staple of scalp lac without lidocaine?

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Painter1

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proabably a dumb question. i had an attending think i was a complete nimcompoop because I didn't numb a scalp lac needing three staples. i've had senoir residents and an attending in the past tell me to forego lido when stapling scalp lacs. this was unheard of according to this attending.
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Agreed I only numb kids with LET gel I rarely numb adults for staples.
 
I was told if its only a few staples then the shot would hurt worse than just putting in the few staples.....


I guess you could argue only a few stitches vs the shot, however, the staples are quick and little movement wont affect anything. Its hard enough to stitch a moving target thats not feeling pain...
 
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1. get a stapler from the ER

2. Get some lido with epi on a 27 G needle

3. numb one side of your head

4. Have someone give you 10 staples on each side of your head


I think you'll numb in the future. I guess if you were only doing 1 or 2 staples you might make the argument not to numb but if you are only doing 1 why bother. You close big scalp defects. You're not doing it for cosmesis and little ones aren't going to matter
 
I've heard the same from many attendings as well...don't numb for a few staples. Although in practice, I have for much larger injuries requiring me to really irrigate and explore the wound.
 
ERMudPhud said:
1. get a stapler from the ER

2. Get some lido with epi on a 27 G needle

3. numb one side of your head

4. Have someone give you 10 staples on each side of your head


I think you'll numb in the future. I guess if you were only doing 1 or 2 staples you might make the argument not to numb but if you are only doing 1 why bother. You close big scalp defects. You're not doing it for cosmesis and little ones aren't going to matter
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More than once, I've given patients the option - I say that I'm going to put one in, and for them to tell me if it hurts - and, more than 5 times, the patients have told me that it did NOT hurt, and I did not numb it up. And this is the gamut from teenager to senior citizen, drunk and sober. Twice, it was 10 staples.
 
Apollyon said:
More than once, I've given patients the option - I say that I'm going to put one in, and for them to tell me if it hurts - and, more than 5 times, the patients have told me that it did NOT hurt, and I did not numb it up. And this is the gamut from teenager to senior citizen, drunk and sober. Twice, it was 10 staples.
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So, five times in what five years you've had people tell you it doesn't hurt? Now throw out all the drunks. Now throw out all the young guys too afraid to admit it hurt in front of their friends. Now throw out all the elderly too demented to know it hurt. Now throw out everyone too stoic or polite to admit it hurt. How many left now?

Seriously, get a stapler and have a colleague bang ten staples into your head then let us know how it feels. There are tons of studies comparing different types of anesthetic for stapling scalp lacs but none that I could find had a placebo arm.
 
So would LET handle the pain from two scalp staples? I hope so, 'cause that's what I did to a five year old the other night...

Please say yes...
 
Dr. Will said:
I've heard the same from many attendings as well...don't numb for a few staples. Although in practice, I have for much larger injuries requiring me to really irrigate and explore the wound.
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I do this as well.
LET for 10 min for 3 staples or less then just do it.
ditto 18g needle to tense paronychia. hurts a lot less than a digital block.
 
ERMudPhud said:
So, five times in what five years you've had people tell you it doesn't hurt? Now throw out all the drunks. Now throw out all the young guys too afraid to admit it hurt in front of their friends. Now throw out all the elderly too demented to know it hurt. Now throw out everyone too stoic or polite to admit it hurt. How many left now?

Seriously, get a stapler and have a colleague bang ten staples into your head then let us know how it feels. There are tons of studies comparing different types of anesthetic for stapling scalp lacs but none that I could find had a placebo arm.
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Wow - more emotion than I've ever seen you show on SDN. Seriously, when you throw out the drunks, the demented (who, actually, for me, WILL squirm, and I have to anesthetize), and the young stoic types (who, even if it DOES hurt, they weren't wincing), there really aren't too many left. At the same time, you've said "10 staples" a few times, whereas I'm talking 5 or 6 - max. And, as I tell the patients, with the staples, when you feel it, it's over. Also, as I said, I offer the patients to get one without anesthetic, to see if they can tolerate it. If they can't, then I numb them up. Don't paint me as "I just staple everyone up with no anesthetic".

