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Speciality Medicine > Lecture 3: Ortho Wounds > Flashcards

Lecture 3: Ortho Wounds Flashcards

1
Q

Emergency Wound Management
* First what do you need to do?

A

First, assess the overall condition of the patient and take care of life-threatening injuries

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2
Q

How do you control bleeding?

A
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3
Q

As always, get a thorough history
* Can there be what?
* What type of water?
* What can be involve?
* What do you need to be worried about healing?
* Allergies?
* What type of status?

A
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4
Q

Risk of wound infection: Anatomic location
* Head, neck=
* Upper extremity=
* Lower extremity=

A
  • Head, neck = low risk = Increased vascularity
  • Upper extremity = moderate risk.
  • Lower extremity = high risk = Decreased vascularity

Increased vascularity – low risk of infections due to higher oxygen and increased healing

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5
Q

Risk of wound infectinon-Time of injury
* The sooner you close it =
* The longer you wait to close it, the higher what?
* Best to close it within what? Think twice if what? Worry about closing it if what?
* If you do close it late then what do you need to do?

A
  • The sooner you close it, the better.
  • The longer you wait to close it, the higher the risk of infection, so consider secondary intent.
  • Best to close it within 3 hours; Think twice about closing it over 6 hours; Worry about closing it if it’s >8-12 hours old
    * If you do, counsel patient and put in the chart
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6
Q

Examining the wound
* When should you cover the wound?
* Assess what?
* Once this part of examine is done then what can you do?
* Always check for what?
* Remove what?

A
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7
Q

wound preparation
* What type of technique?
* Anesthesia?
* What do you give? Where can you not place it?
* How do you stop blood?

A
  • Aseptic technique- no intent to introduce more germs on surface
  • Anesthesia: local or regional block
  • Lidocaine with epinephrine(vasoconstrictor): do not use on fingers, nose, penis, toes (or ears)
  • Hemostasis: direct pressure, epinephrine, Gelfoam, Surgicell, cautery, ligation, blood pressure cuff (brief) or glove with tip cut off
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8
Q

Explain where a digital block goes?

A
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9
Q

Explain where regional blocks go?

A

Radial nerve is lateral to artery

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10
Q

Lidocaine
* What are the types?
* Use what?

A
  • 1% and 2%
  • Also comes in 0.25% and 0.5%.
  • Use lowest possible dose..
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11
Q

KNOW

Lidocaine
* What is the maximum adult dose? How do you figure out the dose?
* What is maximum child dose?

A

Maximum adult dose(toxicity=seizures)
* 4.5 mg/kg/dose; Do not repeat within 2 hours not to exceed 300mg/day.

Maximum child dose is probably 2-2.5 mg per POUND.

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12
Q

Wht is the acting and onset of lidocaine and bupivacaine

A
  • Lidocaine: Short acting and fast onset
  • Bupivacine: Long acting and long onset
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13
Q

KNOW

Percent (%) solution
* How do you figure out grams? mg?

A
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14
Q

KNOW

How many milligrams are in 1% of lidocaine

A

1%x10=10mg/cc

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15
Q

KNOW

  • What is 10cc of 2.5% Bupivacaine?
  • What is 5cc 4% topical procaine?
A
  • 25mg/cc = 250mg of Bupivacaine
  • 40mg/cc = 200mg of procaine
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16
Q

KNOW

Please calculate the maximum possible dose in milliliters per day of 5% lidocaine you could give to a 200kg person?
* 4.5ml
* 6ml
* 8ml
* 9ml
* 18ml

A
  • 6ml
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17
Q

What are amides and esters? What do you give if patient is allergic to both?

A

Amides
* Two i’s
* Ex: Lidocaine

Esters:
* One i
* Ex. Procaine

Allergic to both: Liquid benadryl

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18
Q

What are the different topical anesthesia?

A
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19
Q

Wound preparation:
* What do you need to remove?
* What do you need to disinfect? What do you need to avoid?
* May do what to hair? Do not do what?
* NEVER do what?

A
  • Foreign body removal ( explore )
  • Skin disinfection
    * Avoid Betadine or hydrogen peroxide (tissue toxic)
  • May cut hair (don’t shave it)
  • Never remove eyebrow hair!
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20
Q

Wound Preparation
* Irrigate copiously with what?
* Debride what?
* What do you need to prophylactic with?
* Wound check when?

