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Surface sutures are more likely to produce stitch marks in children because the wounds are under greater tension than those in adults. If the long axis of the crystal is yellow when parallel to the z-axis and blue when perpendicular to it, it is monosodium urate and termed negatively birefringent. This in turn is most commonly the result of blood product misassignment related to clerical error. Anesthesia is not always required, but a digital block can be used to calm an anxious patient and is commonly performed. It usually occurs in the elderly15 and can be quickly assessed by a decreased or absent radial pulse or by the appearance of an expanding hematoma. This important step in wound management provides hydration to the wound, removes deeper debris, aids in visual examination, and also reduces the risk for infection. Anaerobic infections should be suspected when multiple organisms are noted on Gram stain, when a foul odor is associated with the purulence, when free air is noted on radiographs of the soft tissue, and when no growth is reported on cultures. Despite some evidence of their safety, the use of microwave heating devices is not recommended by the Association of Blood Banks because of concerns of hemolysis. A, this man was initially seen while in a coma from a heroin overdose and had been lying on his arm for a number of hours. It has virtually no systemic effects and moderate eschar penetration, and it is painless on application. Because a volar splint does not completely eliminate pronation and supination of the forearm, it may not be ideal for distal radial and ulnar fractures, although many clinicians use this splint for nondisplaced or minimally displaced distal ulnar and radial fractures. B, Small abscesses can be cleaned with a cotton swab swirled in the cavity, which is left open. Turn the stopcock (arrow) to collect and then expel fluid, or inject lidocaine or steroid without moving the needle. Swelling from deep circumferential burns may constrict the chest or limbs and result in compartment syndrome. Give patients general guidelines for length of immobilization and appropriate follow-up care. There may be a small amount of anechoic or hypoechoic fluid present in this space in a normal hip, and correlation with the unaffected side will aid in evaluation. Surrounding the entire structure is the outer layer of a peripheral nerve, the epineurium, which is composed of areolar connective tissue. For extremely short necks, a special c-collar such as the No-Neck (laerdal Medical Corporation) is recommended. Use of this less aggressive approach requires that the patient be counseled that multiple decompressions. Local digital blocks without vasoconstrictors provide effective analgesia for hand wounds. The value of reversing a coagulopathy with blood components before the procedure is not proved, and clinical judgment should prevail. B, Left hydropneumothorax after left subclavian venipuncture (the catheter was removed before this radiograph). The recommended dose of magnesium citrate is 250 ml of a 10% solution in an adult and 4 ml/kg body weight of a 10% solution in a child. The radial aspect of the proximal end of the first metacarpal is the arthrocentesis landmark for this joint. When this constellation of signs and symptoms are present, it is generally late in the course of the disease when tissue death and permanent dysfunction are likely. The patient experienced a contact burn across the dorsa of the toes from an exposed electrical wire. Such injuries are best referred for definitive treatment consisting of either surgery or more complex splinting.

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However, it may also occur following less severe trauma that does not cause fractures, such as crush injuries, severe thermal burns, penetrating trauma, injury to vascular structures in the extremities and, in some cases, even minor injuries. The value or appropriateness of coring, probing, or irrigating the puncture track has not been established. The condition may be or complaint may be an outward manifestation of a serious underlying illness. Ducharme J, Matheson K: What is the best topical anesthetic for nasogastric insertion Bai Y, Miller T, Tan M, et al: Lidocaine patch for acute pain management: a meta-analysis of prospective controlled trials. This characteristic shape occurs because the dense patellar ligament prevents distention of the capsule along its inferior border. Visualize directly with good lighting in a bloodless field, explore the wound with a metal probe, and use radiographs as safer approaches to wound exploration. Follow this by rinsing the container with a small amount of tap water before administering it to the patient to allow ingestion of the full dose. The diameter of the catheter should be large enough to allow rapid delivery of 10 mL of solution. The suprapatellar bursa communicates with the joint space and frequently houses a large amount of fluid. A gauze pack may be placed in the wound for 24 to 48 hours to ensure continued drainage. Advantages include ease of application, reduced need for local anesthesia, evenly distributed wound tension, no need for suture removal, no residual suture marks, minimal skin reaction, superiority for some grafts and flaps, and suitability for use under plaster casts. Because the blood volume in the brain is only approximately 30 mL at any given moment, even 1 mg of lidocaine injected into the carotid artery can theoretically produce toxic concentrations. Do not use cold packs for more than