staple of scalp lac without lidocaine?

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I was taught the 3 staple rule as well.

3 or less = explain lido shot will hurt just as much and offer a choice
more than 3 = give lido shot

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The staples really dont hurt. I just go to town.

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smaller scalp lacs: LET x at least 2 applications 15 min apart. usually leads to blanching and fair anesthesia. lido w/ epi minimally uncomfortable at that point if even needed - usually for bleeding control if nothing else. often don't need it in adults.

larger: just go to town w/ lido w/ epi. too much bleeding for anything else and not controlling the bleeding makes a holy mess - esp if you also have to send them to CT. the manipulation and irrigating is pretty uncomfortable too.

being drunk doesn't make one not in need of anesthesia!!! hell i don't want them waking up from the staples and swinging at me!

i ALWAYS follow the first protocol in kids... if it's not too big of a lac i even use an insulin syringe for the additional lido. they don't feel a thing. tell the kid they're gonna feel something COLD! parents VERY happy over 1. concern for discomfort and 2. you didn't give the kid an emotionally scarring ED visit.
 
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Before any procedure I do everyone gets 0.5-1mg of diluadid if they have an IV.

This isn't just for their comfort; you can suture/line/i&d/spinal tab/reduce better when the pt is calm/not moving/and quiet.
 
Before any procedure I do everyone gets 0.5-1mg of diluadid if they have an IV.

This isn't just for their comfort; you can suture/line/i&d/spinal tab/reduce better when the pt is calm/not moving/and quiet.

I do the same for some procedures but not all. When I do, I've begun to prefer fentanyl so that I don't need to wait as long for it to wear off. Especially if they're going home by themselves afterwards.

NGT always gets intranasal lidocaine (2% viscous). instead of opiates. field blocks for I&D always gets double the expected dose and adjunctive opiates if I'm feeling nice. I've never done it for a spinal tap, though in the rare uncooperative pt or one who has difficulty with coping mechanisms it sounds like a nice idea.
 
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Before any procedure I do everyone gets 0.5-1mg of diluadid if they have an IV.

This isn't just for their comfort; you can suture/line/i&d/spinal tab/reduce better when the pt is calm/not moving/and quiet.

I'm totally coming to your ED with a small laceration, catching a buzz and a good nap.
 
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If it's 1 or 2 staples, I offer the patient the choice. I don't think that lidocaine works that well for scalps anyway, and it hurts a lot going in. For kids, I have been very pleasantly surprised using LET alone; I suppose that if not in a time crunch, this would be just fine for adults as well. Abscess I&D I give some opiate beforehand (if no line, oxy).
 
To the OB, as stated above you're experience with the amount of pain caused by stapling the scalp is multiple orders of magnitude away from the typical experience. Most cognitively intact adults tolerate 1-2 staples with moderate, but very brief discomfort. Pain is a very subjective experience so it may be that your sensation of pain was amplified by feeling judged by the resident or altered by the sleep medicine.

For everyone else, I offer the choice of lido or not to everyone that needs 1-2 staples with my pitch weighted towards the suck it up and you'll be out of here in 10 min and the lido is going to hurt as much as the staples approach. LET sounds intriguing for small kids but honestly would at least triple LOS for these injuries. I can pull a stapler out of a drawer and be done in 2 minutes including irrigating, or I can wait 10-30 min just for the nurse to apply the LET.
 
Out of curiosity, is most lidocaine in the ed buffered with bicarb as standard procedure?
 
Out of curiosity, is most lidocaine in the ed buffered with bicarb as standard procedure?
At my program, as a standard procedure? No. We have bicarb available to the docs who want to use it. I probably use bicarb one time in five, and generally only when the patient is nervous about the procedure. Otherwise, I just inject slowly. With kids, I use bicarb 100% of the time.
 
Tried XAP today. It didn't get good results after 45 minutes. Ended up on old faithful instead. 3x4cm abscess.
 
At my program, as a standard procedure? No. We have bicarb available to the docs who want to use it. I probably use bicarb one time in five, and generally only when the patient is nervous about the procedure. Otherwise, I just inject slowly. With kids, I use bicarb 100% of the time.

Do you do 1:10 bicarb:lido? I've never tried it. Typically use a 30G or insulin needle for more sensitive areas or kids.

Edit: 1:10 volume mixture (8.4% bicarb).
 
Do you do 1:10 bicarb:lido? I've never tried it. Typically use a 30G or insulin needle for more sensitive areas or kids.

Edit: 1:10 volume mixture (8.4% bicarb).

Stupid pet peeve: people calling it a 1:10 mix. It's a 1:9 mix, or it's 1/10th bicarb. I also silently judge people who say "I could care less," but then I'm just an angry pedantic man sometimes.

To answer your question: yes. I draw up 9ccs of lido and then draw 1cc of bicarb into the same syringe. I generally use a 25G and just inject slowly.
 
The epi in the lido slows down the bleeding too.
 
The epi in the lido slows down the bleeding too.
What I do with the abscesses is inject the lido with epi right into the dome. When you see the blanching from the epi, you know exactly where is the anesthetic. I have never given any opiate before I cut an abscess. However, especially after @docB wrote about cutting his own abscess in his (arm)pit, and the associated pain, I always give people a day of Percocet, as I did slash them with a knife.
 
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I love that the patient who posted has so little understanding of the medical system and how it works that she thinks a bunch of medical students are posting here, due to the name of the website. As if medical students would have enough experience to weigh in on the many many lacs they have done, with different methods, and the drugs used (including narcotics, which would be hard for students to actually prescribe.) I love when people come on here just to bitch about a bad experience they had with the healthcare system. You know they were googling their issue, and came across the forums. I wonder if the EM forum gets this more because of the nature of solitary ED visits not being "up to par" for a patient, or if the GI forum gets people bitching about how their colonoscopy went. +1 for Rusted Fox on insomnia- if half the insomniacs worked as hard as a resident, they'd never have probs sleeping. I'm lucky to stay awake long enough to get home after a night shift. And the last vacation I had, I worked 7 straight shifts prior to leaving, and literally slept through the whole 9 hour flight, from take off until the bump signifying landing.
 
Stupid pet peeve: people calling it a 1:10 mix. It's a 1:9 mix, or it's 1/10th bicarb. I also silently judge people who say "I could care less," but then I'm just an angry pedantic man sometimes.

To answer your question: yes. I draw up 9ccs of lido and then draw 1cc of bicarb into the same syringe. I generally use a 25G and just inject slowly.

I got 1:10 from a paper (2nd result in google search for "bicarb in lido") that recommended 1 mL 0.84% bicarb and 10 mL 1% lido.
 
I got 1:10 from a paper (2nd result in google search for "bicarb in lido") that recommended 1 mL 0.84% bicarb and 10 mL 1% lido.

Interesting. If that's how you're mixing it up then you're absolutely correct. I am rarely using a syringe bigger than 10ml to numb someone and doing a 1:10 ratio in a 10cc syringe isn't easily doable.
 
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