NP 615 Test 3 - Sheet1-2 Flashcards
Etiology of “red eye”
Very common. Allergy, infection, chemicals, trauma or systemic disease. Usually self limiting.
Management of most eye conditions
Can be done in the office
Considerations of eye pain
Decide whether the pain is coming from the eye or is referred from surrounding structures
Assessment of eye conditions
Always assess visual acuity, acute problems with vision require referral
Chemical splashes to eye
Priority is first immediate irrigation
Items to cover in a history of ocular problem
Onset. Duration of symptoms, Change in vision. Photophobia. Pain. Mechanism of injury. Use of contacts. History of eye surgery. Current meds. Recent exposure to new cosmetics or person with eye infection. Systemic complaints - fever, rash, genital discharge
Physical exam of eye
Must have visual acuity of each eye. Inspect lids and conjunctiva. Examine periorbital areas. Test extraocular muscle mobility. Inspect cornea for abrasions, haziness, ulcerations, dendrites. Note PERRLA. Determine presence of red fundus reflex. Examine fundus and optic disk
Refer to ophthalmologist
Limbal flush. Irregular pupil. Muscle paresis. Hazy cornea. Corneal dendrite. Corneal ulcer. Vision loss. Elevation of retina on funduscopic exam. Papilledema. Painful eye, red eye, and vision changes.
Etiology of epistaxis
Inflammatory, traumatic or systemic cause, and most are idiopathic
Most common cause of anterior nose bleeds in persons younger than 40
Local insult to the nasal mucosa and results in anterior bleed
Most common nose bleed of persons older than 40
Posterior epistaxis - potentially more serious
Etiologies of 10-15% of adult sore throats
Strep pharyngitis
Populations least often affected by streptococcal sore throats
Children younger than 3 and adults over 50
Onset of strept
Acute, difficulty swallowing, pharyngeal erythema, exudate (50 percent), fever greater than 101.
Pharyngitis that requires prompt recognition and referral
Epiglottitis and peritonsillar / retropharyngeal abscess
What causes peritonsilar / retropharyngeal abscess and epiglottitis to be emergent
Mechanical obstruction to the flow of air and produces stridor
Triad which aids in differentiating epiglottis from croup
Drooling, agitation, and the absence of a cough
Mean ages of those affected with epiglottitis
Children 3-7, but an occur at any age
Removing impaled foreign bodies
Should only occur in the OR
Misleading pt descriptions of foreign bodies of the eye
Can be misleading. Corneal abrasions also give the same sensation
When a child presents with foul odor from mouth, ear, or nose
May likely have a foreign body
Anaphylaxis
A clinical syndrome and may vary widely among patients
Presentation of early signs of anaphylaxis
Can be subtle and not recognized. Must maintain a high degree of suspicion of even innocous signs and symptoms
Major signs of anaphylaxis
Obtain a history of prior occurrences, flushing, urticaria, laryngeal edema / stridor, bronchospasm, hypotension, tachycardia, and anxiety
Acute respiratory distress etiology during anaphylaxis
Laryngeal edema
Treatment triad of anaphylaxis
Epinephrine, benadryl, and steroids.
Urticaria
Fairly common and involves the epidermis and upper layers of the dermis and does not last more than 24-48 hrs. May be with or without angioedema or with a generalized anaphylactic reaction.
Angioedema
Less frequent and involves the deeper layers of the dermia
Clinical appearance of urticarial lesions
Superficial and are red and swollen (“Flare adn wheal”) along with pruritis
Clinical appearance of angioedema
Involves deeper layers and may appear normal and only swelling is noted
Most common offending agent of urticaria
Ingested food, drugs, or insect bites, but can be caused by anything. Most causes are never identified
Most common presentation of snake bites
Most often children and affecting the lower extremities
First step in management of snake bites
Determine whether or not envenomation has occurred
If pt calls your clinic with snake bite
Deflect them from your clinic and have them go immediately to an ED
Process of thermo-regulation
Process of heat accumulation versus heat dissipation.
When do heat emergencies occur
When the body is unable to adequately dissipate heat
Factors that predispose one to heat emergencies
Medical conditions, age, drugs, behaviors
Keys to preventing death due to heat exposure
Early recognition and prompt, appropriate management
First step in prevention of heat-related illnesses
Patient and community education
Causes of tissue injuries secondary to burns
Application of heat, chemicals, electricity, or radiation
Classifications of burns
Partial thickness - first and second degree and full-thickness - third degree
Characteristics of burns which aid in decision to transfer, treat, or hospitalize
Initial assessment. Knowing cause of burn. Location. Age of pt.
Smoke inhalation and burns
All those burned inside a closed areas must be assumed until proven otherwise
Provider responsibility of human and animal bites
Provide immediate first aid, and determine the risk for infection, disability, and complications
Animal bites and infection
Cat bites most frequently infected. Dogs - greater than 90 percent of all animal bites. Must be reported to local health department.
