September 2020

Clinical Question

What do you do if you glue a patient’s eyelid shut?

Title of Paper

Inadvertent tissue adhesive tarsorrhaphy of the eyelid: a review and exploratory trial of removal methods of Histoacryl

Journal and Year

EMJ. 2020.

Lead Author

Zhenghong Liu

Background

– It’s been done before, and it will happen again (touch wood I haven’t been responsible for this particular problem before) – a bit of overzealous tissue adhesive application or a sudden movement from a patient and shut goes the eyelid
– There have been copious case reports and a couple of studies looking at options to encourage the glue to let go testing anything from acetone to margarine, but which should we plumb for in the ED

Methods

– Authors performed an extensive literature search for anything looking at skin glue and identified papers assessing removal methods
– Any compound reported to have positive results for glue removal were included in their study
– Excluding substances which would be harmful to the eye, of course
– They made standardised (3cm long, 0.5cm deep) wounds on cadaveric pigskin which they then glued with Histoacryl
– First – assessed how long it takes for ‘complete closure’ – so that wound edges couldn’t be separated with their fingers
– Attempted every 10s and found that 90s consistently allowed for complete closure (a useful piece of information for your practice in itself)
– Then tested each compound in three ways: (each performed twice for each compound)
1. 45s post application, rubbing with the compound for 5 minutes
2. 90s post application, rubbing with the compound for 5 minutes
3. 90s post application, soaking in compound and reattempting wound opening for 1 minute every hour
– Primary outcome: complete separation of wound edges using gentle traction with fingers.

Summary of Results

– 37 papers providing methods, most often surgical along with 24 suggested successful compounds (including baby powder, margarine and KY jelly, to name but a few)
– 45s – acetone was the only product that worked consistently
– 90s – none of the compounds worked just by rubbing
– Soaking – Polydexa ear/eye drops showed consistent success at 2 hours.

– Polydexa – available in Singapore, couldn’t find it for UK, with the most similar I could see being Ottosporin (Polymixin B Sulphate, neomycin & hydrocortisone) – only difference in Polydexa is dexamethasone.

Authors Conclusion

In our trial of removal methods of Histoacryl on a porcine model, soaking in Polydexa antibiotic drops consistently facilitated removal after 2 hours.

Clinical Bottom Line

1. Let’s just try to avoid glue in the eye In the first place (see ALiEM method below, for example)
2. If it does happen then soaking in ottosporin for a couple of hours is a reasonable alternative to surgery
1. If ottosporin / Polydexa not available, there are other suggested compounds in the paper (cipro ointment for example, which may work but takes longer)
3. Useful to know that 90s is how long for glue to really set – I’m not sure I wait that long but probably will make an effort to now.

Other #FOAMed Resources / References:

ALiEM – Tick of the Trade – Preventing tissue adhesive seepage

Clinical Question:

– should we be ultrasounding suspected skin abscesses before drainage in the ED?

Paper title:

– Point-of-Care Ultrasonography for the Diagnosis of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-analysis

Author:

– Gottlieb, 2020, Annals of EM
https://pubmed.ncbi.nlm.nih.gov/32081383/

Background

– We see lots of skin abscesses and we think we’re pretty good at knowing when it’s cellulitis and when it’s abscess and when it’s worth cracking out the scalpel and some local and draining it.
– there have been several studies suggesting that PoCUS is pretty good at identifying an abscess when it’s there. There’s even a term called “pustalsis” to describe the swirling pus of a nice juicy collection.

Methods

– whenever you read a SRMA you have to identify what the question is. In this case they’re looking at accuracy for identifying abscesses. Which is a very different question from “does scanning before incision improve outcomes.” so keep that in mind
– they describe a fairly thorough search strategy and used the QUADAS tool for assessing quality of included trials.