the first 24 to 48 hours because cold can interfere with long-term healing. The nerve emerges from the psoas muscle and descends between the psoas and iliacus muscles. A, A posteroanterior view of the wrist demonstrates a widened space between the scaphoid (S) and the lunate (l) (arrow) because of ligamentous disruption from an impaction injury. Platelet concentrates contain most of the platelets from 1 unit of blood in 30 to 50 mL of plasma. The most common trigger points are found in the levator scapulae, quadratus lumborum, and gluteus medius muscles. Use the index finger of the nondominant hand to retract the skin at the lower edge of the rib cephalad and pull it up and over the rib. Theoretically, anesthetizing injured ribs eases pain and facilitates deep breathing and coughing. Place additional Webril or gauze between the little and ring fingers to prevent maceration of the skin. Softening of the compartment, improved distal tissue perfusion, return of sensation, Doppler flow signal strength, and oximetry values indicate adequate release. Standing Position Traditionally, standing patients were placed on a backboard by positioning the board behind the patient, stabilizing the head, and lowering the patient and the backboard backward until the patient was lying on it. Once inserted the needle protrudes approximately 2 inches from the skin, which increases the risk for accidental dislodgement. The application of bland, lanolincontaining creams for 4 to 8 weeks after initial healing may reduce dryness and cracking of the healing wound. Medical attention is paid to correction of fluid and electrolyte abnormalities, renal insufficiency, nutrition, and sepsis. Procedure: Manual Detorsion and Spermatic Cord Anesthesia Manual detorsion is performed in the following manner. On the post-reduction view, the humeral head is correctly positioned in the middle of the "Y," over the glenoid. Overall, fewer days of hospitalization were required for the initially admitted group.

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In this instance, probing the wound with a sterilized needle bent into the shape of a crochet hook is frequently successful. Activities that increase intrathoracic pressure, such as coughing or straining, may cause spuriously high measurements. Orlinsky M, Knittel P, Feit T, et al: the comparative accuracy of radiolucent foreign body detection using ultrasonography. Tests for viscosity, serology, and chemistries are done on fluid collected in a red-topped (clot) tube, whereas cytology samples are collected in tubes with an anticoagulant (purple top). Gently pass a small needle along the course of the catheter while puncturing the balloon as many times as necessary. The kleinert splint provides modest hyperextension and avoids pressure on the skin by removing the middle third of the foam padding, thereby eliminating all direct pressure on the injury site. However, absence of these findings does not rule out an underlying fracture or dislocation. In general, a swollen joint is not usually injected with corticosteroids until the possibility of infection has been eliminated. The procedure may be carried out on any patient of any age who is able to cooperate with the clinician. Potential cardiopulmonary manifestations include dysrhythmias, hypotension, syncope, bronchospasm, laryngeal edema, and cardiorespiratory failure. Because compelling circumstances may clinically support gastric decontamination, this chapter discusses specific clinical procedures. Grafts are subject to pseudoaneurysms when there is a breach in the integrity of the graft and they are more likely to rupture. Mazkereth R, Paret D, Ezra G, et al: Epinephrine blood concentrations after peripheral bronchial versus endotracheal administration of epinephrine in dogs. Because of the potential hazard of tendon rupture after local steroid injection, avoid infiltration of steroids into this area. To apply a sheet, place it over a long spine board and then gently logroll the patient by no more than 15 degrees into position on the board. Minimizing Tissue Trauma the importance of carefully handling tissue has been emphasized since the early days of surgery. One must be certain to inflate the distal cuff before the proximal cuff is released; otherwise, the anesthetic will rapidly diffuse into the general circulation. Patients experience recurrent episodes of priapism that often last less than 3 hours and often do not require emergency treatment unless symptoms become markedly prolonged. This patient was seen twice with a scalp wound infection and given two courses of antibiotics with initial improvement, all before the blade of a utility knife (arrow) was discovered in the wound. Certain hardened metal rings, such as tungsten carbide, may not be amenable to the use of a ring cutter. Few randomized controlled trials have evaluated steroid therapy; those that have do not provide substantial evidence supporting its long-term efficacy. Removal of large amounts of ascitic fluid during paracentesis can be accomplished with the assistance of continuous wall suction. Removal of 5 or 6 L is routine and well tolerated, and for therapeutic purposes, at least this volume should be removed. In a study at the Mayo Clinic involving 3000 injections given in 1 year, no infections were reported. Systemic reactions usually consist of fever, chills, and muscle spasm, but severe reactions may result in neurologic sequelae ranging from malaise and headache to paralysis and coma. The process of exsanguination is believed to allow better vascular diffusion of the anesthetic.

