Lecture 13: Pain + Wound Management Flashcards
() is the MC presenting symptom to the ED
PAIN
The two ways we rate pain are via the () scale or () faces
- 1-10 scale
- Wong-baker faces
Systemic opioids are used when pain is severe and ()
Severe nociceptive pain
Almost all NSAIDs should be used with caution in () dysfunction
Renal dysfunction
Almost all NSAIDs cause:
* () upset
* () dysfunction
* Cannot be used in () dysfunction
* ()spasm
- GI upset
- Platelet dysfunction
- Cannot be used in renal dysfunction
- Bronchospasms
Exception: ASA has no bronchospasm
Once you give an initial dose of an opioid, you should then () it to effect
Titrate to effect
Fentanyl is especially useful in opioid-tolerant breakthrough pain in () patients
Cancer
Tramadol is risky because it can contribute to () syndrome
Serotonin syndrome
It is a weak NE and 5-HT reuptake inhibitor
() describes misuse of a medication to the detriment of a patient’s well being.
() describes that abrupt cessation of a medication with cause acute withdrawal symptoms.
- Addiction
- Dependence
Generally, never take tylenol or advil within () hrs of an opioid combined with tylenol or advil.
6 hours
The MC source of misused Rx opioids in adolescents comes from…
Parent’s medicine cabinet
Epinephrine injections are avoided in patients with () vascular injuries
Digital
Topical anesthestics can be applied in 3 major situations:
- On () skin prior to dermal instrumentation
- On () mucosa
- On () skin for pain control or prior to wound repair.
- Intact skin
- Intact mucosa
- Open skin
Nerve blocks are used in place of subdermal injections of large volumes because they do not () the wound.
Distort
Peripheral nerve blocks take about () minutes for a lido injection and () minutes for a bupivacaine injection.
- 10-20 for lido
- 15-30 for bupi
T/F: A flexor tendon sheath will fully anesthetize the distal fingertip
False
Chronic pain lasts either () months or more, beyond reasonable time for an injury to heal, or () months beyond the usual course of an acute disease.
- 3 months
- More than 1 month past the usual healing time for an acute disease
T/F: Opioids are highly recommended for ED treatment of chronic pain.
False
Should you write drug-seeking behavior in a chart?
No. List actual facts not opinions
Lower back pain in the ED is managed primarily with (drug) and (lifestyle) and a 3-day supply of (drug)
- NSAIDs, like naproxen or advil
- Restriction of activity
- 3 day supply of opioid (Not first-line)
Wounds greater than () cm and located in () vascular areas are more likely to be infected.
Longer than 5 cm and in LESS vascular areas are more likely to be infected.
Nonabsorbale sutures retain strength for () days and must be removed. (name some of the non-absorbable ones)
- 60 days.
- Silk, nylon, prolene
You should use these on the Outermost layer!!!
What size sutures does the scalp use? what about face?
- 3 or 4 for scalp
- 6-0 for face
In simple interrupted sutures, you should aim to do () ties relative to suture size
Same ties as suture size (i.e. 4 ties for a 4-0)
Running stitches are specifically not used in (shaped) wounds
Irregular wounds
Buried dermal sutures should not be placed in what layer of skin?
Adipose tissue
what kinds of skin is vertical sutures good for
Thin/lax skin (like the shin)
Horizontal sutures require less stitching, but the main DISadvantage is that they are ()
Very difficult to do
What wound closure device is the LEAST reactive and most cost-effective?
Adhesive tape
Aka steristrips
T/F: A patient needs to come back to get dermabond removed.
False. Sloughs off on its own after 5-10 days.
Why is debridement generally avoided on the face/scalp?
Because it is so vascularized, it generally heals itself well.
Forehead wounds that fall () to the lines of skin tension, () to muscle fibers yield the best cosmetic results.
Parallel to skin tension, perpendicular to muscle fibers
Forehead muscle fascia should be closed via ()-0 suture, whereas the epidermal layer should be closed via ()-0 suture.
5-0 for muscle, 6-0 for epidermal
These 5 kinds of eye injuries should be referred to ophtho instead:
- Involves the () surface of the eyelid
- Wounds that go across () margins
- Injuries to the lacrimal ()
- Wounds with associated ()
- Injuries that extend into the () plate
- Inner surface of eyelid
- Wounds going across lid margins
- Injuries to the lacrimal duct
- Wounds with associated PTOSIS
- Injuries extending into the TARSAL plate
Eyelid injuries within 6-8mm of the () are at risk of canalicular laceration.
Medial canthus
The most important assessment of nasal lacerations is to determine their () and involvement of ()
- Depth
- Deeper tissue layers and septum
A septal hematoma of the nose can produce 3 major complications:
- Permanent () of the septum
- Necrosis and () of the septum
- Septal erosion leading to a () deformity
- Permanent thickening
- Erosion
- Saddle Nose Deformity
Besides checking the nose in direct blunt trauma, you must check the cribiform plate to see if there is any () rhinorrhea
CSF rhinorrhea
For superficial lacerations to the nasal skin, you should use a (size) (abs/non-abs) monofilament simple interrupted stitch.
For anything deeper, you use (size)
- 6-0 Non-absorbable
- 5-0 absorbable for deeper
Since its at the skin surface.
Same for ears pretty much, just use 6-0 non-absorbable
Mucosal lip lacerations do NOT need sutures if they are () and the wound edges sponatenously ()
Isolated with spontaneous approximation
Otherwise, big gaping wounds need absorbable 5-0.
Lip laceration suture techniques are decided by the () border.
Vermilion border
Lip lacs that do NOT include the vermilion border should be closed in ().
