Firm Digital Pressure Research Articles

Is the plastibell of any haemostatic value after 24 h?

Background:The Plastibell is the most popular circumcision method among mothers in our city. Haemorrhage is its major problem. At our centre, we have recorded many circumcision problems resulting from prolonged retention of the Plastibell ring and this study, therefore, sought to explore the ways of reducing complications resulting from prolonged retention of the ring.Patients and Methods:This was a prospective study, in which a total of sixty consecutive male neonates were recruited with all undergoing circumcision using the Plastibell device. Thirty patients were assigned to the subject group, in whom the Plastibell ring was removed by the investigator at 24 h while the other thirty constituted the control group whose Plastibell rings were allowed to fall off on their own. The patients selected were aged between 7 and 28 days.Results:Overall, 4 (6.6%) of the sixty neonatal circumcisions in this study were complicated by haemorrhage. There was minor bleeding in 3 (10%) of the thirty subjects and 1 (3.3%) of the thirty controls. There was no statistically significant difference between the groups (P = 0.3006). One patient each from the subject and control groups bled following slipped ligature a few hours after Plastibell circumcision. The other two patients in the subject group bled following the removal of the Plastibell ring at 24 h. All the bleeding episodes were effectively controlled within 5 min by firm digital pressure only administered through a piece of dry, sterile gauze.Conclusion:Post-circumcision haemorrhage was not significantly different between circumcised babies whose Plastibell rings were removed at 24 h and those in whom it was left to fall off on its own.

Re: Digital compression of facial arteries facilitates cutaneous nasal surgery

Dear Editor, We read with interest the technique described recently by Moran et al.1 for controlling intraoperative haemorrhage during cutaneous nasal surgery. We would like to suggest a similar technique that we have found useful in our department for skin surgery in the temporal region. The superficial temporal artery runs through the temporoparietal fascia, and supplies a wide region of soft tissue superficial to the temporal fascia via the frontal and parietal branches. The trunk of this artery can be found reliably by palpation anterior and superior to the tragus, superficial to the root of the zygomatic arch. Firm digital pressure at this point reduces bleeding from the proximal wound margin of excisions in the temporoparietal region. This can be achieved without discomfort to the patient (Figs ​(Figs11 and ​and2)2) and facilitates haemorrhage control. A short video clip (Video S1; see Supporting Information) is included to illustrate the efficacy of this technique. Fig 1 Firm digital pressure applied to the trunk of the artery facilitates haemostasis. Fig 2 Release of pressure results in haemorrhage from the proximal wound margins.

Intra-articular analgesia of the equine shoulder joint

ANATOMY The shoulder joint is a relatively capacious cavity between the glenoid cavity of the scapula and the head of the humerus. The shoulder joint can be located by palpating down the spine of the scapula towards the ‘point of the shoulder’ that comprises the cranial division of the greater tubercle of the humerus1. Both cranial and caudal parts of the greater tubercle can be palpated and with firm digital pressure a notch between the two can be detected forming the site for arthrocentesis. Arthrocentesis necessitates insertion of a needle through the cutaneous omobrachialis and cleidobrachialis muscles. Communication between the shoulder joint and the bicipital bursa has been reported1.

