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105 Cards in this Set
- Front
- Back
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Lacerations: definition
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acute traumatic interruption in skin integrity
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What is the key to the management of lacerations?
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mechanism of injury key to management and resolution
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Primary prevention of LACERATIONS
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Safe storage of sharps/knives
Avoid picking up broken glass and other sharps Seat belts Protective equipment and clothing |
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Secondary prevention of LACERATIONS
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NONE
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Laceration: history
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History is critical to management
Mechanism of injury e.g. fall, crushing injury, dog bite Other symptoms e.g. loss of consciousness, bleeding, how bleeding controlled Does history match the injury? Consider abuse |
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Laceration: Physical exam
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Site evaluation: depth, length, description, involvement of bone, joint, tendon, muscle, nerve, ligament
Look for underlying bony deformity (?compound fx) Regional evaluation: ROM, function, pain. SHOULD ASSESS PROXIMAL AND DISTAL JOINT IN CASE TENDON INVOLVEMENT |
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Laceration: Primary intention healing PHASE 1: what days and what does it involve
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days 1-5
Inflammatory response cause increase in leukocytes, fibroblasts and proteolytic enzymes (remove damaged tissue debris) among other inflammatory components |
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Laceration: Primary intention healing PHASE 2: what days and what does it involve
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Phase 2: days 5-14
Fibroblasts form collagen fibers form the tensile strength and pliability of healing wound (scar formation) |
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Laceration: Primary intention healing PHASE 3: what days and what does it involve
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day 14 until healing complete
Collagen deposition allows for normal stress – length depends on type of tissue involved and stresses during healing During this time sutures come out high stress area near a joint (like knee- because need collagen for support- sutures in the face would come out during phase 1) |
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Laceration: management
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Bleeding control
Treat other injuries Pain control Consider referral if hand, face, perineum, tendon/ligament/nerve involvement NB: Tetanus prophylaxis with TdaP or Tetanus immuneglobulin (CDC, 2007). Next slide for specifics Do eye injuries such as abrasions require tetanus prophylaxis? |
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NB for management of laceration
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Tetanus prophylaxis with TdaP or Tetanus immuneglobulin
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Do eye injuries such as abrasions require tetanus prophylaxis?
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Yes
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Do burns require tetanus prophylaxis?
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Yes
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Tetanus booster: what does it do
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stimulates the immune system to make antibodies against the tetanus toxin.
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Tetanus booster: who can have it
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may be given to those who have received 3 tetanus boosters in the past.
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Tetanus booster: how long after injury can it be given
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may be given within 72 hours after the wound occurs.
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Tetanus Immune Globulin: what does it do
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contains an antibody that deactivates the tetanus toxin.
pooled blood from donors that already have tetanus immune globulin in it |
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Tetanus Immune Globulin: who can have it
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must be given to those who have not received 3 tetanus boosters in the past.
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If someone has had less than three tetanus boosters and they have a clean, minor wound: tetanus booster or tetanus immune globulin
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tetanus booster (TD)
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If someone has had less than three tetanus boosters and have non clean or minor wounds (other wounds): tetanus booster or tetanus immune globulin
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Given tetanus booster
AND tetanus immune globulin |
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If someone has had 3 tetanus boosters and has a clean or minor wound: tetanus booster or tetanus immune globulin
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possible tetanus booster
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If someone has had 3 tetanus boosters and has had non clean, non minor wounds (other wounds): tetanus booster or tetanus immune globulin
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possible tetanus booster
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If someone is new to the country of unaware of tetanus history what should you give for non clean or non minor wounds
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tetanus immune globulin
and tetanus booster |
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Clean wound (cut by glass washing dishes) when can you have had tetanus vaccine and it be sufficient
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within 10 years
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Non clean wound (digging in garden) when can you have had tetanus vaccine and it be sufficient
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within 5 years
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If you have a wound that involves the bone when can you have a tetanus vaccine and it be sufficient
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within 1 year
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Who should be referred out for lacerations
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Puncture wounds, crush injuries, or injuries in which a deeper structure, such as a bone or joint, may be involved;
Bites: on the: hand, head, neck, or genital region; Or those in patients with immune compromise, (eg, diabetes, liver disease); bite wounds that require surgical repair; and any severe bite or laceration from a human or cat. |
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Pt factors that affect healing from lacerations
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Age
Weight Nutritional status Dehydration Blood supply to wound Immune response Presence of chronic illness Presence of infection or contamination of wound Other injuries |
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Principles of wound closure
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Hemostatis
Sterile technique Irrigate with 500cc of NS to remove debris Avoid tissue toxic solutions such as iodine (may consider in highly contaminated bites) Avoid excess tissue trauma (do not use betadine or hydrogen peroxide) Maintain moisture in tissue Remove necrotic tissue and foreign material Choose wound closure material which will maximize the opportunity for healing and minimize the likelihood of infection Approximate the wound with as little trauma as possible Eliminate all dead space in deeper tissues (suture deep tissues and upward) Close wound with sufficient tension, but loose enough to prevent excess discomfort, ischemia and necrosis Sterile dressing Immobilize if indicated |
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Rabies prophylaxis is _____ % effective
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100% effective
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The decision to administer postexposure rabies prophylaxis is dependent on:
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the type of animal that was involved, whether the exposure was provoked,
the local epidemiology of rabies, and the availability of the animal for observation or testing (impound animal to see if they have rabies during observation) |
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What is the most common bite?
