Acute Pain Management and Wound Care - Exam 3 Flashcards
What is the max daily dose of APAP in the adult? What routes does APAP come in?
4K is max dose but commonly providers tell their pts 3K to be safe
oral, IV and rectal
______ possess little to no effect on platelet function. What age is safe?
COX-2 inhibitors
ibuprofen is safe in infants over 6 months old
Need to be cautious when using celebrex in pts with an allergy to _____
sulfa allergy
What is the normal morphine dose in acute pain? What is the onset? How long does it last? What is the SE?
morphine 0.1mg/kg
Onset: 1-2 minutes
Duration: 1-2 hours
SE: nausea
What is the onset of hydromorphone? How long does it last for?
Onset: 3-5 minutes
Duration < 60 minutes
What is the onset of fentanyl? What is the duration?
Onset: Less than 1 minutes
Duration: 30-60 minutes
What are the pain medications of choice for nociceptive pain? What should you NOT use?
NSAIDs
Duloxetine
avoid long term use of oral opioids
What is the pain medication of choice for neuropathic pain?
TCAs : Amitriptyline
SNRIs: Venlafaxine or duloxetine
Gabapentin/pregablin
What is the recommendation with regards to replacing lost/stolen opioids?
do not replace the full amount, instead replace the amount of opioids until original prescriber is back in office
What are the uses for gabapentinoids? What age range? have risk of _____ when used with opioids
post-op pain control
age less than 75 years old
respiratory suppression
What are the red flags symptoms for drug related behavior?
Requests specific brand names of opioids
Mulitple states/pharmacies in PDMP
Multiple allergies
Hides multiple ER visits for opioids
Belligerent behaviors when refused or redirected
Alters prescriptions
Previous convictions for controlled substances
What is the recommendation for imaging with regards to low back pain?
If atraumatic low back pain and < 4 weeks in onset, most patients do not need imaging!
xray: if low suspicion of fracture, tumor or infectious process
When is lab work indicated for causes of acute lumbar back pain?
infection, metastasis, rheumatologic causes
What pain medication is preferred in kidney stones?
toradol
What findings are consistent with lumbar disc herniation? What are the 2 MC locations?
Sciatica
Weakness along dermatomal distribution of the nerve root
L4-5, L5-S1
What is the treatment for lumbar disc herniation in the ED?
NSAIDs
Acetaminophen
Muscle Relaxers
Short Term Opiates
Ice and Heat
What is the tx for epidural compression syndrome? What s/s would the pt have?
Dexamethasone 10mgIV
Emergent MRI of theSpine
Consult Neuro-Surgery or arrangetransfer
Saddle anesthesia
Fecal and/or urinary incontinence
Sciatica
Diminished rectal tone
_____ is inflammatory disorder damaging the myelin sheaths
transverse myelitis
Back and/or Neck Pain +/- radicular pain to abdomen or legs
Tingling
Burning of Extremities
Weakness or Heaviness of the BLE/BUE
Bowel or Bladder Dysfunction
What am I?
What is the imagine?
What should you do next?
transverse myelitis
MRI of the spine
admission and consult neurology
What are risk factors for a compression fracture? What imaging?
Long term steroid use
Advanced Age
Significant Trauma
History of Osteoporosis
xray of the spine
What is the tx for a compression fracture?
Pain Control Options (Oral vs. IV)
Resume Normal Activity
Consult Neuro/Ortho is angulation of fracture wedge is over 20 degrees
Gradual onset of symptoms
History of recent operation/injury/injection
Pain to palpation/percussion of the affected vertebra
What am I?
osteomyelitis
Fever
Malaise WITH localized back pain
neurologic deficit
What am I?
spinal infections
Constant back pain without relaxing or remitting factors
Possible fever and neurologic deficits
What am I?
discitis
What is the imaging needed in spinal infections?
MRI of spine WITH contrast
What is the disposition for a spinal infection?
Admission with Urgent Consultation to Neuro/Spinal Surgery
Transfer, if needed
What s/s would make you think metastatic bone disease? What imaging is needed? What is the disposition?
History of Cancer + New Onset Back Pain
Presence of neurologic symptoms
xray
contact oncology team
What are the 6 different types of anesthesia?
local
MAC
IV regional/bier block
peripheral nerve block
spinal/epidural
general
What layer of the skin are pain receptors located? Where can you also injection anesthesia that might be more painful for the pt?
hypodermis
dermis
What is the MOA for local anesthesia?
Blocks sodium channels and temporarily inhibits nerve impulses
What drug class?
