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123 Cards in this Set
- Front
- Back
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What dogs are most often involved in fatal dog attacks?
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German Sheppard
Rottweiler Pit bull |
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What organism is suggested in the case of sepsis and contact with a dog or cat?
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Capnnocytophaga canimorsus
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Are cat scratches very different from cat bites?
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No, because the cats often lick their paws
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What is hantavirus pulmonary syndrome?
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A rare febrile illness characterized by bilateral pulmonary infiltrates and respiratory decompensation
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What is B virus?
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A potentially fatal virus that is highly prevalent in macaque monkeys
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How do you manage ferret bites with respect to rabies?
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Same as other domestic animals -> 10 days observation period (ferrets can have rabies and should be vaccinated against rabies)
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What is particular about pig bites?
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They are often very deep and are at high risk of infection
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What are high risk features for bite wound infection?
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-cat, human, primate, pig
-hand, below the knee, through and through, arm, over joint -puncture, crush, contaminated wound, old -diabetes, elderly, asplenia, immunosuppression, PVD, prosthetic valve |
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Which animal bites should not be sutured?
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-human bites to the hand
-cat bites everywhere except the face -monkey bites |
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What is the antibiotic regimen for dog bite prophylaxis?
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cephalexin/dicloxacillin for 5 days
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What is the antibiotic regimen for an established infection in a dog bite?
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Amoxicillin-clavulanate (or clinda and TMP-SMX)
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What is prophylaxis for capnocytophaga canimorsus?
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amoxicillin-clavulanate and penicillin
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What is the treatment for established capnocytophaga canimorsus infection?
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2nd or 3rd generation cephalosporin
OR -ampi-sulbactam OR -clinda and fluoroquinolone |
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What are good prophylactic agents for cat bites?
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-cefuroxime
-amoxicillin clavulanate (either for 5 days) |
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In what other animal bites are prophylactic antibiotics generally recommended?
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-pig
-camel -monkey |
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What is the most important preventative measure against B-virus after monkey bite?
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Immediately wash wound for 15 minutes with providone iodine, chlorhexidine or soap and water
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Where are most closed fist injuries found?
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Over the metacarpophalangeal joint
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How should you treat human bite wounds everywhere but the hand?
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Like any other laceration
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What are good choices for prophylaxis of human bites?
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Amoxicillin-clavulanate
or cefuroxime (either for 5 days) |
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What are the indications to admit a human bite wound to the hand?
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-wound >24 hours
-established infection -penetration of joint or tendon sheath -bone involvement -FB -unreliable patient -diabetic/immunocompromised |
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Which layer of the skin is key for ultimate healing?
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The demis
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What is the superficial fascia?
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The fascia that lies beneath the dermis and encloses the subcutaneous fat
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What is the deep fascia?
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The fascia that lies beneath the fat and covers and protects the underlying muscle
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What processes are involved in wound healing (4)?
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-coagulation
-collagen formation -wound contraction -epithelialization |
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What are risk factors for wound infection
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->8-12 hours since injury
-location (thigh and leg > arm> foot> chest> back>face>scalp -contamination -devitalized tissue, FB, saliva, feces -crush mechanism -subcutaneous sutures -type of repair -sutures >staples>tape -anesthesia with epinephrine -high velocity missile injection |
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How large does a piece of glass need to be in order to be visualized on X-ray?
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1mm
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What is the onset of action and duration of lidocaine?
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seconds
20-60 minutes |
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How much lidocaine is in 1% lidocaine?
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10mg/mL
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How much lidocaine can be safely used?
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3-5mg/kg up to 300 mg/injection
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What is the safe dose for lidocaine with epinephrine?
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5-7mg/kg
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How can you reverse digital artery vasospasm?
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Inject 0.5-2mg of phentolamine locally
or apply topical nitroglycerin |
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What is the duration of action of bupivacaine?
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4-8X that of lidocaine
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What are safe doses for bupivacaine?
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2.5mg/kg - alone
3.5mg/kg - with dpi (max 400mg in 24 hours) |
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How do you add HCo3 to lidocaine, why do we do this? how does it affect the shelf life?