A
  • Irrigate copiously with NS or tap water
  • Debride devitalized tissue(minimum if possible)
  • Prophylactic antibiotics (if indicated)
  • Wound check in 24-48 hours
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21
Q

Prophylactic anx
* Human bites?
* Puncture wound thorugh rubber sole shoes/vibrio species?

A
  • Human bites (dirtiest) in all locations and mammalian bites on hand = amoxicillin/clavulanic acid.
  • Puncture wound through rubber sole shoes/vibrio species = Pseudomonas ( Fluoroquinolones- CIPRO)
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22
Q

Prophylactic Antibiotics Indications
* Full thickness oral laceration?
* Dog and cat bites?
* Contaminated wounds, or those with undetected FBs, may what?

A
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23
Q

What are the types of primary intent closure?

A
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24
Q

What are the different types of non-absorbable suture material

A
  • Braided silk
  • monofilament nylon (Ethilon)
  • Monofilament polypropylene (Prolene)
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25
Q

Braided silk
* Tensile strength?
* What is it used for?

A
  • It has the lowest tensile strength of any nonabsorbable suture.
  • It is rarely used for suturing of minor wounds except for oral mucosa because stronger synthetic materials are now available.
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26
Q

Monofilament nylon(Ethilon)
* Usually used for what?
* What type of suture?
* Popular why?

A
  • USED FOR SKIN
  • Nylon was the first synthetic suture introduced.
  • It is popular due to its high tensile strength, excellent elastic properties, minimal tissue reactivity, and low cost.
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27
Q

What are two types of absorbable suture material?
* Generally used for what?

A
  • Surgical and Chromic gut
  • Vicryl
  • Generally used for SQ closures in a layered repair (fascia, subQ, skin).
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28
Q

Monofilament polypropylene (Prolene)
* Generally used for what?
* Similar to what?
* Especially noted for what?
* Does not hold what?
* Avoid what?

A
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29
Q

Absorbable Suture Materials: Surgical and Chromic gut
* Tensile strength?
* How long for tensile strength of plain gut?
* How long for tensile strength of chromic gut?

A
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30
Q

Vicryl:
* Tensile strength?
* Complete absorption when?

A

Vicryl
* It retains significant tensile strength for three to four weeks.
* Complete absorption occurs in 60 to 90 days.

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31
Q

Suture Removal:
* Face?
* Scalp?
* Chest, back, forarm, fingers, hand, lower extremity, foot?

A
  • Face: 3-5 days
  • Scalp: 7 days
  • Chest, back, forearm, fingers, hand, lower extremity, foot : 10-14 days
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32
Q

Eyelides:
* What do should be referred to oculoplastic surgeons?
* Patients with upper eyelid lacerations should be carefully inspected for what?
* What is required for all eyelid/orbit injuries?

A
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33
Q

What should you do first?

A
  • Must approximate the vermilion in lip laceration 1st.
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34
Q

Cheecks and face: What do you need to check?
* What are the do not miss injuries?

A
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35
Q

Upper extremity:
* What type of exams (2)?
* Rule out what?
* What type of injuries?

A
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36
Q

High pressure injection injuries:
* May appear benign where?
* What images?
* Who do you need to consult?

A
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37
Q

KNOW

Flexor tenosynovitis:
* What is this?
* What are the signs? (4) What are the signs called?

A
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38
Q

Flexor tenosynovitis:
* Call who?
* What abx?

A
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39
Q

Fight bite:
* Often the patient does not wish to do what?
* High What?
* Treat how?

A
  • Classic
  • Often the patient does not wish to give the accurate history
  • High risk of infection
  • Treat presumptively- abx
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40
Q

What is this?

A

Hair tourniquet
* Common between 3-6 months

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41
Q

Hair Tourniquet
* Can be found where?
* Usually happens when?
* History of what?
* You have to think of what?

A
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42
Q

What is this? What do you do?

A
  • This is a felon, absecess in the pulp space
  • Needs to be I and D and give ABX
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43
Q

What is this ? How do you treat it?

A

Paronychia
* Incision and drainage is the definitive therapy.
* In absence of cellulitis, antibiotics may not even be indicated

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44
Q

What is this? What do you do for it?

A

Herpetic whitlow
* Don’t excise and drain this – its viral.

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45
Q

Nonfreezing Cold Injury & Freezing Cold Injury
* What are the nonfreezing cold injury?
* What are the freezing cold injury?