Results

– found 14 studies and 2500 pts which for PoCUS is actually surprisingly good. 1200 pts came from one study
– 95% sensitivity, 85% specificity is the take home. So it’s really good at finding pus when it’s there. But sometimes when it looks like there’s pus then there isn’t.
– worth understanding that there isn’t really a great gold standard here to compare it with – typically it’s going to be “was there lots of pus when someone put a knife in it” but that’s no more objective than swirly grey pus stuff on ultrasound.
– they also quote a prior study on clinical exam for abscess detection that found sensitivity and specificity in the 40s so no matter what way you look at it PoCUS seems somewhat better

Thoughts

– SRMA are always hampered by the quality of the studies and the studies included in this one were by no means perfect. Any numbers generated should be taken with a grain of salt
– secondly most of us don’t use PoCUS for every skin abscess. For most it’s really obvious – it’s either obviously cellulitis or obviously an abscess. But when there’s doubt I will often scan rather than incise it blindly.

www.nice.org.uk

Published in March 2020 this guideline has relevance to us in ED, but also for anyone out there who has a primary care interest too!

The first pearl of the guidance comes early – people of a European family origin are more at risk of AAA apparently.  Annoyingly we couldn’t find the reference for this in the Guideline.

Screening:

There’s an NHS screening program in England and GP or patient can refer themselves directly for this if they are a man over the age of 66 with any of the following risk factors – COPD, generalised atherosclerosis, family history of AAA, HTN, high cholesterol, active or former smoker.

Ladies are at decreased risk when compared to men. We only need to ‘consider’ aortic imaging as screening if you have those risk factors and are over 70.  This is a disease that affects men far more frequently than women.  Depending on your source it can be as high as 4:1 difference.

If you detect an asymptomatic AAA then  complete an outpatient vascular referral to be seen within 2 weeks if >5.5cm, or 12 weeks if 3-5.5cm.

So what about in ED?

You have to be thinking of it in order to diagnose it.

NICE says to consider in patients with new abdominal and or back pain, TLOC or cardiovascular collapse.   Be MORE considerate of it in those with a known AAA, those >60, people who smoke or used to, and those with a history of HTN. Although not included in the guideline – we recommend putting your older renal colic patients int his group as well.

Interestingly a AAA is more likely to rupture in a woman than a man – but women are less at risk ( see above!)

We should be offering POCUS to all of the patients in which we are considering a diagnosis of AAA. If that POCUS shows a AAA you need to pick up the phone to vascular or if you don’t have them in your hospital then need to refer on to regional vascular centre.

In the patients who you either can’t get or do an US locally OR your US is non-diagnostic then speak to the vascular centre anyway ASAP.

When you do your imaging NICE recommends measuring ‘inner to inner’ in line with the screening program. We seem to be taught to measure outer to outer in Ed – which seems reasonable and safe. A really important pitfall when scanning is to ensure you don’t measure the false lumen of a AAA and falsely reassure yourself that the calibre is normal.

Once diagnosis made on US the decision needs to be made as to whether to offer repair and if CT prior to repair is going to be useful.  it helps the surgeons know if a) endovascular repair is an option and b) what they’re dealing with in terms of distal run off etc.

The decision making around suitability of a patient to be offered a repair is one that usually involves the MDT and it should be being made by senior clinicians. Interestingly NICE says no single sign, symptom or prognostication tool should be used to determine if AAA repair is suitable, and likewise no scoring system should be used either.

What about in hospitals without vascular services?

You need to have a collaborative way of getting these folks to a vascular centre.

NICE specifically says there is no single sign, symptom or prognostic test that can be used to define if someone should be transferred. They do note that someone who has a confirmed ruptured AAA and has a cardiac arrest or persistent LOC has a negligible chance of surviving an AAA repair.

Once your patient has been accepted by the vascular centre then ensure they leave your unit within 30mins.

If offering repair it would be worth considering that EVAR is only suitable for infrarenal AAA and confers benefit in patients >70, but open repair in the under 70 is probably better (in ED we won’t be making this decision but if you are considering a CT prior to operative intervention it’s with knowing the rationale for why you’d want the scan!)

Authors:

Dr Mark Winstanley
Dr Michelle Tipping

Links to guidelines and other reviews:

1. BSPED DKA Guidelines
2. NICE Guidelines
3. DFTB article
4. St Emlyn’s article