Laceration Repair Research Articles

A small‐bore wire‐guided chest tube for the initial stabilisation of septic uroperitoneum in a dog

AbstractThe purpose of this report was to describe the emergency management and subsequent surgical treatment of a 6‐year‐old, entire, male Epagneul Breton referred for septic uroperitoneum of 5 days duration. Clinical stabilisation was achieved by the insertion of a percutaneous small‐bore wire‐guided chest tube as an abdominal drain in association with conventional medical treatment. The small‐bore wire‐guided chest tube was inserted percutaneously into the abdomen, under ultrasound guidance, using a modified Seldinger technique. It was connected to a closed active collection system, and successfully drained the peritoneal urinary effusion. The medical treatment associated with the application of the small‐bore wire‐guided chest tube contributed to the patient's stabilisation, which was reached within 5 hours from arrival, allowing for an exploratory laparotomy with repair of the bladder laceration. The small‐bore wire‐guided chest tube was replaced during surgery by a Jackson–Pratt drain, which remained in place for 4 days postoperatively. The dog has completely recovered, and no complications were recorded.

Blok Pleksus Servikalis Superfisialis pada Insisi Abses Submandibula

This case study explores the use of bilateral superficial cervical plexus block as a regional anesthesia method in a 44-year-old male patient with a submandibular abscess. The patient, who has comorbidities of type 2 diabetes mellitus, renal insufficiency, and grade 1 obesity, underwent a 60-minute abscess drainage incision operation. This technique was chosen based on patient factors and the medical team's preference, avoiding the risks associated with general anesthesia. Lidocaine 2% at 6cc per side was used, demonstrating the effectiveness of the cervical plexus block in this procedure and others such as lymph node dissection and laceration repair. The study confirms that regional anesthesia guided by ultrasound is a quick, resource-efficient, and safe option, with the potential to avoid improper analgesic dosing. For longer procedures, local anesthetics like ropivacaine or bupivacaine can be utilized. The main conclusion is that the superficial cervical plexus block is an effective and safe alternative for anesthesia in certain neck procedures.

A Pilot Study Testing the Novel Use of a Snake Bite Compression Device for Field Hemostasis and Wound Repair in an Animal Model.

A commercially available snake bite device was pilot tested for novel use as a method of hemostasis and wound repair at a noncompressible site in a live swine model. The device is light, is plastic, uses a hook-and-loop strap attachment, and is easily deployed. The device could offer a method for the field repair of an actively bleeding laceration at a noncompressible site in an austere environment. This was an interventional, prospective, controlled study in a large animal model. The study was approved by the Rhode Island Hospital Institutional Review Board (IRB) and the Animal Welfare Committee/Institutional Animal Care and Use Committee and the Lifespan Research Conflict of Interest Committee. Each animal acted as its own control. Blood loss was measured and compared between repairs of standardized incisions with and without the device's application. The lacerations were sutured closed. Two proceduralists alternated tasks of wound repair versus blood collection. Blood loss was measured by using gauze sponges to capture the blood during a 30-second free-bleeding period and during the repair itself. Using a one sample t-test (the expected difference in blood loss between the two incision repair methods = 0 if the null hypothesis were true), we calculated the mean difference in the deltas between the repair methods. The mean delta difference was 3.1 g (SE ± 0.97). The t-test demonstrated that there was a significantly greater blood loss during the standard repair method, t(9) = 3.11, P < 0.01 than during the repair with the device in place (see Fig.2). A statistical power analysis conducted showed that with a sample size of 10 animals, there was sufficient statistical power to detect this significant effect (β = 0.82, α < 0.05, one-tailed). There was statistically significantly less blood loss during the repairs with the device's application. This feasibility experiment demonstrates that a commercially available snakebite device may be useful for hemostasis during laceration repair at anatomic sites not amenable to application of tourniquets or compressive dressings. Strengths of the study include the prospective controlled design, including the use of each animal as its own control; alternating proceduralists to account for any variability in suturing efficiency; and the statistical significance of the results despite the small number of subjects. One weakness is that the time required for each repair was not measured. The device's portability and reusability suggest applicability in austere medical environments. Future studies could include timing the repairs, using a skin stapler or wound adhesive instead of sutures, applying a hemostatic agent before the repair, and sequentially applying the device to wounds longer than the device.