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Yang and colleagues122 found that reduction beyond 24 hours was associated with a worse prognosis, but they could not find a significant time factor for those reduced in less than 24 hours. Patients should be referred for outpatient proctoscopy to search for a polyp or malignancy that may have acted as a lead point. The effects of fentanyl can be rapidly and completely reversed with opioid antagonists. Between 2000 and 2006 over 1600 dialysis patients in the United States died from vascular access hemorrhage. If an awake patient begins to vomit during lavage, immediately remove the tube to allow the patient to protect the airway. Polyethylene glycol is nontoxic and nonirritating and may be used anywhere on the body. Insert both jaws of the hemostat proximally to the level of the coronal sulcus and carefully separate any adhesions. Henao F, Jimenez H, Tawil M: Penetrating wounds of the back and flank: analysis of 77 cases. B, When immobilizing an infected human bite, this splint was not held in position until hardened, and the patient reflexively flexed the wrist. Vessels smaller than 2 mm that bleed despite direct pressure can be controlled by pinpoint, bipolar electrocautery. A lateral or oblique view of the hip may help clarify the type of dislocation and allow detection of associated fractures. There are several circumstances, however, in which wrist nerve blocks are more advantageous than other types of blocks or anesthesia. After heating, Woodcast splints are applied in the same manner as conventional splints. Instruct one assistant to apply countertraction (with a sheet wrapped around the waist) and another assistant to apply anteriorly directed pressure on the posterior aspect of the humeral head. Probe the wound with forceps to identify fragments not seen directly in the wound. Most systemic complications of paracentesis are merely temporally related or seen in seriously ill patients with end-stage liver failure who have a plethora of comorbidities. In addition, the use of ultrasound may improve success rates of radial nerve blocks at the elbow and forearm (see Ultrasound Box 31. Patients on anticoagulants, those with a bleeding diathesis, and those who continue to use an injured limb are at increased risk. Advance both jaws of a hemostat proximally between the inner layer of the foreskin and glans. Alternatives to procedural sedation and analgesia include intraarticular injection of local anesthetics, hematoma blocks, peripheral nerve blocks, and regional anesthesia (see Chapters 29, 31, and 32). Calcium gluconate may be injected subcutaneously with a 25- to 27-gauge needle into the nail bed via the fat pad under a digital nerve block. Gasoline immersion injuries resemble scald burns and are usually partial thickness. The quadratus lumborum, gluteus medius, and tensor fasciae latae are commonly affected lower trunk muscles. In the leg, the anterior compartment is involved most often,58 whereas the posterior compartment is most often associated with a delayed diagnosis. In most cases, missing zone 6 injuries can be avoided if a careful physical examination is performed, including thorough wound exploration under sterile conditions using a tourniquet, adequate local anesthesia, and good lighting. With exposure to sunlight, scars in their first 4 months redden to a greater extent than the surrounding skin does. Morbid obesity, in addition to other conditions in which patients are taking steroids or immunosuppressive drugs, or undergoing radiation therapy, are also at higher risk for infection.