Injuries assocated with animal bites
Causes punctures, lacerations or avulsions, crush injuries, or fractures.
Potential complications of animal bites
Infection and / or rabies
Human bites
Less common, but more potentially more serious.
Treatment of bites
Remember to assess Td status and complicating wound healing factors - such as PAD or diabetes
Clinical presentation of CA-MRSA
Often has a dark or black center and is often attributed to spider bites
Treatment of CA-MRSA
Wound cultures should be obtained and abscesses usually require antimicrobial treatment
Suspicion of meningococcemia
Rashes that do not blanch, associated with fever and nuchal rigidity
Suspicion of Stevens-Johnson Syndrome (Erythema Multiforme)
Epidermal detachment, bullae, mucosal ulcerations, and truncal target lesions
Suspicion of necrotizing fascitis (scalded skin syndrome)
Painful, red, swollen and warm areas with sharp margins. Quickly spreads and seen primarily in patients with diabetes or any immunocompromised condition
Causative factor of necrotizing fascitis
Most commonly group A strep or staphylococcal
Out-pt treatment of CA-MRSA
I and D is primary therapy. Emperic antimicrobials if presence of systemic symptoms, severe local symptoms, immune suppression, extremes in age, or lack of response to I and D alone). Obtain culture for antibiotic susceptibility.
Transmission of MRSA
Usually by direct skin-to-skin contact or contact with surfaces that have been contaminated.
Protection from MRSA
Practice good hygiene - most important. Shower after sports. Cover skin abrasions until healed. Avoid sharing personal items - towels or razors. High touch surfaces should be cleaned regularly.
Most appropriate initial action of recent dog bite
Irrigate the wound
Best way to treat anterior nose bleed
Sit down, apply pressure to anterior nose for 20 minutes
Treatment of a recent upper extremity burn caused by spilled hot coffee with several areas where bullae have formed
Cover with nonadherent guaze
Most important component of managing an asthma exacerbation in a clinic setting
Use of short-acting beta agonists to relieve airflow obstruction
Best treatment of a pustular lesion suspected to be CA-MRSA
I and D and send specimen for culture and sensitivity
A fluorescein exam is performed to detect…
Presence of corneal abrasions
According to the CDC the treatment for HA-MRSA is the same for the treatment of CA-MRSA
FALSE
A visual acuity test is used to diagnose glaucoma
FALSE
An alternate to the Snellen chart would be
Holding up two fingers and light perception
A rust colored stain on the cornea should be treated by
Referral to an ophthamologist
Consequence of MRSA in the healthcare setting
Bloodstream infections, pneumonia, and surgical site infections
Treatment of MRSA in the hospital setting
Vancomycin, linezolid, or clindamycin
Bacterial conjunctivitis
Complains of a red, irritated eye, and perhaps a gritty or foreign-body sensation; a thick, purulent discharge that continues throughout the day; and crusting or matting of the eyelids on awakening. Most often unilateral
Viral conjunctivitis
Complaints may be discomfort or burning, with clear tearing, preauricular lymphadenopathy, or symptoms of URI
Allergic conjunctivitis
Main complaint of itching, with minimal conjunctival injection, seasonal recurrence, and cobblestone hypertrophy of the tarsal conjunctivae or bubble-like chemosis of the conjunctiva covering the sclera
Dry eye
If few symptoms are present on awkening but discomfort worsens during the day and can be the result of eye-opening during sleep
Indication of more serious eye problem
Deep pain not relieved by topical anesthetic, severe pain of sudden onset, photophobia, vomiting, decreased vision, and injection that is more pronounced around the limbuc (ciliary flush)
Treatment of bacterial conjunctivitis
Apply warm or cool compresses q4hr, instil ophthalmic antibiotic such as polymyxin B or cipro
Treatment of mild to moderate viral and chemical conjunctivitis
Apply cool compresses and weak topical vasoconstrictors, such as Naphcon every 3-4 hr
Treatment of allergic conjunctivitis
Cool compresses and H1-antihistamine and mast cell stabilizer meds - Zaditor and Optivar
Most serious complication of contact lens wearers
Microbial keratitis - severe pain, irritation, photophobia, and tearing associated with infiltrates and most common cause is Pseudomonas
Treatment of corneal abrasion
Install topical anesthetic drops, perform complete eye exam. Perform fluorescein exam. Remove foreign bodies. Treat with antibiotic drops such as polymyxin B. Prescribe analgesics. Follow up with ophthamologist. Do not patch eye.
Treatment of conjunctival foreign body
Anesthetic drops. Visual acuity. Eye exam. Examine inside of upper and lower lids. Remove loose foreign body. Fluorescein exam. Saline irrigation is needed.
Treatment of corneal foreign body
Anesthetic drops. Visual acuity. Eye exam with magnification. Look for leakage of intraocular fluid. If suspicion of intraocular foreign body, CT scan. Remove if able. Antibiotic eye drops and NSAID eye drops. Oral analgesics maybe.
