ER Exam 1 - Wound etc, Environmental, Endocrine + Hem, Back Pain

these bugs may cause infection in dorsal hand lacerations

staph

strep

corynebacterium

Eikenella

what antibiotic should be given for an infected dorsal hand laceration?

outpatient abx treatment?

Unasyn 3 grams IV

Augmentin 875mg BID

treatment of tendon lacerations

consult hand specialist (distal wrist to MCP)

defer all flexion and thumb tendon injuries (we can do extension injuries)

figure 8 knot

open lac = operative repair

closed lac = splint ± operative repair

suture size for LE

4-0 or larger

you should always document ______________ test when evaluating LE injuries

thompson

when to remove FB in laceration

potential for infection, toxicity, functional problems, persistent pain

removal of wood splinter

tend to break off, so make longitudinal incision over splinter

what is the preferred closure method for a laceration with a foreign body?

clean and irrigate, close only if low risk for infection

tertiary intention

what puncture wounds can receive low pressure irrigation?

uncomplicated clean punctures less than 6 hours old

what is the most common causative agent of infection with puncture wounds?

staph aureus (usually plantar)

abx choice for high risk (bites, plantar) puncture wound

cipro, cephalexin

infected puncture wounds should be evaluated via what to look for FB or boney destruction?

x-ray

what should the management be for high pressure puncture wounds?

- parenteral narcotics for pain

- consult hand surgeon (early surgical debridement)

(digital block contraindicated)

what bugs infect human bite wounds?

Eikenella, staph, strep

what should the initial treatment be for human bites causing lacerations?

copious irrigation + left open and prophylactic abx (Augmentin)

(give Unasyn if infected upon presentation)

what is the treatment for dog bites?

- x-ray (for boney involvement or FB)

- copious irrigation

- primary closure (unless on feet or hands)

- antibiotics (Augmentin or clinda or cipro - infection tends to be polymicrobial)

what is the treatment for cat bites?

- x-ray (for boney involvement or FB)

- copious irrigation

- closure if >2cm

- antibiotics (Augmentin or cefuroxime or doxy)

bacteria common in cat bite

pasteruella multocida

components of procedure note

clinical setting

procedure name

indication

contraindications

consent

anesthesia

description

findings

complications

NO H&P or plan or follow up

soft tissue injury resulting from prolonged exposure to nonfreezing cold and moisture

foot pale, mottled, pulseless and numb

(will not improve quickly with rewarming; will also be painful after rewarming x 2-3 days)

trench foot

painful inflammatory lesions typically affecting ears, hands, and feet from chronic exposure to intermittent damp conditions

localized edema, erythema and cyanosis appearing up to 12 hours after exposure + itching and burning paresthesia

chillblains

what is the treatment for trenchfoot and chillblains?

- elevation, warming and bandaging

- nifedipine (20 mg TID)

- pentoxifylline (400 mg TID)

freezing of tissue that presents with stinging, burning, and numbness

frostbite

how is frostbite classified?

by depth of injury and appearance after rewarming

what degree of frostbite is this describing?

partial thickness skin freezing

erythema, edema and LACK of blistering

1st degree (frostnip)

what degree of frostbite is this describing?

freezing of skin and subdermal plexus

hemorrhagic bullae and skin necrosis

3rd degree

what degree of frostbite is this describing?

deeper skin freezing

formation of clear bullae, numbness followed by aching and throbbing

2nd degree

what degree of frostbite is this describing?

extends deeper into muscle, tendon and bone

mottled skin, nonblanching cyanosis with eventual dry black mummified eschar formation

4th degree

what is the treatment for frostbite?

- rapid re-warming in circulating water (20-30 min @ 37-39 C)

- topical aloe vera

- pain management

- local wound care

- splint and elevate extremity

- tetanus

hypothermia is defined as body temperature of less than ______

35 C (95 F)

what are some sxs/s of hypothermia?

shivering, tachycardia, tachypnea, hypertension (mild)

confusion, lethargy, loss of pupillary reflex, bronchorrhea

(all vitals decrease linearly)

what should the workup be for those with hypothermia?

