Plastics Flashcards
List 4 clinical signs of potential inhalation injury
- Smoke exposure
- Burns on the face
- Singed nasal hairs
- Soot in sputum or visible in upper airway
- Wheezing or rales
BSA % in adults for burns
- Each arm is about 9% TBSA
- Each leg is 18% TBSA
- Anterior and posterior torso area each 18%
- Head is 9%
- Perineum is 1%
- Child palm including fingers is about 1%
Layers / types of burns
superficial (sunburn)
superficial partial thickness (blisters)
deep partial thickness (paler, drier, speckled appearance of dry vessels)
full thickness (no pain, leather, charred)
indications hyperbaric chamber in CO poisoning?
o LOC at scene o persistent neurological symptoms o evidence cardiac injury o significant elevation carboxyhemoglobin level (greater 25%) o pregnant and >20%
When to treat empirically for cyanide poisoning
closed house fire
history of CPR, abnormal vital signs, intubation, evidence hypoxic injury, severe metabolic acidosis
Tx before level back (hydroxycobalamin)
Fluid resus in burns?
parkland formula 4 ml/kg/% BSA over 24 hours (1/2 first 8 hours then ½ over 16 hours) (children less than 5 maintenance added using isotonic fluids with dextrose); monitor urine output with catheter with goal 1 ml/kg/hr
Burns - 5 indications for admission
- 5-10% TBSA burn
- 2-5% full thickness burn
- high voltage injury
- concern for inhalation injury
- circumferential burn
- significant associated trauma or medical comorbidity (ex. Diabetes or SCD)
- more than 1% BSA burns to face, perineum, hands and feet or overlying joints
Burns - 5 indications for transfer to burn center
- greater 10% TBSA burn
- greater 5% TBSA full thickness burn
- high voltage burn
- chemical burn
- known inhalation injury
- burn to face, hands, feet, perineum or joints
- significant comorbidities that could affect treatment
- intentional burns
- major associated injury
What are 2 priorities in wound care?
- Minimizing infection
- Ensuring sterility
- Minimizing fluid loss
Which wounds require abx prophylaxis
heavily contaminated wound, dog (if sutured)/cat/human bites, puncture wounds to hand, stellate laceration, laceration near joints or open fractures, immunocompromised patients, consider in wounds contaminated soil or feces
What are 2 structures that may be injured in a cheek laceration?
- Facial nerve
- Salivary gland and duct
What are 2 structures that may be injured in an eyelid laceration?
- Levator palpebrae muscle
- Nasolacrimal duct
What bug is responsible for necrotizing faciitis?
Group A strep, Staph aureus, mixed anaerobes (bacteroides, clostridium)
What are 3 conditions that put him at risk for necrotizing faciitis?
- History of underlying skin conditions (ie: eczema)
- Recent varicella infection, insect bite
- Immunocompromised state
- Minor laceration or blunt trauma
- type 2 DM
What are 4 life threatening complications of necrotizing faciitis?
- Toxic shock syndrome
- Renal failure
- Sepsis
- Multiorgan failure
- DIC
How to transport amputated finger?
transport amputated finger in saline moistened gauze, in a bag/Ziploc, then place in a ice-water mixture
When to drain subungual hematoma?
trephination/ drainage is recommended when greater than 50% nail bed surface area, to evaluate for underlying nailbed laceration or symptomatic relief of pain
When do you refer a finger fracture to Plastics (list 5)?
- Open fracture (seymour fracture is nail bed injury with distal phalanx SH-1 fracture and is an OPEN fracture)
- Rotational deformity
- Angulation or displacement that cannot be reduced
- Condylar fracture (joint surface becomes disrupted - issues with articulation)
- Unstable fracture (complete spiral, oblique, proximal phalanx fractures)
- Disruption of joint surface
- Digital nerve injury
- Amputation
- Concern for tendon rupture
- Volar plate # or avulsion injuries
- Proximal MCP # of thumb (risk of UCL injury)
- Physeal fractures associated with displacement or deformity (ie: Boney mallet finger)
what is the Terry Thomas sign
Gap > 3 mm seen in scaphoid lunate dislocation
What is a Bennett fracture? Tx?
bennett’s fracture: inter-articular fracture at base thumb metacarpal = special attention (thumb carpometacarpal joint is critical) = closed reduction/CRIF/ORIF = urgent plastic referral
What is a Rolando fracture? Tx?
comminuted fracture base of thumb metacarpal = closed reduction/CRIF/ORIF = urgent plastic referral
Acceptable angulation for metacarpal fractures?
10-20 degrees index finger increasing to 40 degrees for small finger unless UNSTABLE
What are two joint positions that need to be maintained in an ulnar gutter? Why do hands in a split have to be positioned in a specific way?
- Wrist needs to be in slight extension at 20o
- MCPs in 70-90o flexion
- PIP/DIP slight flexion at 5-10o
Goal:
o Minimize stiffness or contractures
o Neutral position / position of comfort
o Balance between flexor and extensor tendons to avoid risk of displacement by increased flexor tendon or extensor tendon activity
Broken and reduced 5th metacarpal - what type of splint and position of the MCP in the splint plus indications for closed reduction
● Ulnar gutter
● Slight dorsiflexion at wrist, 90 degrees flexion at MCPJ, 20 degrees flexion at interphalangeal joints
Closed reduction if:
■ Rotational deformity of fingers or scissoring with MCP flexion
■ Angulation of MCP head >30-40o
■ Pseudo-clawing
Active adduction of the thumb tests which nerve?
ADduction: Ulnar nerve = innervates adductor pollicis
ABduction: Median nerve = innervates opponens pollicis
What is a Skier’s or gamekeeper’s thumb
rupture ulnar collateral ligament due to abduction and hyperextension, rule out avulsion fracture
What is a Seymour fracture?
displaced DIP SH I/II fracture of distal phalanx associated with exposure of proximal aspect of nail and damage to germinal matrix
You are seeing a 14 year old boy with a fracture of the 5th proximal phalanx, which is closed, salter-harris II and angulated 30 degrees ulnarly.
Assuming you cannot consult orthopedics, how would you manage this injury?
- Analgesia through an ulnar nerve block or digital ring block
- Closed reduction (exaggeration (minimal) -> traction (minimal) -> correction)
- Ulnar gutter splint (down to forearm)
- Close follow-up with ortho or plastic surgery for re-evaluation and proper casting (1 week)
3 ways to remove a ring
- string pull
- string compression of skin
- ring cutter
How to remove a hair tourniquet
- blunt metal probe
- hair remover
- incision
