Effect of cold application and compression on pain and bruising in subcutaneous heparin injection

BACKGROUND AND AIM

Subcutaneous administration may result in complications such as bruising and pain at the injection site. This study was performed as in order to determine the effect of cold application and compression on pain and bruising in subcutaneous heparin injection.

METHODS

The study was a randomized controlled trial. 72 patients were included in the study. Each patient in the sample was both experimental (cold and compression) and control groups and 3 different parts of abdomen were used for injection of each patient. The data of the research were collected by using Patient Identification Form, Subcutaneous Heparin Observation Form and Visual Analog Scale (VAS).

RESULTS

In the study, it was observed that after heparin injection, ecchymosis developed in 16.4%, 28.8%, and 54.8% of the patients, respectively, and pain was experienced during injection in 12.3%, 43.5%, and 44.2% of the patients, respectively, on the pressure, cold application, and control site groups, and this difference was statistically significant (p<0.001).

CONCLUSION

In the study, it was found that bruising size of the compression group was smaller in contrast with the other groups. When the VAS mean was examined for the groups, it was found that the patients in the compression group had lower pain than the other groups. In order to prevent complications that may arise in nurses' subcutaneous heparin injections and to increase the quality of patient care, it may be recommended to transfer the 60-second compression application after subcutaneous heparin applications to clinical applications and to conduct studies comparing compression and cold application with other applications for future studies.

Slow versus fast subcutaneous heparin injections for prevention of bruising and site pain intensity

BACKGROUND

Heparin is an anticoagulant medication that is usually injected subcutaneously. Subcutaneous administration of heparin may result in complications such as bruising, haematoma, and pain at the injection site. One of the factors that may affect pain, haematoma, and bruising is injection speed. Several studies have been carried out to determine if speed of injection affects the amount of pain and bruising where the injection is given; however, the results of these studies have differed, and study authors have not reached a clear final conclusion. This is the second update of a review first published in 2014.

OBJECTIVES

To assess the effects of duration (speed) of subcutaneous heparin injection on pain and bruising at the injection site in people admitted to hospitals or clinics who require treatment with unfractionated heparin (UFH) or low molecular weight heparin (LMWH). We also looked at haematoma at the injection site.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 22 June 2020. We undertook reference checking of included studies to identify additional studies.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) comparing the effects of different durations of subcutaneous injection of heparin on pain, bruising, and haematoma at the injection site.

DATA COLLECTION AND ANALYSIS

For this update, two review authors independently selected studies and extracted data via Covidence software and assessed methodological quality using Cochrane's risk of bias tool. The primary outcomes of interest were pain intensity at injection site and size and incidence of bruising. The secondary outcomes of interest were size and incidence of haematoma at injection site. We calculated the odds ratio (OR), mean difference (MD), or standardised mean difference (SMD) with corresponding 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE criteria.

MAIN RESULTS

We identified one new study for this update, resulting in a total of five included studies with 503 participants who received subcutaneous injections of LMWH into the abdomen. Given the nature of the intervention, it was not possible to blind participants and caregivers (personnel) in any of the included studies. Two studies described blinding of outcome assessors. Overall, the methodological quality of included studies was moderate. The duration of the fast injection was 10 seconds, and the duration of the slow injection was 30 seconds in all included studies. Four studies reported site pain intensity after each injection at different time points. Two studies assessed site pain intensity immediately after each injection; meta-analysis showed no evidence of a difference in site pain intensity immediately after slow injection when compared to fast injection (MD -1.52, 95% CI -3.56 to 0.53; 140 participants; low-certainty evidence). Meta-analysis of three studies indicated that site pain intensity may be slightly reduced 48 hours after the slow heparin injection compared to fast injection (MD -1.60, 95% CI -2.69 to -0.51; 103 participants; low-certainty evidence). Five studies assessed bruise size at 48 hours, and two studies assessed bruise size at 60 hours. Meta-analysis showed there may be a reduction in bruise size 48 hours (SMD -0.54, 95% CI -1.05 to -0.02; 503 participants; 5 studies; very low-certainty evidence) and 60 hours (SMD -0.49, 95% CI -0.93 to -0.06; 84 participants; 2 studies; low-certainty evidence) after slow injection compared to fast injection. There was no evidence of a difference in bruise size 72 hours after slow injection compared to fast injection (SMD -0.27, 95% CI -0.61 to 0.06; 140 participants; 2 studies; low-certainty evidence). Three studies evaluated incidence of bruising and showed there may be a reduction in bruise incidence 48 hours (OR 0.39, 95% CI 0.26 to 0.60; 444 participants; low-certainty evidence) and 60 hours (OR 0.25, 95% CI 0.10 to 0.65; 84 participants; 2 studies; low-certainty evidence) after slow injection compared to fast injection. We downgraded the certainty of the evidence due to risk of bias concerns, imprecision, and inconsistency. None of the included studies measured size or incidence of haematoma.

AUTHORS' CONCLUSIONS

Administering medication safely and enhancing patient comfort are the main aims of clinical nurses. In this review, we identified five RCTs that evaluated the effect of subcutaneous heparin injection duration on pain intensity, bruise size and incidence. We found that pain may be slightly reduced 48 hours after slow injection. Similarly, there may be a reduction in bruise size and incidence after slow injection compared to fast injection 48 and 60 hours postinjection. We downgraded the certainty of the evidence for all outcomes to low or very low due to risk of bias concerns, imprecision, and inconsistency. Accordingly, new trials with a more robust design, more participants, and a focus on different injection speeds will be useful in strengthening the certainty of the available evidence.

Facial aesthetic injections in clinical practice: Pretreatment and posttreatment consensus recommendations to minimise adverse outcomes

Facial aesthetic treatment with injectable neuromodulators and hyaluronic acid fillers is well established, with favourable safety profiles and consistent outcomes. As with any medical treatment, adverse events and complications may occur. Adverse events associated with these products are typically transient and mild to moderate in severity. Serious adverse events, such as infection and intravascular occlusion, are rare. Proper patient selection, consent and counselling, preparation and impeccable injection technique are important risk reduction strategies. Both clinicians and patients must be alert to the signs and symptoms of complications so that appropriate treatment can be started promptly. In this article, the authors review the current literature and provide their consensus recommendations for minimising adverse outcomes when treating patients with botulinum toxin or hyaluronic acid fillers.