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1:10 therefore 1 mL hCO3 for 10mL lidocaine
-it decreases pain -the shelf life of the lido + Hco3 is 1 week on the shelf and 2 weeks if refrigerated |
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What can be done if there is concern about potential allergy to local anesthetics?
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Use the cardiac lidocaine which contains no preservatives
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What is the most important consideration in wound care with regards to wound infection?
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debridement
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What is the most effective form of wound cleansing?
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high-pressure irrigation
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How can you achieve an irrigation pressure of 7-8 psi?
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18g needle to a 35cc syringe
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What are wound closure options?
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primary closure
delayed primary closure left open to heal on its own |
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Where should subcutaneous sutures never be places?
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in the hand or in the foot ( there are major structures near the surface in these areas)
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When are vertical mattress sutures useful?
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-gaping deep lacerations
-those over a joint |
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When are horizontal mattress sutures useful?
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To disperse excess skin tension
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Which GSWs require antibiotics?
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-high velocity wounds with fracture
-shot gun wounds |
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What antibiotics should be given for GSW?
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cephalosporin
+/- aminoglycoside + penicillin (vs clostridia) |
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When are antibiotics indicated for bites or puncture wounds?
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-cat bite
-intraoral laceration -some dog bites -some human bites -puncture wounds of the foot |
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What organisms are found in cat bites?
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strep species
staph specieis pasteurella multilocida |
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What is the current antibiotic recommended for cat bites?
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amox-clav
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Which dog bites should be treated with antibiotics?
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-hand wound
-puncture wound -wounds in older, immunocompromised patients |
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Which fight bites need IV antibiotics?
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those with any sign of infection
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What are typical pathogens in human bites?
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strep sp
staph sp eikenella corrodens bacteroides |
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Should puncture wounds of the foot be treated with prophylactic antibiotics?
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probably
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What antibiotics should be given for foot puncture wounds?
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cipro - to cover for pseudomonas usually related to rubber soles
-keflex -TMP-SMX or doxy if concerned about MRSA |
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Why do we use dressings?
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To prevent H20 evaporation and which provides a moist environment for healing
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What are general suture removal guidelines?
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face - 4d
other wounds - 7-14 days |
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Which patients are often inadequately immunized agains tetanus?
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>70 years
-immigrants -no education beyond grade school |
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How long does a single TIG injection provide passive immunization for ?
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4 weeks at least?
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When is TIG indicated?
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in a patient who is incompletely immunized? (<3 injections)
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What is the common pathological feature of all burns?
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Protein denaturation
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At what temperature does protein denaturation occur?
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>60 degrees
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What are the zones of burn injury?
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1 - zone of irreversible coagulation necrosis
2 - zone of ischemia 3 - zone of hyperemia |
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What is the source of airway burns?
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1 - steam
2 - products of incomplete combustion |
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Descrive the different wound depths?
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1st degree - erythema and pain
2nd degree (superficial) - blisters, moist, lanches under pressure (deep) white with erythematous area, blanches less 3rd degree - stiff, white or tan, dry, does not blanch and is not painful 4th degree -charred, thrombosed vessels |
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Why is it important to distinguish between superficial and deep 2nd degree burns?
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They often do not heal within 2-3 weeks and result in severe scarring and contracture. Also, they may progress to 3rd degree burns
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What is important to realize about burn depth estimation?
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It must be done serially as the burn may progress over time
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What category of burn is included in Total Body surface area (TBSA) burn calculation?
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2nd and 3rd degree
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What is the fluid of choice in burned patients?
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Lactated Ringers
(avoids hyperchloremic acidosis) |
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How is the diagnosis of inhalational burn best made?
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Fiberoptic laryngoscopy/bronchoscopy
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What are clinical findings of inhalational injury?
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-Facial burn
-Singed Nasal hairs -carbonaceous sputum -History of injury in a closed space |
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What are findings on fiberoptic laryngoscopy/bronchoscopy of inhalational burn?
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Soot
Charring Mucosal inflammation Mucosal edema Necrosis |
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What are the indications for intubation in the burn patient?
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-Upper airway obstruction
-inability to handle secretions -hypoxemia despite 100% O2 -obtundation -muscle fatigue -hypoventilation (PaCo2 >/=50, pH<7.2) |
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What are interventions that may help in patients with inhalational injury?