Hordeolum - style
Usually at the eye lid. Eye exam. Antibiotic drops. Warm compresses for 15 minutes qid. Follow up if not better in 2 days. May I&D if no better in 2 days
Iritis
Unilateral eye pain, blurred vision, and photophobia, pink-color to eye, usually no discharge. Limbal blush or ciliary flush is usually early sign.
Treatment of iritis
Anesthesic, eye exam, attempt to determine cuase. Determine intraocular pressure. Arrange for follow up in 24 hrs. Oral pain medication - NSAIDs. Not typically treated with antibiotics.
Periorbital and conjunctival edema
Chemosis - edema of conjunctiva - harmless. Determine cause, eye exam, use steroids and Patanol. Cool compresses. Watch for signs of infection. No heat.
Periorbital ecchymosis (black eye)
May have subconjunctival hemorrhage. Determine mechanism of injury. Eye exam. Rule out blow-out fracture of orbit. Assess for bony deformity. CT scan if suspicion of fracture. Edema will subside in 12-24 hrs and discoloration may take weeks to clear. Tylenol.
Subconjunctival hemorrhage
May be spontaneous or after coughing or vomiting. No pain or visual loss. Looks scary. Look for trauma, eye exam, should resolve in 2-3 weeks.
Ultraviolet keratoconjunctivitis (welder’s burn)
Severe, intense, burning eye pain, usually bilateral, beginning 6-12 hr after brief exposure without eye protection. Conjunctival injection and tearing. Ophthalmic anesthetic drops, eye exam, cool compresses, rest, analgesics, lubricate, NSAID eye drops (Diclofenac), should resolve in 24-36 hrs. No eye patches
Common sources for corneal abrasions
Direct trauma - fingers, tree branches, makeup applicators, airbags from MVCs, contact lenses. Surface foreign bodies - dust, chemicals
Clincal presentation of corneal abrasions
Severe pain in affected eye. Foreign body sensation maybe. Blurred vision, redness, tearing, light sensitivity, eyelid swelling, adn blepharospasm
Management of corneal abrasions
Supportive care. Ophthalmic antibiotic ointment - polymyxin B. No patching. Oral analgesics are first-line pain control. No steroids. Should resolve in 3-5 days
Most critical type of chemical burn to eye
Alkaline - can penetrate the anterior eye chamber and cause damage to intraocular structures within minutes
Complications of corneal abrasions
Infection - rare and preventable
Common cause of proptosis among adults
Infectious cellulitis of the orbit
Characteristics of infectious cellulitis
Usually develops in conjunction of infection of face, sinuses, and oropharynx.
Preseptal cellulitis
Infection of the structures anterior to the orbital septum. Can occur because of infection, lid or facial trauma, and URI. Typically unilateral. Presents with eyelid edema and erythema. May have decreased visual acuity because of optic nerve compromise
Diagnosis of preseptal cellulitis
CBC, blood cultures, CT scan is mandatory
Management of preseptal cellulitis
Broad-spectrum antibiotics - celphalosproin or amoxil/clavulante. Clindamycin if MRSA. Follow up with 12-24 hrs.
Complications of perseptal cellulitis
Can be fatal. Blindness - 11 percent. Central retinal artery or vein thrombosis. Brain abscess.
Indication of teardrop-shaped pupil
Globe rupture
Intraocular pressure measurements
Normal - below 20 mmHg. Urgent ophthalmologic evaluation - between 21-30. Emergency situation - above 30 mmHg
Conjunctivitis
Inflammation of the conjunctiva - commonly called pink eye - 80% are viral and most common organism is adenovirus and is spread by direct contact.
Gonococcal conjunctivitis
Typically seen in adults and neonates. If seen in a child consider sexual abuse. Rapid progression is hallmark symptoms. In 2 days can lead to permanent vision loss.
Chlamydial conjunctivitis
Typically in sexually active adults - white, stringy discharge is typical and can last for months with exacerbations and remissions.
Characteristics of viral conjunctivitis
More common in patients older than 12, more commonly associated with burning and foreign body symptoms
Characteristics of bacteial conjunctivitis
Typically accompanied by purulent discharge - yellow or green. Both eyes are glued shut in morning. Itching is less common
Contusions of the eye
Eye is impacted but the wall of the eye remains intact
Lamellar laceration of the eye
Partial-thickness wound to the eye wall, but the integrity of the globe is maintained
Presbyopia
Normal occurrance around age 42-43. Due to decreased flexibility of the human lens. OTC glasses usually help.
Anisocoria
Any variance in the size of pupils between eyes. Can be benign. Can suggest a neurologic, pharmacologic, or anatomic abnormality.