CPR-related thoracic injuries: comparison of CPR guidelines between 2010 and 2015

Background/aim: This study aimed to evaluate traumatic thorax complications in post-CPR patients and to investigate whether or not there has been a decrease in these complications since the adoption of current chest compression recommendations. Materials and methods: Post-CPR patients with return of spontaneous circulation (ROSC) were admitted between January 2014 and January 2016 were analyzed retrospectively. Patients admitted to the ED in 2014 were resuscitated according to 2010 AHA CPR guidelines, while those admitted to the ED in 2015 were resuscitated according to current ERC CPR guidelines. Results: The study population comprised 48 male and 35 female patients. Of the 2010 AHA guideline patients, 39.21% experienced pulmonary contusion, while 54.83% of 2015 ERC guideline patients had pulmonary contusion. It was found that 11.76% of 2010 AHA guideline patients and 3.22% of 2015 ERC guideline patients had pneumothorax, while 9.8% of 2010 AHA guideline patients and 12.9% of 2015 ERC guideline patients experienced hemothorax. Incidence rates of lung contusion, pneumothorax, and hemothorax were higher in patients with rib fractures. Conclusion: In this study, traumatic thoracic complications were investigated in patients with ROSC after CPR. The incidence of CRP-related injuries did not decrease on application of the new 2015 ERC CPR guideline recommendations. The most common injury in this study was rib fracture, followed by sternal fracture, lung contusion, hemothorax, and pneumothorax. Statistically, rib fracture had a positive relationship with lung contusion, hemothorax, and pneumothorax.

Homeopathic Arnica for Prevention of Pain and Bruising: Randomized Placebo-Controlled Trial in Hand Surgery

Homeopathic arnica is widely believed to control bruising, reduce swelling and promote recovery after local trauma; many patients therefore take it perioperatively. To determine whether this treatment has any effect, we conducted a double-blind, placebo-controlled, randomized trial with three parallel arms. 64 adults undergoing elective surgery for carpal tunnel syndrome were randomized to take three tablets daily of homeopathic arnica 30C or 6C or placebo for seven days before surgery and fourteen days after surgery. Primary outcome measures were pain (short form McGill Pain Questionnaire) and bruising (colour separation analysis) at four days after surgery. Secondary outcome measures were swelling (wrist circumference) and use of analgesic medication (patient diary).

62 patients could be included in the intention-to-treat analysis. There were no group differences on the primary outcome measures of pain ( P=0.79) and bruising ( P=0.45) at day four. Swelling and use of analgesic medication also did not differ between arnica and placebo groups. Adverse events were reported by 2 patients in the arnica 6C group, 3 in the placebo group and 4 in the arnica 30C group.

The results of this trial do not suggest that homeopathic arnica has an advantage over placebo in reducing postoperative pain, bruising and swelling in patients undergoing elective hand surgery.

Slow versus fast subcutaneous heparin injections for prevention of bruising and site pain intensity

BACKGROUND

Heparin is an anticoagulant medication that is usually injected subcutaneously. Subcutaneous administration of heparin may result in complications such as bruising, haematoma, and pain at the injection site. One of the factors that may affect pain, haematoma, and bruising is injection speed. For patients and healthcare providers, strategies that can reduce pain and bruising are considered important. Reducing patients' discomfort and concerns whenever and wherever possible is an important aim of nursing. Several studies have been carried out to see if speed of injection affects the amount of pain and bruising where the injection is given, but results of these studies have differed and study authors have not reached a clear final conclusion. This is the first update of the review first published in 2014.

OBJECTIVES

To assess the effects of duration (speed) of subcutaneous heparin injection on pain, haematoma, and bruising at the injection site in people admitted to hospitals or clinics who require treatment with unfractionated heparin (UFH) or low molecular weight heparin (LMWH).

SEARCH METHODS

For this update, the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (last searched March 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2). The CIS also searched trials registries for details of ongoing or unpublished studies. Review authors searched two Persian databases - Iranmedex and Scientific Information Database (SID) - as well as Google Scholar.

SELECTION CRITERIA

We sought randomised controlled trials (RCTs) comparing the effects of different durations of subcutaneous injection of heparin on pain, bruising, and haematoma at the injection site.

DATA COLLECTION AND ANALYSIS

Two review authors (MM, LJ), working independently, extracted data onto a structured form and assessed study quality. We used the criteria recommended by Cochrane to assess the risk of bias of included studies. For the outcomes, we calculated the mean difference (MD) or the standardised MD (SMD) with corresponding 95% confidence intervals (CIs). We pooled data using fixed-effect and random-effects models. We used GRADE to assess the overall quality of evidence supporting outcomes assessed in this review.

MAIN RESULTS

For this update, we identified three new studies and therefore included in the Review four studies with a total of 459 participants who received subcutaneous injections of LMWH into the abdomen. Only one trial reported the injected drug volume (0.4 mL). Owing to the nature of the intervention, it was not possible to blind participants and care givers (personnel) in any included study. Two studies described blinding of outcome assessors; therefore overall, the methodological quality of included studies was moderate. The duration of the fast injection was 10 seconds and the duration of the slow injection was 30 seconds in all included studies.Three studies reported site pain intensity after each injection at different time points. Two studies assessed site pain intensity immediately after each injection, and meta-analysis on 140 participants showed no clear difference in site pain intensity immediately post slow injection when compared to fast injection (low-quality evidence; P = 0.15). In contrast, meta-analysis of two studies with 59 participants showed that 48 hours after the heparin injection, slow injection was associated with less pain intensity compared to fast injection (low-quality evidence; P = 0.007). One study (40 participants) reported pain intensity at 60 and 72 hours after injection. This study described no clear difference in site pain intensity at 60 and 72 hours post slow injection compared to fast injection.All four included studies assessed bruise size at 48 hours after each injection. Meta-analysis on 459 participants showed no difference in bruise size after slow injection compared to fast injection (low-quality evidence; P = 0.07). None of the included studies measured the incidence of haematoma as an outcome.

