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Pharmacotherapy > Bites, Burns, Wounds > Flashcards

Bites, Burns, Wounds Flashcards

1
Q

Insect bites/stings pathophys

A

 Various bugs may bite (e.g., spiders and ticks), sting
(e.g., bees and ants), or emit toxic secretions (e.g.,
caterpillars).
 Most commonly, these injuries are self-limiting skin
reactions (i.e., inflammation).
 Occasionally, serious systemic effects may occur,
leading to anaphylaxis or transmission of disease.
 In North America, deaths are rare

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2
Q

what are some common types of bites

A

spiders, ticks, mosquitoes, bed bugs

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3
Q

spider bites

A

Spiders rarely bite humans. Some are venomous
(e.g., black-widows, brown recluse), but most do
not result in systemic symptoms that would require
hospitalization. Those that do may cause
progressive symptoms from sweating and nausea
to tissue necrosis.

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4
Q

tick bites

A
  • Ticks attach to warmer areas of the body (e.g.,
    armpit, groin, scalp) and feed on blood.
  • Common reactions include redness and swelling
  • Ticks infected with Borrelia burgdoferi may cause Lyme disease, which begins as a bull’s-eye rash and can progress from flu-like symptoms to cardiac and neurological complications.
  • May transmit from animals.
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5
Q

mosquito bites

A
  • Salivary secretions from the female mosquito cause local histamine reactions that typically result in red, itchy papules.
  • Many viral and parasitic infections may be transmitted by mosquitoes including malaria, West Nile, and zika, therefore prevention of bites is key
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6
Q

bed bugs

A
  • Bugs are typically found near mattress and boxspring seams.
  • They often bite the arms and legs in clusters of 3-5, resulting in red, itchy lesions.
  • Unlike lice, they may live up to a year without feeding. - Professional chemical extermination or application of heat and other measures are necessary for eradication
  • not known to spread disease
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7
Q

stinging insects - which 3 insect families

A
  • Three insect families known to cause reactions
    are bees, vespids, and stinging ants
  • In those who are susceptible, venom causes local
    inflammatory reactions (within 4-48 hours), or
    over a larger area (subsiding over 3-10 days)
  • Systemic reactions are more likely with multiple stings
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8
Q

red flags for bites and stings

A

consider normal presentaiton
- localized rxns s (itching, redness, swelling)
- mild allergic rxns (hives, rash, swelling)
use topical management

  • <2 years of age - pro judgement
  • extensive local rxn ? 10 cm in diameter persisting several days
  • multiples bites/stings
  • sting to mouth, tongue
  • history of rxn to previous bites/stings (anaphylaxis)
  • immunocompromised and lesion remains after 7 days with no improvement
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9
Q

bites and stings goals of therapy (4)

A

 Prevent bites and stings
 Prevent diseases or reactions caused by bites and
stings
 Ensure patient receives appropriate care when
warranted (In the case of more serious reactions)
 Provide symptomatic relief of localized reactions

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10
Q

bites and stings prevention

A
  • Avoid using scented products
  • Cover skin as much as possible (Clothing should be tight at wrists / ankles)
  • Avoid tall grasses or standing water
  • Limit time spent outside at dawn / dusk
  • Avoid / use caution when eating outdoors
    -Use mosquito netting, especially for infants <6 months
    of age and for travelers.
  • Avoid situations where insects may feel threatened (i.e. nests)
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11
Q

bed bugs prevention

A

 New environments (e.g., hotel rooms) should be
carefully checked
 Examine seams of mattresses, behind headboards,
under baseboards and in curtains for infestation.
 Bugs can also sometimes be seen before dawn when they are most active and slower-moving from feeding
 Insect repellents have not been shown to be effective for preventing bed bug bites.

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12
Q

insect repellents

examples?

A

Can deter biting insects, but not stinging ones
 Should be applied directly to clothing / exposed skin in ventilated area
 Products containing a Pest Control Product (PCP) registration number on the label
should be chosen.
 Can be used in pregnancy and breastfeeding with the exception of citronella

  • avoid spraying onto face/near eyes/mouth, hands of small children
  • not used in children <6 mos

examples
 DEET (N,N-diethyl-m-toluamide) - offensive smell,
- low conc for greater than 6 mos, high conc older than 12

 PMD (P-menthane 3,8-doil)
- MOA unknown, under age of 3

 Icaridin / Picaridin
- conceals attractants, changes ability of bugs to smell

 Oil of citronella
- offensive taste of smell, not for under 2

 Soybean oil
- all ages safe, conceal attractants, cools skin surface temp

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13
Q

non-pharm treatment for stinging insects

A

For stinging insects:
 Remove stinger to stop injection of venom and decrease local reaction. Remove with tweezers, finger nails or credit card.
 Cleanse area with soap and water to prevent secondary infection.
 Use cold compresses to provide relief and reduce swelling.
Methods such as applying toothpaste or vinegar may help with symptoms, but have not been studied.

