Nail Avulsion

With the ongoing growing trend of nail art, the nail size seem to be growing right along with it, and longer nails are at risk for getting caught and pulled off the nail bed. This can happen in a variety of scenarios from kids during rough play, adults doing hard labor, playing sports, falls, etc., anything that puts undue force onto the nail.

Let's orient us to the different parts of the nail:

We have been taught to replace avulsed nails into the eponychial fold after nail bed repair to act as a splint, reduce pain, and prevent adhesions with the goal of better cosmetic outcomes. However, the last time I had a patient with a toe nail avulsion, a podiatrist came down and told me that once the nail bed laceration is repaired that I could just wrap it with xeroform gauze without replacing the nail or using anything to stent open the nail bed. The podiatrist stated that it takes a long time, but the nail eventually grows back.

Let's set the scene with a case:

5 y/o female presents to the ED with an injury to their left 3rd digit after getting caught in a door while playing with her siblings. There is a nail avulsion from the nail bed with a laceration injuring the nail and nail bed. The patient has a linear laceration on the nailbed and the nail has been avulsed looking like this:

Xrays were done and there is no fracture. The patient requires ketamine for procedural sedation prior to a digital block, irrigation, and repairing the nail bed laceration. Before replacing the nail into the eponychial fold, the patient starts waking up. As you consider re-sedating the patient to replace the nail, you remember the NINJA Trial.

Evidence from NINJA Trial (2023):

• A randomized controlled trial involving approximately 450 children compared outcomes between nail replacement and non-replacement after nail bed repair

• Results showed no significant difference in infection rates at 7 days or cosmetic outcomes at 4 months between the two groups

• Secondary outcomes, including pain, patient satisfaction, and delayed infections, also showed no significant differences

• Healthcare costs were higher in the nail replacement group

Implications:

• Replacing the nail may not be necessary for satisfactory cosmetic outcomes in pediatric patients

• If nail replacement is straightforward, it can be performed; however, if challenging, it is acceptable to omit this step

• Considerations for Subungual Hematomas:

  • Traditional teaching recommends nail removal for hematomas covering more than 50% of the nail

  • Current evidence supports conservative management, such as trephination for drainage, without nail removal

Takeaways:

• Nail replacement after avulsion is not critical for nail regrowth or cosmetic outcomes in children

• Trephination for drainage of subungal hematomas

We all Scream for Sunscreen!

Spring is finally here and summer is around the corner! Today's wellness POTD is about a skincare and healthcare product that is near and dear to my heart: SUNSCREEN! 

If you guys don't know, I carry sunscreen with me everywhere, and even after overnight shifts before walking outside, I put on sunscreen. Of course with all things there are nuances, like do I really need sunscreen at 7am in December? Probably not, since the UV index is low, but it helps me form a habit so that on those sunny days I never forget. Also, picking the right sunscreen for daily use that is moisturizing, lightweight, and that you enjoy using is key to adherence. 

So for all you sunscreen-naive people out there, here is an overview of sunscreen and my favorite ones!

Characteristics of Sunscreen

• Chemical, mineral, or hybrid filters

  • Sunscreens that use hybrid or only chemical filters usually have a lighter texture

  • Mineral sunscreens are heavier and more likely toe leave a chalky residue or white cast

• Clear or quickly absorbing formulas that don’t leave a white cast, even on deeper skin tones

• Gentle and hypoallergenic formulas that contain fragrance-free and soothing  ingredients

• Hydrating formulas that contain humectants like hyaluronic acid without feeling heavy or greasy

• Makeup-friendly formulas that layers well under foundation/BB cream with no pilling or excessive shine

• High SPF, broad-spectrum – ideally SPF 30–50+ with strong UVA protection (PA++++ or “broad spectrum” on US labels)

Korean brand sunscreens are my favorite because of their cosmetically elegant formulations. Here in the US, since sunscreens are a regulated OTC drug by the FDA (which only approves a limited number of UV filters, last updated in 1999) we are wayyy behind South Korea and the EU. The modern “next-gen” filters like Tinosorb S/M and Uvinul A Plus, results in lighter sunscreen formulas. Unfortunately, the 2022 Modernization of Cosmetics Regulation Act (MoCRA), although not directly targeting sunscreens, increased FDA oversight and prompted Korean brands to reevaluate their US distribution. As a result, popular brands like Round Lab, Beauty of Joseon, and Skin1004 reformulated or withdrew their popular SPF50+ products from US channels in 2023–2024. Many US versions now use only FDA-approved filters that often have thicker textures with lower SPF ratings, while others now sell only through international retailers.

Here are my top 5 favorite sunscreens!

1. Beauty of Joseon – Relief Sun: Rice + Probiotics SPF50+ PA++++

• Type: Chemical sunscreen

• Texture/Finish: Lightweight lotion-cream; dewy, non-greasy, no white cast

• Skin Type: Normal, dry, combo, sensitive (great under makeup)

• Price: ~$15 (50 mL; ~$9/oz)

• Where to Buy: YesStyle, Stylevana, Olive Young Global (original Korean version); US version (SPF40) on Amazon

2. Isntree – Hyaluronic Acid Watery Sun Gel SPF50+ PA++++

• Type: Chemical sunscreen

• Texture/Finish: Watery gel; ultra-light, hydrating, no white cast

• Skin Type: All skin types, especially dehydrated and combo/oily

• Price: ~$20–$25 (50 mL; ~$12/oz)

• Where to Buy: YesStyle, Stylevana, Soko Glam, Amazon

3. Skin1004 – Madagascar Centella Hyalu-Cica Water-Fit Sun Serum SPF50+ PA++++

• Type: Chemical sunscreen

• Texture/Finish: Serum-like; hydrating, slightly dewy, zero white cast

• Skin Type: Sensitive, dry, normal (soothing centella-rich formula)

