Nail Injury Arts and Crafts

Should you use a glue stick or needle and thread to repair Nail Bed Injuries?

A common injury in pediatrics (and the adult world) is nail injuries.  Often these can be crush injuries (think of the last child you saw present after their fingers were crushed in a door) or trauma from some sort of sharp device or instrument.  The standard approach if there is a suspicion of a nail bed laceration and/or avulsion is to remove the nail, repair any underlying laceration and then splint the eponychium either with the original nail itself or a substitute.

A functional nail is important for sensation and grasping items, and the cosmetic outcome is important for many patients and families. Therefore, the main goals of nail removal and repair are to:

  1. Facilitate evaluation of the nailbed, and treatment of any discovered wounds if necessary
  2. Promote cosmetic and functional healing of the affected finger

Once you have removed the nail you can assess the damage and determine how will you repair any lacerations you find before reattaching and splinting.  The standard technique is to use rapid absorbing suture for repair of nail bed lacerations and then reattach the splint with 2 simple nonabsorbable sutures.  However, what about using tissue adhesive (Dermabond©) for both steps?  (Closing the Gap has an excellent overview of this wider topic of injuries and repair and they also link to this excellent write up at Academic Life in Emergency Medicine on how to use tissue adhesive to reattach the nail)  Tissue adhesive has been extensively studied in both adult and pediatric populations and is widely viewed as a safe and reasonable option for many forms of laceration repair in children at other anatomical sites.  The first description of tissue adhesive to reattach the nail was described here in 1997 with good results.

In 2008 a randomized controlled trial was performed by E. Strauss et. al.   Adult patients with acute nail bed lacerations were randomized to two groups.  One group used tissue adhesive and the other group used suture material for laceration repair AND nail splint fixation in both steps.    Their outcome measures were cosmetic and functional appearance of the healed nail at a minimum of 4 months as evaluated by both a physician and the patient.  Of note they noted no significant difference between the two groups regarding cosmesis and functionality as well as no significant increase in nail infections. Their study also noted a very significant difference in time of repair (9.5 minutes for tissue adhesive, 27.8 minutes for suture repair). This is potentially quite a significant difference when you are considering a the need for child life, pharmacologic anxiolysis and digital block for the squirmy pediatric patient in your busy ED.  Noted limitations to this study would be the relatively small sample size and that the vast majority of their discussion relates to cosmesis, but little on how well tissue adhesive actually kept the nail splinted.  Can these results be extrapolated to pediatric patients with nailed injuries?

Fortunately Langlois et. al has also since published a follow up study (of sorts) the following year regarding the use of tissue adhesive in pediatric patients.  They performed a prospective trial using solely tissue adhesive for both nail bed repair and reattachment of the nail of 30 patients.  While their sample size was small they had excellent reported results overall, no reported wound infections and overall satisfactory cosmetic and functional results.  Again, this study, like the study by Strauss, has limited generalizability given it’s limited  sample size and  by being a purely prospective study without a control group.

While the data appears to be too limited in children to move fully to using tissue adhesive as the front line material for nail bed injury repair it is favorable in some respects – especially time to procedure completing and cosmesis.  This illustrates, if anything, the need for larger studies to see if this technique can be generalized within the pediatric population and that it truly is not inferior to the time honored suture repair technique. The durability of the repair in the face of a slobbering toddler is paramount. Additionally, any patient in whom the repair could be compromised du to accidental manipulation should be splinted.

If time or the ability to use less sedation/anxiolysis is a major concern, tissue adhesive could be a very viable option in pediatric patients for nail bed repair.  Watch out needle and thread, there’s a new glue stick in town.

References

Langlois; C. Thevenin-Lemoine; A. Rogier; M. Elkaim; K. Abelin-Genevois; R. Vialle “The use of 2-octylcyanoacrylate (Dermabond(®)) for the treatment of nail bed injuries in children: results of a prospective series of 30 patients.J Child Orthop. 2010 Feb;4(1):61-5. doi: 10.1007/s11832-009-0218-1. Epub 2009

Strauss; W. Weil; C. Jordan; N. Paksima; “A Prospective, Randomized, Controlled Trial of 2-Octylcyanoacrylate Versus Suture Repair for Nail Bed Injuries” J Hand Surg. February 2008. 33A.  Pp. 250-253, 2008.

Stanislas; M. Waldram; ‘Keep the nail plate on with Histoacryl.” Inj. Vol. 1997. 28:8, 507-508, 1997.

Reid; M. Duncan; “Interventions for treating fingertip entrapment injuries in children”. Ped Child Health. January 2016. 21.1. Pp. 27-28, 2016.