Effectiveness of a prolonged compression of scalp arteries on migraine attacks

Sirs: A brief digital compression of the superficial temporal artery can relieve the pain of a migrainous attack [1, 2, 5] and of a cluster headache attack [3]. No data are reported in the literature concerning a prolonged compression. In a series of consecutive patients we evaluated the effect of a prolonged (more than 3 minutes) compression of scalp arteries on a migrainous attack and attempted to establish which arterial compression is more effective, especially in relation to the site of pain. The subjects were 94 ambulatory patients (71 female, 23 male, age range 8 to 62 years, mean 21) affected with migraine without aura according to IHS criteria [4]. They were studied during a migraine attack, having been informed of the aim and technique of the compression and having voluntarily accepted it. The intensity of pain, which had been present for from several minutes to few hours, was moderate in 58 cases, severe in 36. In some cases analgesic drugs or triptans had been used at the onset of pain, providing no relief or insufficient relief. The temporal artery was compressed using firm digital pressure against the zygomatic arch in front of the tragus and 1–2 cm downstream; the occipital artery was compressed against the occipital bone. The localization of the arteries was done by means of the perception of their pulse with the finger. The compression, strong enough to interrupt blood flow, was first carried out on a single ipsilateral artery, or bilaterally in the case of bilateral pain. When the pain was prevalent in the anterior part of the head, compression began in the temporal artery or arteries, and in the occipital artery or arteries when in the posterior part. Compression of the first artery was stopped immediately if an initial pain relief was obtained, otherwise it was continued for 3 minutes. After a half-minute interval, the arteries not previously compressed were compressed in the same manner. Subsequently, the artery/ies where the best improvement had been obtained were compressed for 4 minutes. If there was still not significant pain reduction, the temporal and occipital arteries were simultaneously compressed for at least 6 minutes. As a control, in the last 32 patients, sham compression was carried out 1 cm anterior to temporal artery, or 1 cm lateral to the occipital artery, according to the method described above. The sham compression was followed by the true artery compression procedure. Table 1 shows the results in relation to the site of pain and the arteries compressed. Overall, 68 % of patients obtained relevant or complete and enduring pain relief; the percentage reached 90 % (52/58) in the attacks with moderate pain. Not infrequently the arteries, especially the superficial temporals, were tender when compressed; this did not influence the result. Patients generally did not respond when the attack had been in progress for several hours and/or when pain was very intense. The sham artery compression never resulted in pain reduction. No adverse effects were noted. Prolonged (more than three minutes) compression of the occipital and/or superficial temporal arteries is frequently efficacious in reducing or eliminating migraine pain. We found no constant relationship between the site of pain and the ipsilateral arteries giving better relief when compressed. For example, pain more frequently ceased with monoor bilateral occipital artery compression than with temporal artery compression. The possibility of obtaining substantial relief or cessation of pain with this procedure seems relevant in the therapy of migrainous attacks, making it possible to avoid or reduce the use of drugs. LETTER TO THE EDITORS

A bimanual manipulation technique for establishing the CR position

In this work, we demonstrate a modern concept of the cr position. We analyze main characteristics of the central relation position from mechanical and physiological aspects. Furthermore, we discuss the bimanual manipulation technique on the lower jaw, required for balancinh procedures or investigation of premature contacts. Since an effective manipulation technique requires a combination of gentle yet firm digital pressure in a cranial direction., with a good sense of timing, clinician needs to have ! a mental picture of what is happening in TMJs and how are muscles affected by different movements and pressure. We have specifically presented instructions on firm-digital-pressure test. With this test it is possible to effectively verify the consistency of a certain cr position as well as to exclude the intra-articulating problems. Most of the time when the patient is tense and uncooperative, it is because the pressure is applied on the mandibule before the lower jaw is gently positioned into its most cranial position with separate dental arches. It seems, at least for now, that there are no procedures which can provide so much practical benefit for both the clinican and the patient at the same time, as can routine registration of the cr position and verification of its accuracy.

Effect of digital pressure on the neurovascular sheath during perivascular axillary block

We have assessed prospectively the influence of digital pressure on the effectiveness of perivascular axillary block using a catheter technique in two groups of patients. Ninety-eight patients received axillary injections of 2% mepivacaine with adrenaline 20 ml mixed with contrast agent 20 ml. During injection firm digital pressure was applied either on the neurovascular sheath (group 1) or 6-8 cm below it (group 2). The patient's arm was then adducted. Axillary radiographs were obtained in 90 patients after 30 min. In the last eight patients radiographs were obtained after injecting 2, 20 and 40 ml of the mixture to study the dynamics of spread. There were no statistically significant differences in proximal flow of mepivacaine or in the success rate of the block between the groups. Signs of flow obstruction by the head of the humerus were seen in only eight patients. In the majority of patients local anaesthetic spread above the coracoid process, which increased the success rate of the block, but did not guarantee an effective block.

Technical note: the safety of outpatient arteriography using 3F catheters.

There has been a general trend for diagnostic arteriography to be performed as a day-case procedure, thus obviating the need for hospital admission. Most commonly 5F and, more recently, 4F catheters have been used via the femoral approach. After catheter removal, firm digital pressure is applied at the puncture site for 10–15 min following which patients are observed for 2–4 h. Although this approach is undoubtedly safe, problems may arise, particularly in elderly patients, those with hypertension and also in patients with groin scarring, often associated with surgical bypass grafts. Severe bleeding is very rare, but a haematoma or delayed oozing is not unusual. In a recent paper advocating outpatient arteriography with 4F catheters there was no delayed bleeding, but over half the patients had bruising in the groin or slight oozing following the procedure (Dyet et al, 1990). The ages of these patients were not specified but there is nothing to suggest that they were a particularly “atrisk” group.