AUTHORS' CONCLUSIONS

We found four RCTs that evaluated the effect of subcutaneous heparin injection duration on pain intensity and bruise size. Owing to the small numbers of participants, we found insufficient evidence to determine any effect on pain intensity immediately after injection or at 60 and 72 hours post injection. However, slow injection may reduce site pain intensity 48 hours after injection (low-quality evidence). We observed no clear difference in bruise size after slow injection compared to fast injection (low-quality evidence). We judged this evidence to be of low quality owing to imprecision and inconsistency.

Slow versus fast subcutaneous heparin injections for prevention of bruising and site pain intensity

BACKGROUND

Heparin is an anticoagulant medication that is usually injected subcutaneously. Subcutaneous administration of heparin may result in complications such as bruising, haematoma, and pain at the injection site. One of the factors that may affect pain, haematoma, and bruising is injection speed. For patients and healthcare providers, strategies that can reduce pain and bruising are considered important. Reducing patients' discomfort and concerns whenever and wherever possible is an important aim of nursing. Several studies have been carried out to see if speed of injection affects the amount of pain and bruising where the injection is given, but results of these studies have differed and study authors have not reached a clear final conclusion. This is the first update of the review first published in 2014.

OBJECTIVES

To assess the effects of duration (speed) of subcutaneous heparin injection on pain, haematoma, and bruising at the injection site in people admitted to hospitals or clinics who require treatment with unfractionated heparin (UFH) or low molecular weight heparin (LMWH).

SEARCH METHODS

For this update, the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (last searched March 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2). The CIS also searched trials registries for details of ongoing or unpublished studies. Review authors searched two Persian databases - Iranmedex and Scientific Information Database (SID) - as well as Google Scholar.

SELECTION CRITERIA

We sought randomised controlled trials (RCTs) comparing the effects of different durations of subcutaneous injection of heparin on pain, bruising, and haematoma at the injection site.

DATA COLLECTION AND ANALYSIS

Two review authors (MM, LJ), working independently, extracted data onto a structured form and assessed study quality. We used the criteria recommended by Cochrane to assess the risk of bias of included studies. For the outcomes, we calculated the mean difference (MD) or the standardised MD (SMD) with corresponding 95% confidence intervals (CIs). We pooled data using fixed-effect and random-effects models. We used GRADE to assess the overall quality of evidence supporting outcomes assessed in this review.

MAIN RESULTS

For this update, we identified three new studies and therefore included in the Review four studies with a total of 459 participants who received subcutaneous injections of LMWH into the abdomen. Only one trial reported the injected drug volume (0.4 mL). Owing to the nature of the intervention, it was not possible to blind participants and care givers (personnel) in any included study. Two studies described blinding of outcome assessors; therefore overall, the methodological quality of included studies was moderate. The duration of the fast injection was 10 seconds and the duration of the slow injection was 30 seconds in all included studies.Three studies reported site pain intensity after each injection at different time points. Two studies assessed site pain intensity immediately after each injection, and meta-analysis on 140 participants showed no clear difference in site pain intensity immediately post slow injection when compared to fast injection (low-quality evidence; P = 0.15). In contrast, meta-analysis of two studies with 59 participants showed that 48 hours after the heparin injection, slow injection was associated with less pain intensity compared to fast injection (low-quality evidence; P = 0.007). One study (40 participants) reported pain intensity at 60 and 72 hours after injection. This study described no clear difference in site pain intensity at 60 and 72 hours post slow injection compared to fast injection.All four included studies assessed bruise size at 48 hours after each injection. Meta-analysis on 459 participants showed no difference in bruise size after slow injection compared to fast injection (low-quality evidence; P = 0.07). None of the included studies measured the incidence of haematoma as an outcome.

AUTHORS' CONCLUSIONS

We found four RCTs that evaluated the effect of subcutaneous heparin injection duration on pain intensity and bruise size. Owing to the small numbers of participants, we found insufficient evidence to determine any effect on pain intensity immediately after injection or at 60 and 72 hours post injection. However, slow injection may reduce site pain intensity 48 hours after injection (low-quality evidence). We observed no clear difference in bruise size after slow injection compared to fast injection (low-quality evidence). We judged this evidence to be of low quality owing to imprecision and inconsistency.

A blinded, randomized, split-face pilot study of bruising and pain with hyaluronic acid for correction of perioral lines using no lidocaine, lidocaine alone, and lidocaine and epinephrine

BACKGROUND

Hyaluronic acid (HA) fillers are sometimes mixed with lidocaine to mitigate pain. Whether the addition of epinephrine to lidocaine provides greater benefits in bruising and pain has not been fully reported.

OBJECTIVES

The investigators explored the severity of bruising and pain in patients treated with the cohesive polydensified matrix HA (CPMHA) in 3 different preparations: CPMHA (Belotero Balance [BEL]), CPMHA with lidocaine (BEL-L), and CPMHA with lidocaine and epinephrine (BEL-LE).

METHODS

In a blinded, split-face, 14-day study, 30 patients were divided into groups of 10. One group received 1.0 mL BEL in the perioral lines on 1 side and 1.0 mL of BEL-LE on the other side. A second group received 1.0 mL of BEL on 1 side and 1.0 mL of BEL-L on the other side. The third group received 1.0 mL of BEL-L on 1 side and 1.0 mL of BEL-LE on the other side. Over 3 visits, the treating investigator, the patients, and a blinded investigator rated the bruising.

RESULTS

Bruising occurred in each treatment group by day 1 but resolved for half of the patients by day 7 and for all patients by day 14. Split-face comparison did not reveal a significant difference in pain and bruising scores among the 3 preparations.