For ticks:
 Remove using tweezers. Grasp as close to the skin as possible and avoid twisting (head may remain in skin).
 Cleanse area with soap and water to decrease local irritation.
 Methods such as applying petroleum jelly or burning off with alcohol and matches (?!) have no proven efficacy or may damage skin.

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14
Q

Name 6 types of pharm treatments for bites/stings

A 
analgesics
antihistamines
astringents/protectants
anesthetics
counterirritants
corticosteroids
other (ammonia/baking soda After Bite) - local cooling and anti-pruritic
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15
Q

Analgesics for bites and stings

A

 e.g., acetaminophen, ibuprofen
 Typically in oral dosage forms
 Suggest typical doses

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16
Q

antihistamines for bites and stings

A

first-generation (Benadryl® - diphenhydramine, Chlor-Tripolon® - chlorpheniramine)
- more side fx, drowsy, shorter duration of action

second-generation (Reactine® - cetirizine, Claritin® loratadine)
 Both are equally effective
 Oral > topical due to risk of contact dermatitis
 First-gen cause more sedation and have a shorter DOA
 Second-gen are more expensive but also more convenient

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17
Q

Astringents / Protectants for bites and stings

A

e.g., calamine, zinc oxide
 Well tolerated, but cosmetically less appealing, leave a pink/white film
soothe skin

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18
Q

anaesthetics for bites and stings

A

e.g., benzocaine, lidocaine, pramoxine
 Reduce nerve impulses on the skin
 Offer only minor relief and have a short DOA
 Remember, these are known sensitizers

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19
Q

Counterirritants for bites and stings

A

Counterirritants
 e.g., camphor or menthol
 Offer cooling, pain-relieving, anti-pruritic effects

lacks evidence, can cause more irritation later on

20
Q

Corticosteroids for bites and stings

A

e.g., hydrocortisone 0.5% or 1%
 May relieve itch associated with local reactions
4 times a day for max 7 days - no prescription unless children under 2 - need Rx

21
Q

Anaphylaxis

symptoms?
what is the first line treatment? how are they used?

A

may occur minutes to hours after allergen exposure
 Respiratory – coughing, throat tightness, tongue swelling
 Cutaneous – hives, itching, flushing
 GI – nausea/vomiting, cramping
 Other – lightheadedness, sweating, panic

First-line treatment is administration of epinephrine.
 Decreases bronchospasm, enhances blood flow and blood pressure. Patients should go to the emergency department after administration of epinephrine, as some reactions are biphasic (could recur after a few
hours).
 NB: Oral antihistamines are second-line for hives/itching

Epi pens

  • schedule 2
  • go straight to emergency room after 1st dose
  • 2nd dose used 5-15 minutes if there was inadequate response
  • Jr for b/w 15 to 30 kg
22
Q

Monitoring and Follow-Up

provide timelines for:
pain and fever
itching
swelling/redness
local infection
suspected anaphylaxis
A

In most cases, symptoms should be “eliminated” or “reduced a level acceptable to the patient.”

Pain and fever
 Pain should subside in 24 hours
 Fever , if present, should subside within 7 days

Itching
 Monitor daily and with each application/dose of treatment
 Should subside within 7 days

Swelling / redness
 Increase or worsening
 Should normally subside within 24-28 hours

Local infection
 Swelling, redness, tenderness, pus, fever
 Monitor for up to 7 days after exposure

Suspected anaphylaxis
 Monitor for s/sx within at least 30 minutes of exposure

23
Q

Burns pathophys

causes?
factors determining severity?

A

Burns encompass a spectrum of tissue injuries that result in local and systemic responses.

They may result from a number of causes:
 Heat (e.g., flame; hot liquids, gases, or objects; smoke)
 Radiation (e.g., the sun / UV rays, lasers)
 Electricity (e.g., appliances)
 Chemicals (e.g., cleaners)

Burn severity is related to several factors:
 Body location / skin thickness
 Cause of the burn and duration of exposure
 Extent (surface area affected) and depth of burn

24
Q

what are the types of burn?

A 
1st degree
2nd degree (superficial partial thickness)
2nd degree (deep partial thickness)
3rd degree (full thickness)
25
Q

1st degree burns

location, cause, presentation, time for healing?