Characteristics of acute rise in intraocular pressure
Firm, painful eye that is inflamed and associated with a cloudy cornea. Represents an emergency with a strong potential for irreversible vision loss
Causes of chemosis - balloon-like swelling of the conjunctiva
Allergies, mechanical ventilators, trauma, and local inflammation
Epiphoria
Excessive tearing. Can be caused by obstruction of the normal tear drainage system or due to irritation or inflammation. Bilateral occurrence in infants is cardinal sign of congenital glaucoma
Live bug in ear
Fill canal with mineral oil, lidocaine, or benzocains/antipyrine to kill bug
Alkaline battery in ear
Capable of producing a liquefactive necrosis within hours. No irrigation.
Auricular hematoma - cauliflower ear
Occurs from direct, blunt trauma causing a shearing force. Requires immediate treatment to prevent cauliflower ear and infection and is permanent. Needle aspiration and I&D are treatments of choice. Antistaph antibiotics and close follow-up. Use epi only to numb.
Nasal fractures
Most common trauma to nose. Nasal pyramid is the commonly fractured bone in the body
Assessment of a nasal fracture
Determine presence of periorbital ecchymosis, epistaxis, or CSF leakage, trauma to neck or teeth, respiratory and c-spine stability
Classic signs of nasal fractures
Tenderness, crepitation, or movement of bones on palpation.
Incidences of epistaxis
Younger than 18 and older than 50
Where most anterior nose bleeds occur
Kiesselbach’s plexus - a vascular plexus on the anterior nasal septum - very vulnerable
Where most posterior nose bleeds occur
Within the posterior branches of the sphenopalatine artery, are idiopathic or associated with vascular disease and can be difficult to control
If nose bleeds do not stop with direct pressure
Cautery with a silver nitrate stick, nasal packing with a nasal tampon. Packing is not removed for 48-72 hrs. Amoxicil/clavulante or bactrim DS is also prescribed.
Canker sores
Present as one or more flat, even-bordered, round or oval ulcers with a central friable pseudomembranous base surrounded by a bright red halo. Pain is greater than the size of the lesion wound suggest
Steroid use in a pt with herpes mouth sores
Do not give!
What to do for avulsed tooth
Obtain mechanism of injury. Exam for lacerations. Check for fractures with x-ray. Chest x-ray if tooth can not be located. Do not implant primary teeth. If partially out, push back in. May store it under the tongue until at dr office. Irrigate socket and tooth and push back in. Provide antibiotic prophylaxis.
Burning mouth syndrome, burning tongue - glossodynia
Burning, tingling, scalded, or numb sensation in anterior two thirds of tongue that worsens throughout the day. Mostly affects women
Treatment of cellulitis and facial swelling associated with dental pain
10 day course of penicillin VK 500 mg quid. Can drain the abscess/
Use of clove oil secondary dental extractions
Do not use in a tooth cavity when an abscess or cellulitis are present
Pericoronitis
Edema and pain often associated with eruption of wisdom teeth
What to do for pericoronitis
Irrigate with weak peroxide solution. Analgesics. Penicillin if cellulitis is present. Flush food out of mouth. follow up with dentist.
Postextraction alveolar osteitis - dry socket
Severe, dull, throbbing pain 2-4 days after tooth extraction. May radiate into ear and is not relieved by analgesics. May last 10-40 days if not treated.
What to do for alveolar osteitis - dry socket
Local anesthetic. Irrigate with NS and remove debris. Pack with goal soaked in oil of cloves. Take 4000 mg/day of vitamin C. Opiods for relief.
Pulpitis
Acute toothache with sharp, throbbing pain often worse when laying down.
What to do for pulpitis
Analgesics. Use oil of cloves soaked cotton for cavities. Referral to dentist within 12 hrs. No antibiotics
Ellis class I tooth fracture
Involves the enamel only and can be filed down with emory board
Ellis class II tooth fracture
Exposes yellow dentin. Cover with calcium hydroxide composition or dermabond. follow up with dentist next day
Ellis class III tooth fracture
Exposes pulse. Be seen by dentist within 3 hrs. Analgesics
Suturing lacerations that extend across the border of the lips
Bein with approximation of vermilion border to avoid unsightly scars.
Mucocele - mucous cyst
Soft, rounded, nontender, fluctuant cyst, most often found inside the lower lip and usually develop rapidly
Perleche - angular cheilitis
Inflammation and soreness at corners of the mouth. Topical antifungal cream for a few weeks. Keep dry.
Sialolithiasis - salivary duct stone
More commen in men. Rapid swelling beneath jaw while eating. May be painful and usually subsides within 2 hrs. Often transient. Sucking on lemon drops help expel stone. Augmentin if purulent drainage from duct.
Temporomandibular disorder - TMJ
Pain that is dull and unilateral, centered in temple above and behind eye and in and around the ear. Pain with opening and closing mouth. Anti-inflammatories. Follow up with dentist if pain persists after 2-4 weeks.