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Despite the limited literature on the treatment of postburn pruritus, available therapies include oral antihistamines, topical antihistamines, and topical moisturizers. The basilic vein then continues proximally, where it occupies a superficial position between the biceps and pronator teres muscle. An asymptomatic hernia may be manifested as a mass that is found incidentally on physical examination of the abdomen or groin. Coins below the diaphragm are asymptomatic, and the presence of pain or symptoms requires further evaluation. Acid and Alkali Burns Chemical burns cause progressive tissue damage until the chemical is inactivated or removed. Avulsion injuries have the worst prognosis because a significant amount of vascular, nerve, tendon, and soft tissue injury invariably occurs. In contrast to the Sengstaken-Blakemore and Minnesota tubes, the Linton-Nachlas tube is a singleballoon device that consists of a gastric balloon and two ports (esophageal and gastric) for aspiration and lavage. The disadvantage is that two injections are needed with this approach to block both volar digital nerves. It does not stain clothes, is not irritating to mucous membranes, and washes off with water. A, the classic mechanism for this injury is longitudinal traction on the arm with the wrist in pronation. It is important that the emergency clinician (or other nonreplantation specialist) not speculate on the specifics of the ultimate prognosis. If the tube is nonfunctioning yet still in place, the clinician must make a judgment regarding the risk versus benefit of removal and replacement, versus an attempt at unclogging the tube (see the subsequent discussion on unclogging). It is most easily accessible at the ankle but may also be cannulated below the knee and below the femoral triangle. C, the red, warm, swollen, and painful condition of the dorsum of the foot is a common finding with gout but may suggest cellulitis. The most important characteristic of a dressing is that it controls fluids within the wound. Patients who must push hemorrhoids back in after a bowel movement have symptomatic third-degree internal hemorrhoids and would benefit from elective surgical referral. B, In another patient who aspirated, the charcoal can be seen at the carina with a fiberoptic scope. D, Magnetic resonance imaging demonstrates an obvious lateral tibial plateau fracture (arrows), which was searched for only after lipohemarthrosis was noted. Depending on the size of the effusion to be drained, a 10-, 20-, or 30-ml luer-lok syringe can be used. The large number of units that must be given increases the chance of exposure to blood-borne diseases. Computed tomography is often the first imaging study, given its ready availability. A good outcome depends on maintaining the space under the eponychium (cuticle) as the laceration heals and the new nail grows out, which is a slow process. C, A stack splint, with the proximal interphalangeal joint left free to allow relaxation of the distal interphalangeal joint, is kept in place for 6 to 8 weeks. Pregnancy is not a contraindication to either toxoid or immune globulin, although some suggest that the toxoid be used "with caution" during the first trimester. In addition, use of Webril (Curity) cast padding is described, but other suitable cast padding may be substituted. Success has also been noted by injecting the corpus cavernosum with 1 mL of the local anesthetic lidocaine (2%) with epinephrine (1: 100,000) into each side, or 2 mL into one side. Send patients with minor or no injuries to appropriate holding areas for further evaluation. For this reason, some recommend simple reinfusion through a filter without any anticoagulant. Prefabricated Splint Rolls the use of plaster splints in the form of prefabricated splint rolls. However, they may not be economical if used on a mandatory rather than a selective basis. Between dressing changes, coat the wound with petrolatum or an antibiotic ointment before applying these products. In the forearm, it lies in close association with the lateral cutaneous nerve, which supplies sensory innervation to the radial aspect of the forearm.

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The hole in the pad is placed over the fracture and the surrounding pad absorbs the pressure. A, Upper gastrointestinal endoscopy demonstrating dilated and straight veins (small esophageal varices) in the distal end of the esophagus (arrows). However, circumcision rates vary with religious affiliation, racial and ethnic group, as well as socioeconomic status. Marhofer P, Nasel C, Sitzwohl C, et al: Magnetic resonance imaging of the distribution of local anesthetic during the three-in-one block. Injection of a cocaine-heroin mixture ("speedball") may predispose users to abscesses by inducing soft tissue ischemia. Again, other agents are equally efficacious and safer; select these over cocaine-containing mixtures whenever possible. To identify trigger points in the infraspinatus muscle it is important to palpate along the entire length of the muscle bundles, and also across the grain of the muscle. Treat symptomatically with acetaminophen, a warming blanket, antihistamines, and inhaled or subcutaneous -agonists for bronchospasm or subglottic edema. However, the knee is probably the easiest joint to enter, and removal of a tense hemarthrosis will relieve pain and facilitate examination for ligamentous injury. Before the procedure, a simple explanation of what the patient should or may feel will facilitate cooperation. Corticosteroid injections have been found to be safe procedures with few complications (Box 52. The choice of equipment is less important than the skill and experience of the personnel using it. If a depilatory is not successful in 30 to 60 minutes, surgical removal is indicated. C, If the wrist is involved, a removable plaster splint may be applied over the dressing. Many of them are fairly economical and simple to use, whereas others are more expensive and do not allow the versatility of a simple, inexpensive