A

Distal EXTREMITIES are most away from heart to get warm blood. Highest chance of frostnip and frostbite.

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46
Q

Chilblains (DRY)
* Caused by what?
* What are the sx? When do they start?

A
  • Caused by chronic, intermittent exposure to damp, nonfreezing cold air
  • Pruritis and burning pain
  • 12-14 hrs after exposure
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47
Q

Trench Foot (immersion foot)
* What type of conditions?
* What are the sx?
* What is hyperemic phase?
* What happens after 2-3 days?

A
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48
Q
A
  • Right: Trench foot
  • Left: Chiliblains
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49
Q

Non freezing injuries txt:
* What should you do for the feet?
* What can you give in terms of meds?
* What is more prone to re-injury?

A

Essentially supportive
* Rewarm, gently bandage, elevate feet
* Possibly oral nifedipine (prevents vasoconstriction in chilblains/Reynauds) although most recent studies noted no significant benefit otherwise
* Affected areas are more prone to re-injury

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50
Q

Non-freezing injuries txt:
What is the Prevention ?

A

Ensure good boot fit, change out of wet stocks frequently, never sleep in wet socks

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51
Q

Frostnip and frostbite
* What type of injuries?
* Can occur where?
* Usually where?
* What is the difference between frostnip and bite?

A
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52
Q

Frostnip and frostbite
* What temp is the skin?

A

Tissue temperature drops below 0 degrees C
* 32 degrees F. – can happen if humidity and wind are right for it to be above 32 degrees (Wind sheid lower=still get it)

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53
Q

Frostbite
* What happens within cells?
* What complications?
* Patients are at risk of what?
* Ultimately there is what?

A
  • Ice crystals ultimately form within cells
  • There are ischemic and vascular complications
  • Patients are at risk of reperfusion injury->Acidosis from the vasoconstriction and stasis
  • Ultimately there is necrosis demarcation and gangrene
    (tell them you don’t know how much damage there is).

Blood goes back to the core with metabolic acidosis. Crystals cause damage to cells. Don’t rewarnm if know they will be exposed to more cold and recrystallize the cells and cause more damage.

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54
Q

FROSTBITE:
* What are the EKG findings with hypothermia?

A

Osborne J waves (positive deflection at the end of QRS)

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55
Q

What is this?

A

Superficial vs. Deep Frostbite

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56
Q

Treatment of frostbite
* What should happen to injured extremity?
* Do not forget what?
* Probably should aspirate what? Which ones do you not? Why?

A
  • Injured extremity should be placed in gently circulating water that is 40 to 42 degrees centigrade (104-108 degrees F) for 10-30 minutes
  • Don’t forget pain medicine!
  • Probably should aspirate or debride clear blisters but not hemorrhagic blisters (will cause more damage)
    * Fluid contains inflammatory components—-further damage
  • Otherwise, watch and wait
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57
Q

txt of Frostbite:
* What should you prophylaxis them (vaccine)?
* What abx? Why?
* Avoid early what? Why?
* What do some studies say?

A
  • Tetanus prophylaxis (see the schedule completion to see if to give immunoglobulin or toxoid)
  • Pen G – Prophylax against Streptococcal infection –> Consider MRSA coverage
  • Avoid early surgical debridement –> not until full demarcation (necrotic area and then normal area – no more damage will happen so go ahead and debride.
  • Some studies recommend tPa/Alteplase for thrombolysis following rewarming
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58
Q

Brown Recluse Spider Bite
* Bite?
* What happens within several hours?
* 24 hours in?
* 3-4 days in?
* What forms by a week?

A
  • Initially painless
  • Within several hours, severe pain, erythema, blister formation
  • Bluish discoloration at 24 hours
  • Necrotic lesion over 3-4 days
  • Eschar formation by a week
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59
Q

Brown Recluse Spider Bite
* Ulcer may not reach maximum size until when?
* Significant what?
* What is the managment?

A
  • Ulcer may not reach maximum size for weeks (don’t call Sx immediately)
  • Significant cosmetic defects
  • Supportive management, do late surgical debridement
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60
Q

Black widow spider
* Bite?
* May develop what?
* What happens with muscle?
* What are the sx?

A
  • Patient feels a “pinprick” and often sees the spider
  • May develop a target lesion at site
  • Muscle spasm not only at site but other large muscle groups
  • Severe abdominal pain and cramping
    * Can be confused with surgical abdomen

Can look like a surgical abdomen but with BS present normally. Peritonits has no BS – so don’t call Sx.

