Risk Management: Focusing on Fingers

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Using a safe tourniquet to obtain a bloodless field is critical to reduce risk.

***This article was written by one of EPM’s advertising partners as a promotional supplement.***

Finger lacerations are one of the most common injuries we see. With greater than five million visits annually, they account for 4% of ED visits. These injuries are a common focus for risk managers, as nearly 25% of all emergency department claims are due to failure to diagnose a tendon or nerve injury, or a wound foreign body.


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This is exacerbated by the fact that fingers bleed profusely, making it difficult for providers to identify these injuries. The ability to perform a safe, thorough examination to accurately diagnose and treat these injuries is critical to reduce risk and maximize outcomes.

KEY POINT #1: To avoid missing an injury, always use a tourniquet

Experts agree that the most critical aspect in the management of digit injuries is a thorough exam in a bloodless field. ACEP’s Emergency Care of the Hand:


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“It is critical to wound management that the wound is carefully explored in a bloodless field, obtained through careful tourniquet application.”

Many providers do not routinely us a digit tourniquet, noting traditional methods can be makeshift, difficult to size correctly and prone to excessive pressure.  Many only use a tourniquet for severe injuries: amputations, tip avulsions and arterial injuries.

ERROR #1: Failing to recognize that small, simple appearing lacerations have the highest rate of complications and are commonly explored without a tourniquet and adequate hemostasis. Most missed injuries occur on small (< 2cm), innocuous looking finger lacerations.

STANDARD OF CARE: Explore all wounds to their base, through a full range of motion, in a bloodless field. Must also perform and document a thorough tendon and nervovascular exam.


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Plaintiff attorneys have argued that exploring a finger wound without using a tourniquet to actively achieve hemostasis does not meet the standard of care.  They claim it is not feasible to probe a wound to its full depth, through a full ROM without causing bleeding. If you miss an injury or foreign body and haven’t used a tourniquet, it will likely be argued that you haven’t met the standard of care.

RISK REDUCTION: Always use a tourniquet when exploring finger lacerations

KEY POINT #2: To avoid causing an injury, always use the T-RING

Any time a tourniquet is applied, there is risk of injury.  While this risk has been minimized with modern pneumatic tourniquets that apply exact pressure to limbs, traditional digit tourniquets apply unknown pressures and have well documented risks associated with their use.  Two prospective randomized studies evaluated complications related to elastic bands, rolls and straps similar to traditional digit tourniquets reported nerve in jury in 71% and 77% of patients.

In a June 2020 ED risk management update, the Emergency Physician Risk Retention Group cited data showing that all traditional digit tourniquets apply excessive pressure. While only 110-130mmHg is necessary to occlude the digital arteries, most digit tourniquets apply several times this amount.

The complications include vascular injury leading to digital ischemia and necrosis, and digital nerve injury resulting in temporary paresthesia to permanent sensory loss. Increasing the risk is the fact that many our ED patients have conditions that put them at high risk for pressure related neurovascular injury. The more dramatic, but less common complication is digital necrosis from a forgotten tourniquet; most commonly associated with low profile tourniquet methods.

ERROR #2:  Not recognizing that traditional digit tourniquets may apply excessive pressure and cause neurovascular injury, even when applied for short periods of time.

STANDARD OF CARE:  To minimize the risk of causing a pressure related injury, you must always use the least amount of pressure necessary to achieve hemostasis.

The T-RING solved the problem of inexact and excessive pressure.  In a 2010 study (Lahham, WJEM), the one-size-fits-all T-RING was shown to automatically adjust to any digit size to apply the same, ideal pressure (152 mmHg) on the smallest (45 mm circumference) and largest (85 mm) finger. The T-RING immediately stopped bleeding on all digit sizes, while applying the lowest pressure of all tourniquet methods every time.  The T-RING’s high profile also makes it virtually impossible to forget on a digit.

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EMERGENCY & TRAUMA CARE, ELSEVIER, SEPT 2019:

“Surgical gloves, penrose drains and the Tourni-cot™ all exceed the pressure required for digital hemostasis, & dramatically increase the risk of neurovascular injury. These injuries can be devastating for the patient. The T-RING is now used to replace these other methods.  It is one-size-fits-all, and applies an even pressure to any digit, creating the required bloodless field with minimal pressure.”

RISK REDUCTION: When using a digit tourniquet, always use the T-RING

KEY POINT #3: Perform a thorough exam using a stepwise approach

A stepwise approach, based on expert recommendations, is critical to minimize risk associated with finger lacerations:

  • Prior to T-RING application — assess capillary refill, note any arterial injury, assess two point discrimination (using T-RING’s discriminator) and appropriate tendon function.
  • Apply T-RING and provide anesthesia: If wound is simple (clean cut less than 2.5 cm), apply T-RING first, then anesthetize using topical lidocaine for five to 10 minutes. If wound is complex, dirty or very painful, perform digital block then apply the T-RING.
  • Irrigate and Explore Wound: Once anesthetized, irrigate the wound. Simple lacerations can be cleansed using tap water irrigation; use pressure irrigation for dirty or higher risk wounds. Once cleansed, explore wound to its base, through a full ROM to exclude deep tissue injury or foreign body

Make sure to document your complete exam, noting “the exam was performed in a bloodless field achieved through careful tourniquet application.”

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KEY POINT #4: T-RING also makes wound closure faster, easier and less painful

The good news is that greater than 95% of finger lacerations do not have a deep tissue injury; most are simple skin lacs < 2 cm.  These are ideal for Topical Laceration Closure™ (TLC™), which is faster, easier and less painful to apply than sutures, and has a lower cost and infection rate. TLC™ requires a completely bloodless field: with the T-RING already in place, simply close the wound with the T-STRIP, seal with Dermabond, wait one to two minutes and remove the T-RING.

TLC™ is great for children as there are no painful injections, needles or follow up visits for suture removal.

SUMMARY: Finger injuries are common and high risk.  It is critical to have a standard approach to minimize risk. Use the T-RING to safely control bleeding, perform and document a thorough exam, clean well and avoid sutures on small, simple lacerations that are better suited for topical closure.

ABOUT THE AUTHOR

Dr. Green is a Fellow of the American College of Emergency and has been a board certified emergency physician for the past 27 years. He is currently an emergency physician at Hoag Hospital in Newport Beach, CA. He is the inventor of the T-RING digit tourniquet, the T-STRIP wound closure strip and the Topical Laceration Closure™ system. Contact: wgreen@theTring.com

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