Lin. “Nailbed Inuries, Part II” https://lacerationrepair.com/anatomic-regions/nailbed-injuries-part-ii/ Accessed on 11/10/16

Rezaie; “Trick of the Trade: Nail Bed Repair with Tissue Adhesive Glue.” https://www.aliem.com/2014/trick-trade-nail-bed-repair-tissue-adhesive-glue/. Accessed on 11/10/16

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AAP 2016 Top 10 #3: Dopamine versus Epinephrine

Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock

Ventura, Andréa M. C. MD, Shieh, Huei Hsin MD, Bousso, Albert MD, Góes, Patrícia F. MD, Fernandes, Iracema de Cássia F. O. MD, de Souza, Daniela C., Paulo, Rodrigo Locatelli Pedro MD, Chagas, Fabiana RN, Gilio, Alfredo E. MD

The Bottom Line

Epinephrine is a better vasopressor than dopamine in fluid refractory shock

What They Did

  • This was a randomized controlled trial of 1-15 year olds with fluid refractory septic shock (not responsive to 40ml/kg crystalloid) with the primary outcome 28 days mortality
  • Randomized to either dopamine (5-10 μg/kg/min) or epinephrine (0.1-0.3 μg/kg/min) through a peripheral IV or IO
  • 13 (20.6%) died in the dopamine group and 4 (7%) died in the epinephrine group (p=0.033)
  • Dopamine and death, OR=6.5 (95% CI, 1.1-37.8; p=0.037)
  • Dopamine and healthcare-associated infection ,OR = 67.7 (95% CI, 5.0-910.8; p=0.001)

What You Can Do

  • This is further supportive of the fact that epinephrine is a more effective choice as an initial vasopressor in fluid refractory shock
  • Doses may not have been similar to what everyone uses – nor equivalent between doses
  • It was also a single site study – so the results should be interpreted in light of how this affects validity across the board

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AAP 2016 Top 10 #2: A metronome in simulated CPR

Use of a Metronome in Cardiopulmonary Resuscitation: A Simulation Study

Links   PubMed   Pediatrics  pdf

The Bottom Line

Using a metronome during CPR may help chest compressors maintain their rate.

What They Did

  • The investigators conducted a prospective crossover randomized controlled trial of pediatric residents, fellows, nurses, and medical students who they randomly assigned to do chest compressions on a mannikin with and without a metronome
  • The metronome sounded at a rate of 100 times per minute
  • The investigators also piped in “background noise”
  • Each participant did 2-minutes of CPR, twice with a 15-minute break in between cycles. One group had metronome first, the other metronome second.
  • The CPR rate and depth were recorded electronically via the ResusciAnne Wireless SkillReporter software
  • Metronome on 72% adequate rate (90-100 compressions/minute)  vs 50% off (95% CI, 15% to 29%)
  • No significant difference was noted in the mean percentage of compressions within acceptable depth (38–51 mm)
  • Interestingly the metronome had a larger effect amongst med students, residents and fellows as opposed to the pediatric nurses

What You Can Do

  • This is one of those “so simple why didn’t I think of it” ideas
  • Go ahead and try using a metronome the next time you run a sim or practice CPR. Maybe you even bring one into your resuscitation area?
  • The reason why PALS teachers recommended “listening to” Stayin’ Alive by the Bee Gees is that the song is 103 beats per minute. Interestingly a study from 2011 looked at compression rates while CPR participants listen to either “Achy Breaky Heart,” “Disco Science” or no music at all.

Listening to DS significantly increased the proportion of prehospital professionals compressing at 2010 guideline-compliant rates. Regardless of intervention more than half gave compressions that were too shallow. Alternative audible feedback mechanisms may be more effective.

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AAP 2016 Top 10 #1: The reliability of telemedicine assessments

Reliability of Telemedicine in the Assessment of Seriously Ill Children

Lawrence Siew, MD, Allen Hsiao, MD, Paul McCarthy, MD, Anup Agarwal, MBBS, Eric Lee, BS, Lei Chen, MD.
Pediatrics, 2015
Links   PubMed   Pediatrics  pdf

The Bottom Line

Telemedicine can offer a reliable way to assess children with fever and respiratory distress when compared with the bedside examination.

What They Did

  • A convenience sample of 2 to 36 month olds with fever were evaluated with the Yale Observation Score and 2 to 18 year olds with respiratory symptoms were assessed via a visual signs only respiratory score  score by both bedside assessment and via FaceTime on an iPad
  • The primary objective of the present study was to determine the reliability of telemedicine observations, compared with bedside observations as assessed by Pearson’s correlation coefficient. A strong agreement is generally κ >0.8.
  • 132 febrile infants were assessed with overall κ=0.81 between the live and FaceTime examiner
  • 145 patients with respiratory symptoms were assessed and κ=0.85 for “impression of respiratory distress” and κ>0.6 for the majority of the remaining components, with intercostal retractions having the lowest agreement.

What You Can Do

  • Recognize that telemedicine is a solution to providing care to locations with limited access
  • Many of you already have it available to you and don’t even know it – current applications I have used include video interpreter services, remote consultant with critical care medicine and mental health evaluations in the ED.
  • Know that it doesn’t replace the initial bedside assessment, but with the fidelity of current video devices as well as the improving availability of broadband internet it is easier than ever to connect with a colleague in another part of the country. You need to communicate what you are seeing, and know that the telemedicine interaction is only as good as the data the patient relays to you.

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