Quiz #2 Flashcards
2 situations that are considered an orthopedic emergency?
Open fractures
Neurovascular injury
What requires emergent intervention?
vascular compromise
What is required to dx or exclude a fracture?
imaging
1 view is ?
NO VIEWS
If your suspicious that a sample is not showing up on 1st day of injury what should be done?
splint as if fractured and F/U for imaging in 7-10 dys
What things should be known/ done with a high index of suspension?
mechanism of injury location point tenderness pain w/ PROM "old school" tuning folk
In a extremity fracture what is the first thing that needs to be checked?
neurovascular status
What should always be checked and documented in a extremity fracture?
distal neurovascular status before and after splint
Once you have splinted what’s next?
document and check w/ repeat x-ray in splint
A splint should have what?
plenty of padding
What should you document with parents and they should understand?
potential growth plate involvement
Salter Harris I
A fracture across the physis
Salter Harris II
A fracture “A” fracture above the physis
Salter Harris III
A fracture below the physis
Salter Harris IV
A fracture through the physis
Salter Harris V
A compression fracture of the physis
When should a pt follow up after a extremity fracture?
2-3 days with orthopedic specialist
D/C instructions for a fracture?
Elevate and keep the splint clean, dry, and intact
Monitor the fingers or toes
Which injury can result in long-term disability?
Hand injuries and disorders
What are 3 types of hand injuries?
burns
tendon or nerve injury
injection injuries
Any type of ??? can lead to functional injuries?
hand
What type of hand injuries lead to abnormal digit movement and “Scissoring”
fractures
If a hand burn patient is being discharged, whom should they be referred to?
burn center or specialist
Always inspect wounds for ???
tendon damage
How is tendon damage inspected?
by having the pt fully flex and extend digits
Perform full AROM movements
Sensation tests
What are 3 types of injection injuries
air, water, others
What does high pressure injection injuries lead to?
dissection along planes of least resistence
How do you treat air and water injection injuries?
tetanus, abx, immobilization, monitor
How do you treat “other” injection injuries?
tetanus, abx, immobilization, monitor PLUS immediate debridement
What are considered high risk injuries?
fight bite, cat bites, other punctures
Treatment for hand infections?
drain any pus collection
immobilize and elevate in position of function
Start Abx
Admit for observation and ortho follow up
Flexor tenosynovitis
closed space infection of flexor tendon sheath
Ortho EMERGENCY!
Flexor tenosynovitis
What is the presentation of Flexor tenosynovitis?
fusiform swelling (on both sides) Finger in slight flexion Pain w/ passive extension Pain w/ palpation tendon sheath
Txt for Flexor tenosynovitis?
IV Abx w/ elevation
w/ emergent ortho consult
What is the goal of the ED when it comes to back pain?
r/o serious patho and improve pain
What are 6 serious back pain problems?
Abdominal aortic aneurysm or dissection Cauda Equina Epidural abscess Discitis Tumor or mass Fracture
What are 4 red flags of back pain?
Infection
Recent Fractures
Cauda Equina or Central Cord compression
Aortic Dissection/Aneurysm
What PE findings should be documented to rule out red flags?
Temp skin condition overlying pain Abdominal exam Midline spinal tenderness ROM Straight leg raise LE strength, including bilateral great toes and foot plantar/dorsiflexion LE sensation, including lateral foot, 5th toe, and medial thigh LE reflexes \+/- rectal tone
Who gets a emergent MRI in back pain?
S/S of central cord compression or cauda equina
Who gets a CBC in back pain?
infections
Who gets a X ray for back pain?
recent trauma, elderly or any concern for cancer
Who gets a CT for back pain?
increased details of fractures
Who gets a out patient MRI?
all other pathology w/o high risk for long term disability (herniated discs)
What are 3 types of infections?
soft tissue
open fracture
joints
Fast spreading, gas producing infection?
necrotizing fascitis
Often requires amputations?
Necrotizing faciitis
What should be done in necrotizing fasciitis?
mark outlines of cellulitis to follow progression
What should be palpated in necrotizing fascitis?
crepitus and severe TTP
What imaging is used for necrotizing fasciitis?
Xray or CT- looking for gas
What is a open fracture?
an open wound overlying fracture site
What abx are required for a open fracture?
1st gen Cephalosporin (Cefazolin)
Aminoglycoside (gentamicin) for large wounds
ADD- gram neg abx for wounds w/ organic matter
What is the txt for open fracture?
irrigate superficial debris from wound (NO HIGH PRESSURE)
Schedule for surgery
What are two types of joint infections?
spontaneous
associated w/ injury
How to determine if a penetrating injury compromises joint capsule?
wound exploration and joint capsule injection w/ sterile saline (or methylene blue)
TXT for joint infection?
IV Abx and surgery
If surgery is used to treat a joint infection what do orthopedics NOT want?
abx prior to surgery or arthrocentesis
Joint is erythematous, warm to touch, w/ swelling and effusion
joint infection
Pain w/ all ROM and axial load?
joint infection
All suspected septic joints MUST have?
arthrocentesis
What 3 things findings of septic arthritis?
purulent appearance
Leukocytosis > 50K
+ Gram stain and culture
Injury leading to increased pressure within a fascial compartment compromising the circulation of the tissues within?
Compartment Syndrome
What should be suspected in crush injuries, fractures, and soft tissue injuries w/ severe pain
Compartment syndrome
What does compartmental pressure lead to if not corrected?
tissue necrosis
pain out of proportion, pulsessness, wood like feeling w/ palpation
compartment syndrome
Dx for compartment syndrome?
direct compartment pressure testing
TXT for compartment syndrome?
