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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 15, Number 3 • May 1997

arch relieved her symptoms. She has been asymptomatic for the last year. This research was supported by a generous grant from Beth Ross, Orlando, FL.

HEATHERR. WRIGHT,BA DAVID B. DRAKE,MD ANDREWJ.L. GEAR, BA BRENDONM, STILES,BA RICHARDF. EDLICH, MD, PHD

Department of Plastic Surgery University of Virginia School of Medicine Charlottesville, VA

References 1. Legerton CW, Smith EA, Silver RM: Systemic sclerosis (scleroderma). Clinical management of its major complications. Rheum Dis Clin North Am 1995;21:203-216 2. Tuffanelli DL, Winkelman RK: Systemic scleroderma: A clinical study of 727 cases. Arch Dermatol 1961 ;84:359-367 3. Bennett R, Bluestone R, Holt PJL, Bywaters EGL: Survival in scleroderma. Ann Rheum Dis 1971 ;30:581-588 4. De Takas G, Fowler EF: Raynaud's phenomenon. JAMA 1962; 179:99-106 5. Bolster MB, Maricq HR, Left RL: Office evaluation and treatment of Raynaud's phenomenon. Cleveland Clin J Meal 1995;62:51-61 6. Raynaud M: On local asphyxia and symmetrical gangrene of the extremities and new researches on the nature and treatment of local asphyxia of the extremities. In Badow T (translator): Selected monographs, vo1121. London, UK, New Sydenham Society Publishing, 1888. 7. Dabich L, Bookstein JJ, Zwifler A, Zarafonetis CJD: Digital arteries in patients with scleroderma: Arteriographic and plethysmographic study. Arch Intern Med 1972; 130:708-714 8. Drake DB, Kesler RW, Morgan RF: Digital sympathectomy for refractory Raynaud's phenomenon in an adolescent. J Rheumatol 1992;19:1286-1288 9. Adson AW, Brown GE: Treatment of Raynaud's disease by lumbar ramisection and ganglionectomy and perivascular sympathetic neurectomy of the common iliacs. JAMA 1925;84:1908-1910 10. Baddeley RM: The place of upper dorsal sympathectomy in the treatment of primary Raynaud's disease. Brit J Surg 1965;52:426430 11. Flatt AE: Digital artery sympathectomy. J Hand Surg 1980;5: 550-556 12. Jones NG: Ischemia of the hand in systemic disease: The potential role of microsurgical revascularization and digital sympathectomy. Clin Plastic Surg 1989;16:547-556

provides minimal information and no references on the specifics of the procedure. The following technique was taught to one of the authors (Dr Schwartz) several years ago, and he has used it numerous times with complete success. The only equipment needed is a scalpel (a no. 15 blade works best), an instrument to grasp the splinter once it is exposed, and a good light source. Depending on the age of the patient, an assistant may or may not need to hold the injured extremity. The technique should be reviewed with the patient and family to gain their cooperation. The physician sits facing the patient and places the blade over that portion of the nail under which lies the foreign body. Strokes are made from the proximal portion of the nail distally (toward the physician) (Figure 1). The length of the stroke can vary in proportion to the length of the splinter. With each stroke, aim to remove only a small shaving of the nail. The blade is initially held at a 90 ° angle to the nail; however, once the physician begins the procedure, the optimal

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SUBUNGUALSPLINTER REMOVAL To the Editor:--A recent patient with a subungual splinter prompts us to share the following technique with other emergency medicine physicians. At the teaching hospital at which we work, one of the pediatric surgeons asked for our advice. He was going to remove a long splinter from under the toenail of a 2-year-old child. The method he proposed was to first use a digital block, then remove the nail, and finally remove the splinter. We discussed other techniques, including the wedge technique described in a standard reference books on procedures in emergency medicineJ Making a wedge in the nail and attempting to extract the splinter can be painful and often requires a digital block. In addition, there is potential for nail bed injury. If the splinter is wood or plastic, parts of the splinter may be left in place. It is obviously important to remove all parts of the splinter to minimize the risks of infection. Another technique, preferred by the authors, was recommended and worked well in the case discussed. A search of the literature showed a paucity of material on the technique which we will describe below. A recent issue of Emergency Medicine Reports2 makes a brief reference to this technique but

FIGURE 1. (A) The scalpel is initially held 90 ° to the nailbed. Repeated, light strokes are made, proximal to distal, gradually creating a U-shaped defect in the nail, and exposing the entire length of the splinter. (B) Once the splinter is completely exposed, it is easily removed, and the tract can be thoroughly irrigated, reducing the risk of infection.

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angle between the blade and the nail will quickly become apparent. Be careful not to press down too firmly against the nail to (1) minimize the discomfort to the patient and (2) avoid injuring the underlying nail bed. With a little patience, the physician will create a U-shaped defect in the nail and have the entire length of the splinter exposed. Then carefully lift up on the splinter and remove it. Should any smaller pieces of splinter remain, they are easily removed since the length of the splinter has been exposed. One can then irrigate the exposed nail bed and use whatever dressing is preferred. The physician can treat the wound and arrange follow-up as per local custom. Normal growth of the nail will "heal" the U shaped deficit in the nail with no (or minimal) residual defect, One of the authors has used this technique on himself and can attest to its efficacy. Advantages of the technique include its ease of performance and the minimal equipment and time required. There is no need for a digital block unless the patient is extremely uncooperative. In this case, conscious sedation may be used. The 2-year-old child mentioned above did well without sedation or digital block. The technique insures complete splinter removal and minimizes further nailbed injury. Irrigation of the complete wound tract minimizes the risk of infection. The authors encourage other emergency physicians to try this simple but very effective technique the next time they are confronted with a subungual splinter that is wedged deeply under the nail. GERALDR. SCHWARTZ,MD