triangular muslin bandage. Ethyl Chloride and Trichloromonofluoromethane and Dichlorodifluoromethane (Fluori-Methane) Sprays the bottle 25 cm from the skin and spray a stream along the proposed incision site until the area turns white and hard. This gas can either be delivered by a demand-flow system using a handheld mask or be delivered to young children using a nose mask in a continuous-flow system under close clinician supervision. In heavily contaminated wounds, especially those with abundant adipose tissue, remove all exposed fat and all fat impregnated with particulate matter. It may be superior to silver sulfadiazine with regard to minor burn wound healing. Biologic Dressings Burn Dressings Biologic dressings are natural tissues, including skin that consists of collagen sheets containing elastin and lipid. After achieving this position, use the fingers of one hand to prevent the hernia contents from overriding the external ring, while using the other hand to provide steady but gentle pressure on the contents of the hernia sac. Symptoms can be treated with acetaminophen or nonsteroidal antiinflammatory drugs. The continuous subcuticular (or dermal) suture technique is ideal for these situations; the wound can be closed with an absorbable subcuticular stitch, thereby obviating the need for later suture removal. These six tendons can be seen over the dorsum of the hand, where they are poorly protected and prone to injury. Heavily contaminated wounds (such as wounds in contact with saliva, pus, or feces) often become infected despite antibiotic treatment. B, this infected pseudoaneurysm (arrowhead) precipitated the spontaneous massive hemorrhage seen in A. Reactions may be local or systemic, and the pain may be severe and is often described as "shocklike," "itching," "burning," or "throbbing. Though no longer taught as a mandatory procedure in the Advanced Trauma Life Support course, venous cutdown is considered optional and continues to be taught at the discretion of the instructor.

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B, To prevent this complication, place the first stitch at the vermilion-cutaneous border to obtain proper alignment. D, this infant received a severe blistering sunburn at the beach despite being in the shade most of the day. Ring Removal Frequently, a ring must be removed to prevent laceration of tissue or vascular compromise. When obtaining a specimen for culture, the most accurate and complete culture results will be obtained if one aspirates pus with a needle and syringe before I&D. Burch Jm: Blood transfusion, microfiltration, and the adult respiratory distress syndrome. A, Fine, absorbable sutures are used to repair the nail bed under a bloodless field provided by a finger tourniquet. Take a supine abdominal film 1 to 2 minutes after instillation of dye to optimize visualization of the gut. A patient with an easily reducible hernia can be discharged safely for outpatient follow-up and elective repair, whereas an acutely incarcerated and strangulated hernia is a surgical emergency. Place a blood pressure cuff on the middle to upper part of the arm, wrap several more layers of cast padding around the cuff, and then inflate it to 260 to 280 mm Hg. A, To remove them, professional facial gel is spread with a fan brush, thin at the edges. Patients with small-volume and minimally symptomatic extravasations may be discharged. If no paresthesia is produced, advance the needle inward, again at a 45-degree angle, until it hits the posterior aspect of the tibia. Infuse half of the calculated 24-hour fluid needs in the first 8 hours following the burn. In rare and yet undefined selected instances, prevention of further absorption of toxin by various decontamination procedures may theoretically ameliorate the morbidity or reduce mortality. Ketamine mitigates propofolinduced hypotension, and propofol mitigates ketamine-induced vomiting and recovery agitation. In scalp wounds that penetrate this layer, bacteria may be carried by these vessels to the meninges and the intracranial sinuses. In a patient with multiple injuries and several urgent problems, control hemorrhage temporarily with a compression dressing. Pack moistened cotton into the concavities of the pinna until the cotton is level with the most lateral aspect of the helical rim. Methods of checking for silent pulmonary aspiration include assessing tracheal aspirates with a glucose oxidant reagent strip or placing methylene blue in the formula and monitoring tracheal aspirates for pigmentation. Subsequently, hairs become ingrown, bacteria invade, and an abscess develops in the sacrococcygeal region. Unlike the middle three fingers, which require blocking of only the two volar (palmar) digital nerves, all four nerves are usually blocked in the thumb and fifth finger, particularly to obtain anesthesia of the fingertip and nail bed. They may have restricted or normal range of motion and normal strength; however, they usually complain of tenderness on palpation over the bicipital groove. They may not be able to tolerate even minor physical insults and have fragile conditions that require careful evaluation, short-term observation in some cases, and close follow-up for delayed healing and infection. In 1968, Edlich and colleagues, from the University of Minnesota, modified the Sengstaken-Blakemore tube by adding an esophageal aspiration port and increasing the capacity of the gastric balloon. Moderate sedation is frequently insufficient for effective anxiolysis and immobilization in younger, frightened children, and deep or dissociative sedation is an appropriate alternative. Insert the saline-primed filter spike into the autotransfusion bag spike port with a firm twisting motion. Having the patient flex the elbow to 90 degrees and isometrically contract and relax these muscles will help define their borders. Hemorrhagic blisters, however, are said to represent deeper injury and are best left intact to protect tissues against desiccation. However, there are circumstances in which vascular access is either not available or contraindicated.