Fasciotomy
What are 3 skin injuries?
Lacerations
Abrasions
Bites
What is the first thing that should be done with a laceration?
Stop bleeding
When is a tetanus booster needed?
> 5yrs
A laceration should be cleaned well with?
antiseptic
What are 3 definitive closure options?
staples
glue
suture
What are 2 temporary closure options?
suture
gauze/ occlusive dressing
What is the first thing that should be done with a abrasion?
Stop the bleeding
A huge depth and area should be treated where?
burn center
What can be used to help with the scaring of a abrasion?
Asphalt
What is the txt for a abrasion wound?
cover w/ antibiotic ointment
place a non-stick bandage over wound
Iodoform for continued debridement
What is the txt for severe abrasions of palms and over joints?
PT to avoid contractures and maintain ROM
What animals do we considered rabies?
animal acting aggressive, odd, or feral
animals vaccinations not up to date
If an animal can be found.. what happens?
animal services sequesters animal and monitors for dx
If an animal CAN’T be found.. what happens?
Rabies vaccine series
What is the rabies vaccine series?
1st dose in ED
2nd-4th dose in public health or local clinic
What is given in addition to the rabies vaccine series?
rabies immune globulin in ED
What is the TXT for ALL bites?
clean well w/ antiseptic
tetanus booster as needed
closure
antibiotics
What areas only get closure?
face or scalp
Why is the face or scalp only given closures?
due to high vascularity and cosmetic reasons
What abx is used for most bites (cats, dogs, humans)?
Amoxicillin- clavulanate- (Augmentin)
A fight bite can lead to ?
rapidly spreading tendon sheath infection
Means nothing without associated findings, corroborating or focal signs or symptoms
fever
What are the 5 Ws of fever?
Wind (atelectasis or lung infection) Water (urinary tract infection) Wound (wound/skin infection) Walking (venous embolism) Wonder Drug (medication induced fever)
Wind
atelectasis or lung infection
Water
Urinary tract infections
Wound
wound/ skin infection
Walking
venous embolism
Wonder drug
medicated induced fever
What is the 1st question to approaching fever?
“Have you checked your temperature or do you fell warm”
NOT A FEVER
<100.4
Who should receive a core temp?
All < 3mo patients
<2yr w/ complaint of fever and normal temp by other means
Immune compromised or severely ill
What things should be done in a febrile fever pt?
Vitals IV access IV hydration Anti-pyretic or cooling blankets CBC w/ diff CMP Blood cultures \+/- Wound culture or indwelling device culture UA w/ urine culture Lactate VB and ABG Appropriate imaging
What is considered neutropenia?
<500 mm3
Fever is a temp over >
> 100.4
What should never be done in a neutropenic fever?
a rectal exam due to potential bacterial seeding
What are neutropenic pts at a increased risk for?
sepsis and worse outcomes
Any fever in a neutropenic pt is suspicious for?
infection
What is the TXT for neutropenic fever?
Abx within 60 min- Cefepime 2g q 8hrs
What is the DX for neutropenic fever?
blood cultures x2 + culture from indwelling lines (prior to abx)
urine culture
Why is Cefepime given in neutropenic fever?
bc it covers Pseudomonas
What is a fever of unknown origin (FUO)
A fever without localizing signs or symptoms
What is FUO?
fever > 100.9 for 3 weeks w/ no obvious source despite investigation (3 outpatient visits or 3 days in hospital)
What are FUO mostly commonly due to?
infection, malignancy and vascular disease
What is a febrile infant fever?
> 100.4 rectal/core temp
Oral temps are ?? lower than rectal/core?
1 degree
Axillary temps are ?? lower than rectal/core?
2 degree
Tympanic and forehead temps are ?? to core temp?
1-2 lower
What is the workup for a <28day old?
CBC CMP Cath UA and urine culture Blood culture x1 Chest xray Lp Abx Admit
What is the work up for 29days- 2 or 3mo?
guidelines based
What are the guidelines that can be used for >29days old?
Boston
Rochester
Philadelphia
Milwaukee
What is the difference between the guidelines?
avoid LP and admission
What do many clinicians do on all infants < 2months regardless?
LP
What are the 2 planes of least resistance?
neurovascular bundles and fascial planes
Pathogen in neutropenic fever?
Pseudomonas
Which guideline doesn’t require a lumbar puncture?
Rochester
What is the difference between the febrile 3 mo- 3yr children ?
immunizations
What is done with a 3mo-3yr child with immunizations and a known source?
No w/u needed
What is done with a 3mo-3yr child with immunizations and a unknown source?
UA and urine culture via catherization
What is done with a 3mo-3yr child with incomplete immunizations?
full work up
+/- LP
What is done with a 3mo-3yr child that ill appearing?
full work up
LP regardless
What is sepsis?
presence of bacteria in the blood w/ clinical/ systemic symptoms
What is bacteremia?
presence of bacteria in blood stream
What is Systemic Inflammatory Response syndrome?
SIRS Temp > 100.4 or <96.8 HR >90 RR> 20 or <32 WBC >12K
What is sepsis?
SIRS + Infection
What is severe sepsis?
Sepsis + End organ damage from hypotension
What is Septic Shock?
Hypotension and increased Lactate w/ adequate hydration
Why doesn’t qSOFA work?
its better at quantifying BUT not identifying sepsis
What are the 4 types of shock?
Hypovolemic Shock
Distributive Shock
Cardiogenic Shock
Obstructive Shock
What can shock lead to?
death