Joint Military Medical Centers Residency in Emergency Medicine SARAHANN SCHWEN,MD

Division of Acute Care 59th Medical Wing Lackland AFB San Antonio, 7X

References 1. Roberts JR, Hedges JR (eds): Clinical Procedures in Emergency Medicine. Philadelphia, PA, Saunders, 1991 2. Steward C: Foreign body removal: A reference guide for ED physicians. Emerg Med Rep 1996;11:101-110

TOPICAL EPINEPHRINETHERAPY OF ACUTE UVULITIS To the Editor:--Uvulitis is an uncommon and occasionally life-threatening condition that has multiple etiologies. Various therapies, depending on the cause of the uvulitis, have been proposed for treating this disorder and have demonstrated variable efficacy. We present a case of uvular swelling that responded rapidly to topical application of epinephrine. A 20-year-old man presented ambulatory to our emergency department (ED) with a chief complaint of a sensation of fullness in his pharynx and dysphagia which he noted upon arising 2 hours before presentation. His medical history was remarkable only for hay fever, and he denied any antecedent oral trauma (including oral sex), vocal changes, fevers, chills, cough, or shortness of breath. He stated that he had ingested six 12-ounce beers the previous evening, denied intake of any medicine or illicit drugs, and was not a smoker. The physical examination was completely within normal limits except for an edematous and elongated uvula. A soft tissue lateral radiograph of the neck revealed a normal epiglottis without evidence of airway obstruction. A complete blood count was within normal limits and pulse oximetry was 100% on ambient oxygen. Initial therapy consisted of intravenous methylprednisolone (125 rag) and four 15-minute nebulized inhalation treatments of 0.3 cc albuterol in 3 cc of normal saline solution over a 2-hour period without relief of symptoms or diminution in uvular size. Topical

epinephrine (1:10,000 solution) Was applied with a cotton-tip applicator to the entire surface of the uvula and near-complete resolution of the swelling was evident within 15 minutes. The patient was observed for another 2 hours without evidence of any rebound swelling or return of symptoms. He was discharged from the ED on prednisone (40 rag) once daily for 5 days and on phone call recheck had remained asymptomatic. The uvula is attached to the soft palate and is composed mainly of glandular tissue with some muscle fibers, connective tissue, and mucous membrane components.1 The uvula (and soft palate) is displaced upward during acts of swallowing or phonation, functioning to seal off the nasal cavity from the pharynx. 2 Swelling of the uvula may occur from infectious, traumatic, irritative, neoplastic, and allergic events. 3 In addition to the present case, one of us (RJR) has noted repetitive episodes of uvulitis in an individual associated with excessive beer intake, as well as in another patient during vigorous rehydration with crystalloid solution during resuscitation from diabetic ketoacidosis (unpublished data). Immediate treatment concerns for uvulitis include evaluation of the airway for signs of compromise and etiologic determination (ie, angioedematous versus infectious). Fever suggests an infectious cause which can occasionally be associated with life-threatening disease (ie, epiglottitis), though such presentations can also occur without the presence of fever.4 Respiratory compromise suggests associated laryngeal edema (eg, C' 1 esterase inhibitor deficiency) or concomitant pulmonary disease (eg, asthma). 3 In young children, a distended uvula may obstruct the glottis, and in such instances the child should be allowed to remain recumbent rather than upright. 5 Infections caused by susceptible organisms (eg, bacteria) can be treated with appropriate antibiotics. Oral or parenteral antihistamines are effective in allergic uvulitis6 but side effects (eg, dryness, drowsiness) can be unpleasant for patients. Parenteral epinephrine, though effective, must be used with caution in patients with preexistant cardiovascular disease. Steroids are commonly administered, but efficacy is unproven.6 Aerosolized sympathomimetic agents (eg, albuterol, terbutaline), especially if administered against a closed glottis, can coat the target organ (uvula) with medication droplets to bring about the desired therapeutic effect, although this was seemingly not effective in our patient. Decompression of the uvula by multiple needle perforations or partial distal uvulectomy has been advocated for failed medical therapy7,8; however, decompression was ineffective in a patient treated previously by one of us (RJR) and may induce significant oral bleeding, thereby potentially further compromising the airway. Patients suspected of having hereditary complement deficiency should receive aminocaproic acid. 6 We utilized topical epinephrine solution because of its excellent reputation for decreasing local edema and congestion in clinical practice situations (eg, as an adjunct to nasal intubation, wound repair, etc) and noted dramatic results. We believe that this occurred because the medication was delivered directly to the target organ in a more concentrated manner than by aerosol or parenteral routes. We are unaware of any other reports of use of topical epinephrine for the treatment of uvular edema but believe this method deserves consideration because it is rapid, easy to administer, cost-effective, does not require special equipment (eg, nebulizers, intravenous access supplies, etc), and allows a smaller amount of medication to be administered, thus theoretically minimizing systemic effects. RAYMONDJ. ROBERGE,MD

Department of Emergency Medicine Western Pennsylvania Hospital TIMOTHYSULLIVAN,MD

Affiliated Residency in Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh, PA