One patient I DID staple without anesthetic (because the patient was REALLY vacillating between the pain from the stick and burn of the lido or just getting stapled) was a cutter - all sorts of scarified lesions, transversely on the forearm of the nondominant hand. Three fresh, and into the sub-Q fat - you KNOW they hurt to cut. I ended up Dermabonding one, stapling and Dermabonding another, and stapling the third (which got the best approximation) - and, in my mind, I marveled at the irony of this woman complaining about the needle vs the staple (and the minimal lavage), with the self-inflicted wound having been the most painful of all.

edit: the twice when it was 10 staples were drunks. That is all.
 
I use either LET or lido with epi for everyone but people who are self-anaesthetised (drunks).
 
I always numb mine. If it is large enough to staple it is large enough to anesthetize.
 
I never numb it up when an alcoholic ended up with a scalp lac because they fell while drunk.
 
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Apollyon said:
More than once, I've given patients the option - I say that I'm going to put one in, and for them to tell me if it hurts - and, more than 5 times, the patients have told me that it did NOT hurt, and I did not numb it up. And this is the gamut from teenager to senior citizen, drunk and sober. Twice, it was 10 staples.
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I can only give my opinion from a patient's POV. I was given the option when I needed three and I appreciated it. I asked to skip the drugs. It wasn't that bad. It hurt, but I don't think it was any worse than a shot for numbing a site would be. If I needed more than five, I would have wanted it numb.
I have a highish pain threshold, for what it's worth.
 
wow surprising.. I will say if the defect is huge then yeah i will numb but most require 4-5 and LET get works great esp in kids.
 
I had 5 staples placed in a scalp lac without anesthesia. Not that big of a deal--somewhat painful, but probably no more than it would be for needle anesthesia. The additional benefit is that the entire uncomfortable experience is over much quicker.

In one of the ACEP news fliers a few months ago they had a clinical pearl for stapling head lacs in kids. They noted that most kids don't react until after the first staple, so you can use a double stapler technique for most small to moderate head lacs. You and an associate can each staple at the same time. You can close most head lacs with 2 staples with no need of an invasive needle. Additionally, at our peds hospital, some people successfully sew lacs up with just LET and no needle anesthesia.
 
I agree with apollyon.
Usually about 3 or fewer I don't anesthesize. If they're with it, I'll ask and let them decide. Lidocaine stings a bit for most of us who have had it. I would much rather the couple of pops of a staple gun, but I do give the option.

More than this especially 10 staples I would always anesthesize(Ithink we all would).

Another topic that I think someone brought up was dermabond on staples. How often do people dermabond over staples or sutures? Very rarely, I've had kids pick there sutures or staples out shortly after placing them and had to redo them. So the next time I closed them I put dermabond over them. Anyone else do this??
 
macdaddy23 said:
I agree with apollyon.
Usually about 3 or fewer I don't anesthesize. If they're with it, I'll ask and let them decide. Lidocaine stings a bit for most of us who have had it. I would much rather the couple of pops of a staple gun, but I do give the option.

More than this especially 10 staples I would always anesthesize(Ithink we all would).

Another topic that I think someone brought up was dermabond on staples. How often do people dermabond over staples or sutures? Very rarely, I've had kids pick there sutures or staples out shortly after placing them and had to redo them. So the next time I closed them I put dermabond over them. Anyone else do this??
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Hmm. I've never dermabonded over sutures or staples. Maybe I should for kids who pick, I just really never thought of it.

I numb for more than 3 staples in head lacs.

The worst one I had was trying to put 20+ staples in a guy once across his abdomen -- he had a superficial abdo wound from a knife fight -- and I had to stick him about 10 times with the 18ga to even ATTEMPT to anesthetize the whole area with lido. Then, it was crappy anesthesia anyway because of the large area and subcutaneous fat. He felt at least 1/2 of those 20 staples. It was such a torture test for both of us. After, I tried to think what we could have done.

Was I gonna conscious sedate him? Hell no.

Was I gonna use more iv analgesia (fentanyl) next time. Yeah, I would.

Somebody even suggested an epidural might have been appropriate, but jesus, this seems like a lot of labor and considerable risk for repair of a superficial wound.
 
I used to feel like 1-2 staples didn't need lido. Then I did one on someone and they screamed bloody murder. Staples hurt like crap. Lido doesn't hurt that bad.