Temporomandibular joing dislocation - jaw dislocation
Can occur with or without trauma. Attempt reduction if no trauma. If trauma, x-ray to rule out fractures. After reduction, soft collar to reduce ROM of TMJ. Refer to oral surgeon.
Acute uvular edema
Foreign body sensation or lump or fullness in the throat. Uvula is boggy, swollen, pal,e and genatinous looking. May be caused by strep, allergic reaction, or H. influenzae
Epiglottitis
Acute inflammation of epiglottis and typically caused by a bacterial infection. More comon in adults. Rare and can be deadly.
Clinical presentation of epiglottitis
Severe odynophagia, dysphagia, fever, SOA, inability to swallow, lymphadenopathy, cough, drooling, stridor, respiratory distress, hoarseness, tripod positioning, use of accessory muscles. Do not examine pharynx with tongue depressor!
Management of epiglottitis
Sit upright, humidified oxygen, close observation of airway, antibiotics, and steroids. Hospitalization. Avoid sedation. Immediately refer to ED. Protect airway
Peritonsillar abscess
Accumulation of pus located within the peritonsillar tissue. Most common deep infection of head and neck.
Presentation of peritonsillar abscess
Typically fever, chills, fatigue, malaise, foul breath, and severe odynophagia, may appear acutely ill and complain of pain radiating to eat on affected side. Usually unilateral.
Management of peritonsillar abscess
Oral antibiotics are not enough. Surgical intervention is required with needed aspiration, I&D, or tonsillectomy. Hydration. Can be very serious if abscess ruptures.
Most common causes of pharyngitis
Rhinovirus and adenovirus
Presentation of viral pharyngitis and tonsillitis
More common, suden onset of sore throat, fever, malaise, cough, headache, myalgias, fatigue, rhinitis, conjunctivitis, congestion, and productive cough
Centor score of 4 regarding GAS - pharyngitis and tonsillitis
Indicates a presumative diagnosis and confirmatory testing is not necessary
Presentation of infectious monomucleosis
More common in adolescents and young adults. Headache, malaise, fatigue, and anorexia prior to sore throat. Hepatosplenomegaly. Positive monospot test.
Presentation of URI
Cough, congestion, rhinitis, sneezing, injected conjunctiva, erythematous and edematous nasal mucosa, erythematous pharynx
Presentation of anaphylactic reaction
Depends on organ system affected
Common presentation of anaphylaxis
Urticaria, erythema, pruritus, cutaneous wheals, angioedema, syncope, nausea, vomiting, vertigo, flushing, and weakness
Management of anaphylaxis
Protect the airway is main concern. Epi IV is first-line treatment.
Epi dose in adult
1:1000 dilution - 0.2-0.5 mg IM or SC every 5-15 minutes as needed to a max dose of 1 mg
Epi dose in child
1:1000 dilution - 0.01 mg/kg per dose in children, max of 0.3 mg, IM or SC; repeat every 20 minutes to 4 hours as needed to a max dose of 0.5 mg/dose
Acute urticaria
Intense itching. Rash consists of sharply defined, slightly raised wheals surrounded by erythema and tends to be circular or apear as incomplete rings. Lasts no more than 8-12 hrs. May occur immediately after contact or be delayed by days.
Management of acute urticaria
Identify cause if possible. Epi 0.3 mg IM. Benadryl 25-50 mg IV. Tagamet, zantac, or pepcid. Prednisone immediately and for 4 days. No topical steroids or antihistamines.
Prevelance of acute urticaria
More common in young adults, children, and atopic individuals. Often attributed to exposure to food allergens, food additives, medications, contrast.
Prevelance of chronic urticaria
More common in middle-aged women and does not show the same predilection for individuals with atopy. 60% are idiopathic. Can last more than 6 months
Six “i’s” to include with history of urticaria
Infections, ingestants (food), injectants (drugs), insect stings, inhalants (pollen), and internal disease
Heat stroke
Core body temps exceed 103 degrees and CNS abnormalities occur - seziure, confusion, hallucinations, headache, bizarre inappropriate behavior, psychosis, coma, dehydration, tachycardia, tachypnea. Key characteristics are red, hot, dry skin.
Heat exhaustion
Less severe in which core temp is higher than 100 degrees, but no more than 104. Can rapidly progress to more severe and potentially fatal heat stroke. Generalized malaise, cramps, nausea, vomiting, hypotension, tachycardia, sweating, thirst, vertigo, anorexia, anxiety, but no CNS involvement
Heat syncopy
Vertigo that occurs with standing for long periods or sudden rising during heat exposure
Heat cramps
Muscle pains or spasms occurring in individuals performing physical activity in heat
Management of heat-related illnesses
Maintain airway. Vital signs. Transport to ED. IV fluids. O2. Goal is to lower core body temp, rehydrate, and replenish electrolytes.
Complications of heat-related emergencies
Rhabdomyolysis, renal, hepatic, or cardiac failure. Injuries can be permanent.