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61
Q

Black widow spider
* What is the txt?
* What else can you give? What should you NEVER GIVE?

A

ABC’s, clean site, opiods and benzodiazepines; there is an antivenom

Calcium gluconate: evidence it’s not effective
* NEVER use Ca Carbonate – will necrose the skin.

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62
Q

Snake Bites
* Venomousbites lead to what?
* Txt?

A
  • Venomousbites lead to coagulopathy and neurotoxic effects
  • Treatment geared towards antivenin and blood products replacements
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63
Q

What is the trick to remember if snack is venomus?

A
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64
Q

Marine Wounds
* Never advise what? Why?
* What is appropriate?
* What should you be worried about stringray stings?
* Always cover for what?

A
  • NEVER advise to urinate on to marine wound (bc osmosis will cause mroe injury)
  • Vinegar is appropriate
  • Stingray stings: need x-ray
  • Always cover for Vibrio species: Cipro or Tetracycline+3rd Gen Cephalospoirin
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65
Q

Thermal burns
* What is first and second degree?

A
  • First degree: only epidermis (sunburn); “not counted in BSA determination”
  • Second degree: into dermis; superficial or deep partial- thickness; blisters/bullae; painful
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66
Q

Thermal Burns
* What is 3rd and 4th degree?

A
  • Third degree: full-thickness – all skin layers; skin is charred, pale, painless, leathery
  • Fourth degree: SQ fat, muscle, bone
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67
Q

What is this?

A

First degree burn

68
Q

What is this?

A

Second degree burn

69
Q

What is this? If the patient has no pain?

A

third degree: NO PAIN
* Pain on perp is possible

70
Q

Major burns:
* When do you have to transfer patients to brun unit? (7)

A
71
Q

What is the rules of 9s for adults and infant?

A
72
Q

Txt of burns:
* What is first?
* Need for what?
* What about inhalation burns?
* Give what?

A
  • ABC’s
  • Need for c-spine immobilization? Trauma?
  • Fiberoptic bronchoscopy (for inhalation burns)
  • Establish the percentage of burns(BSA)/Document
  • Give fluids through IO if unable to get peripheral access
73
Q

Treatment for burns:
* What booster?
* Wound care?
* What needs to be controlled? Why?
* What else?

A
  • Tetanus booster
  • Wound care: saline soaked dressing, sterile drapes
  • Pain control and anxiolytics to prevent psychosocial issues
  • Escharotomy
74
Q

What is the parkland formula?

A

Parkland Formula: 4mL LR x weight kg x %BSA over 24 hours: half in 8 hours(from burn time), balance over the next 16 hours

75
Q

Maintenance fluid after 24h for burns:
* What can you use?
* What is the timeline?

A
76
Q

Burn

What are the indications for intubation?

A
77
Q
A

7200ml total; 3600ml over 8hrs (450/hr); 3600ml over 16hrs (225ml/hr)

78
Q

Chemical burns:
* What does acid produce?
* What acid also act as?
* Skin absorption results in what?
* In general, what should you do?
* Call who?

A
79
Q

Chemical burns:
* Which burn is worse?
* Burns to eye have to be what?

A
  • Alkali burns are worse than acid
  • Burns to eye have to be irrigated copiously until pH 7.5
80
Q

Hydrofluoric Acid (HF)
* Acts like what?
* What does it cause?

A
  • Acts like an alkali – causes Liquefication necrosis
  • Causes progressive tissue loss and even bone destruction, cardiovascular & systemic toxicity
81
Q

HF
* How do you tx it?

A
  • Copious water irrigation at least 30 minutes
  • Calcium (may be delivered in many ways)
  • Call poison center. 1-800-222-1222
82
Q

Electrical burn
* What is alternating current?
* What is more common?
* Where?
* What type of wounds?

A

in house outlets
– V-fib occurs more commonly
– Household and commercial
– Explosive exit wounds

83
Q

Electrical burns: Direct current
* What is more common?
* Where?
* What type of wounds?

A

Direct current (DC) - better
* Asystole occurs more commonly
* Lightning, Industrial, batteries and welding
* Discrete exit wounds

84
Q

Electrical burns:
* More resistance where in tissues?

