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Emergency Medicine - BT > Ch 5. Analgesia and sedation, Hand injuries > Flashcards

Ch 5. Analgesia and sedation, Hand injuries Flashcards

1
Q

What is your target MAP for septic shock, hemorrhagic shock in trauma, and traumatic brain injury (3)?

A
  1. Septic shock: MAP >65
    
2. Hemorrhagic shock in trauma: MAP >40

  2. TBI: MAP >90

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2
Q

What is normal CVP, and how do you use CVP to measure “volume responsiveness”?
 (2)

A
  1. Normal CVP is 2-8. <4 suggests volume responsive, 2. CVP >12 suggests high right-sided pressures
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3
Q

How do you assess volume responsiveness? (3)


A
  1. Passive leg raise: like a 300mL bolus in 1 min (lasts 2-3mins). Assess for HR, BP, CVP.

  2. If you have CVP? Infuse 250mL NS. CVP increases <3 = volume responsive, CVP increases >5 = volume overload
    
3. Mechanically ventilated? Pulse pressure variation >10% predicts volume responsiveness

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4
Q

What is the Frank-Starling curve? (1)


A

Increased preload initially leads to a large increase in CO, and increasing preload past that gives modest increases in CO, and eventually too much preload decreases CO as the myocardium is stretched too far. 


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5
Q

What is Beck’s triad for cardiac tamponade (3)?


A
  1. Low BP

  2. Distended neck veins

  3. Muffled heart sounds
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6
Q

What is the toxic limit for local anaesthetics? (3)


A 
7:5:3 rule

1. 7mL/kg lidocaine w epi

2. 5mL/kg lidocaine

3. 3mL/kg bupivacaine

* 1% lidocaine is 10mg/mL, so you can use 40mL in an 80kg human

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7
Q

What is the treatment of local anaesthesia systemic toxicity? (1)


A
  1. Intralipid 20% 1.5mL/kg
*

Beware peri-orbital numbness, tinnitus, seizures, tachy-arrhythmia


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8
Q

How do you test the motor function of the radial, median, and ulnar nerve? (3)


A
  1. Radial = thumbs up
  2. Median = A-OK (anterior interosseous nerve)
  3. Ulner = Peace sign (also PAD DAB)
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9
Q

What is the hands position of safety (1)


A
  1. Sandwich holding position!
-

Because of the CAM effect (lessens contractures in the hand)


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10
Q

Describe the anatomy of FDS and FDP.


What does a laceration of each produce? (3)


A

Laceration of FDS – cant flex PIP


Laceration of FDP – cant flex DIP


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11
Q

What is the sensory innervation of the leg and foot? (5)


A
  1. Saphenous nerve = medial leg
  2. Superficial peroneal = lateral leg and dorsum of foot
  3. Deep peroneal = first-second webspace
  4. Lateral foot = Sural
  5. Plantar foot = Tibial nerve
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12
Q

Describe the arterial supply to the leg (5)


A
  1. The aorta

  2. Common iliac into internal and external iliac

  3. External iliac into superficial and deep femoral artery

  4. Superfical femoral into popliteal artery

  5. Popliteal into Anterior tibial, posterior tibial, and fibular (peroneal)
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13
Q

Complete: receptor, dosing, peak effect, half life (15)


  1. Midazolam: 

  2. Fentanyl: 

  3. Ketamine: 

  4. Propofol: 

  5. Etomidate: 

A
  1. Midazolam: GABA receptor, 0.1mg/kg IV, 2 mins, 20 mins
    
2. Fentanyl: opioid receptors, 1-2mcg/kg IV, 3 mins, 30 mins
    
3. Ketamine: NMDA antagonist, 1mg/kg IV, 1 min, 20 mins

  2. Propofol: GABA receptor, 0.5-1mg/kg IV, 30 seconds, 5 mins
    
5. Etomidate: GABA receptor, 0.15mg/kg IV, 30 seconds, 5 mins
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14
Q

Non-opioid medications for chronic pain (8)


A
  1. Ibuprofen

  2. Tylenol 

  3. Topical diclofenac

  4. Local injection/anaesthesia

  5. Ketamine

  6. Haloperidol

  7. Amitriptyline

  8. Gabapentin

  9. Duloxetine/Cymbalta

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15
Q

Which human bites, dog bites, cat bites of the body need antibiotics? (3)


A
  1. Human: hands, feet, face (Eikenella)
    
2. Dog: hands, feet, face (Capnocytophagacanimorsus)
    
3. Cat: all (Pasturella multicida)

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16
Q

Septal hematoma: treatment (3)


A
  1. Surgical drainage (18 guage needle)

  2. Anterior nasal pack to stop reaccumulation

  3. Rx Clavulin (poor evidence)

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17
Q

Treatment of an auricular hematoma (3)


A
  1. Drain the blood

  2. Apply a pressure dressing

  3. FU with plastics/ENT

18
Q

Treatment of fight bite injuries (4)


A
  1. Visualize the full extent of the wound

  2. Irrigate copiously

  3. Splint in position of function

  4. Injury to extensor tendons or joint capsule? Surgery FU

  5. PO Clavulin or IV cefazolin

19
Q

Treatment of extensor tendon laceration (3)


A
  1. <50% transection: 5-0 absorbable suture

  2. > 50% transection: Figure-of-8 stitch, 5-0 non-absorbable

  3. Splint in position of comfort
    
4. FU with plastics

20
Q

What is the injury?