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The system relies on a mixing valve preset to deliver a fixed ratio and will deliver gas only when oxygen is flowing. Advance the hemostat to the level of the coronal sulcus and then close it, effectively crushing the interposed anesthetized foreskin. Though uncommon, there may be occasions in which nonfasting patients require urgent procedures with a substantial depth of sedation that may be more safely managed in the operating room with endotracheal intubation to protect the airway. The risk for adverse effects is increased in patients with anemia, respiratory or cardiovascular disease, and deficiencies in glucose-6-phosphate dehydrogenase or methemoglobin reductase. Once considered a traditional empirical treatment, there is no evidence-based proven benefit from hyperbaric oxygen therapy for carbon monoxide poisoning. If blood is obtained from either source, then esophageal balloon inflation is required. Technique There are two types of osmotic cathartics: saccharide cathartics (sorbitol) and saline cathartics (magnesium citrate, magnesium sulfate, and sodium sulfate). A three-way stopcock placed between the needle and the syringe is an option for draining large effusions. Initial therapy for carpal tunnel syndrome consists of modification of activity and splinting; the latter is particularly helpful at night. Gentilello lM, Sanzone a, Wang l, et al: Near-infrared spectroscopy versus compartment pressure for the diagnosis of lower extremity compartmental syndrome using electromyography-determined measurements of neuromuscular function. Note that this puncture-type wound had to be significantly extended to adequately visualize the extent of the injury. Angulated fractures around the knee (shown above) Temporary immobilization of injuries prior to operative repair Knee injuries in patients with extremities too large for a knee immobilizer the knee immobilizer has largely replaced the posterior knee splint in modern emergency department practice. Kaufman Z, Schpitz B, Dinbar A: Reinsertion of a catheter for feeding jejunostomy. However, it is important to note that a properly fitting sports helmet holds the head securely in the neutral position, provided the athlete is also wearing shoulder pads. The Universal Head Immobilizer is made of a Herculite nylon and a polyethylene foam platform that fastens to the stretcher with Velcro straps. New guidelines are in development at the time of publication, but the executive summary for the 2015 revision notes allows for removal prior to transport to mitigate these issues. Notwithstanding the difficulties just described, the diagnosis of compartment syndrome is primarily a clinical one that may be supplemented by direct measurement of compartment pressure. Though often clinically insignificant, its occurrence suggests air under pressure in the small bowel. Because midline catheters do not enter the central circulation with high flow, delivery of medication and infusion types are limited, and routine blood withdrawal is not recommended. In other cases, supplementing nonpharmacologic techniques with topical or local anesthesia and anxiolysis with oral midazolam may be sufficient to permit successful wound repair. Small abscesses can initially be managed on an outpatient basis with simple I&D, described previously. If bleeding is too brisk to permit adequate wound evaluation and irrigation, control hemorrhage by clamping and everting the galea or dermis of each wound edge with hemostats. If the patient is tense, contraction of the quadriceps will greatly hinder entering the joint. Drain a perianal abscess through a cruciate incision because if a simple linear incision is used, the abscess cavity has a propensity to close prematurely without adequate drainage. Keep an adequate volume of diluent available, such as normal saline or distilled water. Suture the nail bed if a large subungual hematoma is associated with an unstable or avulsed nail. If a paresthesia is still not elicited, deposit 3 to 5 mL of anesthetic in the proximity of the nerve at a depth of 1 cm under the tendon. Insert a 20- to 22-gauge needle at a point just medial to the anterior tibial tendon and directed into the hollow at the anterior edge of the medial malleolus. This may result in dyspnea, hypoxemia, or hypercapnia that may not be tolerated by patients with underlying pulmonary dysfunction.