Surgical Specialty Consultation for Pediatric Facial Laceration Repair: An American and Canadian Survey.

We sought to describe patterns of and indications for surgical specialty consultation for facial laceration repair in pediatric emergency departments (PEDs). We performed a multicenter survey of PED leadership throughout the United States and Canada evaluating the practice patterns of surgical specialty consultation for patients presenting for facial lacerations requiring repair. We measured demographics of PEDs, factors influencing the decision to obtain a surgical specialty consultation, and the presence and components of consultation guidelines. Factors related to consultation were ranked on a Likert scale from 1 to 5 (1 = Not at all important, 5 = Extremely important). We evaluated relationships between reported rates of surgical specialty consultation and PED region, annual PED volume, and reported factors associated with PED consultation. Survey responses were received from 67/124 (54%) queried PEDs. The median self-reported rate of surgical specialty consultation for facial lacerations was 10% and ranged from 1% to 70%, with resident physicians performing the repair 71% of the time a subspecialist was consulted. There was regional variability in specialty consultation, with the highest and lowest rate in the Midwest and Canada, respectively ( P = 0.03). The top 4 influential factors prompting consultation with the highest percentage of responses of "Extremely Important" or "Very Important" were: discretion of the physician caring for the patient (95%), parental preference (39%), limited PED resources (32%), and patient requires sedation (32%). Surgical specialty consult guidelines were used in only 6% of PEDs with consensus that depth necessitating more than 2-layer repair or involvement of critical structures should prompt consultation. Surgical specialty usage in the management of patients who present with facial lacerations to PEDs has significant variation related to patient, provider, and department-level factors that influence the decision to consult. Lack of consult guidelines represent a potential opportunity to standardize care delivery to this common presentation.

Imaging Mismatch of Nail in the Eyeball: What’s next?

Introduction : A retained foreign body (FB) can lead to severe complications, the most devastating of which is eye loss. We present a discrepancy of imaging that resulted in a dilemma in the approach management of a mixed global-adnexal FB case.&#x0D; Case Illustration : A 31-year-old man came to the emergency room with blurry vision for 1.5 hours after a nail hit his right eye (RE). The visual acuity of RE is light perception. Ophthalmological examination revealed a central Y-shaped full-thickness corneal laceration with iris and vitreous prolapse. The lens appeared cloudy, and the posterior segment was difficult to assess. Imaging showed a foreign metal object asa nail in the oculi to intraconal without penetration to the orbital wall. He was planned to undergo FB extraction with corneal laceration repair and aspiration of lens mass irrigation. However, the nail was hard to find intraoperatively because the vitreous and choroid kept coming out. Hence evisceration with DFG was performed. The nail was found more posteriorly and attached to the bone.&#x0D; Discussion : While primary repair is the standard practice for open globe injury, managing retained intraocular metallic foreign bodies is controversial. Imaging such as CT scans can help determine the location of FB and approach management. In this case, imaging showed the FB was in the iris plane and not penetrating the orbital wall, so primary repair and FB extraction were planned.&#x0D; Conclusion : The imaging may not always be accurate in determining the exact location of FB, and the surgical approach may need to be adjusted accordingly.

Evaluating suturing methods for surgical repair of muscle belly lacerations: a scoping review of biomechanical studies

Evaluating suturing methods for surgical repair of muscle belly lacerations: a scoping review of biomechanical studies

Sneeze-induced transvaginal small bowel evisceration and obstruction nine months after iatrogenic vaginal vault laceration: a case report

Transvaginal evisceration (TE) is the extrusion of intra-abdominal viscera through the vagina. According to the literature, few cases have been reported, most of them involving elderly women who underwent previous pelvic surgery. Here we present the case of a 72-year-old woman who was admitted to our hospital due to the sensation of vaginal obstruction that appeared after a sneeze nine months after a repair of a vault laceration following prior complex pelvic surgery. A clinical diagnosis of small bowel transvaginal evisceration with obstruction was quickly made. In this case, adhesions, bowel obstruction, and the presence of a fibrotic scar on the vaginal vault were the main obstacles to the repair. However, a multidisciplinary evaluation and a combined laparoscopic-transvaginal minimally-invasive approach proved to be safe and effective in achieving good surgical outcomes in the treatment of this condition.