• Price: ~$18 (50 mL; ~$10/oz)

• Where to Buy: YesStyle, Olive Young Global, Amazon

4. Purito – Daily Go-To Sunscreen SPF50+ PA++++

• Type: Hybrid sunscreen (chemical + a bit of mineral)

• Texture/Finish: Light cream; moisturizing but sinks in quickly, low white cast

• Skin Type: Sensitive, combo, dry (good for barrier repair)

• Price: ~$20 (60 mL; ~$10/oz)

• Where to Buy: YesStyle, Stylevana, Amazon (official Purito store)

5. Round Lab – Birch Juice Moisturizing Sun Cream SPF50+ PA++++

• Type: Chemical sunscreen

• Texture/Finish: Moisturizing but lightweight; satin finish, no white cast

• Skin Type: Dry, normal, combo (very hydrating but not heavy)

• Price: ~$18 (50 mL; ~$10/oz)

• Where to Buy: YesStyle, Olive Young Global (original); US SPF45 reformulation available

I hope you all have a happy and skin-healthy day!!!

Neonatal Code Cart

The neonatal code cart contains more specialized equipment for resuscitation of neonates, typically <28 days old. 

Having to resuscitate such a tiny baby is a daunting task, and fortunately very rare, but unfortunate as we are not well-versed with all the moving parts. In these cases, just like with the Broselow cart, familiarizing ourselves with the contents of the neonatal code cart will be essential to a proper resuscitation.

Setting the scene...

We get a call that a mother just delivered in the ambulance and the baby is not responsive: not crying, not moving; ETA 5 minutes.

First: ask a PCT to locate the baby warmer and get it to resus 51 along with a bunch of dry towels.

Head to resus 51 and clear all the obstacles to the neonatal code cart and take note of several things outside the code cart that are important:

We open the neonatal airway box which sits on top of the neonatal code cart and hook up the infant ambu bag, have suction ready, and lay out the intubation supplies.

Next, we open the first drawer which is the medications:

As the nurses are opening the rest of the drawers, EMS rolls in with mother and baby, another team is taking care of mom, and the baby is handed over to us into the baby warmer and we are using the abundance of dry towels to dry off the baby and stimulate, stimulate, stimulate!

EMS reports: Baby is mother's 3rd baby, ex-39 weeks female, no known complications during pregnancy as she had no prenatal care, baby is 4kg. Vitals en route: HR 70bpm, O2 sat 85%, BP 65/35, BGM 80

Meanwhile, the nurses are hooking up the baby to the monitor, getting vitals, and attempting to start an IV.

Drawers 2-4 has IV materials, fluids, EKG leads, suction, etc:

It has been 2 minutes since the baby arrived in the ER and the HR is 75 bpm and the baby is not breathing spontaneously or crying. You've already dried, stimulated, suctioned, and have been using the infant ambu bag to give some positive pressure support with good bilateral chest rise and positive breath sounds bilaterally and O2 saturation is 95%.

Someone taking care of the mother comes in and reports that the mother had taken several tabs of morphine for the painful contractions that her father had left over for back pain.

Patient is 4kg, and so 0.1mg/kg is 0.4mg, 0.4mL of Naloxone is given to the patient via IV (can be given IM or through an ETT).

Patient starts breathing spontaneously with O2 sat 100%, heart rate improves to 90, but BP is still 65/35. You ask the nurse to start IV fluids but after the Narcan was administered the IV stopped working and they are having difficulty obtaining a 2nd IV for access.

You decide to do an umbilical vein catheterization and look to the last drawer:

Umbilical vein catheterization:

1. Sterile prep of the umbilical area and drape

2. Securely tie a cord tie around the base of the umbilical stump

3. Cut cord horizontally at the distal end of the stump to expose vessels about 1-2 cm distal to the cord tie

4. Identify the umbilical vein (thin-walled, larger, single vessel vs. two thicker arteries)

5. Dilate gently with forceps and insert catheter (3.5 Fr for neonates <3.5kg, 5Fr for neonates >3.5kg)

6. Aspirate for blood return, then advance to appropriate depth

   • For a full term infant insert to about 4-5cm (about 2cm further than where you get blood return) for emergency access and approximately 10-12cm for long term access (based on umbilicus to shoulder measurement).

7. Flush with saline to ensure patency

8. Secure catheter with umbilical tape or suture

9. Verify position with Chest/abdominal X-ray to confirm tip location at inferior vena cava–right atrial junction, typically at T8–T9

10. Adjust as needed based on imaging

Patient received IV fluids and blood pressure improved to 80/45, vitals otherwise stable. Patient admitted to the NICU.

Takeaways:

• All the equipment and medications used for resuscitations are included in the neonatal code cart. 

  • Streamlines processes as we do not need to waste time and search for the proper equipment when time is so important during a resuscitation.

• Familiarity with the equipment and medications in the code cart helps us prepare for those rare and unexpected resuscitations

• Umbilical vein catheterization can be done for patients who have poor peripheral access, requires further resuscitative medications, or for central venous monitoring.

References:

Aziz K, Lee CHC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Niermeyer S, Schmölzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin J. Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2021 Jan;147(Suppl 1):e2020038505E. doi: 10.1542/peds.2020-038505E. Epub 2020 Oct 21. PMID: 33087555.

Chen, Linda & Law, Brenda. (2023). Use of eye-tracking to evaluate human factors in accessing neonatal resuscitation equipment and medications for advanced resuscitation: A simulation study. Frontiers in pediatrics. 11. 1116893. 10.3389/fped.2023.1116893. 

Drone E, Vera AE, Lucas JK. Umbilical venous catheters. In: Ganti L, eds. Atlas of emergency medicine procedures. New York, NY: Springer; 2020