A

 Affect the epidermis only
 Causes: sunburn, low-intensity heat
 Presentation: dry, pink, blanches with pressure,
some pain but no edema, skin remains intact
 Healing: 3-7 days without scarring

26
Q

2nd degree (superficial partial thickness)

location, cause, presentation, time for healing?

A

 Affect the epidermis and upper dermis
 Causes: scalds, flame, dilute chemicals
 Presentation: moist, weeping, blanches with
pressure, extreme pain, small blisters
 Healing:3-7 days, some pigment changes,
generally no scarring

27
Q

2nd degree (deep partial thickness)

location, cause, presentation, time for healing?

A

 Affects the epidermis and deep dermis, including hair
follicles and sweat glands
 Causes: scalds, oil/grease, flame, prolonged
exposure to dilute chemicals
 Presentation: wet/waxy or dry, variable color (red/white), blisters, no blanching with pressure, pain only with pressure
 Healing: >21 days with possible scarring and contractures (tightening of tendons/muscles)

28
Q

3rd degree (full thickness)

location, cause, presentation, time for healing?

A

 Affects the epidermis, dermis, and subcutaneous layer
 Causes: immersion/scalding, concentrated chemicals,
electricity
 Presentation: dry/waxy, to charred and black, no
blanching with pressure, painless (Why?)
 Healing: requires intervention (e.g., surgery, grafts), high risk of fluid loss, infection, scarring, and contractures

29
Q

Name 3 complications wtih burns

Name 5 factors that increase risk of infection

A

 Infection
 Fluid / electrolyte imbalance
 Scarring

factors
 Medical conditions like diabetes or vascular diseases
 Age (<5 or >60 due to probable skin thinness)
 Immunosuppressive drug therapy
 Malnutrition
 Smoking

30
Q

red flags for burns

A
  • refer for deep partial-thickness or full-thickness burns
    Referral is warranted in the following situations:
     >10% TBSA for adults or >5% TBSA for children
     Any size of burn that is more serious*
     Any burn involving thin skinned areas or individuals
    presumed to have thin skin (face, ear, eyelid)
     Burns on hands/feet or circumferential burns (circumference of digit/extremity/torso)
     Concomitant trauma (e.g., electrocution)
     Chemical burns (may progress), electric or inhalation burn
     Possible inhalation injury
  • < 5y or >60 y
  • monitor if there is underlying medical condition that can delay healing
31
Q

Non-pharm/first aid for burns

A

 Remove the patient from the causative agent
 Cool by applying cool tap water
 Reduces pain, inflammation, and tissue damage
 Remove jewelry or other restrictive items in case of swelling
 Clean any secretions or debris with mild soap and tap water
 Leave blisters intact; if they break, gently clean
 Cover with non-adherent gauze dressing - [rotects from friction and contamination
 Avoid antiseptics or disinfectants - may impair healing

32
Q

Pharm for burns

Antibacterial Agents

A

 Poor evidence
 Topical antibiotics (e.g., Polysporin®) not recommended unless an infection is present
 Silver sulfadiazine (Flamazine® - Rx) historically used, but newer dressing options may lead to better healing outcomes

33
Q

Pharm for burns

Analgesics

A

 Usual doses of acetaminophen or ibuprofen (or opioids)
 Avoid ASA, as may promote bleeding from deep wounds
 Lidocaine/benzocaine/pramoxine often marketed for burns, but little evidence for use and may sensitize
 Camphor/menthol/phenol could have cooling effect, but also little evidence for use

34
Q

Antipruritics

A

 Itch is common during healing phase
 Colloidal oatmeal (Aveeno® products) and other topical moisturizing products may provide symptom relief
 Oral diphenhydramine (Benadryl®, cetirizine (Reactine®), or hydroxyzine (Atarax® - Rx), may be beneficial if itching is bothersome

35
Q

other pharm options for burns (4)

A

 Suggest the use of sunscreen as burned skin is susceptible to damage
 Honey – anti-microbial and anti-inflammatory properties may improve healing by 4-5 days
 Aloe vera – inconclusive evidence, may cause some irritation
 Tetanus vaccine – for partial- or full-thickness burns

36
Q

Monitoring and Follow-Up

4 things to look out for

A

Pain
 Every 4-6 hours initially, then daily
 Use a pain scale (0 no pain  10 worst pain)

Itching
 Every 4-6 hours initially, then daily

Burn healing
 Every 2-3 days initially, then weekly

Infection
 Daily at dressing changes
 Consider swelling, redness, pus, fever, etc

37
Q

wounds pathophys

A

Wounds occur due to mechanical trauma that disrupts normal skin structure and functioning

May be of partial- or full-thickness
 Affecting the epidermis and dermal layers, or penetrating to subcutaneous tissue and exposing fat, muscle, or bone.