CONCLUSIONS

No significant difference was found in bruising or pain in patients treated with BEL, BEL-L, and BEL-LE. Studies with a considerably larger sample size are warranted to determine statistically significant and clinically meaningful differences between and among the various formulations.

Slow versus fast subcutaneous heparin injections for prevention of bruising and site-pain intensity

BACKGROUND

Heparin is an anticoagulant medication that is normally injected subcutaneously. Subcutaneous administration of heparin may result in complications such as bruising, haematoma and pain at the injection site. One of the factors that may affect pain, haematoma and bruising is injection speed.

OBJECTIVES

To assess the effects of the duration (speed) of subcutaneous heparin injection on pain, haematoma and bruising at the injection site in people admitted to hospitals or clinics who require treatment with unfractionated heparin or low molecular weight heparin.

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched August 2013) and CENTRAL (2013, Issue 7). We searched MEDLINE, EMBASE, CINAHL and two Persian databases Iranmedex and SID (August 2013).

SELECTION CRITERIA

We sought randomised controlled trials (RCTs) comparing the effects of different durations of subcutaneous injections of heparin on pain, bruising and haematoma at the injection site.

DATA COLLECTION AND ANALYSIS

Two review authors, working independently, extracted data onto a structured form and assessed study quality. We used the criteria recommended by the Cochrane Handbook to assess the quality of included studies. The study outcomes were summarised using quantitative and qualitative methods.

MAIN RESULTS

One RCT was identified which met the inclusion criteria, involving 50 participants with a mean age of 55.25 (± 12.37) years. In this trial it was not possible to blind the participants and care givers. The method of sequence generation and allocation concealment was not described. The overall quality of the evidence was moderate due to the single small included study. Each participant had two injections, one in the left side and one in right side of the abdomen. One of these was injected slowly (intervention) and the other was injected fast (control). The second injection was 12 hours after the first injection. The duration of fast injection was 10 seconds and the duration of slow injection was 30 seconds. The study reported a significantly lower pain intensity for slow versus fast injection. The mean pain intensity was 13.9 ± 17.1 mm with the slow injection and 20.6 ± 22.3 mm with the fast injection (P < 0.001). In addition the bruising sizes were smaller with slow injections compared to fast injections at 48 hours follow-up (mean bruising size 18.76 ± 9.32 mm(2) with the slow injection and 109.2 ± 468.66 mm(2) with the fast injection, P = 0.033) and 72 hours follow-up (mean bruising size 21.72 ± 76.16 mm(2) with the slow injection and 110.12 ± 472.86 mm(2) with the fast injection, P = 0.025). The incidence of haematoma was not measured as an outcome.

AUTHORS' CONCLUSIONS

There is only limited evidence of any difference in pain intensity and bruising sizes following slow versus fast injections due to the inclusion of only one small unblinded trial. The single included study suggests that slow injection might have slightly lower pain intensity and bruising size at the heparin injection site, but the results should be considered with caution. Until more reliable evidence emerges, slow injection might be the preferred approach.

Comparative analysis of the protective effects of caffeic acid phenethyl ester (CAPE) on pulmonary contusion lung oxidative stress and serum copper and zinc levels in experimental rat model

The aim of this study was to investigate the effects of caffeic acid phenethyl ester (CAPE) in the lungs by biochemical and histopathological analyses in an experimental isolated lung contusion model. Eighty-one male Sprague-Dawley rats were used. The animals were divided randomly into four groups: group 1 (n = 9) was defined as without contusion and without CAPE injection. Group 2 (n = 9) was defined as CAPE 10 μmol/kg injection without lung contusion. Group 3 (n = 36) was defined as contusion without CAPE-administrated group which consisted of four subgroups that were created according to analysis between days 0, 1, 2, and 3. Group 4 (n = 27) was defined as CAPE 10 μmol/kg administrated after contusion group divided into three subgroups according to analysis on days 1, 2, and 3. CAPE 10 μmol/kg was injected intraperitoneally 30 min after trauma and on days 1 and 2. Blood samples were obtained to measure catalase (CAT) and superoxide dismutase (SOD) activities and level of malondialdehyde (MDA) and for blood gas analysis. Trace elements such as zinc and copper were measured in serum. The lung tissue was also removed for histopathological examination. Isolated lung contusion increased serum and tissue SOD and CAT activities and MDA levels (p < 0.05). Both serum and tissue SOD, MDA, and CAT levels on day 3 were lower in group 4 compared to group 3 (p < 0.05). Further, the levels of SOD, MDA, and CAT in group 4 were similar compared to group 1 (p > 0.05). CAPE also had a significant beneficial effect on blood gases (p < 0.05). Both serum zinc and copper levels were (p < 0.05) influenced by the administration of CAPE. Histopathological examination revealed lower scores in group 4 compared to group 3 (p < 0.05) and no significant differences compared to group 1 (p > 0.05). CAPE appears to be effective in protecting against severe oxidative stress and tissue damage caused by pulmonary contusion in an experimental setting. Therefore, we conclude that administration of CAPE may be used for a variety of conditions associated with pulmonary contusion. Clinical use of CAPE may have the advantage of prevention of pulmonary contusion.

The effect of lidocaine when mixed with large gel particle hyaluronic acid filler tolerability and longevity: a six-month trial

OBJECTIVES

To determine if there is any effect on tolerance, adverse events or clinical outcome when lidocaine is added to large gel particle hyaluronic acid (LGP-HA).

MATERIALS AND METHODS

Single-centered, double-blinded, randomized, with-in patient trial, comparing patient comfort when receiving LGP-HA injections versus injections of LGP-HA mixed with lidocaine hydrochloride 2% (LGP-HA + L). Results were determined through patient questionnaires, standardized Canfield photography and blinded physician assessors. Participants were followed for six months.

