ER PEARLS

Question 1

What 4 techniques can you use to relocate a shoulder?

Answer 1

Traction-counter-traction; External rotation; Scapular rotational; Stimson’s

Question 2

Which technique involves having a patient in the prone position holding a weight?

Answer 2

Stimson’s

Question 3

What’s the MOI for a shoulder dislocation?

Answer 3

Adducted and externally rotated

Question 4

After you reduce a shoulder what should you do?

Answer 4

Check sensation/circulation; Post-reduction films; immobilize shoulder (sling & swath); Educate patient that they can’t externally rotate/abduct shoulder → F.U with ortho!

Question 5

What should we remember about older patients with shoulder dislocation?

Answer 5

More likely to get adhesive capsulitis (will need sooner f.u with ortho and possibly hanging motions)

Question 6

What are the stages of wound healing?

Answer 6

Inflammatory phase (2-5 days; vasoconstriction, platelet agg, and phagocytosis)

Proliferative phase (up to 3 weeks; collagen deposition & wound contraction)

Remodeling phase (3 weeks – 2 years; new collagen which increases tensile strength [scar tissue])

Question 7

What are the 3 sub-phases of the proliferative phases?

Answer 7

Granulation (new capillaries/fibroblasts lay a bed of collagen)
Contraction
Epithelialization

Question 8

When it comes to wound closure, what involves wound edges approximated at or close to the time of injury and is best for wounds that are clean and uncomplicated?

Answer 8

Primary intention

Question 9

If you allow a wound to heal on its own, usually for wounds that are >12 hours old or abscesses, fight bites, or dirty wounds?

Answer 9

Secondary intention

Question 10

What is it known as when a wound is left open for 1-several days and is then surgically closed? Often done to allow tissue edema to reduce or likely have a chance of infection.

Answer 10

Tertiary intention

Question 11

What is important to remember when initially evaluating a wound?

Answer 11

Don’t miss potential injuries → Consider deeper structures (move extremity through flexion/extension while visualizing the tendon)

Clean & Irrigate!

Evaluate blood supply

Question 12

If a wound is non-surgical, how is it closed?

Answer 12

Dressing only, steri-strips, and dermabond

Question 13

If you have a laceration that needs suturing in the eyebrows, what do you do about the hair?

Answer 13

Don’t shave it off! Some don’t grow back…

Question 14

Do inner lips require suturing?

Answer 14

No

Question 15

If a laceration crosses over the lips, what is key to success?

Answer 15

Attention to the vermillion border (first stitch is the most important)

Question 16

What should you do if a laceration involves the full-thickness of the ear and cartilage?

Answer 16

Speak with ENT or plastics

Question 17

What is it known as when there is a collection of blood between the nailbed & fingernail?

Answer 17

Subungual Hematoma

Question 18

How/when do you treat a subungual hematoma?

Answer 18

Always indicated if hematoma involves greater than 50% of nail

Trephination (with cautery stick)

Question 19

What must you always do prior to trephination?

Answer 19

Clean the nail!! But alcohol can catch fire… so just use betadine

Question 20

What is the desired effect of conscious sedation?

Answer 20

Relaxation, cooperation while the patient maintains protective airway reflexes

Question 21

What medications are commonly used for conscious sedation?

Answer 21

Benzos (but CAN produce respiratory depression → reversal with flumazenil)

Narcotics (morphine, fentanyl, dilaudid)

Dissociative agents (Ketamine)

Hypnotics (propofol)

Question 22

What must we always monitor when using conscious sedation?

Answer 22

Continuous pulse Ox; sequential BP monitoring; cardiac monitoring

Question 23

What bacteria is the most common cause of an abscess?

Answer 23

Staph aureus (MRSA is on the rise)

Question 24

What’s the definitive treatment for an abscess?

Answer 24

Scalpel (possibly add Abx)

Question 25

Pus should spontaneously drain, once all the pus is out, what do you do?

Answer 25

Irrigate → pack → dress

Question 26

When should the person f/u and what will you do at that time?

Answer 26

24-72 hour; removing packing, re-irrigate and sometimes re-packed

Question 27

What bacteria is the most common cause of paronychia?

Answer 27

Staph aureus… again

Question 28

Are topical Abx used for paronychia?

Answer 28

Nope! Oral (cephalexin or Dicloxacillin)

Question 29

How would you treat paronychia?

Answer 29

Scapel & drain pus (lido not needed)

If nail is involved = wedge resection (linear cut) with a DIGITAL NERVE BLOCK

Question 30

How do you reduce a nursemaid’s elbow?

Answer 30

How do you reduce a nursemaid’s elbow?

Question 31

What must we always remember with ankle dislocations and evaluating for other injuries?

Answer 31

Associated fractures are the rule, not the exception

Question 32

What must we always check with ankle dislocations (any dislocation really)?

Answer 32

Vascular compromise & sensation

Question 33

What is our primary goal with ankle dislocations?

Answer 33

Immediate reduction of the joint & relief of neurovascular stress

Question 34

What’s the most common direction for an ankle dislocation?

Answer 34

Posterior

Question 35

How do we reduce an ankle dislocation (posterior)?

Answer 35

Plantar flexion with axial traction; then downward pressure on the tibia; followed by anterior replacement

Question 36

Do you always HAVE to get a finger xray before relocation?

Answer 36

Not if significant delay would result

Question 37

What must we always do after relocated a finger dislocation?

Answer 37

Confirm tendon function!!! Then splint/post-reduction xrays

Question 38

What direction does a finger most commonly dislocate? How do you relocate it?

Answer 38

Usually dislocates dorsally

Reduce with traction, increase angle slightly, then reset in position

Question 39

What are some methods to extracting ear foreign bodies?

Answer 39

Irrigation, grasping with forceps, lighted cerumen loop, right angle needle or suction catheter

*But be careful since it can be painful and TM can be easily damaged

Question 40

What are some techniques to nasal foreign body removal?

Answer 40

Blow their nose while occluding other nostril; mother’s kiss; consult ENT!