Central Retinal Artery Occlusion Associated With Periocular Corticosteroid Injection for Juvenile Hemangioma

Intralesional corticosteroid injections are an accepted treatment for periocular juvenile hemangiomas. This treatment is felt to be relatively free of complications. We report, however, a case of central retinal artery occlusion associated with steroid injection for a periocular juvenile hemangioma in a four-year-old child. It is presumed that the force of injection or digital massage caused retrograde arterial flow, moving steroid suspension particles into the central retinal artery where vascular occlusion occurred. As a result of this case, our treatment regimen has been modified. We now use 0.1 cc steroid alloquats injected slowly through a 30-gauge needle and avoid firm digital pressure on the lesion.

The Scalp Stimulation Test

Intrapartum fetal heart rate response to various scalp stimuli and its correlation with scalp pH was studied in a prospective manner. One hundred fetuses with heart rate tracings judged by the resident responsible for the patient to be suggestive of fetal asphyxia were entered into the study. Each fetus was subjected to firm digital pressure on the head followed by a gentle pinch of the scalp with an atraumatic clamp. Scalp blood sampling was then performed in the usual manner. Rcsponse to either of these stimuli by an acceleration of the fetal heart rate of 15 bpm lasting at least 15 seconds was uniformly associated with a scalp blood pH of ≥7.19. Fifty-one fetuses so stimulated responded with an acceleration. Of the remaining fetuses, 19 had a scalp pH 7.19. Clinical application of such a scalp stimulation test could, therefore, reduce the necessity for scalp blood sampling by approximately 50% in the presence of a fetal heart rate pattern suggesting acidosis. Such a provocative test may also be very useful with an abnormal fetal heart rate pattern suggestive of acidosis when the cervix is sufficiently dilated to permit scalp blood sampling.

The scalp stimulation test: A clinical alternative to fetal scalp blood sampling

Intrapartum fetal heart rate response to various scalp stimuli and its correlation with scalp pH was studied in a prospective manner. One hundred fetuses with heart rate tracings judged by the resident responsible for the patient to be suggestive of fetal asphyxia were entered into the study. Each fetus was subjected to firm digital pressure on the head followed by a gentle pinch of the scalp with an atraumatic clamp. Scalp blood sampling was then performed in the usual manner. Response to either of these stimuli by an acceleration of the fetal heart rate of 15 bpm lasting at least 15 seconds was uniformly associated with a scalp blood pH of greater than or equal to 7.19. Fifty-one fetuses so stimulated responded with an acceleration. Of the remaining fetuses, 19 had a scalp pH less than 7.19 and 30 were associated with a pH greater than 7.19. Clinical application of such a scalp stimulation test could, therefore, reduce the necessity for scalp blood sampling by approximately 50% in the presence of a fetal heart rate pattern suggesting acidosis. Such a provocative test may also be very useful with an abnormal fetal heart rate pattern suggestive of acidosis when the cervix is sufficiently dilated to permit scalp blood sampling.

Factors Influencing Distribution of Local Anesthetic Injected into the Brachial Plexus Sheath

Several technical modifications of the various perivascular techniques of brachial plexus block have been advocated but their efficacy has never been documented. The present study used injections of radiopaque anesthetic solutions to illustrate the effect of various technical maneuvers on the flow of the solutions injected into the sheath at several levels. Axillary block studies indicated that solutions injected through a needle placed high in the axilla and centrally directed achieve a higher level than similar volumes injected through a needle that is perpendicular to the neurovascular bundle at the more traditional lower level. Furthermore, the studies demonstrate that a rubber tourniquet applied around the arm distal to the needle is unable to prevent retrograde flow of the injected solution, especially when the usual volumes utilized clinically are injected. Firm digital pressure applied immediately distal to the needle, on the other hand, is effective in preventing retrograde flow and, in so doing, enhances central flow. Bringing the arm to the side while maintaining digital pressure results in even further central spread by removing the obstacle provided by the head of the abducted humerus. Studies carried out using the infraclavicular technique indicate that because the direction of the properly placed needle is lateral, most of the injected solution passes distally out along the sheath. Again, firm digital pressure high in the axilla occludes the sheath, preventing distal flow and causing the solution to move centrally. Studies carried out using the interscalene technique show that with the usual technique the injected solution moves cephalad into the cervical portion of the sheath as well as caudad into the brachial portion. Firm digital pressure applied superior to the needle prevents cephalad flow and thus forces all of the injected solution to move caudally as far as the dome of the lung and laterally into the axillary sheath.