RESULTS

Eighteen females were enrolled and completed the study. The average pain rating was significantly less when LGP-HA + L was administered as reported by participants and blinded investigators. Average rating of bruising and redness were less with LGP-HA + L, but not significant. After six months, 100 percent of participants and 100 percent of the primary and secondary blinded investigators reported no difference in clinical outcome or longevity between the different treatments. There was no difference in adverse events.

CONCLUSION

This is the first trial to report a six-month follow-up in a split-face study comparing LGP-HA + L to LGP-HA alone. All participant and investigator reports found symmetry of the NLFs at six months, thus demonstrating that the addition of lidocaine to LGP-HA does not affect longevity. Administration of LGP-HA + L is associated with less patient discomfort than administration of LGP-HA alone.

[Principle energy substrate changing as a technique of myocardium protection against ischemic damage in experimental mechanic cardiac contusion]

By changing the principal energy substrate, trimetasidine has reduced severity of ischemic myocardial damage as shown by greater integrity of membrane structures, improvement of contractile and rhythmic functions, central hemodynamics and lethality early after experimental myocardial contusion.

Review: the use of sodium hypochlorite in endodontics — potential complications and their management

Aqueous sodium hypochlorite (bleach) solution is widely used in dental practice during root canal treatment. Although it is generally regarded as being very safe, potentially severe complications can occur when it comes into contact with soft tissue. This paper discusses the use of sodium hypochlorite in dental treatment, reviews the current literature regarding hypochlorite complications, and considers the appropriate management for a dental practitioner when faced with a potentially adverse incident with this agent.

[School accidents--an epidemiological assessment of injury types and treatment effort]

Children and adolescents spend up to 50% of their time at school. The purpose of this study was to assess injury patterns with their treatment of school accidents in a Trauma Service of a German University Hospital and to compare these data to the literature. All school accidents from 01.07.1999 to 30.06.2004 were statistically analysed in a retrospective manner by chart review. There were 1399 school accidents treated in our department. Average age of the injured children was 11.8 years with a boy:girl ratio of 3:2. Almost 40% of the injuries occurred during school sport. The most frequently injured region was the upper extremity including the hand (36.8%). Distortion and contusion were the most frequent diagnoses of all injuries. 16% of the cases had to be treated surgically and/or under general anaesthesia and also a total of 16% of the patients had to be admitted to the hospital. It can be concluded for school facilities that special attention has to be paid during school sports activity and breaks because they account for most accidents. Traffic education may reduce severe injuries. For diagnosis and treatment of school accidents specific knowledge of the growing longbones of the upper extremity and the hand is important.

[Diagnostics of lung contusion in patients with thoracic closed injury and prophylaxis of complications]

Among 304 patients hospitalised with thorax closed injury 205 patients had lung contusion. The use of a complex diagnostics allowed to discharge 176 patients without any complications. The development of complections was observed in 128 patients, which occurred after the patients had had their injuries. Application of endoscopic sanation and treatment allowed to discharge patients in early terms.

Effect of Homeopathic Arnica montana on Bruising in Face-lifts

OBJECTIVES

To design a model for performing reproducible, objective analyses of skin color changes and to apply this model to evaluate the efficacy of homeopathic Arnica montana as an antiecchymotic agent when taken perioperatively.

METHODS

Twenty-nine patients undergoing rhytidectomy at a tertiary care center were treated perioperatively with either homeopathic A. montana or placebo in a double-blind fashion. Postoperative photographs were analyzed using a novel computer model for color changes, and subjective assessments of postoperative ecchymosis were obtained.

RESULTS

No subjective differences were noted between the treatment group and the control group, either by the patients or by the professional staff. No objective difference in the degree of color change was found. Patients receiving homeopathic A. montana were found to have a smaller area of ecchymosis on postoperative days 1, 5, 7, and 10. These differences were statistically significant (P<.05) only on postoperative days 1 (P<.005) and 7 (P<.001).

CONCLUSIONS

This computer model provides an efficient, objective, and reproducible means with which to assess perioperative color changes, both in terms of area and degree. Patients taking perioperative homeopathic A. montana exhibited less ecchymosis, and that difference was statistically significant (P<.05) on 2 of the 4 postoperative data points evaluated.

Pre-incision infiltration of local anesthetic reduces postoperative pain with no effects on bruising and wound cosmesis after thyroid surgery

Optimizing postoperative pain control is an important aspect in perioperative patient care. The aim of this study was to investigate the efficacy of preincision local anesthetic infiltration in postoperative pain management for thyroid surgery and its relationship to bruising and wound cosmesis. In a randomized single-blinded study, 39 consecutive patients listed for thyroid surgery were assigned into two groups. Group I (n = 19) received subcuticular preincision infiltration with 10 ml of bupivacaine (0.5%) and Group II (n = 20) received no infiltration. Postoperatively, the pain experienced was evaluated by two methods: verbal response scores and linear analogue scores (0-100 mm) at different time intervals following surgery. Bruising and cosmetic effects resulting from surgery were assessed using a linear analogue score at discharge. The two groups were well matched for confounding variables. Pain scores were significantly different at 6 hours post operatively (p = 0.0341) with mean scores Group I = 33 and Group II = 50, but this difference disappeared at 24 hours. No patients (0%) received IV morphine in Group I compared to 5 patients (25%) in Group II. There was no significant difference in the mean bruising scores (p = 0.8864) and mean cosmetic scores (p = 0.3339) at discharge. Preincision infiltration with bupivacaine provides easy and better analgesic control postoperatively in patients following thyroid surgery with no effects on bruising or wound cosmesis.

Soft forceps

OBJECTIVE

The risk of maternal and fetal trauma and, chiefly, the fear of law suits, have contributed to a significant decline in rates of forceps-assisted deliveries and an increase in rates of cesarean sections, especially in the United States. Our experience with gas-sterilized forceps blades covered with a soft rubber coating--the "soft" forceps--is described.

METHOD

Ninety-six women who required a forceps-assisted delivery for standard indications were randomly allocated to 2 groups. There were 51 women in the regular forceps group and 45 women in the soft forceps group. Low forceps delivery with a Simpson instrument was used in all cases. The groups were compared for fetal injury.