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-5000-10,000 U heparin in 3mL of saline - nebulized
-nebulized NAC (3-5 mL 20% NAC) |
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Wen should IV fluids be given to burn patients?
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>20% TBSA in adults
>10-15% TBSA in children |
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What is the Parkland Formula?
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4cc/kg/%TBSA burned
-1/2 in the first 8 hours -1/2 in the next 16 hours |
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Which burn patients may require more fluids then the Parkland formula?
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-inhalational injury
-electrical injury -delayed resuscitation |
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What is fluid creep?
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Over fluid resuscitation in burn patients
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What is a significant risk of fluid creep?
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Abdominal compartment syndrome
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What is the best way to cool a burn?
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tap water @ 12-18 degrees (not ice or ice H20)
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What is the consensus on burn blister management?
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-There is none
-it seems from small studies that it is better to leave blisters intact |
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What is the purpose of burn dressings?
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-protect the wound
-reduce pain -absorb exudate -decrease evaporative heat loss |
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What are potential complications of silver sulfazidine?
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-allergy (especially in those with sulfa allergy)
-bone marrow suppression |
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What are 2 methods of treating 2nd degree burns?
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-open method with topical antimicrobials
-closed method with synthetic occlusive dressing |
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When should a burn be referred to a surgeon?
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-extensive burn
-involves the face or the hands -dry or deep |
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What should be applied to a 3rd degree burn in a patient being transferred?
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Petrolatum dressing (NOT silver sulfazidine)
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What is an escharotomy?
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Release of a constricting burn eschar with a scalpel or cautery
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How is an escharotomy performed?
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Make a longitudinal incision down to the fat (typically the biggest mistake is not making it deep enough)
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How can you evaluate if an escharotomy was deep enough?
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re-evaluate Doppler signal and pulse oximetry
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What are the 3 types of emergent/resuscitative pain felt by burn patients?
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-background pain
-breakthrough pain -procedural |
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What are non-pharmacologic ways to decrease pain in a burn patient?
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-cool the burn with H20
-apply a moist dressing |
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List patient groups at higher risk for FB?
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Neurologically impaired
Edentulous Some psychiatric conditions Incarcerated persons Extremes of age |
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What are two delayed sequelae of the intraocular FB?
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enophthalmitis
siderosis bulbi |
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Why is a history of radial keratotomy (LASIK) important when seeing a patient with a potential ocular FB?
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Potential for FB entrapment in the corneal incision (may gape for 6 years post procedure)
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List methods for removal of conjunctival and corneal FB?
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Sweep with moistened cotton-tipped applicator (bulbar or palpebral conjunctiva, not over cornea)
Forceps Eye spud small gauge needle |
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What common procedure for near sightedness makes prolonged attempts at FB removal less desirable?
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LASIK
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What is the recommendation for management of rust rings?
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Outpatient FU with ophthalmology in 24-48 hours for re-examination and removal
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What are the two anatomic narrowings of the ear canal that predisposes to FB lodging?
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Near the inner end of the cartilaginous portion of the canal
Bony narrowing |
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How is the external ear canal locally anesthetized?
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Injecting all 4 quadrants of the canal with lidocaine using a tuberculin syringe inserted through the otic speculum
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List substances used to kill or immobilize insects in the ear canal?
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lidocaine 10% spray
Lidocaine liquide Lidocaine gel 2% Mineral oil with 2% or 4% lidocaine Alcohol |
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List methods of extracting ear canal FB?
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Suction with small catheter
grasping with forceps blunt-tipped right angled hook balloon tipped catheter indirect with irrigation |
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Why is cyan-acrylic tipped swabs not recommended for removal of otic FB?
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risk of contaminating the ear canal
risk of TM rupture |
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Are antibiotics recommended in cases of TM rupture?
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Yes by rosens
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Which particular nasal FB is the exception to the general principle that serious sequelae from nasal FB are rare?
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Alkali button batteries
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What are two general presentation for pediatric nasal FB?
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Early (hours) - child admits to or is observed placing FB in nose
Delayed (days) - purulent, unilateral malodorous nasal discharge or persistent epistaxis |
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List methods by which positive pressure may be used to attempt to expel a nasal FB?