Layers
The order in which you close a lip lac WITHOUT vermilion border inclusion:
- Mucosal layer: (size) (abs/non-abs)
- Orbicularis oris muscle fascia with (size) (abs/non-abs) via simple int or horizontal mat
- Skin with (size) (abs/non-abs)
- Mucosal: 5-0 absorbable
- Muscle fascia: 4-0 or 5-0 absorbable
- Skin 6-0 NON-absorbable
The process in which you suture lip lacs WITH vermilion border involvement:
- First stitch must repair vermilion border via (size) (abs/non-abs) suture to align edges precisely
- Repair vermilion + skin with (size) (abs/non-abs)
- Repair mucosa + muscle with (size) (abs/non-abs)
- 6-0 nonabsorbable for first stitch
- Vermilion + skin with 6-0 nonabsorbable
- Mucosa + muscle with 5-0 absorbable
Intraoral lacerations only need closure if they are large enough to () or have a tissue flap that interferes with ()
- Trap food
- Interferes with chewing
An intraoral suture uses (size) (abs/non-abs)
4-0 absorbable
Drip some 1% lido in their wound first
Most cheek/facial lacs can be repaired via 6-0 non-abs or dermabond and stuff. However, if the () duct is injured, operative repair is indicated.
Parotid duct
In a full-thickness cheek lac, you want to repair the wound in ()
Layers
Scalp sutures/staples should be removed after () days
14 days
Forehead, external ear, or lip sutures should be removed after () days
5 days
Eyelid, nose, or face sutures should be removed after () days
3-5 days
Intranasal packing should be removed after () days
1-2 days
Generally, the wrist, forearm, and hand should use (size) sutures, while the arm should use (size) sutures.
- Wrist/forearm/hand: 5-0
- Arm: 4-0
An upper extremity wound is generally more prone to infection if it is sutured more than () hours after the injury occurred.
> 12 hrs post injury
The mainstay of treating a subungal hematoma is via…
Trephination of the nail plate
Stabbing a hole in the nail via scalpel or cautery
You should only remove a nail if there is associated partial () or surrounding () disruption
- Associated partial nail avulsion
- Surrounding nail bed disruption
Generally, foot and leg wounds use (size) sutures and are removed after (0 days.
- 4-0 sutures
- 10-14 days.
T/F: You should remove all foreign bodies within soft tissue
False. Weigh risk vs benefit
Any splinter parallel to skin surface should be removed along its () axis
Long
The technique to remove deep fishhooks is…
Advance-and-cut
For normal fishhooks, the most successful technique is…
Incision technique
Make wound entrance bigger
The MC organism seen in puncture wounds
Staph aureus
The MC organism in plantar puncture wounds that resulted in osteomyelitis
Pseudomonas
ABX prophylaxis is indicated in puncture wounds that are (location), due to a (), or with heavy ()
- Plantar located
- Due to a bite
- Heavy contamination
ABX prophylaxis for a established infected puncture wound are (), () or ().
If it is a plantar puncture, you must use ()
- Normal infected wound: First-gen cephalo, augmentin, or FQ.
- Plantar: Ciprofloxacin (anti-pseudomonal FQ)
F/u in 48 hrs!
For needle sticks, you can get Post-exposure prophylaxis for () and (), but not ()
- HIV and Hep B
- You’re out of luck for Hep C
In high pressure wounds, it is recommended to avoid (), which can increase pressure in the finger compartments. Ideally, you should do surgical () within 6 hours to reduce the risk of subsequent ()
- Avoid digital nerve blocks
- Do surgical debridement
- Reduces risk of amputation
Bites
The current practice is to () primary wound closure in patients with systemic immunodeficiencies and higher-risk wounds
AVOID PRIMARY WOUND CLOSURE
Suturing showed higher infection rate. Re-eval in 24-48 hrs!
You just debride and clean
The MC organism within dog and cat bites is…
Pasteurella Multocida
ABX are indicated in bite wounds:
- all (animal) bites
- Bites in () hosts
- (animal) bites that puncture
- hand wounds
- Any injury that will undergo surgical repair
- All cat bites
- Immunocompromised hosts
- Dog bites that puncture
Use augmentin.
Pen V or ampicillin works for Pasteurella infections too
In PCN-allergic pts, the abx for a cat bite is () or ().
For a dog bite, it is () + ()
- Cat bite: doxy or cefuroxime
- Dog bite: clinda + FQ
What is worse, a human bite or a cat/dog bite?
A human bite
What is one of the MC ways you can get a human bite equivalent injury?
Closed-fist injury
Punching their mouth
There is a very specific G- rod that is present in human bites known as (E)
Eikenella corrodens
The initial ABX for a human bite is:
Cephalexin
Augmentin alternative.
You should give to every human bite unless its extremely superficial.
The only place where you SHOULD do primary wound closure on a human bite is…
Face
The treatment for a rodent is IV () followed by oral ()
- IV PCN for 5-7 days
- Oral PCN for 7 more days
Freshwater fish bites can contain (bacteria), which saltwater can contain (bacteria)
ABX for freshwater bites is:
ABX for saltwater bites is:
- Freshwater = aeromonas = FQ or bactrim
- Saltwater = Vibrio = FQ or doxy
Salty docks vibrate, Fresh arrows are trimmed
Rabies MC comes from () in the US
BATS
Tetanus guidelines
- No tetanus vaccination or Ig if minor wound with complete vaccination hx.
- Tdap + Ig is for incomplete hx and contaminated wound
After draining an abscess, your patient should follow up in () days
2-3 days