RESULTS

The rates of severe facial abrasion and minimal marking were 4.1% and 61%, respectively, in the regular forceps group and 1.9% and 34% in the soft forceps group.

CONCLUSION

The soft forceps may reduce the rates of neonatal facial abrasion and skin bruises. The forceps should be further perfected, as well as vacuum extractors; they should both continue to be part of the obstetrician's armamentarium.

Thromboembolic Prophylaxis as a Risk Factor for Postoperative Complications after Breast Cancer Surgery

Hematoma and bruising (sugillation) are frequent problems after operations for primary breast cancer. In the present study we evaluated the influence of various methods of perioperative thromboembolic prophylaxis on the postoperative incidence of hematoma and suggilation. From June 1994 through August 1996, a series of 425 patients consecutively operated on for primary breast cancer were included. Thromboembolic prophylaxis was low-molecular-weight heparin (LMWH) in 310 patients and thigh-long graded compression (TED) stockings in 102 patients. Postoperative complications including deep vein thrombosis, pulmonary embolism, wound hematoma, and sugillation were recorded, and 17 variables with a potential influence on complications were analyzed by logistic regression analysis. Heparin prophylaxis compared to prophylaxis with TED stockings was significantly and independently associated with postoperative hematoma [odds ratio (OR) 3, 13; 95% confidence interval (CI) 1.38-7.13] or sugillation (OR 3.34; 95% CI 1.93-5.78). No clinically overt thromboembolic complications were diagnosed. After operations for breast cancer we found that LMWH was significantly associated with postoperative hematoma and sugillation compared to TED stockings for perioperative thromboembolic prophylaxis.

Sideline splinting, bracing, and casting of extremity injuries

Emergent and nonemergent splinting, bracing, and casting are effective ways to safely remove an injured athlete from the playing field, allow immediate return to play, and permit an athlete to return to play before an injury has completely healed. Sideline providers should be familiar with the materials and resources currently available, and be aware of the sport-specific guidelines regarding their use. Properly applied splints, casts, braces, and padding should function to prevent further injury, promote comfort, and not pose a risk of injury to other participants.

Are needle-free injections a useful alternative for growth hormone therapy in children? Safety and pharmacokinetics of growth hormone delivered by a new needle-free injection device compared to a fine gauge needle

The clinical safety, use and pharmacokinetics of a new needle-free device for delivery of growth hormone (GH) were compared with those of conventional needle injection devices. In an open-label, randomized, 4-period crossover study, 18 healthy adults received single subcutaneous injections of Genotropin administered by the Genotropin ZipTip needle-free device and by conventional injection. Bioequivalence was established between the devices. In a separate open-label, randomized, multicenter, 2-period crossover study, pediatric patients underwent 2-weeks Genotropin treatment administered by the Genotropin ZipTip and by a fine-gauge needle device (>95% used the Genotropin Pen). In total, 128/133 patients who were treated completed the study. Genotropin ZipTip was well tolerated and >50% of patients found no difference between the devices for all parameters assessed. After study completion, >20% patients preferred to continue using Genotropin ZipTip. Although statistical analyses demonstrated superiority of the Genotropin Pen versus Genotropin ZipTip for bleeding, pain, soreness, and bruising, Genotropin ZipTip was considered to provide a safe and bioequivalent alternative to needle injection.

The effects of topical vitamin K on bruising after laser treatment

BACKGROUND

Pulsed dye laser treatment and other cosmetic procedures result in significant bruising. Claims have been made regarding the efficacy of topical vitamin K in both preventing and speeding the clearing of bruising; however, well-controlled studies are lacking.

OBJECTIVE

The purpose of this study is to evaluate the effects of topical vitamin K versus placebo in the prevention and clearing of laser-induced purpura.

METHODS

A total of 22 patients were enrolled in this double-blind randomized placebo-controlled study. The patients were divided into pretreatment and posttreatment groups; the 11 patients in the former group applied vitamin K cream to half of their face and vehicle alone to the other half of their face twice daily for 2 weeks before laser treatment. The latter group followed the same procedure for 2 weeks after laser treatment. On day 0, all subjects underwent laser treatment for facial telangiectases using a 585-nm pulsed dye laser. Bruising was rated by the both the patient and physician by means of a visual analogue scale on days 0, 3, 7, 10, 14, and 17.

RESULTS

The side of the face treated with topical vitamin K before laser therapy showed no significant difference in bruising as compared to placebo. However, the side of the face treated with vitamin K cream after laser treatment had significantly lower scores of bruising severity when compared with the side treated with placebo.

CONCLUSION

Although pretreatment with vitamin K did not prevent bruising after laser treatment, use of vitamin K cream after laser treatment did reduce the severity of bruising, particularly in the initial days of application.

Influence of the design of facilities at auction markets and animal handling procedures on bruising in cattle

The movements of cattle at 12 livestock auction markets were observed to determine the possible causes of trauma leading to carcase bruising. Design faults included right-angled bends in races, dead ends, flooring with insufficient slope or grip, and steps. Sliding gates were often misused for goading cattle. Projecting fittings and square-edged corners were potentially injurious; conversely, rounded posts and curved races assisted the flow of cattle with minimal impacts. At all the markets, some cattle were hit directly and poked with wooden sticks, and the variations in their use could partially explain the differences between the markets in the prevalence of carcase bruising. Most harder hits were directed at less valuable parts of the body, such as the spine, hips and shoulders, and a survey of bruising at the abattoir showed that these were the areas with most bruising. In this survey of 48,926 carcases, the overall level of commercially significant bruising of 4.1 per cent was lower than the 6.5 per cent found in a previous survey. Carcases of cattle from markets had a greater incidence and severity of bruising (P<0.001) than those arriving directly from farms or dealers. Carcase bruising in young bulls was less (P<0.001) than in heifers and steers.