Numb it up. is my philosophy
 
Lido injection isn't too painful in the scalp - worth doing it prior to staples. The problem is when you don't numb enough of the area and the staples still cause pain -- double whammy.

JoeG
 
Pain is such a subjective thing, though. My threshhold is pretty low, but I have a good pain tolerance once the anticipation turns into a sensation I can process.

As a patient, I absolutely HATE the feeling of lido burning. To me, it feels like hot lava expanding and searing everything. I get great anasthesia, but it's a wave of numbness behind a wave of searing pain. Sutures take long enough that okay, it's worth it.

Matter of fact, I had three pilar cysts removed from my scalp a couple weeks ago. Lido was definitely in order, what with all the wrenching and pulling, followed by sewing. For staples, I'd accept an offer not to numb, as long as I could whine and swear for 30 seconds in between smacks.
 
fuegofrio17 said:
I had 5 staples placed in a scalp lac without anesthesia. Not that big of a deal--somewhat painful, but probably no more than it would be for needle anesthesia. The additional benefit is that the entire uncomfortable experience is over much quicker.
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I have had sutures without lidocaine twice (once as a child and once in college). Not the end of the world, although I wouldn't want a lot of them that way.

I don't numb for a few staples. If I'm going to do a lot & the person isn't self-medicated with EtOH, then I'm fine with some lidocaine.
 
ERMudPhud said:
Now throw out all the drunks. Now throw out all the young guys too afraid to admit it hurt in front of their friends. Now throw out all the elderly too demented to know it hurt. Now throw out everyone too stoic or polite to admit it hurt. How many left now?

.
Click to expand...

Ummmm....not very many. Who else gets huge scalp lacs?
 
Pain is such a subjective thing, though.
Click to expand...

Agreed....I have a pretty high pain tolerance.......except for the visceral "Oh my ****ing God my aorta is dissecting!" pain of kidney stones....if it happens again, I'm hoping to convince the doc that ketamine is logical choice to make me stop screaming.
 
A little off the subject, but as we're discussing staples in the scalp......be sure to let your patients know that hairdryers and scalp staples DO NOT MIX. I wish the ED resident who'd stapled me up had clued me in. Sweet baby james those little suckers heat up fast!!
 
ERMudPhud said:
1. get a stapler from the ER

2. Get some lido with epi on a 27 G needle

3. numb one side of your head

4. Have someone give you 10 staples on each side of your head


I think you'll numb in the future. I guess if you were only doing 1 or 2 staples you might make the argument not to numb but if you are only doing 1 why bother. You close big scalp defects. You're not doing it for cosmesis and little ones aren't going to matter
Click to expand...


put two staples in a 6 y/o head w/o lido. he did fine.
 
ERMudPhud said:
Seriously, get a stapler and have a colleague bang ten staples into your head then let us know how it feels. There are tons of studies comparing different types of anesthetic for stapling scalp lacs but none that I could find had a placebo arm.
Click to expand...

I didn't numb until I had a lac on my leg that needed suturing. Rather than have it sutured, I just threw in one staple -- which did the trick. However, I now know how much it hurts and will ALWAYS use lidocaine. I didn't realize just what I was doing to myself when I fired the trigger.
 
I had a gentleman have two episodes of syncope last week as I was suturing a rather complex scalp avulsion requiring 7-8 packs of suture. We sat him back up, put a little more Lido in the area I was repairing, for a total of 8 cc of 2% via an 18 guage needle, and kept on going. I felt a bit like a creep, but with the limited resources I had, and a desire to cover his skull as thoroughly as possible, I did the best I could. As bad as I was controlling his pain, the nurses that generally repair the wounds do not attempt to anesthetize. From all appearances, their suturing technique took many seconds of practice to perfect. :scared:

(**picture a 6-8 inch laceration beginning on the left neck, crossing under the chin, and extending toward the right angle of the jaw, with a single running stitch spaced at intervals of 1-1.5 inches apart**)

If I have a choice I will always anesthetize any repairable wound I can. Not only will it provide immediate relief but it will have the added benefit of relieving the pain for 30 min to 1 hour afterward. From a patients perspective, although it probably feels the same as a single staple or two, they will feel "better" after and appreciate the fact that the physician tried to alleviate the pain the best he/she could.

