KC soft tissue Flashcards
*8 reasons for high risk infection in otherwise healthy patient
- Location: Leg and thigh, then arms, then feet, then chest, then back, then face, then scalp
- Contamination with devitalized tissue, foreign matter, saliva, or stool
- Blunt (crush) mechanism
- Presence of subcutaneous sutures
- Type of repair: Risk greatest with sutures > staples > tape
- Anesthesia with epinephrine
- High-velocity missile injuries
- Diabetes
*5 high risk features of wounds for infection
o Prolonged time since injury
o Crush mechanism
o Deep wounds longer than 5 cm
o Age of patient
o High-velocity missiles
o Location on lower extremities
o Contamination with saliva, faces, soil, or other foreign matter
o Use of local anesthetic with epinephrine
*What 8 wounds would routinely be given abx prophylaxis?
Some examples
- over joint
- over tendon
- over bone
- puncture
- contaminated
- crush
- dog bite to hand
- cat bite
- human bites
- through-and –through oral laceration
- monkey bite
- pig, camel
- Laceration over MCP
- wound with infection at presentation
- wound in an immunocompromised patient
*5 methods to decrease the pain when injecting local anesthetic
- Buffer with NaHCO3 in 1: 10 ratio (1cc NaHCO3: 10 cc lidocaine)
- Inject slowly
- warm anesthetic
- Use counter irritation
- Use distraction techniques
- topical
- small needle
*Which anesthetic has an increased risk of systemic toxicity
- bupivacaine
*Signs and symptoms of systemic toxicity of local anesthetics (5)
o Metallic taste
o Tongue numbness
o Drowsiness
o Nystagmus
o Slurred speech
o Seizures
o Coma
o Respiratory arrest
o Bradycardia
o Hypotension
o Cardiac arrest
*Extensor tendon laceration, three techniques to repair
- Horizontal mattress stitch
- Figure-of-eight stitch
- Roll stitch
- Modified Bunnell
- Modified Kessler
*Hand lac (extensor tendon laceration) 4 things to do prior to discharge
- hand surgery consult
- ABx
- Td
- Splint in hyperextension”
List 2 classes of local anesthetic and 2 examples of each
Esters: procaine, tetracaine
Amide: lidocaine, bupivacaine
List the maximum dose of each of the following:
Lidocaine
Lidocaine with epi
Bupivacaine
Bupivacaine with epi
Lidocaine 4-5mg/kg
Lidocaine with epi 7mg/kg
Bupivacaine 2mg/kg
Bupivacaine with epi 3mg/kg
Describe which patients receive tetanus and tetanus toxoid in the ED
Fully vaccinated within 10 years: no vaccination or toxin
Partially or unknown vaccination with minor wound: vaccination only
Partially or unknown vaccination with major wound: Tetanus toxoid 250mg IM + vaccination series
- High risk wound: >6 hr old, >1cm deep, contaminate, denervated, ischemic, infected
How much lidocaine is in 1 ml of 1% lidocaine? 2% lidocaine? 0.25% bupivacaine
1ml of 1% = 10mg
1ml 2% = 20mg
1 ml of 0.25% = 2.5mg
3 options for primary closure of wounds
1- Primary closure
2- Delayed primary closure (4 days), Reason: concern about infection
3- Secondary Intention : Wound left open & allowed to heal on its own
4 indications for delayed primary closure
1- Infected wound
2- Heavily contaminated (e.g. feces, soil, saliva)
3- Associated extensive tissue damage (e.g. missile injury)
4- Some bite wounds (especially human)
*4 Non-Pharmacological management for cat bites
• Wound cleansing
• Water Irrigation
• Wound exploration
• Splint/elevation
• Plastic surgery/Hand surgeon consultation
*Bacteria to be concerned about in cat bites
Pasteurella species
*Antibiotic for cat bites (and human bites and sutured dog bites)
AmoxiClav
*THREE complications of a cat bite
Abscess
Cellulitis
Tenosynovitis
Septic joint
Osteomyelitis
Mycotic aneurysm
*23M drinking night prior, woke up with lac to 2nd MTP. Thinks he may have been in fight. List 5 steps in your management.