Lidocaine
Bupivocaine
Prilocaine
-amides
What drug class?
Procaine
Tetracaine
Benzocaine
-esters
What is epi good for in anesthesia? When do you need to monitor epi with what comorbid conditions?
good for vasoconstriction!!!!
HTN
Use of Beta Blockers
MAOIs
TCAs
What is the max dose of lidocaine WITHOUT epi? with epi?
WITHOUT Epinephrine = 5 mg/kg
WITH Epinephrine = 7 mg/kg
** What is the max dose of epi in the pediatric population?
Use 80% of the maximum dosage
said to only use 1/2 of max dose in lecture
Where is lidocaine metabolized?
in the liver and kidneys, approximately 50% of dose
What is the onset of lidocaine? What is the duration? Give with and without epi
Onset = Within 2-5 minutes
Duration = 30 minutes – 2 hours (WITHOUT Epinephrine)
3 hours (WITH Epi)
What is the underlying cause of lidocaine toxicity? What are some s/s?
Sodium channels blocking the non-targeted tissues such as the brain and heart
Seizures, Tachyarrythmias, Cardiac Arrest or Death
_______ is the medication given to extract lidocaine from the tissues in a state of toxicity
intralipid
What is the tx for lidocaine toxicity?
manage the s/s
Seizures – manage withanti-seizuremedications
Tachyarrythmiasand Cardiac Arrest – manage with resuscitation measures
intralipid
What is the caution for bupivacaine? What is the max dose with and without epi? What is the timing?
caution in pregnancy patients!!!
WITHOUT Epinephrine = 2 mg/kg
WITH Epinephrine = 3 mg/kg
Onset: 5-10 minutes
Duration: > 6 hours
What are the 2 uses for procaine? **What is the super highlighted one? Does it have a low risk or high risk of systemic toxicity?
Dental Procedures
**Alternative if allergic to –AMIDE class
low risk of systemic toxicity
What is the max dose for procaine? What is the timing? Give both with and without epi
WITH Epinephrine: 9 mg/kg
WITHOUT Epinephrine: 7 mg/kg
Timing
Onset = 5-10 minutes
Duration = 1.5 Hours
How do you calculate the dose of anesthetic needed?
3-4 cm laceration requires 3-5 cc of anesthetic solution
If larger wound, consider a regional or procedural block
What are 4 ways to decrease the pain associated with local anesthesia?
Warming the anesthetic solution
Add sodium bicarbonate to the lidocaine
Use a smaller gauge needle (27G)
Inject the solution slowly into the area
What are the 3 options for topical anesthetics?
EMLA
LET gel
Benzocaine spray
What are the different indications for EMLA vs LET gel vs benzocaine spray?
EMLA: intact dermis only
lidocaine and prilocaine
LET gel:
can use on open dermis
needs 30 minutes to set
Benzocaine spray:
ORAL mucosa
1 second spray = 20 minutes of action
What is another name for a regional block?
nerve block
What 5 things do you need to assess for both before and after the procedure when using regional anesthesia?
Skin Color
Skin Temperature
Capillary Refill
Pulses
Sensation
When doing a regional block the use of _____ with the block can increase duration of pain relief
dexamethasone
What medications are commonly used in the ED for anxiolytics? Why are these agents preferred? Under what circumstances are they commonly used?
Nitrous Oxide; Midazolam; Fentanyl; Ketamine
Airway, Ventilation and CV efforts are UNaffected
LPs
I&D
Simple Fracture Reductions
Laceration Repairs
What are the moderate sedation agents used in the emergency room? What things are usually maintained with these agents?
Propofol, Etomidate, Ketamine, Fentanyl + Midazolam
Airway, Ventilation and CV efforts are USUALLY maintained
When are moderate sedation practices commonly used?
Dislocated Joints
Cardioversion (synchronized)
_____ foot wounds have an increased risk for infection. If pseudomonas is suspected, should use ____ abx
plantar
cipro
What hand things should you document if the wound is on the hand?
nerve, blood vessel, tendon,
sensation to the median, ulnar and radial nerve distributions, light touch to the mid-palm and thenar eminence
flex, extension, abduction, adduction, opposition and composite fist
pulses and cap refill
What is the proper way to measure a wound?
Length x Width x Depth
What are the 6 things you should document when describing a wound?
Location
Wound Type
Wound Drainage
Wound Measurements
Characteristics
Periwound skin
What is the proper way to manage hair when cleaning/debriding a wound?
Move hair away from the field
Use petroleum jelly or saline to wet
Try not to shave the hair as this can lead to infection
What should you do next after removing a foreign body from an acute laceration?