Coding Hotline

This month’s Coding Hotline addresses questions about coding for social determinants of health, repair of laceration of the lip, and 2 distinct E/M services.

Increasing the use of anxiolysis and analgesia for paediatric procedures in a community emergency department network: a quality improvement initiative

Prior reports describe the care children receive in community EDs (CEDs) compared with paediatric EDs (PEDs) as uneven. The Emergency Medical Services for Children (EMSC) initiative works to close these...

Adjuvant misoprostol or mifepristone for cervical preparation with osmotic dilators before dilation and evacuation

ObjectivesThis study aimed to compare effectiveness and safety of cervical preparation with osmotic dilators plus same-day misoprostol or overnight mifepristone prior to dilation and evacuation (D&E). Study designWe conducted a retrospective cohort analysis of 664 patients initiating abortion between 18 and 22 weeks at an ambulatory health center. We abstracted medical record data from two consecutive 12-month periods in 2017 to 2019. All patients received overnight dilators plus: 600 mcg buccal misoprostol 90 minutes before D&E (period 1); 200 mg oral mifepristone at time of dilators (period 2). Our primary outcome was procedure time. We report frequency of patients experiencing any acute complication, defined as unplanned procedure (i.e., reaspiration, cervical laceration repair, uterine balloon tamponade) or hospital transfer and bleeding complications. ResultsWe observed higher mean procedure time in the mifepristone group (9.7 ± 5.3 minutes vs 7.9 ± 4.4, p = 0.004). After adjusting for race, ethnicity, insurance, body mass index, parity, prior cesarean, prior uterine surgery, gestational age, provider, trainee participation, and long-acting reversible contraception initiation, the difference remained statistically significant (relative change 1.09, 95% CI 1.01, 1.17) but failed to reach our threshold for clinical significance. The use of additional misoprostol was more common in the mifepristone group, but the use of an additional set of dilators was not different between groups. Acute complications occurred at a frequency of 4.1% in misoprostol group and 4.3% in mifepristone group (p = 0.90). ConclusionsWe found procedure time to be longer with adjunctive mifepristone compared to misoprostol; however, this difference is unlikely to be clinically meaningful. Furthermore, the frequency of acute complications was similar between groups. ImplicationsOvernight mifepristone at the time of cervical dilator placement is a safe and effective alternative to adjuvant same-day misoprostol for cervical preparation prior to D&E and may offer benefits for clinic flow and patient experience.

Removal Large Fragment of Metal Wire from Eye Using Vitrectomy. Clinical Case

Purpose. Demonstration of non-standard clinical case of removing large fragment of metal wire from the eye. Patient and methods. Patient, 37 years old, with penetrating right eye injury with intraocular foreign body (IOFB) introduction — a fragment of metal wire. After unsuccessful attempt to remove IOFB during primary repair of eye injuries lacerations by ophthalmologist of the surgical department of the district hospital, he was sent to the Khabarovsk branch of the S. Fyodorov Eye Microsurgery Federal State Institution. On admission: VIS OD — 0.01 uncorrected, intraocular pressure (IOP) — 16 mm Hg (noncontact tonometer TOMEY, Japan). OD — metal IOFB protrudes by 1.0 mm from the corneoscleral laceration in projection of corneal limbus at the 13 o’clock position, postoperative aphakia; according to B-scan ultrasonic data: metallic foreign body of linear shape, 14.3 mm long, about 1.5 mm thick. There is hemorrhage in the vitreous cavity. Results. Initially, conditions for visualization of the vitreous cavity were created by performing 25G vitrectomy. The course of wire location was specified: under the choroid and retina, going out through the sclera in the equatorial region. After conjunctival tweezers expanded wound edges, the embedded fragment of wire was delicately remove: 25 mm in length and 2 mm in diameter. A single retinal break was delimited by cryotherapy and laser photocoagulation. On the 2nd day: VIS OD — 0.3 with diaphragm, uncorrected; IOP — 13 mm Hg. After 3 months: VIS OD — 0.01 sph + 13.0 D = 0.7, IOP — 14 mm Hg. Silicone removal was combined with intraocular lens implantation model RSP-3 (+23D). The next day: VIS OD — 0.3 with diaphragm, 0.5 cyl — 6.0 D ax 170 = 0.5; IOP — 16 mm Hg. Conclusion. Use of 25G vitrectomy for removal IOFB localized between the inner membranes of the eye created optimal conditions for visualizing depth of its penetration, which minimized traumatic impact and avoided severe intra- and postoperative complications.