• Check extensor function
• Analgesia/anesthesia
• Reduction
• Splinting (wrist extended 30 degrees, MCP joint flexed to 90 degrees, PIP/DIP kept in extension)
• Post-reduction X-rays
• hand surgeon
• Abx (Amoxiclav)
• Td
Which animal bites always require antibiotics
Cat, human, monkey, pig, camel, bear
Which dog bites require antibiotics
High risk:
Location: hands, feet
Wound: puncture, crush, devitalized tissue, closed primarily
Pt: age >50, PVD, immunocompromised
In a high risk wound, what areas are safe to suture
Face only
List 3 potential antibiotics that can be used in bite wounds
Amox-Clav
Moxifloxacin
Clindamycin (plus Septra or Cipro)
What is one potential worrisome organism in dog bites
Capnocytophaga canimorsus
Risk of progressing to sepsis, DIC, 30% mortality
What dangerous virus can be transmitted via monkey bites? What is the treatment?
Monkey B virus
Prophylaxis of acyclovir is needed if any skin or mucosal exposure or high risk source (ill monkey, monkey known to be infected)
What two organisms are associated with rat bite fever
Streptobacillus moniliforis or Spirillum minus
List 4 snake families
Columbidae, Elapine (sea snakes), Viperidae (vipers), Attractaspididae (mole vipers)
List 3 physical features that may help identify a venomous snake
triangle shaped head, elliptical shaped pupil, fangs, rattle
Which red and yellow snake is venomous
Red next to yellow, kill a fellow with black nose (coral snake; deadly)
Red next to black, venom lack with a red nose (scarlet king snake)
Describes the grades of envenomation
Grade 0: minimal, <1 inch of edema, no systemic manifestations
Grade 1: minimal envenomation, fang wound, 1-5 inches of edema and erythema, no systemic manifestations
Grade 2: moderate envenomation, edema towards the trunk, petechiae, ecchymoses, N/V/febrile
Grade 3: severe envenomation, progressive, generalized. Tachycardia and hypotension. Abnormal BW
Grade 4: very severe envenomation. Sudden pain, rapidly progressive, muscle fasciculations, cramping, convulsions, arrest
What is one complication of antivenom
anaphylaxis, especially with a hx of allergy to horse or sheep products
What is the dosing of antivenom in reptile injuries
4 vials over 60 mins, repeated up to 18 vials in severe toxicity
Describe the presentation of a black widow bite
Spider: glossy black with red stripes on abdomen
Sx: Releases a neurotoxin in the venom; parasthesias, cramps, ptosis, N/V
Rx: diazepam, antivenom
Describe the presentation of a brown recluse spider bite
Spider: brown with violin shaped marker on its body
Sx: bulls eye bleb that slowly develops over a few days, fever, chills, rash, hemolysis
Rx: supportive care, no antivenom available
What is the treatment of a sting from a marine animal
immersion in hot (110F) water for 30-90 minutes for string rays or bony fish
prophylactic antibiotics if suspicious for residual foreign body (cipro)
*What 2 layers of skin are burned in a partial thickness burn?
- Epidermis
- Dermis
*What additional layer of skin is burned in a full thickness burn?
Superficial partial thickness burns are limited to the upper or papillary dermis.
Deep partial thickness burns include the deeper reticular dermis.
*Using the Rule of 10, what is his hourly fluid requirement?
Estimate burn size to the nearest 10%. Multiply %TBSAx10 = Initial fluid rate in mL/hr (for adult patients weighing 40 kg to 80 kg). For every 10 kg above 80 kg, increase the rate by 100 mL/hr.
*Give 2 scenarios where you would choose a non-occlusive dressing over an occlusive dressing?
- Contaminated
- Large burn
- Large amounts of exudate
Non-occlusive dressings need daily dressing changes
*What are 2 indications for an occlusive dressing to be changed?
- Saturation
- Malodorous
- Painful
*List 3 benefits of occlusive dressings over non-occlusive dressings
- Support moist wound-healing environment that is optimal for healing
- Daily dressing changes not required
- Absorbs exudate
- Anti-microbial
*Burn patient, 100 kg. 25% Deep partial burns: both legs, anterior torso. Legs non-circumferential.
a. What Fluid will you give to resuscitate him and what total volume? What rate?