A

More resistance in tissue causes higher heat generation
* Bones (more dense so worst cutanous outcomes) vs nerves

85
Q

Lightening injuries
* How many deaths in year?
* FL?
* Voltage?
* Temp?

A
86
Q

KNOW

Lightening injuries
* What is the most serious injuries?
* What is a must?

A

Most serious injuries occur with direct strike to the patient (asystole).
– Prolonged Cardiac Resuscitation is a MUST, because those in cardiac arrest from lightening have a reasonably good prognosis with prolonged resuscitation

87
Q

What do you need to worry about with this patient?

A

Look for pulse, palpate for hardness, etc because one arm looks bigger

88
Q

Acute compartment syndrome
* Do not forget there are compartments where?
* Most commonly, see where?

A
  • Don’t forget there are compartments in the arms and legs, hands and feet.
  • Most commonly, you’ll see compartment syndromes in the leg due to tibial fractures(swelling/edema)
89
Q

What is this?

A
90
Q

Compartment syndromes
* What are the Ps?

A
91
Q

What are early and late signs of compartment syndromes?

A
  • Early: Pain and paresthesia
  • Late: Pulseless
92
Q

Sxs of compartment syndrome:
* What happens to affected muscles?
* Decreased what?
* Increased pain elicited by what?
* Impaired sensation due to what?
* May progress to what?

A
93
Q
A
93
Q

What are the complications of acute compartment syndrome?

A
  • Neurovascular injury
  • Infection
  • Amputation
  • Rhabdomyolysis
  • Myoglobinuric renal failure
94
Q

How do you tx myoglobinuric renal failure?

A
  • Alkalinization of urine
  • Forced volume diuresis
    * Muscle damage will release myoglobin - Myoglobinuric renal failure is treated by maintaining a high urine output and alkalization of urine by bicarbonate mixed in NS.

Trying to prevent rhabdo

95
Q

How do you check preseures in compartment syndrome?

A
96
Q

What nerve is most likely injuried here?

A

radial n.

97
Q

Type of fracture:
* What is a typical fx?
* What is pathologic fx?
* What is stress fx?

A
  • Typical fracture – significant trauma to healthy bone
  • Pathologic fracture – results from minor trauma to abnormal bone
  • Stress fracture – fatigue from repeated stress before bone & supporting tissues can recover (usually don’t show up on x-ray)/new bone(callous presumptive evidence)

If cant see fracture but you think they have it – splint them and re XR them in 7-10 days. New bone will form (Callous), then you can cast it.

98
Q

Salter-Harris fx:
* In who?
* What are the types?

A

In “growing bones”
* Type I – Physis (splint it)
* Type II – physis/metaphysis (most common)
* Type III – epiphysis/physis
* Type IV – epiphysis/physis/metaphysis
* Type V –crush injury of the physis

99
Q

Review

A
100
Q

Review

Describing Fractures:
* Fx extends into joint
* Fx just above the condyles of humerus
* Running from the greater to lessser trochanter
* Just below the trochanter

A
  • Intraarticular
  • Supracondylar
  • Intertrochanteric
  • Subtrochanteric
101
Q

Review:

Decribing fx:
* Shattered into pieces?
* How do you term a displacement?

A
  • Comminuted
  • Displacement: may be measured or expressed in percentages-refers to the to the position of hte distal fragments as they relate to proximal fragments
102
Q

Open fx

Communication between the fracture site and the external surface of the body
* What is type 1
* What is type 2
* What is type 3?
* Most dreaded complication?

A
  • Type I: open fx with clean wound < 1 cm long
  • Type II: open fx with laceration > 1 cm long without extensive soft tissue damage
  • Type III: open segmental fx, open fracture with extensive soft tissue damage, traumatic amputation
  • Most dreaded complication: osteomyelitis (bone infection)
103
Q

Osteomyelitis txt?

A

Need 6-8 weeks of IV ABX with PICC line.
* If cant fix the infection – cut the bone out.

104
Q

Open fx txt:
* Type one and 2?
* Type 3?

A
105
Q

Open fx txt:
* All types with fresh water contamination?
* All types with salt-water contamination?
* All types with soil/fecal contamination?

A

All types with fresh-water contamination – Ceftriaxone
* With PCN allergy – ciprofloxacin

All types with salt-water contamination – Doxycycline + (cipro for vibro)

All types with soil/fecal contamination – (metronidazole-Flagyl)

106
Q

Dislocations:
* What type of issue?
* There may be what?
* What happens in knee, elbow and scapula?

