Subungual Hematoma Evacuation: Preparation and Procedure

00:01 Hi, my name is Glenna Lashley and I'm a family nurse practitioner.

00:05 Here at Lecturio, we like to talk about skills that you may not encounter in your clinical rotations. So today we're going to share a new skill with you that we are passionate about, giving you the opportunity to see as a Certified Family practice Nurse practitioner and educator.

00:23 I'm going to teach you how to perform a successful subungual hematoma evacuation, and I'm going to show you, step by step how to perform the skill.

00:33 As I do this, I'm going to explain the terminology that you need to know to document this procedure for your patient's records, as well as coding and billing purposes.

00:43 We will talk about what situations make this procedure necessary and patient variables you'll need to consider. I will give you some ideas on how to talk to the patient, what equipment you will need, and what aftercare will be needed for this patient. Before we get started, let's talk about the procedure and why you might need to consider performing this procedure.

01:04 Subungual hematomas are a collection of blood under the fingernail or toenail, usually due to blunt trauma like door closing on a finger.

01:14 I've also had this happen where someone dropped an air conditioner on their finger.

01:19 Most patients present to advanced practice providers because of the pain and the pressure of the blood, or because a loved one is very concerned because oftentimes it doesn't look very good. If the hematoma covers more than 25% of the nail bed, less than 48 hours old, and if the patient is having significant pain, you want to evacuate the hematoma via trephination, which is the standard of care.

01:45 The procedure is also often performed in emergency care and urgent care settings.

01:50 It is also common for the nail itself to be removed depending on the amount of damage.

01:55 Those who present with additional complications, such as nail avulsion or fractures, may require more complex care.

02:03 Let's talk about patient consent and assessment.

02:06 Before the procedure, explain the goal, which is to relieve the pain and avoid further damage to the nail bed by releasing the pressure.

02:14 Examine the nail bed and the in the fingers for displacement of the joints or unstable bones.

02:22 Significant swelling or bruising that indicate a deep tissue injury.

02:27 If a distal phalanx fracture is suspected, x rays should always be obtained.

02:32 Capillary refill distal to the injury should be assessed and compared to the other sites.

02:38 If the patient is a pediatric patient, procedural sedation may need to be used, so you may want to consider to refer to a higher level of care.

02:47 Gathering supplies and preparing.

02:50 Because splashing is possible, you want to make sure you're wearing goggles or face protection mask. You also want to make sure you're wearing gloves, of course. Depending on what you have access to, some facilities will use electric cautery device, which melts a hole through the nail.

03:07 Once encountering the hematoma, the device is removed.

03:10 The blood is drained. If using Electrocautery, you want to ensure that the patient does not have acrylic nails, as this is a fire risk.

03:19 Less common practice is use of a sterile 29 gauge extrafine insulin syringe needle inserted at the hypochondrium to the nail at the most distal portion of the hematoma.

03:32 Then pressure is applied at the base of the nail while the needle is withdrawn.

03:37 A third practice is the use of 2 to 3 millimeter punch biopsy tool over the hematoma site, allowing it to drain through the hole.

03:46 The most common practice you are likely to see is the one that I'm going to demonstrate for you today. It is the use of a sterile 18 gauge needle to puncture through the nail bed for free drainage of the hematoma. You'll need iodine or chlorhexidine solution, depending on allergies, for your patient to disinfect the area, but not alcohol because alcohol is flammable.

04:08 You'll need a sterile gauze and sterile bandages for dressing the site.

04:14 Before you get started, don't forget to think about managing your patients pain.

04:19 The standard pain management in a healthcare facility setting is going to be the use of a digital block. You can see how to perform a digital block in our other video content.

04:30 Other options for pain management could be topical lidocaine, cream to the area, ice packs or oral medication.

04:38 Again, you want to check for numbness with a pricking sensation to make sure that the patient only feels pressure. You do not want them to feel pain.

04:47 Place the patient's hand or foot comfortably so that you have access to the finger or toe to make it in immobilized. Cleanse the affected area with a solution appropriate for the patient.

04:59 In this case, we're going to use chlorhexidine solution.

05:03 And you also want to have your 18 gauge needle.

05:07 You can heat or not heat the needle per protocol to be able to advance it into the nail.

05:14 The goal is to be able to have the hematoma evacuated.

05:19 You want to twist or spin it gently at the center of the hematoma to drill a hole through the nail.

05:25 Continue the pressure until blood begins to drain.

05:28 At this point, you want to stop drilling and allow the drainage to continue.

05:34 Apply sterile dressing to absorb the blood and then bandage the nail gently.

05:40 Post-procedure care bandaging routine antibiotics are generally not recommended unless there's an associated open wound or fracture.

05:47 In cases of distal fractures, you may be placing distal limbs or fingers in splints for follow up with other providers.

05:55 Instruct the patient to keep the finger clean and dry for the next few days.

05:59 Avoid soaking it to reduce the risk of infection.

06:03 Change the dressing daily as needed and watch for signs and symptoms of infection such as redness, swelling or increased pain.

06:12 Inform the patient that the nail may remain discolored or could completely fall off.

06:19 This happens sometimes several months later.

06:22 Advise them to return if they're experiencing any ongoing pain or if the hematoma does not resolve as expected. Potential complications of the procedure are obviously infection.

06:33 It's important to consider increased risk factors in specific patient groups.

06:38 If your patient is immune-compromised already or gave you the impression that they may not be adherent to your post-care instructions, having the patient return to the provider for a wound check is generally a good idea in most situations.

06:52 So talk to your patient about coming in for additional visit.

06:57 The advantages of simple trephination or evaluation of a hematoma include less pain for the patient and less costly intervention.

07:07 This is a common procedure for advanced practice providers, such as nurse practitioners or physician's assistants, especially in primary care settings or even in urgent care or emergency.

07:19 Thank you for watching.