A prospective randomised trial of tourniquet in varicose vein surgery

A prospective randomised trial of 50 patients was carried out to assess the autoclavable Lofquist cuff (Boazal, Sweden) as a tourniquet in varicose vein surgery and determine the effect on bleeding, bruising, cosmesis and patient pain and activity. Patients undergoing unilateral long saphenous vein ligation, stripping and avulsions were randomised to tourniquet or no tourniquet. Lofquist cuffs were applied after inflation to 120 mmHg to the upper thigh for the duration of the surgery. Varicose vein grade, duration of surgery, blood loss, extent of bruising at 7 days, pain and activity scores over the first week, and wound complications and cosmetic result at 6 weeks were recorded. Patients' age, sex, and varicose vein grade were similar in the two groups. Peroperative blood loss (median, range) was significantly reduced in the tourniquet group (0 ml, 0-20 ml) compared to the no tourniquet group (125 ml, 20-300; P < 0.01). Operative time and thigh bruising (median, range) were also reduced in the tourniquet group (30 min, 11-47 min; 72 cm2, 30-429 cm2), respectively, compared to the no tourniquet group (37 min, 18-50 min; 179 cm2, 24-669 cm2) both (P < 0.01). There was no difference in pain and activity scores in the two groups and cosmetic results were also similar. The use of the Lofquist cuff tourniquet during varicose vein surgery reduces peroperative blood loss, operative time and postoperative bruising without any obvious drawbacks.

Post-tumescent liposuction care. Open drainage and bimodal compression

The goals of post-liposuction care must be to minimize edema, bruising, and patient discomfort. The postoperative pain and edema resulting from sutured incisions and prolonged post-liposuction compression is an irrational remnant from the days before the tumescent technique. This article discusses various issues involving post-liposuction care.

Injury rates in Shotokan karate

OBJECTIVE

To document the injury rate in three British Shotokan karate championships in consecutive years. In these tournaments strict rules governed contact, with only "light" or "touch" contact allowed. Protective padding for the head, hands, or feet was prohibited.

METHODS

Prospective recording of injuries resulting from 1770 bouts in three national competitions of 1996, 1997, and 1998. Details of ages and years of karate experience were also obtained.

RESULTS

160 injuries were sustained in 1770 bouts. The overall rate of injury was 0.09 per bout and 0.13 per competitor. 91 (57%) injuries were to the head. The average age of those injured was 22 years, with an average of nine years of experience in karate.

CONCLUSIONS

The absence of protective padding does not result in higher injury rates than in most other series of Shotokan karate injuries. Strict refereeing is essential, however, to maintain control and minimise contact.

The effect of pressure bandaging on complications and comfort in patients undergoing coronary angiography: a multicenter randomized trial

OBJECTIVES

To determine the effectiveness of pressure bandaging in reducing bleeding and bruising in patients undergoing coronary angiography and to investigate the contribution that pressure bandages make to patient discomfort after angiography.

DESIGN

A prospective multicenter, randomized study.

SETTING

Three university hospitals in Melbourne, Australia.

PATIENTS

One thousand seventy-five patients undergoing coronary angiography were randomized to receive a pressure bandage (N = 556) or no bandage (N = 519) after manual compression of the right femoral artery puncture site.

RESULTS

Patients without pressure bandages had a higher incidence of bleeding (P < 0.05) and bled earlier (mean 2.4 hours; SD 3.6 hours) after catheter removal (P < 0.001) than patients with bandages (mean 5.3 hours; SD 3.8 hours). The incidence of bleeding in patients without pressure bandages was 6.7%. The incidence and extent of bruising was the same for both groups. Patients with pressure bandages experienced a higher incidence of back (P < 0.05), groin (P < 0.001), and leg pain (P < 0.001), nausea (P < 0.05) and urinary difficulty (P < 0.01).

CONCLUSIONS

In view of the associated increase in patient discomfort and the delay in time of onset of bleeding, pressure bandages should not be used routinely in the management of patients after coronary angiography, especially in the context of early discharge from the hospital.

Evaluation of the KTP 532 laser in aesthetic facial surgery

This study investigated the ability of the KTP 532 laser to reduce postoperative swelling and bruising in aesthetic facial surgery. Thirty consecutive patients receiving a laser-assist procedure (following skin incision with a scalpel, dissection and hemostasis were accomplished primarily with the laser) were compared to 16 patients who had similar technical operations but relied on scissor/scalpel dissection and electrocautery for hemostasis. Evaluations were performed by comparison of serial photographs after surgery and by patient self-assessment. The clinical observations demonstrated a noticeable reduction in postoperative swelling, bruising, and discomfort in the patients whose procedure was performed with the aid of the laser.

Effect of glutamic acid on broilers given submarginal crude protein with adequate essential amino acids using feeds high and low in potassium

Broiler males were examined for their response to feeds containing CP 1 to 2% below levels advocated by NRC (1994) and when supplemented with L-glutamic acid. Crude protein and glutamic acid treatments were imposed in starting, growing, and finishing feeds over 7 wk with K at high and low levels likely to occur in practice (0.80 vs 0.65 to 0.55%). All feeds were formulated to be isocaloric (3.20 kcal ME/g) and satisfy NRC (1994) essential amino acid (EAA) minimum requirements. Improved live weight gain occurred during the first 6 wk with supplementation of glutamic acid to the low CP feed but not when intact protein per se was used to increase CP. A similar advantage in growth was obtained from glutamic acid in response to its addition at equivalence of 1 to 2% CP as well as when dietary adjustments maintained low CP. Response to altered K could not be interpreted because of concurrent differences in glutamic acid and AMEn intakes. High glutamic acid levels did not decrease abdominal fat unless CP increased concurrently, whereas carcass back bruising and drumstick deformations were relieved by supplemental glutamic acid independent of CP. Increased weight gain from glutamic acid was only evident with drumsticks and debris that included the back when carcasses were cone-deboned. Supplemental glutamic acid is believed to improve the rate of connective tissue formation during rapid growth.

