This year I published a Novel, Simple Method for Achieving Hemostasis of Fingertip Dermal Avulsion Injuries in the Journal of Emergency Medicine 1 — a technique I’ve used in my local ED for several years. In brief, this involves achieving hemostasis over a fingertip skin avulsion by using a tourniquet followed by tissue adhesive glue. After bringing the technique to press and sharing this video, I’ve received great tips from peers and subsequently refined it with some additional ideas. Thus I present for the first time on ALiEM: Dermal Avulsion Injuries 2.0.
The video above illustrates the entire revised technique in detail, while the outline below highlights the key concepts in the technique revision:
1. Start with an “epi dip.”
The first step in caring for any minor wound is controlling the patient’s pain. In my article, I recommended digital blockade for this purpose. While this works, there is a better way, and it was described right here at ALiEM in 2011. As a means of anesthesia, have the patient dip the injured finger in 1% lidocaine with epinephrine for 5 minutes. One can pour 10-20 cc of this solution into a small medicine cup or urine specimen cup, and the patient simply soaks the afflicted finger.
Soaking the injured digit in 1% lidocaine with epinephrine provides analgesia and helps decrease bleeding through vasoconstriction.
Epinephrine has the added benefit of vasoconstricting the troublemaking-little bleeders that necessitated use of the technique in the first place. In fact, in the 2011 post, it was described as a sole means of achieving hemostasis. I would argue that it’s a good start, but the epinephrine effect alone is not enough to get the job done.
Thus, it’s a perfect first step for the technique that follows.
2. Apply the “just right” tourniquet.
Applying a tourniquet can be tricky. Sometimes it is difficult to achieve the level of tightness that achieves hemostasis without making it so tight that the patient can’t handle the discomfort. There are commercial tourniquet systems available that mean to circumvent this problem, but they can be expensive and are not readily available to all providers.
Quick bedside solution: Take your usual IV start tourniquet. Generally these are on the wide side, so slice it in half lengthwise with a pair of trauma shears if you prefer. Encircle the proximal digit, then clamp it with a needle driver. Crank the driver until you’ve achieved a level of compression that stops the bleeding from the wound, but remains tolerable for the patient. I have found that the right number typically falls between 5-10 “twists.” Apply the tissue adhesive glue over the dermal avulsion. When the glue is dry, it is time to release the tourniquet. This is done by simply releasing the needle driver. Thanks to Dr. Jeannie Tyan for this tip!
Take a shortened piece of rubber tourniquet and encircle the finger, then clamp it with a needle driver.
Twist the needle driver to crank the tourniquet tighter, adjusting to a level that provides hemostasis but is tolerable for the patient.
3. Apply the tissue adhesive glue and create a “mini blow dryer” for a quick-dry
In order for this technique to be effective, preparation is key: the limb must be elevated, the tourniquet needs to be applied, the digit must be exsanguinated–or else you end up with a bloody, gluey mess. Then, the glue must be totally dry before the tourniquet is released and the limb is lowered. The glue, however, may not dry quickly. Especially with deeper avulsions, the glue almost seems to form a little pool within the wound that can exceed the digital tourniquet time with which I am comfortable.
Solution: Take suction tubing, hook it up to a compressed air source, and use it as a mini “blow dryer” for the wound. The patient can control the dryer while you handle other tasks. I’ve found use of this method significantly reduces tourniquet time, overall procedure time, and patient satisfaction. Thanks to Leonard Ng (Kaiser San Francisco ED technician) for this tip!
Suction tubing can be attached to a compressed air source or oxygen tank and used as a blow dryer for the tissue adhesive glue.
Final thoughts
These simple modifications to the dermal avulsion hemostasis technique can be generalized to the care of many wounds of the fingers where you might not initially consider tissue adhesive glue as an option. I have used combinations and iterations of these tricks for bleeding lacerations up and down the finger that I thought I would have to suture. Keep these pearls in mind when you are doing your next shift around dinner time when a novice chef comes in with a sliced fingertip!
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