Of course, most of you guys have done this much longer than me...
 
If a kid just needs 1 staple, I will just sneak up and do it (with parent's knowledge of course) without lido since they are usually relaxed and not expecting it. If I give them lido, then they get all riled up no matter how numb they are...
Besides, it makes me feel like an stealthy assasin, sneaking up and popping a cap in the back of the head....

Anything more than 1 staple in a kid and I will numb them up. I give adults the option if it just a couple of staples. Anything more than a couple in an adult gets lido...
 
spyderdoc said:
If a kid just needs 1 staple, I will just sneak up and do it (with parent's knowledge of course) without lido since they are usually relaxed and not expecting it. If I give them lido, then they get all riled up no matter how numb they are...
Besides, it makes me feel like an stealthy assasin, sneaking up and popping a cap in the back of the head....

Anything more than 1 staple in a kid and I will numb them up. I give adults the option if it just a couple of staples. Anything more than a couple in an adult gets lido...
Click to expand...
We put EMLA on them, send them back to the waiting room or a hallway bed, and let them wait for 30 minutes until they're numb.
 
southerndoc said:
We put EMLA on them, send them back to the waiting room or a hallway bed, and let them wait for 30 minutes until they're numb.
Click to expand...

I sure would love it if our triage RN would throw the LET on the wound at triage time, but they don't like going the extra mile (union workers). I don't like putting patients back in the waiting room when the dispo clock is ticking away. These "quickie" patients help "pad" your dispo times....
 
southerndoc said:
We put EMLA on them, send them back to the waiting room or a hallway bed, and let them wait for 30 minutes until they're numb.
Click to expand...

I thought EMLA was only to be used/effective on intact skin (ie over an area prior to IV start etc...) NOT to be used in open wounds.

We use LET or TAC. EMLA only over LP area or IV site at the Children's ED.

This is just what we learned/were told by our peds EM faculty who put on our procedural sedation course.

Is this right? can you use EMLA on open wounds?

later
 
Painter1 said:
proabably a dumb question. i had an attending think i was a complete nimcompoop because I didn't numb a scalp lac needing three staples. i've had senoir residents and an attending in the past tell me to forego lido when stapling scalp lacs. this was unheard of according to this attending.
Click to expand...
I am a patient with a scalp lac who joined your forum just to reply to some of the insensitive responses to a valid question. I am a lifelong insomniac who needs prescribed meds to sleep. When I need to use the restroom in the middle of the night, I often am very close to sleepwalking when I make my way down the hall (past the stairs) to the bathroom. I often don't fully awaken. Last week, in this semi-coherent state, I fell down the stairs on my way back to bed. I didn't wake up until I hit the floor at the bottom of the stairs. My sleeping meds leave me uncoordinated and less than clear-headed. I was not drunk. I was under the influence of prescribed medication for a medical condition. My local ER (part of an Ivy League Medical School hospital) did not offer me the option of any kind of numbing agent even though each and every one of the 5 staples put in my scalp caused such excruciating pain that I screamed aloud with each one. Now I wonder if I was deemed "not worthy" of pain management by of one of the student doctors that have posted here. I have no complaints if the doctors treating me were under the (mistaken) impression that I wouldn't need it and were following what they perceived to be proper medical procedure. What I do object to is the idea of some holier-than-thou med students playing God with patients' pain management. There's a Hippocratic Oath for a reason. Do no harm means all patients. Not just the ones who are sober. (Even prescribed meds can cause a state similar to drunkeness.) I'm not a wimp. I've sustained various sports and job-related injuries over the years. In my career as an animal handler I've taken my share of hard knocks. I kept working after a one-ton draft horse stepped on my foot. Yet nothing I've experienced before or since can compare to just 1 of those staples going into my head. I was too out of it from both my medication and the pain (I had shoulder and hand contusions so painful that x-rays were taken to rule out fractures ) that I didn't question the fact that nobody offered to numb my scalp before staples. Frankly, until they started stapling, my head didn't really hurt. It just felt like I'd bumped my head. I came across this forum while trying to find information on getting my staples removed. I was seeking information to try to find out if their removal would be as painful as getting them put in. Instead, I found this site. For all of you who are serious in this inquiry, give your patients the choice. Don't deny pain relief to those who might need it.
 