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-kiss from parent
-BVM |
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What premedication adjuncts may aid procedural removal of nasal FB?
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Vasoconstrictors (racemic epinephrine)
anesthetic (lidocaine or benzocaine) |
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List methods of nasal FB removal (after appropriate sedation and restraint)
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-plug other bare and have parent blow into mouth
-blunt tipped right angled probe -suction catheter -alligator forceps -balloon tipped catheters |
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what is penetration syndrome?
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For an aspirated FB
Symptoms fo choking, sensation, resp distress with coughing wheezing and dyspnea which occurs as the object penetrates the air space |
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How does a coin tend to orient on the AP xray when it lodges in the trachea or the esophagus?
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Saggital orientation - suggests tracheal position as does the appearance inside the tracheal column on lateral X-ray
Coronal orientation - suggests esophageal position as does the appearance posterior to the tracheal column on the lateral xray |
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What is the emergent management of airway FB causing airway obstruction?
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Attempt to force the FB out with maneuvers
Perform laryngoscopy with attempts to remove under direct visualization Control the patient's airway |
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What is the initial procedure for a choking infant
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Five back blows with infant in the head down position
Five chest thrusts Intubation Needle cricothyrotomy |
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If during direct laryngoscopy the FB cannot be removed, how may the airway be controlled and the patient at least partially oxygenated and ventilated?
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-intentional intubation of the right mainstem bronchus pushing the FB distally allowing ventilation and oxygenation through the left side of the pulmonary tree
-cricothyrotomy below the level of the obstruction |
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list three constriction points of the esophagus and their radiographic locations?
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Proximal at the cricopharyngeus muscle and thoracic inlet (clavicular level)
midesophagus at the level of the aortic arch and mainstem bronchus (near the carina) distal esophagus just proximal to the esophogastric junction (2-4 vertebral bodies cephalad to the stomach bubble) |
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Why are button disc batteries bad?
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Pressure
Electrical current Corrosive leaks Heavy metal poisoning |
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What pharmacologic agents can be used to attempt esophageal relaxation and impacted food bolus migration distally into the stomach?
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-carbonated beverages
-glucagon (0.5-2mg IV) -nitroglycerin or nifedipine -GI |
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Observation of gastric or bowel FB is continued until what end points?
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Object appears in the stool
Object causes obstruction or perforation Object shows no evidence of progression on xrays taken 24 hours apart |
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How should you manage button batteries in the GI tract?
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-remove if in the esophagus
-if in the stomach, repeat xray in 24 hours to ensure movement into the intestinal tract -once in the intestines, xray every 3-4 days |
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List techniques for attempted rectal FB removal in the ED?
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Digital disimpaction
anoscopy or vaginal speculum +/- ring forceps +/- foley catheter vacuum device forceps sigmoidoscopy |
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What infectious bezoar can act as a urinary tract FB?
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candida bezoar
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List risk factors for candida bezoar?
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DM or immunosuppressed
Neurogenic bladder antibiotic use indwelling catheter |
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Compare FB aspiration in children vs adults?
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Children:
FB is more likely food located in the proximal airway <50% of the time FBs are commonly in the bronchial tree Adults: FB is more frequently non-food 75% of the time it is in the proximal airway |
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What are radiographic findings in the case of FB aspiration?
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Direct signs: identification of the FB itself
Indirect signs: CXR narrowed subglottic space atelectasis bronchiectasis bronchial stenosis airtrapping (flat fixed diaphragm on the involved side with shift of the heart to the uninvolved side during expiration) soft tissues of the neck: prevertebral swelling soft tissue emphysema |
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What are indications for removal of an esophageal FB?
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signs of esophageal rupture
FB ingested >24 hours failed expectant management sharp object disk or button battery wider than 2cm or longer than 5cm |
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What are complications associated with impaction of an esophageal FB?
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Tracheal compression
Esophageal erosion or perforation mediastinitis esophagus to airway fistula esophagus to vascular fistula extraluminal migration formation of esophageal strictures or diverticula |
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What is an appropriate ventilator strategy for burn patients?
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low tidal volume
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