10L RL (4cc/kg x %). 5 in the first 8 hr and 5 over 16 hr
*What are 3 indications for emergency escharotomy in limbs?
- Compartment pressure >30 mm Hg
- Compartment pressure within 20 mm Hg of DBP
- Absent doppler arterial flow in limb* (without systemic hypotension)
- SpO2 <95% in affected limb (without systemic hypoxia)
- Seven Ps (parasthesias, paralysis, pulselessness, pallor, POOP…)
*What are 8 indications to transfer a patient to a burn centre?
- Partial thickness burns greater than 10% TBSA
- Burns that involve the face, hands, genitalia, perineum, or major joints
- Third degree burns in any age group
- Electrical burns, including lightning injury
- Chemical burns
- Inhalational injury
- Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality
- Any patient with burns and concomitant trauma (such as, fractures) in which the burn injury poses the greatest risk of
*4 complications of giving too much fluid in burn resuscitation
“Overly aggressive fluid resuscitation has been coined “fluid creep” and can have devastating results, including worsening local tissue edema with burn conversion, extremity compartment syndrome, abdominal compartment syndrome, and pulmonary edema.”
*What is the best clinical measure of fluid resuscitation in burns?
“Of all parameters, urine output is most accurate in assessing the clinical response to fluid resuscitation with limited evidence of increased benefit with utilization of more invasive hemodynamic monitoring.”
Differentiate between superficial, partial, and full thickness burns
Superficial: red, blistered, painful, fast cap refill. Treated with supportive care
Superficial partial thickness: wet, red, blistered, painful, fast cap refill. Treated with supportive care
Deep partial thickness: less wet, red or white, decreased sensation, sluggish cap refill. May need grafting
Full thickness: dry, white, no cap refill, no sensation. Needs grafting
Describe the rule of 9s in adults in children
see photo
What % BSA defines a severe burn in adults and children
> 10% in children, >20% in adults
List indications for intubation in burns
somewhat trick question; same as regular indications
see photo [Box 56.1]
List 5 signs of inhalation injuries
stridor, facial burns, hoarseness, drooling, carbon sputum, singed nasal hairs, soot in the airway, edema in the airway
List 2 exposures that should be tested for in burns
CO, cyanide
What is the Parkland formula
4cckg%BSA of RL. 1/2 in the first 8 hours, 1/2 in the next 16
List 6 criteria for referral to a burn centre
[Box 56.2]
What dressings can be used in burn injuries
Moist, non adherent gauze dressing ex. adaptive, Mepilex (silicone coated form), polysporin dressing, acticoat (silver), Bacitracin
Silver sulfadiazine (not used anymore) due to studies showing poor healing outcomes
List 3 indications for an escharotomy
compartment syndrome, lack of distal pulses, or circumferential burns
*Hydrofluoric acid spill on arm young guy, Two ways of decontamination
- Irrigation with copious amounts of water for at least 15-30 minutes
- Removal of blisters, as necrotic tissue may harbour fluoride ions
- Clothing removal
*4 treatments for dermal HFA exposure
- Topical calcium gluconate gel, which can be made by mixing 3.5 g of calcium gluconate powder in 150 ml of water-soluble lubricant (e.g. K-Y jelly) and secured with an occlusive cover
- Infiltration of subcutaneous calcium gluconate for deeper burns (note: this is painful, so consider a regional nerve block)
- Intravenous calcium gluconate
- Intra-arterial calcium gluconate
Pain control
*2 most common metabolic complications of HFA
Hypocalcemia and … acidosis? Hypomag?
*One most serious complication for large volume HF inhalation
Pulm edema vs pneumonitis
List 3 chemical exposures that should not be irrigated with water
dry lime, elemental metals (ex. sodium, potassium, magnesium, phosphorous, lithium, cesium) phenol
Why is hydrofluoric acid exposure particularly dangerous
Behaves like an alkali; penetrates the cell membrane through liquefication necrosis
Fluoride scavenges calcium and magnesium, risk of life threatening hypocalcemia
