2009-CDEM-April.indd 18 3/12/09 7:59:35 AM 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 2009-CDEM-April.indd 19 3/12/09 7:59:35 AM 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] 2009-CDEM-April.indd 20 3/12/09 7:59:36 AM