A

Emergencies

There may be neurovascular compromise
* Knee (Popliteal Artery)
* Elbow (Brachial Artery)
* Scapula (thoracic Aorta)

107
Q

Ordering X-rays
* Need to obtain what?
* Do what?
* Order x-rays that include what?

A
  • Need to obtain the history
  • Do a thorough exam, cannot Xray everything
  • Order x-rays that include the joint above and the joint below where the injury is thought to exist
108
Q

What is this?

A

Extensor tendon isnt intact

109
Q

Boutonniere deformity secondary to what?

A
110
Q

What is this?

A

Mallett finger

111
Q

What is this?

A

Tendon Injury – not intact

112
Q

What is going on here

A

such a deep injury that patient damaged peroneal nerve leading to foot drop

113
Q

What is this?

A

Salter II proximal phalanx
* Above epiphyseal plate

114
Q

DeQuervain’s Stenosing Tenosynovities
* What is it from?
* Tenosynovitis of what tendons?
* What is the sx?
* What diagnosis test should you do?

A
115
Q

How do you tx DeQuervain’s Stenosing Tenosynovities?

A

TX with anti-inflammatories and immobilization with splint, not a cast. No Sx.

116
Q

What is this? What is it from?

A
117
Q

What is this?

A

Un-opposed flexion – radial nerve is out

118
Q

What does it mean if there is pain in anatomic snuff box? tx?

A

Scaphoid fracture – one BV supplies it. If miss it – necrosis and cant use the hand anymore.
* Get thumb-spica splint.

119
Q

Carpal Tunnel Syndrome
* What is type of neuropathy?
* What is entraped?
* What signs can you do? (2)

A
  • Peripheral mononeuropathy
  • Entrapment of the median nerve in the carpal tunnel
  • Positive Tinel sign (Tap over carpal ligament)
  • Positive Phalen sign

tx: Split (cock up split)+NSAIDs then if that does not work steriod injection, last line is cut shelth

120
Q

What is going on here? What do you do?

A

Nursemaids elbow.
* S/P Reduction with Supination forearm and radial head pressure flexing the elbow OR hyperpronation

121
Q

What is going on here?

A

Shortening/Abduction/Ext Rotationo due to fx
* Internal is dislocation

122
Q

What is going on here?

A

Post. Dislocation=shortening/adduction/ internal rotation

123
Q

What is this?

A

Distal femur communited posterior angulation

124
Q

What is this? How do we fix it?

A

Patellar dislocation
* Extend leg fully and push patella back in place.

125
Q

What is this view?

A

Sunrise view of patella

126
Q

What is going on here?

A

Achilles tendon rupture
* Do thompson test

127
Q

What is thompson test?

A

Thompson test can be used for assessing suspected achilles tendon ruptures. If there is no plantarflexion movement at the foot on squeezing the calf then a rupture is likely.

Lay prone and squeeze the calf. If tendon is interrupted – foot wont move.

128
Q

Reductions:
* most reductions will require what?
* Can achieve anesthesia with what?

A
129
Q
A
130
Q
A
131
Q
A
132
Q
A
133
Q
A
134
Q
A
135
Q
A
136
Q
A
137
Q
A
138
Q
A
139
Q

Procedural sedation
* What is sedation?
* Sedation represents what?
* What is conscious sedation classes?
* How many clinicians is needed?
* Make sure you assess what?

A
  • Sedation – controlled reduction of environmental awareness
  • Sedation represents a continuum from light to general anesthesia
  • “Conscious Sedation” now classified as Minimal, Moderate, Deep, Anesthesia
  • Have to be 2 clinicians – 1 doing the monitor and 1 giving you meds.
  • Make sure you assess ASA Class and Mallampati
140
Q

What is this?

A
141
Q

What are the 4 classes of mallampati score?

A
142
Q

Precedural sedation
* Continuous what?
* What do you need to monitor?
* Place patient on what?
* Keep what at bedside?
* What should be quickly available?

A
  • Continuous Pulse Oximetry/Suction prn
  • EKG Monitor
  • Place patient on Oxygen
  • Keep Narcan at bedside
  • Airway Cart quickly available

Must include discharge counseling

143
Q

Sedation drugs: Preference of attending
* Most like what? What what can it lead to? Allergic rxn?