Wow, bumping a >8 year old thread. Impressive.

I think the general consensus of above is that many-staple lacs should have lidocaine; a-couple-staple-lacs are optional, because the pain of 3 staples is likely roughly equivalent to the pain of the lidocaine injections.

Of interest, on my last 5 scalp lacs of 2-4 staples, I've sat down and explained the options. 1 chose lidocaine. They were happy with their choice. The other 4 chose no lido. 3 commented that the staples didn't hurt much and they were happy they made the right choice. 1 thought the staples hurt worse than expected, and would chose lidocaine in the future.

N=5
 
I always give the patient or parent the choice. If 1-2 I recommend no lido. If more, I recommend lido. If they're already in a lot of pain, I recommend and use marcaine. Because hey, if you want it numb for pain control, you want it numb for as long as possible.
 
Strange... My practice is to never use lido for staples.. Guess im a saddist? Ive put staples into myself to try it out 10 or so and it didnt hurt bad.

Sent from my LG-D801 using Tapatalk
 
Another one of these one-off posters who confirms what we've all said here a hundred times... many of our patients are histrionic by nature, and need 'exceptional' therapies and interventions simply in order to perform activities of daily living.

"Its the WORST... EXCRUCIATING pain there is!"
"I'm allergic to ALL medicines."
"I have a HIGH threshold for pain."
"I passed out TEN TIMES today."

Lolz. Veers... where are you.

you-are-not-a-beautiful-and-unique-snowflake.jpg


I've had at least three scalp lacs in my adult life, and three sport-related ones on my face. I have never once needed or had local anesthesia; nor did I ever feel pain that was worse than the accident during the repair.

Sack-up, man. Your grandfather would slap you.
 
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Just woke up and saw this. Made me giggle a bit, and almost aspirate my coffee!

Mr/Mrs "Patient Perspective" needs a healthy dose of Lyrica. I am simply shocked that those doctors used staples on you which hurt worse than having your foot crushed by a large animal. The intense pain of a tiny piece of metal pinching your skin really calls for some life-long therapy to treat your post-traumatic stress disorder. I'm also happy to recommend fentanyl patches and/or extended release oxycontin to relieve the debilitating chronic scalp nerve pain caused by this ordeal. On the plus side, all of the narcotic therapy you'll be on for the rest of your life will certainly cure your insomnia.
 
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I'm going to go out on a limb and confess this to the online community; because it really is "for the greater good".

I was caught being a "giant sis-pants" as a resident, and I (in my then-mind) felt I was totally justified.
It was then-and-there that I learned that this whole "attitude" of entitlement/enablement/pussification/whatever is very much a generational thing.

I was (and still am) on very good terms with my program director. She and I e-mail or text regularly about cases, life events, whatever.

I remember the day that I was standing in front of her, complaining about the schedule and the flip-backs, and the lack of sleep, and the whatever; and then in the middle of my soliloquy; it hit me.

She did the same thing that I did many years ago. With kids. And she WROTE OUR CURRICULUM to be "nice" to us.

I shut the **** up right there in front of her, in mid-sentence. I realized what I was saying, and then I stopped and said:

"Waaait. You did this, with like, 2 kids and stuff. Nevermind, I'll never complain to you or to anyone else. Again."

I'm still embarrassed about that to this day. I realized that "my Dad raised me better than that".

So, to "patient perspective"... get a freaking grip. If local anesthesia to your scalp lac is the worst tribulation that you must endure in life... then good on yah. Otherwise... buckle up, motherfcuker. I got a grandma in room 4 with a shattered hip that politely declined tylenol, as its "too strong for the pain".

(EDIT: for perspective; I am 33 years old. I was born in 1982. I have been an attending for 3 years. I ride that border between "Gen-X" and the "Millennials". My first job was at age 15 (legal to work!) on a christmas tree plantation, trimming trees. I recognize the value of work, austerity, character, and I look at those "millennials" and say: "Jeeezus, man - you should try WORKING for a living." I fear for the future.
 
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Also, insomnia.... I can't believe how many of my cohort complain to me about insomnia and ask "the doctor" to do something about it.