Cleanse thoroughly with:
Hibicleans and Sterile Water
25% Peroxide and 75% Sterile Water
What are the irrigating solution options for would irrigation?
Normal Saline or Sterile Water
Can addHibiclenssolution as well
How long should you apply direct pressure when trying to maintain hemostasis? How long should you use a tourniquet for?
Direct pressure via pressure dressing (>10 minutes)
Tourniquet
Caution with Tourniquet Time (only 20-30 minutes)
What are 5 ways to control bleeding?
Direct pressure via pressure dressing (>10 minutes)
Use of epinephrine
Surgifoam/Surginet/GelFoam
Cautery
Tourniquet
What anesthetic options are good choices for wound closure?
Injectable: Lidocaine 1% with or without Epinephrine
Topical: LET Gel or EMLA
_____:Larger Suture used for areas of large tension
_____: Smaller used for cosmetically important areas
3-0 and 4-0
5-0 and 6-0
What are absorbable suture material options? How many knots does it take to secure?
Secured after 3 knots
Examples: Vicryl, Monocryl, Dexon
What are non-absorbable suture material options? How many knots does it take to secure?
Secured after 5 knots
Examples: Prolene, Silk, Nylon
**When can the suture be removed for the following body parts:
face
eyelids
neck
scalp
trunk/UE
LE
hands, palms and soles:
Face: 5 days
Eyelids: 3-7 days
Neck: 5 days
Scalp: 7-10 days
Trunk and Upper Extremity: 7 days
Lower Extremity: 8-10 days
Hands, Palms and Soles: 10-14 days
What part of the body are staples mostly used? What anesthetic should be used? What should you document?
mostly used on the scalp
Topical Lidocaine
Sub Q lidocaine?
document the # of staples placed
What is the skin adhesive? How long does it last? When should it be removed?
dermabond
holds for approximately 5-10 days
falls off naturally
When should dermabond NOT be used? What are the indications?
Do not apply to overlying infected or contaminated wounds (animal or human bites)
caution with use around the eyes
Small, less than 2 cm linear lacerations
Not all lacerations require abx, when they are indicated _____ is used for uncomplicated ones, ____ for contaminated/animal bites/IC. ______ used for plantar foot wounds
Uncomplicated = Keflex (Clindamycin)
Contaminated/Animal
Bite/Immunocompromised = Augmentin (Clindamycin and/or Bactrim or Fluroquinolone)
Plantar Foot Wounds = Cipro (Keflex)
How long does the animal need to be kept in observation for rabies? Where should the rabies vaccine be administered?
10 day observation period
Adults: Deltoid
Children 3-18 yo: Deltoid
Children < 3 yo: Thigh
What are the indications for a pt who has NOT been previously vaccinated for rabies?
IF unvaccinated, repeat the rabies VACCINE on days 0, 3, 7 and 14 post incident
Possible Day 28 dose if patient is immunocompromised
When is the rabies immunoglobulin administered? How is it dosed? Where should you give it?
Given as post exposure prophylaxis
Weight based (20 IU/kg)
Directions
Infiltrate area of wound as much as possible, then inject the remainder IM, opposite of the injection site of the vaccine
Given on day 0
What are the indications for an updated tetanus shot?
Contaminated wounds
Deep structure involvement
Burn Injuries
Crush Injuries
Compound, Open Fractures
When do you need to give the tetanus immune globulin?
for mod/severe wounds and tetanus vaccine status is unknown or the pt has had LESS than 3 doses
What are the tetanus vaccine and immune globulin recommendations? Consider looking at this graph again
What is the tx for a low risk puncture wound that is within 6 hours of injury and uncomplicated?
Irrigate the Wound, Cleanse and Update Tetanus if indicated
What is the tx for a high risk puncture wound that went through an athletic shoe?
Irrigate the wound, Cleanse and Leave Open
prescribe abx: cipro or keflex
What is the tx for a cat or dog bite?
Cleanse the Wound
Prescribe Antibiotics (Augmentin BID x 7 days)
Close follow up
Possible admission to hospital if surgical debridement indicated
What are the s/s of cat scratch disease? **What bacteria?
Lymphadenopathy within 14 days of cat bite/scratch
**Bartonella henselae
What is the tx for cat scratch disease?
Antibiotics:
Augmentin / Bactrim
Possible admission to hospital if failed outpatient treatment
What is the tx for a human bite? What should you NOT do?
Cleanse the wound
Augmentin BID for 10 days
close follow up and consider admission
DO NOT suture!! unless the bite is on the face