- rectal temperature

- expose pt and remove all clothing

- CBC, BMP, TSH, Lactic acid, clotting

- CXR (looking for infection or aspiration)

- EKG

- routine labs

what are some EKG findings that may be present for hypothermia?

prolongation of PR, QRS, and QT segments

Osborn or J waves

what is the treatment for hypothermia?

- ABCs (ACLS as required)

- gentle rewarming (avoid aggressive rubbing and friction - arrhythmia risk)

- admit if symptomatic or secondary to underlying disease

(pharm therapies ineffective below 30-32 degrees C)

self limited edema in initial exposure to warmth

heat edema

blockage of sweat pores

pruritic erythematous rash

prickly heat (heat rash)

decrease vasomotor tone and peripheral blood pooling in the poorly acclimatized patient

heat syncope

painful cramps in heavily exercised skeletal muscle

treat with fluid replacement with oral electrolyte or IV normal saline

heat cramps

what are the cardinal symptoms/features of heat stroke?

hyperthermia (>40ºC), altered mental status, anhidrosis, seizure

what is the treatment for heat emergencies?

- ABCs

- cool pt down (many methods)

- ICU admissions (most likely)

what is the general local reaction of bites and stings?

pain, erythema, edema, pruritus

what type of insect can cause a sterile pustule that evolves over 6-24 hours and possible cause necrosis and scarring?

fire ant

direct venom effect with GI disturbances and bronchospasm

toxic reaction

would a reaction to a insect bite or sting be worse in severity when the reaction comes on quicker or more delayed?

quicker

what symptoms can a pt experience during a delayed reaction from an insect bite or sting?

fever, malaise, HA, urticaria, lymphadenopathy, polyarthritis

what is the treatment for reactant insect bites and stings?

- remove stinger by scraping

- ice and elevation

- oral antihistamines

- epinephrine .3mg IM

- EpiPen for home and allergist appointment

- admit if severe, >100 stings, extremes of age

Hx: target lesion after a "pinprick feeling"

induration, erythema, blistering

black widow bite

what is the treatment for spider bites?

supportive

what insect bite causes immediate pain and paresthesia with a positive "tap test"? what is the treatment?

scorpion (bark scorpion produces toxicity)

antivenom, resolves 24-48 hours without antivenom

what insect bite causes intense pruritus with burrows concentrated on web spaces, fingers, and toes?

scabies

what is the treatment for scabies?

elimite (permethrin) cream (from neck down)

or

ivermectin PO

what is the treatment for bed bug bites?

local wound care, topical steroids, oral antihistamines

_________ is the most common diving affliction and is caused by the direct mechanical effects of pressure

barotrauma

a medical condition that results from pressure changes that occur when a person descends in water or ascends in altitude

dysbarism

this results from breathing compressed air for excessive depth and time while diving

causes excessive bubble formation in tissue and circulation causing acute occlusive and delayed inflammatory response

decompression sickness (DCS)

what is the treatment for decompression sickness?

high flow oxygen and IV fluids

immediate need for hyperbaric oxygen

death from laryngospasm and hypoxemia without aspiration

dry drowning

survival following asphyxia due to submerging

near drowning

indicators of poor prognosis following near drowning

compromised NV or CV status - CPR required at some point

what assessment should be done for a patient with a "near drowning"?

- ABCs (100% O2, CPAP or intubation)

- assess GCS and O2 sat.

- routine blood work (ABG)

- EKG

- CXR + cervical films

what is disposition largely based on for a near drowning?

GCS score and O2

admit also if associated injury or comorbid condition requiring additional testing or monitoring

(if score >13 and O2 >95% they can be observed for 4-6 hours, then send home)

what type of injury from a burn increases the risk of death, and is very important to evaluate for?

inhalation injury

larger burn, female, older

what type of burn is this describing?

red painful skin without blistering

only epidermis

superficial (1st degree)

what type of burn is this describing?

blistering of skin and exposed dermis is red and moist and very painful

superficial partial thickness (2nd degree)

what type of burn is this describing?

