A Meeting with the Curb: Review of Lip Laceration Repair


Medical Student Pearl by Nick Ellingwood

MD Candidate, Class of 2024

Dalhousie University

Reviewed by Dr. B Ramrattan

Copy Edited by Dr. J Vonkeman

Pdf Download:  EMSJ NEllingwood Review of Lip Laceration Repair


Case Presentation

A 68-year-old female presents to the ED with facial trauma. She tells you that she was walking in a parking lot trying to remember where she parked when she suddenly tripped over a curb and scraped her face on the asphalt. She remembers the event and did not lose consciousness. She denies any nausea/vomiting, headache, or blurry vision. She arrived at the ED by EMS who say that her GCS has remained 15. She tells you that she is a healthy individual other than her diabetes for which she takes Metformin and Ozempic. She does not smoke or drink alcohol. She tells you numerous times during your history that she is very worried about her lip injury and how it will look after it heals.

On exam, she is alert and oriented to person, place, and time. She has an abrasion over her nasal bridge and a laceration at the midline of her lower lip which is approximately 1.5cm deep extending all the way through the vermillion. Her upper right incisor is chipped. She is tender over her nasal bone. Her pupils are equal and reactive, and she has normal extra-ocular movements. She has normal facial sensation and strength and there is symmetrical rise of the uvula. There is no battle sign, hemotympanum, or periorbital bruising. You quickly test her sensation and strength is all her extremities which is normal.

Figure 1: Similar lip laceration as the patient in this case. (Benjamincousinsmd.com)


Associated Injuries

Before repairing a lip laceration, associated injuries must be considered. Common associated injuries include dental fractures, LeFort fractures, nasal bone fractures and jaw fractures.1 Much less common, but can’t miss, associated injuries include intracranial bleed, basal skull fracture, or orbital floor fractures.


Impression/Plan

Given that she is older than 65 years old, you can’t rule out a head injury based of the Canadian CT Head Rule. However, given the mild mechanism of injury and the lack of signs/symptoms of intracranial pathology you decide to forego a CT head and turn your attention to the lip laceration.


Background

When repairing a lip laceration, extra vigilance is needed to ensure proper cosmetic appearance and to preserve the functionality of the lips. It is often one of first facial features people look at when talking to someone and therefore, minimal scarring and good aesthetic are often very important to patients presenting with these lacerations. The lips are also important in tactile sensation, phonation, and mastication.


Evaluation

Lip lacerations are almost always repaired with primary closure because of the difference in aesthetic outcome between primary and secondary closure. Secondary closure may be appropriate in patients with a delayed presentation, signs of infection (erythema, drainage of pus), or contamination in the wound.1 Evaluation of the laceration includes location, length, depth, involvement of the vermillion border and presence of contamination or foreign bodies. Make sure to examine the internal and external lip as partial thickness without vermillion border involvement could be managed conservatively.

Figure 2: Anatomy of the superficial and deep structures of the lips (UpToDate, 2023)1


Anesthesia

Local anesthesia is often avoided in lip lacerations as it can cause swelling which will contort the laceration making it more difficult to maximize the cosmetic appearance. In young children, conscious sedation is needed as they will not stay still for the repair even if they are anesthetized. In adults, infraorbital nerve blocks are used for upper lips lacerations and mental nerve block are used for lower lip lacerations. These nerve blocks provide excellent anesthesia and the landmarking for these blocks are relatively simple. The supraorbital foramen, infraorbital foramen and mental foramen are lined up in a midsagittal plane (See figure 3). Another way to landmark the mental foramen is to find the midpoint between the alveolar crest of the second premolar and the inferior border of the mandible.2 When the mental foramen is located, inject 2-3cc of 1% lidocaine with epinephrine and bicarbonate approximately 1cm under the skin towards the mental nerve. If your laceration is at the midline, then bilateral mental nerve blocks will be needed. Next, wait 15-20 minutes to allow for the anesthetic to take full effect before starting the repair.