Frostbite
90 percent occur in hands and feet and classified as grades I-IV on basis of severity or simply as superficial or deep.
Hypothermia
Core body temp below 95 degrees.
Partial-thickness frostbite
Blistering can occur within 24-48 hrs. With rewarming, area will appear mottled and swollen, with superficial blisters developing within 6-24 hrs
Deep frostbite
Skin may be hard or wooden in appearance. Through the next several days, there is progression from edema, nonblanching, cyanosis, and hemorrhagic blisters to tissue necrosis.
Management of frostbite
Do not massage. Wrap wounds in non-adherent dressings. Analgesics. Transport to ED
Frostnip
Occurs when skin surfaces, such as tip of nose and ears, are exposed to an environment cold enough to freeze the epidermis. They become hyperemic and very painful when rewarmed
Epidermal burns
1st degree. Painful, red, and moist. Blistering does not occur. Healing within 5-7 days with no scarring. Most common is sunburn
Superficial partial thickness burns
One type of 2nd degree. Involves the epidermal layer and several dermal layers. Painful and heal with minimal scarring in 2-3 weeks.
Deep partial thickness burns
One type of 2nd degree. Involve the epidermal and dermal layers and may involve some of the dermal appendages. Not painful because of loss of sensory nerves. May take more than 3 weeks to heal.
Rule of 9s
Head and each arm = 9 percent. Genitals = 1 percent. Anterior, posterior trunk and each leg = 18 percent
Goal of burn treatment
Stop burn, identify extent of burn, administer pain meds quickly.
Full-thickness burns
3rd degree. Dry, leathery, and insensitive. Color can be white, brown, or black.
Cause significant scarring, loss of function, and usually require skin
grafting. Doesn’t blanch and is insensitive. Swelling may be massive
Full-thickness burns - 4th degree
Involves all tissue as well as bone. Has a charred appearance
Dressings for partial and full-thickness burns
LR 4 ml x wt in kg x percent TBSA. 1/2 in first 8 hrs, 1/4 in second and third 8 hr segments
Initial fluid resuscitation of burns
LR 4 ml x wt in kg x percent TBSA. 1/2 in first 8 hrs, 1/4 in second and third 8 hr segments
Factors that determine severity and distribution of electrical injuries
Type of current, voltage, amperage, tissue resistance, surface contacted, pathway of current, duration of contact, and other associated trauma
Lichtenberg’s flowers
Linear, punctate, feathery burns often associated with lightening injuries
Zone of coagulation
The innermost zone of a burn and represents the most damaged area. Cellular death and thrombosis of blood vessels occurs in this area.
Zone of stasis
Second zone of burn and is where blood flow is compromised. May quickly progress to ischemia or may return to normal.
Zone of hyperemia
Outermost zone. Received minimal damage and is characterized by increased blood flow and will fully recover
Low-risk burn patients
Those between ages 10-50
High-risk burn patients
Younger than 10 and older than 50 or those with underlying medical conditions such as heart disease, diabetes, or pulmonary problems
First intention wound healing
Skin is closed with sutures, staples, skin adhesive, or Steri-stripe. Can be lacerations or surgical wounds
Second intention wound healing
Wound is left open to heal on its own. This is slower and allows for granulation from the inside out. Can be caused by abscess, ulceration, puncture, or bite.
Third intention wound healing
Delayed primary closure. Contaminated wounds may be closed 4-5 days after occurrence
Puncture wounds
Difficult to predict outcome because inability to visualize the end of the wound. Area of injury, level of contamination affect healing.
Treatment of choice of puncture wounds
Copious irrigation - no pressure irrigation
Treatment for stepping on a nail through rubber soled shoe
Often includes Pseudomonas and treat with fluoroquinolone for adults and bactrim for children
Risks of infection with bites
Dogs - less frequent. Cats - more frequently because usually deeper and smaller punctures. Human - often infected with staph
Closing bites
Bites on the hands, any human or cat bites should not be closed. No closure if more than 8 hrs old.
Treatment of infected bites
Fresh cat and human bites - 3-5 days prophylaxis. Infection - 7-14 days when soft tissue involved: 21 days if bones or joints involved. Augmentin 500 mg tid for 5-7 days most effective. Cultures of new wounds not effective
Reactions to stings
Can be local, toxic, systemic, or delayed reactions.
Toxic reactions to stings
GI distress, lightheadedness, syncope, headache, fever, drowsiness, muscle spasms, edema, and occassionally seizures
Systemic reaction to stings
Anaphylaxis, which initially is manifested as itchy eyes, facial flushing, generalized urticaria, and dry cough. Finally respiratory distress.
Delayed reaction to stings
Can occur after 10-14 days and cause fever, malaise, headache, urticaria, lymphadenopathy, polyarthritis, and more systemic illnesses
Management of stings
Local wound care, removal of stinger, ice packs, H1 and H2 blockers, topical steroids, topical or systemic antibiotics, NSAIDs.