May be acute or chronic
 Acute wounds include bites, burns, scrapes, and minor surgical procedures; they usually heal within 3 weeks.
 Chronic wounds occur due to delayed or impaired healing and are beyond the scope of this lecture
 e.g., pressure ulcers, diabetic foot infections

38
Q

what conditions are needed for healing of wounds? (4)

name 4 healing phases

A

regenerate/repair skin - scar tissue

conditions
 Well vascularized
 Clear of infection
 Free of necrotic tissue - may harbor bacteria
 Moist - accelerates epidermal migration and dermal repair

Wound healing involves 4 phases
1. Hemostasis phase – begins within minutes, release of inflammatory mediators assists with clot formation, etc.
2. Inflammatory phase – lasting ~4 days, WBC migration prevents infection
and begins repair process.
3. Maturation phase – also within 4-5 days, collagen forms early scar tissue to close and strengthen the wound.
4. Proliferative phase – lasting ~24 days, the wound remains red and raised but starts contracting.

  • collagen can continue to strengthen the wound for up to 2 years depending on the type of wound
39
Q

complications with wounds - infection

A

Minor infections
 Redness, tenderness, warmth, discharge

Major infections
 Discharge, odor, delayed healing, increased pain

Wound factors that may increase risk:
 Foreign matter in the wound
 Location of the wound (exposure to contamination)
 Depth of wound and involvement of other tissues
 Presence of devitalized tissue

Patient factors that may increase risk:
 Age (thinner skin delays healing process)
 Underlying medical conditions (e.g., diabetes)
 Extremes of body weight (poor nutrition)
 Smoking (decreased blood flow to area)
 Drug therapies (e.g., that affect immunity or clotting)

40
Q

complications with wounds - swelling

A

 Occurs when collagen and glycoprotein deposit at the wound site.
 Moist healing environments decrease the extent of scarring by accelerating the phases of repair.
 Discoloration of the area can occur, but this may be
minimized by using sunblock for ~6 months while the wound is healing.
 Darker the skin type, the more likely the body is to form a thicker scar. Believed to be caused by genetics, skin coloring, and the area of the body (i.e. earlobes)
 Options exist for preventing scar formation or minimizing existing scars. e.g., silicone gels

41
Q

red flags for wounds

A

Wounds that continue to bleed despite application of
pressure:
 Wounds that expose fat, muscle, or bone
 Visible foreign material despite irrigation
 Gaping / large wounds (>2cm)
 Deep puncture wounds

 Wounds from animal bites
 Wounds causing severe pain
 Chronic wounds or those at risk of delayed healing due to wound / patient factors
 Signs of infection

42
Q

goals of therapy for wounds (4)

A

 Optimize wound healing and prevent deformity
 Prevent infection
 Minimize further trauma
 Minimize patient discomfort

43
Q

non pharm treatment for wounds (3)

A

Cleanse the wound
 Once obvious debris is removed, cleanse with water (just as effective as normal saline). If any debris remains, it may be removed with tweezers or brushed away with gauze (if reasonable to do so!).

Stop any bleeding
 Apply dressing or gauze for 10 minutes. Those on
anticoagulants may take ~15 minutes.

Apply a dressing
 Choose a dressing that maintains moisture
 Minor wounds may be closed with a Band-Aid® or liquid bandage. Major wounds that are gaping, deep, or jagged may require stitches

44
Q

pharm for wounds

Cleansing and antiseptic agents

A

Normal saline, distilled water
 Fine to use; may not be necessary

e.g., hydrogen peroxide 3%, isopropyl alcohol 70%,
iodine
 In general, avoid direct application to the open wound. Most of these measures are irritating and potentially cytotoxic. Unless there is a high risk of infection, encourage plain water (and mild soaps).

45
Q

pharm for wounds

Topical Antibacterials

A

Prophylaxis – generally not recommended unless there is a high risk of infection

Treatment – for superficial, mildly infected wounds
 e.g., Polysporin® cream or ointment – OTC
 e.g., fucidin acid (Fucidin® - Rx) or mupirocin (Bactroban® - Rx)
 All are applied BID to TID, may cause localized irritation
 Should be used only as long as is necessary

46
Q

pharm for wounds

Oral Antibiotics

A

 Indicated for human/animal bites, deep wounds, or those persisting >2 weeks despite proper care

47
Q

monitoring (3 parameters)

A

Bleeding
 Should stop within 10 minutes
- 15 for immunocompromised pts

Infection
 Monitor daily at dressing changes

Wound healing
 Monitor daily for 4-14 days

Pharmacotherapy (14 decks)

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