A

Most like propofol
* Can lead to hypotension, heart block and asystole
* Allergic Rxn with egg allergy

144
Q

Sedation drugs: Preference of attending
* Some attending like what? What is the onset, duration, amnesia?

A

Sometimes just versed
* Quick onset, short duration, retrograde amnesia

145
Q

Sedation drugs:
* What else can be used?
* What can it cause? What is common?
* Avoid with hx of what?

A

Ketamine (IM in kids)
* Can cause HTN and tachycardia
* Hypersalivation is common
* Avoid with hx of aneurism, HTN

146
Q

What are causes of Rhabdomyolysis?

A
147
Q

Presentation of Rhabdo

A
  • Myalgias
  • Stiffness
  • Weakness
  • Dark brown urine/Tea color
148
Q

What do the labs show in Rhabdo?

A
  • Elevated CPK/ K
  • “ Dip of urine (+) blood/ but no RBC’S in UA”
    * Specific to MYOGLOBIN being present
    * Can’t differentiate Hb from Myoglobin
149
Q

What are complications of Rhabdo?

A
150
Q

Txt of Rhabdo:
* What about hydration?
* What type of fluids?
* Urine what? How?
* Consider what after volume replacement?
* Consider what?

A
151
Q

radiculopathy
* Radiculopathy suggests what?
* It is best evaluated by what?

A

Radiculopathy suggests that signs and symptoms
are coming from a single nerve root.

It is best evaluated by CT, not Xray
* XR may be sufficient in patients with pain without radiculopathy symptoms

152
Q

Patients with Radiculopathy may have what? (3)

A
  • Sensory Abnormality
  • Motor Weakness
  • Altered Reflexes
153
Q

Radiculopathy:
* This can be due to what?
* What type of radiculopathy?

A
  • This can be due to mechanical compression of the nerve by a disk herniation, a bone spur (osteophytes) from osteoarthritis, or from thickening of surrounding ligaments
  • C7Radiculopathy(positionof comfort)
154
Q

Back/Neck Pain Differential Dx

A
155
Q

Neck and back pain:
* If patient awaken at night with the pain think what?
* If the pain worse with cough, valsalva or sitting and relieved by supine position, think what?
* What are some other things you need to ask?

A
156
Q

What hx do you need to get for neck and back pain?

A

Disc always herniated backwards to the sides. Ischemia and death of tissue will result.

157
Q

Autonomic Dysreflexia
* Spinal cord injury (typically above T6 level) results in what?

A

results in severe HTN due to autonomic dysregulation
* Occurs in 20% to 70% of patients, 1 month to 1 year after spinal cord injury

158
Q

Autonomic Dysreflexia
* HTN is provoked by what?
* What is commonly seen?
* How do you txt?

A
  • HTN is provoked by reflex sympathetic activity below the lesion, causing vasoconstriction. Due to lesion, the parasympathetic response is inadequate
  • Bladder retention and fecal retention are commonly seen
  • Tx: Symptomatic (HTN meds, intravesical lidocaine, botulinum)
159
Q

Exam: Back and neck
* What test can you do? What do they do/assess?

A
160
Q

Malignant Spinal Cord Compression
* Consider this in who?
* Pain first symptoms may occur when? What are the sx?
* Sx are excerbated with what? Improves with what?
* Loss of what?

A

Consider in any cancer patient w/ back pain until proven otherwise
* Pain first symptom & may occur months prior to neurologic dysfunction
* Weakness
* Sensory loss

Exacerbated w/ recumbency (lying down), improves w/ being upright

Loss of bowel & bladder (retention) control (usually a late finding)

161
Q

Malignant Spinal Cord Compression
* What is the most sensitive test?

A

MRI of whole spine

162
Q

Malignant Spinal Cord Compression
* What is the txt?

A

Tx: Corticosteroids
* Most common regimen: 10 mg bolus then 16 mg/day (divided over 4 doses)

Radiation therapy emergently
* Relieves pain in most patients
* Pre-treatment neurologic function is a strong predictor of response
* Underlying tumor type also predictor

Aggressive surgery
* New data shows that all patients should be considered for decompressive radical resection

163
Q

Discharge of Acute Trauma Injury
* Most will require what?
* Most will need acute script for what?

A
164
Q

Opioids:
* Injury severity score?
* HB_
* Max what?
* Mostly for what?
* Most access what?
* Must prescribe what?

A

Speciality Medicine (12 decks)

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