Systemic reaction to brown recluse spider bite
Fever, chills, nausea, vomiting, myalgia, arthralgia, petechiae, hemolysis, or seizures within 24-48 hrs
Response to black widow spider
May be mild to moderate painful, erythema, swelling, and muscle cramping begins at the site within 30 min to 12 hrs. HTN can be serious, anxiety and confusion can occur
Mainstay for therapy of moderate to severe venomous snakebites
Antivenom
Emperical treatment of MRSA abscesses
Bactrim DS 10 days - 1-2 tabs q12 hr. Severe infections with vancomycin IV
Goal of wound healing through sutures/staples
Facilitate decreased healing time, reduce infection, and minimize scarring
Initial assessment of the eye
Subjective; history - HPI, past medical and ocular history, family history, social history, and occupation
Things to cover in history of ocular problem
Onset. Duration of symptoms. Change in vision. Photophobia. Pain. Mechanism of injury. Use contact lenses. History of eye surgery. Current meds. Recent exposure to new cosmetics, deodorants, or persons with eye infection. Systemic complaints - fever, rash, genital discharge.
Objective data of eye
Thorough exam of eye, structure and function, enlarged lymph nodes adn rashes. Visual acuity, pupil responses. Intraocular pressure (opth), visual fields (opth), and extraocular movements. Eye lids and lashes. Lacrimal system. Anterior and posterior segments of eye
Red eye
Hyperemia of the conjunctiva or sclera. Redness of the adnexal structures or periocular areas.
Common causes of red eye
Conjunctivitis - allergic, bacterial, or viral. Episcleritis or scleritis - inflammatory conditions
Episcleritis
Inflammatory. Involves the tissue between the conjunctiva and the sclera
Scleritis
Inflammatory. Involves the sclera
Causes of sudden vision loss
Acute angle-closure glaucoma. Central retinal vessel occlusion. Hypema or trauma. Endophthalmitis. Iritis or uveitis. Meningitis. Migraine. Optic or retrobulbar neuritis. Retinal hemorrhage. Stroke. Vitreous hemorrhage.
Causes of graudual vision loss
Amblyopia. Cataracts. Corneal opacities. Glaucoma. Iritis or uveitis. Macular degeneration. Pituitary tumor. Retinal detachment. Vitreous opacities.
Herpes simplex conjunctivitis
Subjective - red eye, photophobia, eye pain, blurred vision, foreign-body sensation. Objective - periorbital vesicles (weeping areas around eye). Fluorescein staining (dendritic pattern with bulbar terminal ending - branching). Refer to eye dr.
Who should be referred regarding eye complaints
Acute change in vision. Concern for sight threatening disease. Recent trauma, ocular surgery, use of contact lenses. Neonates. Immunocompromised patients.
Iris
Pigmented structure that forms the posterior aspect of the anterior chamber and acts as a shutter for the eye by controlling the amount of light through the pupil. Blood vessels not typically seen on surface.
How to assess the iris
Use a penlight and a magnifying glass
Nevi neoplasms of the iris
Nevi neoplasms - melanoma.
Lisch nodules of the iris
Harmartomas (dark pigmented dome shaped areas that project from the surface of the iris
Waardenburg syndrome of iris
Genetic abnormalities. Hearing loss and changes in coloring of hair, skin, and eyes. Often have very pale blue eyes or different colored eyes or an iris composed of different colors.
Sarcoidosis of iris
Inflammatory nodules.
Iris neovascularization
Presence of abnormal blood vessels and suggest ocular ischemia. Seen in - Proliferative diabetic retinopathy and Central retinal vein occlusion. Requires urgent ophthalmology consultaiton.
Uveitis
Inflammation of the uveal tract. Contains the iris, ciliary body, and choroid
Evaluation of iritis or uveitis
Objective findings. Instillation of a topical anesthetic if needed. Limbal flush. Slip lamp exam - WBCs in clear aqueous humor. Pupil reaction - sluggish in the affected eye.
Limbal flush
Circumcorneal injection - a table of fine ciliary vessels - visible through the sclera
Management of iritis
Refer to ophthalmologist. Urgen problem - can lead to blindness if not treated properly.
Angle-closure glaucoma
Presentation is acute. An ocular emergency. Needs immediate attention. Ultimately results in increased intraocular pressure and decreased visual fields.
Charcteristics of angle-closure glaucoma
Severe eye pain. N and V. Halos around lights. Photophobia. Corneal cloudy with variable decrease in vision. Conjunctival hyperemia. Pupil mid-dilated adn fixed. Firm globe. Shallow anterior chamber.
Typical case presentation of angle-closure glaucoma
Elderly pt who presents with periorbital pain and visual disturbances. Pain is severe and boring, ipsilateral headache. Blurred vision, halos, N and V, abd pain. Past medical history - may have no history of glaucoma. Medications - ANticholinergics, sympathomimetics, recent headaches.