Handling of sheep at markets and the incidence of bruising

Most sheep sent for slaughter in the United Kingdom are sold through livestock markets. This study counted the potentially bruising events at two markets handling 12,119 sheep in 549 groups and recorded the bruises on carcases of sheep from these markets. There were 1324 and 744 potentially bruising events per 1000 sheep at markets A and B, respectively. The unloading of 1501 sheep in 40 groups and the pre-slaughter handling of 1085 sheep in 60 groups were observed at the commercial slaughterhouse where the bruises were recorded. The number of potentially bruising events at the slaughterhouse was 694 per 1000 sheep. The bruising on the carcases of 58 groups of sheep from market A and 29 groups from market B, and of 30 groups of sheep sent to slaughter direct from farms was assessed. The sheep from market A had 581 bruises per 1000 sheep, those from market B had 377 per 1000 sheep, and the sheep sent direct from farms had 399 bruises per 1000 sheep. There were some differences in the distribution of the bruises on the carcases from the three sources, but no significant differences between the total numbers of bruises.

Perioperative and postoperative tranexamic acid reduces the local wound complication rate after surgery for breast cancer

A randomized double-blind trial has shown that, in 160 women with breast cancer undergoing lumpectomy or mastectomy with axillary clearance, perioperative and postoperative administration of tranexamic acid 1 g three times daily resulted in a significant reduction in the mean postoperative drainage volume compared with patients given placebo (283 versus 432 ml, P < 0.001). The frequency of postoperative seroma formation was also decreased by tranexamic acid administration (27 versus 37 per cent, P = 0.2). Haematoma formation was infrequent in both groups and was not altered by administration of tranexamic acid. No infectious complications occurred. Age over 60 years was a significant risk factor for overall wound complications but tumour size and regional lymph node metastases were not. Tranexamic acid may be used to reduce the frequency of postoperative wound complications following surgery for breast cancer.

A review of brain retraction and recommendations for minimizing intraoperative brain injury

Brain retraction is required for adequate exposure during many intracranial procedures. The incidence of contusion or infarction from overzealous brain retraction is probably 10% in cranial base procedures and 5% in intracranial aneurysm procedures. The literature on brain retraction injury is reviewed, with particular attention to the use of intermittent retraction. Intraoperative monitoring techniques--brain electrical activity, cerebral blood flow, and brain retraction pressure--are evaluated. Various intraoperative interventions--anesthetic agents, positioning, cerebrospinal fluid drainage, operative approaches involving bone resection or osteotomy, hyperventilation, induced hypotension, induced hypertension, mannitol, and nimodipine--are assessed with regard to their effects on brain retraction. Because brain retraction injury, like other forms of focal cerebral ischemia, is multifactorial in its origins, a multifaceted approach probably will be most advantageous in minimizing retraction injury. Recommendations for operative management of cases involving significant brain retraction are made. These recommendations optimize the following goals: anesthesia and metabolic depression, improvement in cerebral blood flow and calcium channel blockade, intraoperative monitoring, and operative exposure and retraction efficacy. Through a combination of judicious retraction, appropriate anesthetic and pharmacological management, and aggressive intraoperative monitoring, brain retraction should become a much less common source of morbidity in the future.

Wound compression pads are of no value after local anaesthetic breast biopsy

In a randomised study of 120 patients undergoing breast biopsy, wound compression pads did not reduce the frequency of postoperative bruising or haematoma formation, and 12% of the 62 patients having pads had complaints regarding their use. Wound compression pads are of no value after local anaesthetic breast biopsy.

[Occupational injuries caused by breakages of hoses]

During the period 1.1.1984-31.12.1986, 77 accidents caused by breakages of hoses or connections in connection with snap-couplings were notified to the Danish Directorate of National Labour Inspection. These consisted of 33 (42.9%) accidents in connection with employment pressurized air hoses, 25 (32.5%) accidents in connection with employment of steam hoses or hoses with warm water and 19 (24.7%) accidents while employing hoses with chemicals. Accidents with pressurized air resulted in bruising on the neck, head, eyes and upper limbs. Accidents with steam hoses caused scalds scattered over the entire body. Accidents with hoses containing chemicals were mainly responsible for corrosive injuries to the eyes. Prophylactic measures which would probably have prevented approximately 85% of the abovementioned injuries are suggested.

Clinical evaluation of three techniques for administering low-dose heparin

The purpose of this study was to investigate the effect of three techniques for administering subcutaneous low-dose heparin on the formation of bruises at the injection site in adult postoperative cardiothoracic surgery patients. Forty-three subjects comprised the sample. All received subcutaneous injections of heparin, 5,000 units every 12 hours postsurgery. Three subcutaneous injection techniques, identified to study the variables of needle manipulation and tracking of the medication, were administered randomly to each subject. Forty-eight hours after the third injection, the sites were observed and bruises, if present, were measured. Data were analyzed by means of the Friedman test, and a 0.569 level of significance was obtained. It was concluded that, for this sample, none of the three techniques appeared clearly superior in yielding smaller or fewer bruises.

Bruising in cattle fasted prior to transport for slaughter

Three trials, each with 100 bullocks previously grazing improved pasture, compared bruising in cattle fasted for 0, 24 and 48 hours prior to transport for slaughter. Overall the weight of bruised trim from unfasted bullocks (0.48 kg) was significantly less (P less than 0.01) than from bullocks fasted for 24 h (0.99 kg) or 48 h (1.03 kg). length of fast overall had no significant effect. This pattern was not consistent within trials.

Effect of tipped horns on cattle bruising

Six trials in Queensland compared the bruising of 960 cattle with untipped, tipped and no horns. In three of the trials the treatment groups were kept separate during transit to the abattoir. In the other trials all cattle were handled as the one group. Tipped and untipped cattle had similar bruising, whether sent for slaughter as separate groups or together. Thus tipping was ineffective in preventing bruising. Hornless cattle had significantly (P less than 0.05) less bruising than horned cattle when consigned as separate groups. However, this advantage was lost when hornless cattle were mixed with tipped or untipped animals.