Figure 3: Anatomical location of the supraorbital foramen, infraorbital foramen, and mental foramen. (Can J Anesth/J Can Anesth 56, 704–706 (2009).)2


Laceration Repair

Once the laceration is fully anesthetized, you can irrigate the wound and thoroughly examine the laceration. You need to rule out any foreign bodies in the lip through palpation as teeth fragment may not be initially visualized. If in doubt, a lateral XRay may rule out any teeth fragments in the lips as they are radiopaque. You may need to get an extra set of hands to help evert the lip when closing the inner lip portion of the laceration. The most important suture in this repair is the suture at the vermillion border as lining up the vermillion border perfectly will yield the best cosmetic result.3,4Some clinicians prefer to close the inner and outer fibrofatty junction before the vermillion border, whereas some will put their first suture at the vermillion border before closing the deeper tissues. After these steps, you simply need to bring the rest of the lacerations back together. Most clinicians will use either 4-0 or 5-0 absorbable sutures for their deep sutures then 5-0 or 6-0 absorbable sutures for the superficial sutures depending on the anticipated tension on the wound when closed.


Aftercare

The main considerations for aftercare of wounds are tetanus, prophylactic antibiotics, and follow-up.

  • A tetanus booster should be given to patients who are unsure as to when their last dose was or if it has been greater than 5 years since their last Tdap.
  • The evidence of prophylactic antibiotic treatment for lip lacerations is lacking. One study by Steele et al showed that there may be a benefit to prophylactic antibiotics in full thickness lip lacerations such as our case, but their results were not statistically significant.5 The face in general is such a highly vascularized area that if the patient is healthy and not taking any immunosuppressants medications, then the risk of infection is low, and antibiotics are not needed. Irrigation with salt water 2-3x/day is sufficient.
  • Lastly, simple lip lacerations that were repaired in the ED with satisfactory results don’t need Plastics follow-up. If the lip is quite disfigured and you are worried about the cosmetic results, then these patients should be seen by Plastics either in the ED or within 24 hours. Follow-up after several days or more should be avoided as the laceration will already be in the healing stage. This would make any revision and/or alteration to cosmetic results difficult.

References

  1. Hollander, J., & Weinberger, L. (2022, September). Assessment and management of lip lacerations. UpToDate.
  2. Tsui, B.C.H. Ultrasound imaging to localize foramina for superficial trigeminal nerve block. Can J Anesth/J Can Anesth 56, 704–706 (2009).
  3. Espinosa MC, Hohman MH, Sivam S. Oral and Maxillofacial Surgery, Facial Laceration Repair. [Updated 2023 May 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
  4. Armstrong, B. Denise. “LACERATIONS OF THE MOUTH.” Emergency medicine clinics of North America 18.3 (2000): 471–480. Web.
  5. Steele, Mark T et al. “Prophylactic Penicillin for Intraoral Wounds.” Annals of emergency medicine 18.8 (1989): 847–852. Web

 

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Chest tube insertion – Pigtail

Pigtail Catheter Insertion Procedure

EMSJ Faculty Pearl

Dr. Paul Frankish & Dr. Matt Greer

Updated April, 2023


See Video of Pigtail Catheter Insertion Here


Equipment Update: 

Adults: Trauma carts should be stocked with 28Fr, 24Fr, 20Fr standard chest tubes and 14Fr pigtail catheter kits. It is recommended that we discontinue stocking larger sized chest tubes (32Fr, 36Fr) and Cook 9Fr pneumothorax set with metal trochar/needle.

Pediatrics: PALS carts should be stocked with 10Fr seldinger kits, 14Fr pigtail catheter kits and 20 Fr standard sized chest tubes.


  1. Obtain informed consent if possible, obtain all supplies needed, have drainage system opened and ready to go.
  2. Confirm 3-way stopcock attached to tube, then insert obturator through this 2. Sterile prep, drape, gown/glove.
  3. Identify triangle of safety (5th IC, mid axillary, pectoralis). – or use PoCUS to guide site safety and depth (DL)
  4. Anesthetize skin, subcutaneous, rib, intercostal, and pleura. Consider procedural sedation.

