ER Pearls Lecture

Question 1

2nd MC joint to dislocate

done by abducting and externally rotating arm

high re-dislocation rate in young people and athletes (90%)

Answer 1

Shoulder dislocation

Question 2

When should you Xray a shoulder dislocation?

Answer 2

BEFORE and AFTER reduction

Question 3

External rotation technique
Scapular rotation technique
Stimson’s technique
Traction counter-traction

Answer 3

Ways to reduce shoulder dislocation

Question 4

2 people required

common for muscular pts/dislocated for long periods of time

Answer 4

Traction Counter-Traction

Question 5

What is the Stimson’s technique?

Answer 5

Lying prone with weight attached to arm

Question 6

Immobilize with sling, swath
Get post reduction films
Circulatory and sensory status (axillary N.)
Advise pt to avoid abduction and external rotation (ie brushing hair)

Answer 6

Steps following shoulder reduction

Question 7

ALWAYS follow up with ortho
Immbolization for 2-4 weeks
PT

*older pts at risk for developing adhesive capsulitis

Answer 7

Shoulder dislocation

Question 8

1. inflammatory phase
2. proliferative phase
3. remodeling phase

Answer 8

phases of wound healing

Question 9

Immediate to 2-5 days

Hemostasis: vasoconstriction, platelet aggregation, thromboplastin makes clot

Answer 9

Inflammatory phase

Question 10

In the ______ phase, bacteria and debris are phagocytosed and removed, and factors are released that cause the migration and division of cells involved in the proliferative phase.

Answer 10

Inflammatory

Question 11

the _________ phase characterized by angiogenesis, collagen deposition, granulation tissue formation, epithelialization, and wound contraction.

Answer 11

proliferative

Question 12

2 days-3 weeks

Granulation
Contraction
Epithelialization

Answer 12

Proliferative phase

Question 13

3 weeks-2 years

New collage forms which increases tensile strength to wounds

Answer 13

Remodeling phase

Question 14

Scar tissue is only ___% as strong as original tissue

Answer 14

80%

Question 15

Wound edges are approximated at or close to the time of injury

Typically allows for the best cosmetic result to follow

Best performed on wounds that are ‘clean’ and uncomplicated

Answer 15

Primary intention

Question 16

Wound is not surgically closed

Allowed to heal on own through granulation and re-epitheliazation

Often allowed for abscesses, fight bites or other dirty wounds

May be chosen as closure method for wounds >12 hrs old

Answer 16

Second intention

Question 17

Delayed primary closure or secondary suture

Pt’s wound is intentionally left open for 1-several days and then surgically closed.

Often done to allow tissue edema to reduce (orthopedic injuries)

Often chosen for wounds with a likely chance of infection (ab. incision post ruptured appendix etc.)

Answer 17

Tertiary intention

Question 18

True or False…

Road rash must be scrubbed and washed thoroughly to prevent “tattooing” (esp on the face)

“ragged” edges should be debrided or trimmed with scissors

Answer 18

True

Question 19

True or False

you can use a temporary tourniquet during suture repair

Answer 19

True

Question 20

How should you use antibotics with lacerations?

Answer 20

Sparingly!

Question 21

what is the time frame you can suture in?

Answer 21

6-12 hours (controversial)

Question 22

Initial dressing is often left on for..

Answer 22

24-48 hours

*second dressing applied back in office

Question 23

Advise pts to avoid sun/use sunblock post injury to avoid…

Answer 23

hyperpigmentation at site

Question 24

Time frame for suture removal of:

face, extremities, hands, feet?

Answer 24

4-14 days

Question 25

A collection of blood between the nailbed and the fingernail \*painful \*usually the result of a crush type injury \*often results in nail deformities \*often associated with distal phalanx tuft fracture

Answer 25

Subungal hematomas

Question 26

Tx used in subungal hematomas Can dramatically reduce pain May save nail Always indicated in hematomas\>50% of nailbed May be indicated in hematomas\<50% depending on pain level

Answer 26

Nail trephination

Question 27

**Sedation and analgesia administered to pts for the benefit of facilitating diagnostic or therapeutic interventions** IV typical but IM can be utilized Pharmacologic agents used alone or in combination produce a depressed level of consciousness while the pt still can maintain patent airway and airway reflexes (i.e. gag)

Answer 27

Conscious sedation

Question 28

Desired effects= Relaxation Cooperation Maintains protective airway reflexes Purposeful responses to verbal or tactile commands Safe return to baseline and ambulatory D/C

Answer 28

Conscious sedation

Question 29

Benzos Narcotics Dissociative agents Hypnotics ...drugs typically used for..?

Answer 29

Conscious sedation

Question 30

Can be used in conscious sedation \*these drugs are **sedatives and hypnotics** They help with anxiolysis, sedation and amnesia Midazolam, Diazepam, Lorazepam

Answer 30

Benzos

Question 31

All produce **anterograde** amnesia All produce tranquility All produce drowsiness all CAN produce respiratory depression

Answer 31

Benzos

Question 32

Will last 20-40 mins Will reverse respiratory depression caused by narcotics May potentiate aggression

Answer 32

Narcan

Question 33

This dissociate agent has an onset of 10 mins often choice with pediatric population who need sedation

Answer 33

Ketamine

Question 34

Short acting, IV hypnotic drug **shortest recovery time**

Answer 34

Propofol

Question 35

MC cause of abscesses?

Answer 35

Staph Aureus

Question 36

Definitive treatment…….scalpel! If not drainable initiate antibiotic therapy and recheck in 24-48 hrs. If incised, drained and packed antibiotic therapy remains controversial but typically prescribed.

Answer 36

Abscesses

Question 37

If treated correctly, when is the only time an abscess pt should be discomfort?

Answer 37

during initial anesthetization

Question 38

Where should you cut into an abscess?

Answer 38

at the apex

Question 39

Inflammation of the nail fold Can be accute or chronic More frequent in smokers

Answer 39

Paronychia

Question 40

MC cause of paronychia

Answer 40

Staph aureus

Question 41

Warm soaks can be used 3 or 4 times a day for acute paronychia Antibiotics such as Cephalexin or Dicloxacillin. Bactrim/Doxy /Clinda if MRSA suspected (obtain Cx perhaps)

Answer 41

Paronychia

Question 42

Do topical abx or anti-bacterial ointments work for paronychia?

Answer 42

NO

Question 43

Treatment of choice for paronychia on toe involving an ingrown toe nail

Answer 43

Wedge resection

Question 44

Radial head subluxation (nursemaid elbow) is seen in kids...

Answer 44

under 5

Question 45

Proximal radius is held in proximity to the ulna by a ligament known as the _______ ligament

Answer 45

annular

Question 46

Which ligament is displaced in nursemaid's elbow?

Answer 46

Annular

Question 47

Kid usually holds arm at side in a semi extension, NOT 90 degree flexion

Answer 47

Nursemaid elbow

Question 48

2 motions to do when reducing nursemaids elbow

Answer 48

Flex Supinate

Question 50

Child should exhibit spontanous and full ROM of affected arm within..

Answer 50

10-15 mns post reduction (nursemaids elbow)

Question 51

As the joint moves into plantar flexion, the talus becomes narrower, resulting in decreased stability This combined with inversion can create a set up for...

Answer 51

dislocation of the ankle

Question 52

Because of the force involved with ankle dislocations, what else is typically seen with it?

Answer 52

Fractures!! | (and neurovascular is main priority)

Question 53

most common type of ankle dislocation?

Answer 53

Posterior

Question 54

plantar flexion and axial traction 1st downward pressure on tibia 2nd anterior replacement

Answer 54

reduction of ankle dislocation