ER Pearls Lecture Flashcards
2nd MC joint to dislocate
done by abducting and externally rotating arm
high re-dislocation rate in young people and athletes (90%)
Shoulder dislocation
When should you Xray a shoulder dislocation?
BEFORE and AFTER reduction
External rotation technique
Scapular rotation technique
Stimson’s technique
Traction counter-traction
Ways to reduce shoulder dislocation
2 people required
common for muscular pts/dislocated for long periods of time
Traction Counter-Traction
What is the Stimson’s technique?
Lying prone with weight attached to arm
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)
Steps following shoulder reduction
ALWAYS follow up with ortho
Immbolization for 2-4 weeks
PT
*older pts at risk for developing adhesive capsulitis
Shoulder dislocation
- inflammatory phase
- proliferative phase
- remodeling phase
phases of wound healing
Immediate to 2-5 days
Hemostasis: vasoconstriction, platelet aggregation, thromboplastin makes clot
Inflammatory phase
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.
Inflammatory
the _________ phase characterized by angiogenesis, collagen deposition, granulation tissue formation, epithelialization, and wound contraction.
proliferative
2 days-3 weeks
Granulation
Contraction
Epithelialization
Proliferative phase
3 weeks-2 years
New collage forms which increases tensile strength to wounds
Remodeling phase
Scar tissue is only ___% as strong as original tissue
80%
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
Primary intention
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
Second intention
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.)
Tertiary intention
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
True
True or False
you can use a temporary tourniquet during suture repair
True
How should you use antibotics with lacerations?
Sparingly!
what is the time frame you can suture in?
6-12 hours (controversial)
Initial dressing is often left on for..
24-48 hours
*second dressing applied back in office
Advise pts to avoid sun/use sunblock post injury to avoid…
hyperpigmentation at site
Time frame for suture removal of:
face, extremities, hands, feet?
4-14 days
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
Subungal hematomas
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
Nail trephination
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)
Conscious sedation
Desired effects=
Relaxation
Cooperation
Maintains protective airway reflexes
Purposeful responses to verbal or tactile commands
Safe return to baseline and ambulatory D/C
Conscious sedation
Benzos
Narcotics
Dissociative agents
Hypnotics
…drugs typically used for..?
Conscious sedation
Can be used in conscious sedation
*these drugs are sedatives and hypnotics
They help with anxiolysis, sedation and amnesia
Midazolam, Diazepam, Lorazepam
Benzos
All produce anterograde amnesia
All produce tranquility
All produce drowsiness
all CAN produce respiratory depression
Benzos
Will last 20-40 mins
Will reverse respiratory depression caused by narcotics
May potentiate aggression
Narcan
This dissociate agent has an onset of 10 mins
often choice with pediatric population who need sedation
Ketamine
Short acting, IV hypnotic drug
shortest recovery time
Propofol
MC cause of abscesses?
Staph Aureus
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.
Abscesses
If treated correctly, when is the only time an abscess pt should be discomfort?
during initial anesthetization
Where should you cut into an abscess?
at the apex
Inflammation of the nail fold
Can be accute or chronic
More frequent in smokers
Paronychia
MC cause of paronychia
Staph aureus
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)
Paronychia
Do topical abx or anti-bacterial ointments work for paronychia?
NO
Treatment of choice for paronychia on toe involving an ingrown toe nail
Wedge resection
Radial head subluxation (nursemaid elbow) is seen in kids…
under 5
Proximal radius is held in proximity to the ulna by a ligament known as the _______ ligament
annular
Which ligament is displaced in nursemaid’s elbow?
Annular
Kid usually holds arm at side in a semi extension, NOT 90 degree flexion
Nursemaid elbow
2 motions to do when reducing nursemaids elbow
Flex
Supinate
Child should exhibit spontanous and full ROM of affected arm within..
10-15 mns post reduction (nursemaids elbow)
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…
dislocation of the ankle
Because of the force involved with ankle dislocations, what else is typically seen with it?
Fractures!!
(and neurovascular is main priority)
most common type of ankle dislocation?
Posterior
plantar flexion and axial traction 1st
downward pressure on tibia 2nd
anterior replacement
reduction of ankle dislocation