Try this:

Abraham-lincoln-chopping-wood2.jpg


Gasp! Manual labor ! No; that's ... unconstitutional, or whatever.

When I get out of work and drive home... if there's sun, I know that I owe myself a 3-mile run to stay in shape. I get mad when I can't "get my run in". I pass the hell out within 10-20 breaths after my head hits that cool, cool pillow.

I (honest to God) had a friend complain to me the other day about insomnia. I know that his day consists of his morning donut, then desksitting and clicking for 2 hours. Then, this is followed by a fast-food lunch and griping about whatever. Complaining is hungry work, after all. After his afternoon session of paper-shuffling and collating, interrupted by twitter and dicking-around, he goes home to sit on the couch and eat (something terrible) before more complaining and the bedtime routine of whatever.

Hey; millenials: Go chop some wood. Go on a run. Go do something. Your daily exercise can't be "I beat Mega Man 4" again (great game).

Go and BE ... Mega Man.

You won't need a sleep aid.
 
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RustedFox said:
I'm going to go out on a limb and confess this to the online community; because it really is "for the greater good".

I was caught being a "giant sis-pants" as a resident, and I (in my then-mind) felt I was totally justified.
It was then-and-there that I learned that this whole "attitude" of entitlement/enablement/pussification/whatever is very much a generational thing.

I was (and still am) on very good terms with my program director. She and I e-mail or text regularly about cases, life events, whatever.

I remember the day that I was standing in front of her, complaining about the schedule and the flip-backs, and the lack of sleep, and the whatever; and then in the middle of my soliloquy; it hit me.

She did the same thing that I did many years ago. With kids. And she WROTE OUR CURRICULUM to be "nice" to us.

I shut the **** up right there in front of her, in mid-sentence. I realized what I was saying, and then I stopped and said:

"Waaait. You did this, with like, 2 kids and stuff. Nevermind, I'll never complain to you or to anyone else. Again."

I'm still embarrassed about that to this day. I realized that "my Dad raised me better than that".

So, to "patient perspective"... get a freaking grip. If local anesthesia to your scalp lac is the worst tribulation that you must endure in life... then good on yah. Otherwise... buckle up, motherfcuker. I got a grandma in room 4 with a shattered hip that politely declined tylenol, as its "too strong for the pain".

(EDIT: for perspective; I am 33 years old. I was born in 1982. I have been an attending for 3 years. I ride that border between "Gen-X" and the "Millennials". My first job was at age 15 (legal to work!) on a christmas tree plantation, trimming trees. I recognize the value of work, austerity, character, and I look at those "millennials" and say: "Jeeezus, man - you should try WORKING for a living." I fear for the future.
Click to expand...
Like x 1,000
 
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RustedFox said:
Also, insomnia.... I can't believe how many of my cohort complain to me about insomnia and ask "the doctor" to do something about it.

Try this:

Abraham-lincoln-chopping-wood2.jpg


Gasp! Manual labor ! No; that's ... unconstitutional, or whatever.

When I get out of work and drive home... if there's sun, I know that I owe myself a 3-mile run to stay in shape. I get mad when I can't "get my run in". I pass the hell out within 10-20 breaths after my head hits that cool, cool pillow.

I (honest to God) had a friend complain to me the other day about insomnia. I know that his day consists of his morning donut, then desksitting and clicking for 2 hours. Then, this is followed by a fast-food lunch and griping about whatever. Complaining is hungry work, after all. After his afternoon session of paper-shuffling and collating, interrupted by twitter and dicking-around, he goes home to sit on the couch and eat (something terrible) before more complaining and the bedtime routine of whatever.

Hey; millenials: Go chop some wood. Go on a run. Go do something. Your daily exercise can't be "I beat Mega Man 4" again (great game).

Go and BE ... Mega Man.

You won't need a sleep aid.
Click to expand...
Like x 1,000
 
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I always numb lacs, but in I&Ds, lido doesn't always work. I tried a circumferential block around an buttock abscess, and the Pt was in tears. Won't try that again.
 
I don't think many are doing 10 staples without anesthesia. However, 45 minutes and topical XAP work remarkably well and require no needles. With that said, if it's 2-3 I'll give patients the option. I really don't care, but judging by their reaction to the lidocaine it definitely hurts both ways.
 
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