May need up to 20 cc of local, consider refreezing with larger spinal needle, withdraw until the air bubbles stop to freeze the pleura


5. Insert large “seeker” needle at desired IC space, with fluid filled syringe attached, withdraw as you go.


Note the depth when you get air bubbles for when you dilate the tract


6. Slide over superior aspect of rib and stop when you withdraw air bubbles/fluid.
7. Detach syringe and insert guidewire through needle. There should be no resistance. Only about 10 cm inside the thoracic cavity is required. Remove needle while leaving the guide-wire in place.
8. Make a small incision with 11-blade alongside guidewire, then dilate to required depth with dilator, then insert pigtail with obturator over wire to appropriate depth.


Remove the obturator once tube is within pleural cavity, then advance pigtail into chest


9. Insert as far as possible until resistance is felt to ensure all fenestrations are within the thoracic cavity.


You can always pull it back out if it’s in too far


10. Attach tubing extension, then to either Heimlich valve or underwater seal/wall suction.


Heimlich valve function is unidirectional. Attach blue end to chest tube


11. Suture in place as per usual chest tube technique. Ensure dressing optimizes skin seal (sticky/occlusive).
12. Confirm placement with chest x-ray.


 

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An approach to removing hair tourniquets

Getting out of a hairy situation – an approach to removing hair tourniquets 

Resident Clinical Pearl (RCP) May 2020

Renee Amiro – PGY3 FMEM Dalhousie University, Saint John NB

Reviewed by Dr. Kavish Chandra

 

A two-month-old male presents with his mother to the emergency department with two tightly wound hairs around his fourth and fifth toes. He is visibly upset and crying excessively. His mother says that his toes looked like this when he woke up this morning. He is otherwise well and has had his two-month immunizations.

His toes look like this:

 

 


Hair tourniquet syndrome

Definition – a tightly wound hair, thread, rubber band that is wrapped around an appendage and causes impaired blood flow.

Why this is bad – the constriction causes edema which restricts venous blood flow causes more edema which then impedes arterial blood flow and that can cause ischemia and if left undetected could cause amputation.

Most common appendages involved – Toes, external genitalia, fingers

Most common presenting symptom – excessively crying young child or swollen appendage found by mom or dad.

 

Management

Goal is to remove the restricting band ASAP!

Remember to treat pain! Using emla gel on the digit prior to any manipulation and use other analgesics as you deem appropriate. Remember the use of sugar for pain management in babies.

In all management types- ensure you have gotten all of the hair and have released the constricted band completely.

  1. Try and unwind the hair!
  • Works best if caught early
  • You can use a cutting suture needle to try and get underneath the hair and release it.

 

  1. Depilatory Cream
  • Apply Nair to the affected toe and allow 2-8 minutes to see if the hair dissolves.
  • Should not be used on open wounds and can cause skin irritation.
  • Does not dissolve cotton, polyester or rayon threads.

 

  1. Dorsal Slit Procedure (for digits)
  • Do a slit on the dorsal surface along the long axis of the digit through the area of constriction down to the bone to ensure release of tourniquet.
  • Lateral aspect contains nerves and blood vessels and should be avoided. You may cut the tendon doing a dorsal slit along the long axis- but you won’t affect function of the digit.
  • Ensure that the patient has close follow up to ensure healing and complete resolution of the tourniquet.

 

The bottom line

  1. Think of this diagnosis and LOOK for it in a young child brought to the ED with “excessive crying”
  2. Ensure adequate pain management prior any invasive removal of the tourniquet.
  3. Move quickly down the list to the dorsal slit procedure (for digit) if deeply embedded hair with significant edema or tissue compromise.

 

Copyedited by Kavish Chandra

 

References

Lin, Michelle 2012. https://www.aliem.com/trick-of-trade-hair-tourniquet-release/

Fox, Sean 2015. https://pedemmorsels.com/hair-tourniquet/

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What we missed in FOAM October 2017

Welcome to SJRHEM’s newest feature, “Best of FOAM”. This is a quick curated list of the best free open access medical education the internet has to offer!

Subscribe to our twitter feed for regular updates and enjoy!

 

EM procedures

 

Clinical summaries

 

Kavish Chandra, R3 FMEM, Dalhousie University, Saint John, New Brunswick

 

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