Sterile vs Nonsterile Gloves for the Repair of Wounds and Lacerations

This systematic review and meta-analysis discusses use of sterile vs nonsterile gloves for the repair of wounds and lacerations.

Objective structured assessment of medical students’ technical skills in second-degree perineal laceration repair with sponge model-based training

PurposeIn this cohort study, we used a sponge simulator to train students in second-degree perineal laceration repair. We examined whether the training course improved the students’ skills, as measured with an objective structured assessment of technical skills (OSATS) and by a senior physician. We also examined the correlation between these ratings to assess the validity of OSATS application in this context.MethodsBetween April and July 2022, 40 medical students took part in gynecological/obstetrics training that included a lecture about perineal trauma and the viewing of a video that demonstrated second-degree perineal laceration repair using a sponge model. They then underwent initial evaluation by a senior physician and OSATS application, yielding two independent scores. After training with the sponge model, a second evaluation was performed. The OSATS assessed practical skills (8 items) and suture results (2 items). The senior physician assigned ratings on a five-point ordinal scale ranging from 1 (excellent) to 5 (poor).ResultsTraining with the sponge simulator significantly increased students’ OSATS (practical skills, p < 0.001; suture results, p < 0.05) and senior physician (p < 0.001) ratings. The OSATS and senior physician ratings correlated strongly (Spearman’s r: first assessment, – 0.72; second assessment, – 0.74; p < 0.01).ConclusionThe sponge-based training improves students’ skills for the repair of a second-degree perineal laceration. The OSATS for the sponge model might be a valid option to examine medical students in an obstetrical course.

How It Works 3: Perineal Trauma – The Importance of Assessment and Repair

The perineum can undergo trauma after a vaginal birth. Poor or no repair of perineal lacerations can result in negative short and long-term outcomes for the birther. As midwives, it is imperative that we have the knowledge and skills to properly assess and perform perineal repairs within our scope as well as correctly identify more advanced tears in order to consult a specialist. A review of the relevant anatomy and suturing process is discussed so midwives can feel more confident in this common procedure and essential skill.

P073 Cosmetic tattoo models: a novel approach for laceration repair instruction

P073 Cosmetic tattoo models: a novel approach for laceration repair instruction

Defining the clinical and procedural opportunities available to residents during rural rotations.

Many emergency medicine (EM) residency programs include clinical rotations in rural emergency departments ("rural rotations") as part of their curriculum. These rotations are designed to expose residents to clinical scenarios that are less frequently encountered in tertiary centers. The objective of this study was to determine the rate at which residents were exposed to certain clinical and procedural experiences (CPEs) while on rural rotations compared to their usual academic training hospital. We conducted a retrospective chart review of all patient encounters involving EM residents at a large academic hospital in Rochester, Minnesota, compared with two rural hospitals in Austin, Minnesota, and Albert Lea, Minnesota, from July 1, 2019, to June 30, 2020. The frequency of each CPE was calculated and expressed as the number of CPEs encountered per 100 clinical hours worked. These values were compared between the rural and academic sites. A total of 33,417 patient encounters over a total of 41,700 resident clinical hours were analyzed between the three study sites. The two settings (rural vs. academic) had significant differences in baseline patient demographics including age, acuity, and admission rates. Several CPEs were found to occur at a higher frequency in the rural hospitals versus the academic hospital: ambulance necessity documentation (9.3/100 h rural vs. 0.07/100 h academic, p ≤ 0.0001), laceration repair (3.39/100 h rural vs. 2.0/100 h academic, p = 0.0004), and splint/cast application (1.53/100 h rural vs. 0.07/100 h academic, p ≤ 0.0001). Rural EM rotations provide residents exposure to a variety of valuable educational experiences. These rotations may provide residents with superior exposures to some clinical experiences compared to academic hospitals, particularly out-of-ED transfers and orthopedic procedures. Residency programs without a current rural rotation should consider creating this as an option for their trainees.

