08 September 2008

I learned something today


From Saturday Morning Breakfast Cereal. Funny, funny, very sick awful comic.

Seriously, I recently had a guy with a complex ear laceration. He had rolled his ATV and tore the hell out of his pinna (the upper ear) and almost pulled it off of his scalp. It was as challenging a laceration as I am willing to tackle myself without Plastic Surgery backup. I finished a very nice job of putting it back together, but it just wouldn't stop bleeding. Ears are, like the scalp, very vascular, but you can't use epinephrine on them to blanch the blood vessels and stop the bleeding. So direct pressure is the only option, but that can be tricky with the complicated three-dimensional structure that is the ear. And this wound was really just ooozing and oozing and would not stop. So I created a bolster to go behind the ear, and an absorbent pad to go over the ear, and I wrapped an ACE bandage around the head several times, really tight, to create a pressure dressing. And it worked beautifully -- finally, the bleeding seemed to be stopped.

As I stepped away from the patient, I noticed his scalp (he was bald). It was a deep purple hue. I realized that my clever pressure dressing had effectively created a tourniquet for the scalp. What the hell was I going to do? I couldn't just leave it like that, could I? If I loosened the dressing, the bleeding would stop again. Maybe I should just leave it on. What were the ill effects of a scalp tourniquet left on overnight? I'm pretty sure there's no good research on that topic. So how long was it going to take for a good solid clot to form so the bleeding would not restart? Maybe an hour or two.

"How's your scalp feeling?" I ventured to ask him.
"It's OK, maybe a little tingly."
"Um, you may find it a little uncomfortable when you get home. If you do, it's OK to loosen that wrap I put on, after a couple of hours."
"OK, thanks doc."

There just is no instruction manual for this job.

5 comments:

Matt Dick said...

So you couldn't find a very small clamp that could do the job? I find that surprising. With the bolster you described I would imagine a black binder clip (the office supply staple) would be almost perfect. It might need to be loosened a bit on clamping pressure, but it seems a simple solution.

kferp

shadowfax said...

The total laceration length was about 7.5cm, and it was a stellate laceration, so there was no single point of bleeding to clamp. It was just oozing briskly from the entire area. I could have stopped the bleeding by cinching the stitches down tighter, but that's not real desirable in the ear, because you'll just get blood collecting under the skin and the swelling will distort the nice repair I did.

rlbates said...

It really is okay to use epinephrine on the ear. You just don't want to do it circumferencially. It can be used say on the ear lobe or in the area behind the ear or just the pinna.

Cynic said...

Agree with Dr. Bates, it makes life easier.

http://www.ncbi.nlm.nih.gov/pubmed/16372813

http://www.emedicine.com/proc/TOPIC83294.HTM

Seattle Plastic Surgery on Lake Union said...

Shadow- I applaud your effort and technical confidence to tackle a complex ear laceration. Kudos.

I would like to hear your opinion on a topic that is rapidly growing near and dear to my heart...the scenario is thus:

I'm on call, the local plastic surgeon, for the local ER. You are seeing a nice family with a child that has sustained a simple facial laceration. No fractures, no missing tissue, just a simple, linear, forhead laceration.

The Mom asks that a plastic surgeon be called to come in from home and close the wound. You reply that you are able to do the closure, the child is medically stable, and that a you are qualified to close the wound. The family presses you: call the plastic surgeon.

Can you tell me, from an ER doc's standpoint- what is the most appropriate response from the on call plastic surgeon?

In your experience, are families aware that they may be sent a second bill for the ER laceration closure by the on-call plastic surgeon? Are they made aware of this possibility?

Without question, if an ER doc tells me that they need me to close a laceration, due to its location, complexity etc...I come in to close it. But these 'parent requests' plastic surgeon call are becoming more frequent.

I'd appreciate your thoughts on this matter.