  1. Mallet finger deformity
  2. Swan neck deformity
  3. Boutinniere deformity
  4. Jersey finger (3)

A
  1. Mallet finger deformity – loss of the DIP extensor
  2. Swan neck deformity – from unrepaired mallet finger (transected DIP extensor)
  3. Boutinniere deformity – injury to the PIP, with central slip rupture, allowing the lateral bands to slip and flex the PIP instead of extend it – splint and refer urgently to minor surgery
4. Jersey finger – avulsion of FDP – splint and refer urgently to minor surgery
21
Q

Treatment of mallet finger deformity? (1)


A
  1. Splint the DIP, the PIP should be mobile. 6-8 weeks. Follow-up hand surgeon
22
Q

What is Gamekeeper’s thumb? What is the pathological problem? Dx? Treatment? (4)


A
  1. Gamekeeper’s = UCL injury at the MCP joint
    
2. The problem is a Stener lesion (entrapment of adductor pollicis between the UCL ends, which impairs healing)

  2. Dx = joint laxity >30 degrees, or 15 degrees more than the other thumb

  3. Treatment: thumb spica. Refer to plastics within 7 days

23
Q

Terry Thomas sign? (1)

Spilled teacup sign (1)?


A
  1. Terry Thomas sign = Scapholunate dissociation

  2. Spilled teacup sign = Lunate dislocation

  3. Carpal bones not lining up in the lateral = perilunate dislocation

24
Q

Flexor tendons in the forearm (6)


A
  1. Flexor carpi radialis

  2. Flexor carpi ulnaris
  3. Palmaris longus
    
4. Flexor pollicis longus

  4. Flexor digitorum superficialis

  5. Flexor digitorum profundus

    ** Treatment: splint in position of safety. Urgent plastics FU (before the tendon retracts)
25
Q

What is the Gustilo Classification system for open fractures (4)


A

I. Wound <1cm - Ancef

II. Wound >1cm, - Ancef

III. Wound >10cm, severe mechanism/contamination - Ancef + Gent

IIIC. Wound >10cm, severe mechanism/contamination/soft tissue loss/vascular injury Ancef + Gent + Penicillin (concern for anaerobes/clostridia)


26
Q

Q. What are the bones of the wrist? (8)


A
  1. Scaphoid

  2. Lunate
  3. Triquetrum

  4. Pisiform

  5. Trapezium
  6. Trapezoid
  7. Capitate
  8. Hamate
27
Q

Q. Joints of the thumb? (3)


A
  1. Carpometacarpal (CMC)
    
2. Metacarpophalangeal (MCP)
  2. Interphalyngeal (IP)
28
Q

What is the motor and sensory test for radial nerve, median nerve, ulnar nerve (6)?


A
  1. Radial - M= thumb or wrist extension “power to the people or thumbs up”. S=dorsal thumb webspace
  2. Median - M=thumb opposition. “A-OK” S=Distal pointer finger
  3. Ulnar - M=fingers “peace” S=Outside small finger
29
Q

Fingertip amputation classification and treatment (6)

A

Zone I - no bone - heal by secondary intent
Zone II - some distal phalynx - rongeur bone and close (or call plastics)
Zone III - distal phalynx - rongeur bone and close (or call plastics)

30
Q

Fingertip amputation classification and treatment (6)

A

Zone I - no bone - heal by secondary intent
Zone II - some distal phalynx - rongeur bone and close (or call plastics)
Zone III - distal phalynx - rongeur bone and close (or call plastics)

31
Q

What is jersey finger? (1)

A

Rupture of the FDP tendon

32
Q

Acceptable degree of angulation for metacarpal neck/shaft fractures? (5)

A 
D1 0
D2 0
D3 10
D4 20
D5 30
33
Q

What is a Bennett and Rolando fracture? (2)

A
  1. Bennett: 2 part intra-articular fracture at the base of the thumb
  2. Rolando: 3 part intra-articular fracture at base of thumb
    * Remember because BEN-NETT (2) and RO-LAN-DO (3)
34
Q

Treatment of clinical scaphoid fracture? (2)

A
  1. Thumb spica.
  2. Repeat Xray in 10 days
    * 20% are radiographically occult*
35
Q

Treatment of high pressure injection injuries? (3)

A
  1. Broad spectrum antibiotics (cefazolin)
  2. tetanus
  3. Emergency consultation with plastics
    * Avoid ice, digital nerve blocks, local anaesthetic (theoretical risk of worsening vascular status)
36
Q

Indications for antibiotics in hand lacerations (6)

A
  1. Immunocompromised
  2. Open fracture (except Tuft fracture)
  3. Gross contamination
  4. Animal bites / fight bite
  5. Penetrating tendon injury
  6. Crush injury
37
Q

Management of Tuft fracture? (2)


A
  1. Trephination if the hematoma is >25% (make 3-4 holes!)
2. Splint the DIP
-Tell them that this will be painful for a few weeks!

38
Q

Kanavel signs of flexor tynosynovitis (4)


A
  1. Pain and redness along the tendon

  2. Finger held in slight flexion
  3. Pain with passive ROM

  4. Swelling of the digit
39
Q

Treatment of flexor tynosynovitis (3)


A
  1. Splint

  2. IV antibiotics

  3. Urgent plastics referral (STAT if sausage digit ++ bad)

40
Q

Fracture with pain over the hypothenar eminence (1)


A
  1. Hook of hamate fracture

Emergency Medicine - BT (16 decks)

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