Using of Emicizumab in Pediatric Hemophilia a Patients: KSA Single Center Experience

Introduction Emicizumab, a bispecific monoclonal antibody plays a crucial role in restoring adequate hemostasis by acting as a bridge between factors IX and X, effectively simulating the activity of factor VIII. Emicizumab is approved in several countries for bleeding episode prophylaxis in patients with HA with or without FVIII inhibitors regardless of severity. This study aimed to report results from an assessment of tolerability, efficacy, and safety of Emicizumab prophylaxis in pediatric patients with HA at a single center in Saudi Arabia. Methods This study was a retrospective study conducted between April 2019 and July 2023 at a Center for Blood Disorders for Pediatric Patients, Jeddah, Saudi Arabia. Eligible study participants were individuals &amp;lt; 16 years of age, weighing over 3 kg, presenting severe or moderate congenital hemophilia A with or without FVIII inhibitors and those who were treated with Emicizumab for at least 3months at our center. We decided to administer Emicizumab to patients with inhibitors, poor venous access, especially those of younger ages,and those with repeated breakthrough bleeds despite regular prophylaxis with FVIII concentrates. Parental drug preference was considered and discussed in all cases. The initial 2 loading injections of Emicizumab (3 mg/kg once weekly for four weeks) were administered at the center, and the patients were observed for 1 h for signs of any acute adverse events. Following discharge, the caregivers of the patients were educated about proper medication administration techniques and instructed to contact our center in case of any adverse events. Annual bleeding rate (ABR) were calculated at baseline pre and post-Emicizumab administration.Weight-based Emicizumab dosage adjustments were made at the end of each patient visit. Results 23 children with HA who started Emicizumab was initially included. A total of 6 patients were excluded as they didn't met the eligible criteria.10 patients with severe hemophilia (59%) and 7 patients with moderate hemophilia (41%). Patient were followed for median duration range of 217 weeks (15-232 weeks). All study patients were males and median (range) age at enrollment was 8.0 (11 months to 16 years).All of them were treated previously with factor either on demand or as prophylaxis. Two patients presented with inhibitors, while the rest were the non-inhibitor type. Among these patients, 2 received a maintenance dose of 3 mg/kg of Emicizumab every 2 weeks, while 16 patients received a monthly dose of 6 mg/kg. Selection of regimen was based guardian preference and also approximate the dose to available drug concentration to avoid drug wastage. Prior to enrollment, 9 patients had target joint involvement; among theses patients, 6 patients demonstrated improvement after Emicizumab initiation (66% reduction), while 3 patients still had persistent target joint involvement. The initial baseline ABRs median (Range) was 48 (Range 5-120). Compared to the ABRs after initiation of Emicizumab which showed median of 2 (Range 0-18), the ABR mean value decreased from 38.5 at baseline to 4.6 after Emicizumabtreatment. All bleeding events were traumatic and resolved with less than 48 h. one or two doses of Factor was/were required in four cases while bleeding was self-limited in others. 11 (64.7%) patients experienced zero bleeding. We observed unusual side effect of asymptomatic persistent neutropenia was observed in 10 (58.8%) out of 17 patients. The absolute neutrophil count (ANC) ranged from 0.6 to 1.45 cells/µL in these cases. There was no other adverse event was observed. Two patients underwent a tooth extraction without post-surgery bleeding, and neither required factor VIII treatment. Additionally, one patient underwent facial laceration repair and received a prophylaxis dose of factor VIII, leading to a successful outcome without any bleeding during and after the procedure. Conclusion Our study demonstrates the effectiveness of Emicizumab prophylaxis for treating patients with moderate to severe HA.The participants reported high adherence to the treatment, improved satisfaction rates and the concept of subcutaneous injections was well accepted. Although neutropenia is considered a unusual side effect of this treatment, the treatment progressed smoothly and favorable safety profile was observed.

Management of Soft Tissue Injuries in Children-A Comprehensive Review.