+- blisters; exposed dermis is pale white/yellow

no cap refill and absent pain sensation (parts more superficial are still painful)

deep partial thickness (2nd degree)

what type of burn is this describing?

waxy, leathery and lifeless, +- charring

death of all skin layers, including sweat glands, hair follicles, and nerve endings

full thickness (3rd degree)

what type of burn is this describing?

charring present

epidermis, dermis, subQ, muscle, and sometimes bone involvement

4th degree

what are some clinical indications of an inhalation injury?

facial burns, singed nasal hair, soot in upper airway, hoarseness, wheezing

when estimating burn size adults what percent of the body is the chest?

18

when estimating burn size adults, what percent of the body is each arm (front and back)?

9

when estimating burn size in adults, what percent of the body is the back?

18

when estimating burn size in adults, what percent of the body is the perineum?

1

when estimating burn size in adults, what percent of the body is the whole head?

9

when estimating burn size in adults, what percent of the body is each leg (front and back)?

18

what is the treatment/management of a burn patient?

(ABCs)

airway - faicial burns, wheezing, stridor

breathing - 100% O2

circulation - aggressive IV fluids (Parkland formula)

- apply cool compresses as needed (no more than 10%)

- keep patient warm

- sedation and analgesics

- foley catheter

T/F you should apply ice to burns

FALSE - never

what is the Parkland Burn formula and how is it given?

4 mL x kg x %BSA burned

half in the first 8 hours and other half in 16 hours

(make sure to measure output as well)

an incision made into the necrotic tissue resulting from a severe burn (especially if circumferential)

may be necessary in chest to support breathing

escharotomy

what labs and diagnostics should be ordered for thermal injuries?

ABG w/ carboxyhemoglobin level, CBC, BMP, CXR

what are some treatment options for minor burns?

silvadene (avoid on face can stain) or bacitracin or triple antibiotic ointment

what is the outpatient management for less severe burns?

- cool areas

- cleanse wound

- debride larger or ruptured blisters

- dress with non-adherent dressing

- keep covered from sun

what is the minimal urine output that a burn patient should have?

0.5 mL/kg/hour

when are burn victims sent to a hospital with a specialty burn unit?

3rd degree

<10 or >50

chemical

inhalation

comorbid

trauma like fx

hospital poorly equipped

long term rehab needed

what is the treatment for chemical burns?

decontamination prior to examination

water

what is the treatment for chemical burns from sodium, potassium, calcium, or lithium?

mineral oil (not water in these circumstances)

do alkaline or acidic burns penetrate deeper?

alkaline

AC electricity (standard household electricity) causes _________

DC (ex: lightning) causes ___________

tetany, fibrillation (AC more life threatening)

instant muscle contraction, asystole

what is the treatment for electrical/lightning injuries?

- ABCs

- myoglobin level/CK level

- EKG

treatment high voltage injuries

deep burns may require amputation

acts like crush injury - rhabdomyolysis

fasciotomies

escharotomies

fluid resuscitation

what should the work-up be for lightening injuries?

- EKG

- check for rhabdo

- eye and ear injury

Distinctive feathering marking found on lightning strike victims

Lichtenberg figure

is cardiac monitoring/other testing indicated in a healthy person that has been tasered?

no (likelihood of electrical injury is very low)

Hx of exposure to gas heat, smoke inhalation, acidosis or coma

flu-like symptoms to coma

carbon monoxide poisoning

this is an important lab to measure for carbon monoxide poisoining

COHb (carboxyhemoglobin)

what is the treatment for carbon monoxide poisoning?

highest concentration O2 available

what are the clinical features of hypoglycemia?

sweating, shakiness, anxiety, nausea, dizziness, confusion, slurred speech, blurred vision, HA, lethargy

how can the diagnosis of hypoglycemia be made?

low blood sugar (<50-60) and symptomatic

what is the treatment for hypoglycemia with altered mental status?

50% dextrose 50 mL IV

may need continuous infusion of 5% dectrose to keep glucose >100 (i.e. they took a long acting sulfonylurea)

what is the treatment for hypoglycemia if no IV access?

1 mg glucagon (IM or SQ)

what is the treatment for hypoglycemia that is sulfonylurea induced?

treat as usual

if not responding, give octreotide