Physical exam of angle-closure glaucoma
Only able to visualize hand movements. Pupil irregular shaped, fixed and dilated. Slit-lamp - corneal edema, irregular pupil shape. Increased IOP - greater than 20
Corneal surface of eye
Injury causes epithelium interruption of corneal. Common causes finger, tree branches, makeup applicators, contact lenses, deployment of airbags. Surface foreign bodies - dust. Chemical splashes.
Diagnostics of corneal ulcer/foreign body
Fluorescein stain. Corneal ulcer (C and S if immediate opth consult can not be obtained)
Preseptal cellulitis
An infection of the structures anterior to the orbital septum. Absent are: proptosis, ophthalmoplegia and visual loss
Orbital cellulitis
Occurs posterior to the orbital septum. 90 percent of cases occur as a secondary extension of acute or chronic bacterial sinusitis. Infections of face, eyelids, lacrimal sac, dental. After trauam, orbital or periorbital surgery. Can lead to rapid blindness and fatal consequences.
Traumatic ocular disorder
May be mechanical or chemical injuries. Presentation is highly variable.
Laceration of cornea - tes
Seidel’s test - moistened fluorescein strip is liberally applied to the ocular surface. When viewed with a cobalt blue light source, a laceration is confirmed if a stream of aqueous disrupts the thick layer of fluorescein.
Acid chemicals in the eye
Can be quite destructive to the ocular surface - however the eye proteins act as an acid buffer to limit ocular penetration
Alkaline chemicals in the eye
They release hydoxyl ions that interact with the structural proteins of the eye wall and allow deeper ocular penetration
Initial treatment of chemicals to the eye
Immediate copious irrigation and requires emergent follow up
Normal pH of eye
7.0-7.3. You must neutralize the chemical and return the pH to neutral to avoid further eye injury
Reasons to refer to ophthalmologist
Limbal flush, irregular pupil, muscle paresis, hazy cornea, corneal dendrite, corneal ulcer, vision loss, elevation of retina on fundascopic exam, papilledema, and painful eye, red eye, and vision change.
Management of epiglottitis
Emergency. Surgical intervention - needle aspiration I&D, or tonsillectomy. Antibiotics - cephalexin or another first generation cephalosporin with or without metronidazole. Cefuroxime (with or without metrodnidazole).
Management of heat illness
Goal is lowering of core body temperature, rehydration, and electrolyte replenishment
When to refer heat related illnesses
Refer a heat stroke or heat exhaustion immediately to an ED
Pathophysiology of anaphylaxis
There is a rapid release of immunoglobulin E immune response mediators from mast cells and basophils
When to transfer or refer burns to a burn center
Third-degree (full-thickness) over 5 percent. Second-degree (partial-thickness) burns over 10-15 percent (5-10 percent in children under 10). Extensive burns involving the face, hands feet, joints, or genitalia. Elderly patients and patients with significant comorbidity.
Vision threatening conditions
Pain, redness, vision change
Eye hemorrhage
No subjective symptoms. No treatment necessary.
Keratitis
Inflammation of cornea associated with pain, photophobia, corneal cloudiness with stromal involvement. Refer to opthalmology urgently.
Hyphema
Blood layering the anterior chamber usually after blunt trauma. Refer urgently to ophthalmology.
Periorbital cellulitis
Acute infection of tissues surrounding eye. May progress to orbital cellulitis with protrusion of eyeball. Complications include meningitis. Refer to hospitalization and IV antibiotics
Foreign object
Even small abrasions can cause intense pain and photophobia. Easily seen. Usually heal within 24 hours. May need to be treated with prophylactic topical antibiotics, analgesics. No patching. Reevaluate within 24 hrs.
Dendritic ulcer
Associated with herpes simplex infection. Immediate referral to ophthalmology.
Ruptured globe
Hemorrhage, limited EOM, and extrusion of eye contents. Irregular tear shaped pupil
Treatment of ruptured globe
Cover with shield. No pressure. Supine at 30 degrees. NO drops or ointments. NPO. Transport immediately.
Acute glaucoma
Aqueous fluid can’t assess drainage pathways causing ocular pressure to increase rapidly. Ophthalmological emergency and can lose vision in eye within hours.
Symptoms of acute glaucoma
Severe pain. Red eye. Nausea and vomiting. Halos. Photophobia. Cornea may be cloudy. Pupil may be middilated and sluggish. Eye can feel rock hard.
Retinal detachment
When retina is lifted from its normal position. Symptoms - floaters in field of vision, light flashes, appearance of curtain. Immediate referral.
Chemosis
No pain. No vision loss. Complaint of itching. Treat with topical antihistamines and cool cloths
Steroid and antibiotic use with eye injuries
Use of steroids with bacterial infections will exacerbate infection. Steroids with corneal abrasions can lead to corneal melting. Treating herpatic keratitis with antibiotic will delay treatment and lead to serious complications.