Airway injury, Ocular injury and neurovascular tissue damage, burns is all a spectrum of pediatric soft tissue injury complex. Soft tissue injuries to the head and neck area in children are challenging to manage, because these injuries significantly affect the child's overall health and development. Management of such injuries requires a multidisciplinary approach involving surgical and nonsurgical interventions and close collaboration among health care professionals, parents, and caregivers. This article reviews the various causes of injuries, specific considerations for each region of the head and neck, and approaches to the surgical management of soft tissue injuries in pediatric patients, including surgical and adjuvant therapies. Specific anatomic regions reviewed include the scalp/forehead, periorbital region, nose, cheeks, lips, ears, and neck/airway.Laceration repair in the growing pediatric populations may require revisions in the future. Facial soft tissue injuries are prone to poor cosmesis as in many occasions as may be constrained by available surgical specialists, thus proper multispecialty team approach along with surgical alignment and symmetry should be considered comprehensively.

Primary Reconstruction of Bladder Neck Transection and Vaginal Laceration Post Blunt Abdominal Injury a Case Report

Blunt abdominal injury is not uncommon in the paediatric population. The presentation can be immediate or delayed, and if not promptly recognized may be attended with complications such as septicaemia, shock or death. Simple, readily available and cheap imaging techniques such as abdominal radiograph and ultrasound scan still remain relevant in the diagnosis of blunt abdominal injuries where abdominal computerized tomography is unavailable or unaffordable. This can expedite the decision for an early surgical exploration. In girls, complete bladder neck transection with vaginal wall injury is a rarely reported and unusual association of blunt abdominal injury more so with delayed presentation in the absence of an associated pelvic fracture. This rare trauma entity in a child can pose a diagnostic difficulty leading to delayed presentation. This is a case of 3 year old girl with 3 weeks history of trauma to the abdomen from collapsed building fence during a heavy downpour. She later developed progressive abdominal distension with pain, constipation, vomiting, fever and drainage of clear fluid per vaginam. She had visited several hospitals but was managed non-operatively. Over the period the patient had some relief of symptoms until she presented to our facility with poorly defined features of peritonitis following a referral from a peripheral hospital. Abdominal ultrasound scan revealed intraperitoneal fluid collection. She was resuscitated and had exploratory laparotomy with primary reconstruction of the bladder neck transection and vaginal wall laceration. She did well immediate postoperative except for the superficial surgical site infection and during follow-up visits. Primary repair of traumatic bladder neck transection and vaginal wall laceration in paediatric patients with delayed presentation of blunt abdominal injury is a feasible option of management. However, long term follow up is recommended as secondary procedures may become necessary.

Structured Workshop for Repair of High-Grade Perineal Lacerations Among Obstetrics and Gynecology Residents, The Need for Repetition and Retraining.

The objective of this study was to evaluate the effectiveness of structured workshops in improving the knowledge and skills of obstetrics and gynecology residents for repairing high-grade perineal lacerations. This quasi-experimental multicenter study evaluated the baseline knowledge of obstetrics and gynecology residents using an online patient-management problem (PMP) tool. After the initial evaluation, a workshop was conducted using sponge models to teach the practical technique for repairing high-grade perineal lacerations, including external and internal anal sphincter repair. The residents' knowledge was reassessed by PMP exams at 3 and 6months after the workshop, and the scores were compared to the baseline statistics. Eighty residents participated in the study, including 26, 22, and 32 at the first, second, and third-year levels of residency, respectively. The total PMP scores significantly improved after three months of the workshop, with an increasing total score from 15.5 (baseline) to 31.3 (p = 0.027) (range of total score from - 63 to + 52). The senior residents performed better before and after three months of the intervention. However, in the six-month follow-up, the total PMP score of all residents decreased to 12.3 with no significant difference with pre-education scores at all levels. Similar significant results were also reported for each PMP question at all levels of residency. The study found that obstetrics and gynecology residents had substandard knowledge in repairing perineal lacerations. Although the training workshop significantly increased residents' knowledge, its effectiveness diminished over time, indicating a need for continuous or periodic training. The online version contains supplementary material available at 10.1007/s13224-023-01792-6.