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Dog bite
(80%) - ONLY CAT BITES ARE MORE LIKELY TO BECOME INFECTED |
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what kind of animals carry rabies
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ONLY MAMMALS
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Rabies bites gets reported to _____
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gets reported to health department
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Can rabies be transmitted person to person?
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NO
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****NB: What is the infection rate for cat bites?
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50%
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What bacteria often causes infections related to cat bites?
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Pasteurella Multocida
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****NB: If human, cat, severe, or immunocompromised: TREATMENT (MEDICATION/CLOSURE)
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Augmentin 875 bid x 5-7 days prophylaxis duration or
Rocephin 1-2 g IV Consider non-suture if present more than 24h – controversial to close at all |
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The most suitable single agent to cover the pathogens of concern in animal and human bites
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oral amoxicillin and clavulanate potassium (Augmentin) or, if intravenous therapy is necessary, ampicillin sodium and sulbactam sodium (Unasyn)
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what is another agent other than augmentin that can be used in bite treatment
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Second-generation cephalosporins may be adequate, but they may be less active against anaerobes than the aforementioned agents.
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what agent can u give to a pt with a bite that is allergic to pcn
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Doxycycline may be considered in patients who are allergic to penicillin, although the anaerobic coverage may be less than ideal.
The most suitable single agent to cover the pathogens of concern in animal and human bites is oral amoxicillin and clavulanate potassium (Augmentin) or, if intravenous therapy is necessary, ampicillin sodium and sulbactam sodium (Unasyn) |
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Length of treatment for bites: prophylactic and established infection
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prophylactic oral therapies are given for 5 - 7 days, and the duration for established infection is usually 7 - 14 days
(AUGMENTIN IS DRUG OF CHOICE) |
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Bite: Education
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Signs and symptoms of infection
Wound care Pain control Wound recheck in 1-2 days if high risk |
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Bites: Complications of healing
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Infection
Wound dehiscence Rabies possible if mammal bite Scarring including keloid formation – especially seen in AAs |
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Bite: Economic, ethical, legal psychosocial, cultural, family considerations
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Unless severe, unlikely to impact employment, or create ethical or legal complications
May be devastating injury if involving face, perineum, hand May require assistance with wound care May require time from employment or family obligations |
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Burns: definition
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tissue injury due to heat, chemicals, electricity or radiation
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Extent of injury is due to the _____________
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duration and intensity of exposure
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Burns: Primary Prevention
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Avoid excess sun exposure, sunscreen
Maintain temperature on water heater to <120 degrees F Close monitoring of common hot liquid including coffee Kitchen safety with hot fluids from meal preparation Safe handling and locking up of chemicals Pots turned to inside of stove to avoid toppling Safety plugs on electrical outlets Safety near open flames Extinguishers readily available home/work/school Smoke detectors Fully extinguish cigarettes Maintain adequate electrical wiring Evacuation plans Be aware of home and workplace fire, chemical, electrical, and radiation risks |
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**********NB: If _____ or ____ ______ present, unable to evaluate depth of wound or determine thickness of burn
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eschar or black crusting
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BURNS: Superficial, Superficial partial thickness, and Partial thickness: DEFINE
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superficial layers of epidermis
varying layers of epidermis and dermis |
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BURNS: Full thickness
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destruction of skin with coaguation of subdermal plexus
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Burn Classifications : Superficial Burn: CAUSE, APPEARANCE, SENSATION, HEALING TIME, SCARRING
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CAUSE
Ultraviolet light, very short flash APPEARANCE Dry and red; blanches with pressure SENSATION Painful HEALING TIME 3-6 days SCARRING None |
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Burn Classifications: Superficial-partial thickness burns: CAUSE, APPEARANCE, SENSATION, HEALING TIME, SCARRING
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CAUSE
Scald (spill or splash), short flash APPEARANCE Blisters; moist, red and weeping; blanches with pressure SENSATION Painful to air and temp HEALING TIME 7-20 days SCARRING Unusual; potential pigmentary changes |
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Burn Classifications:Deep partial- thickness burn : CAUSE, APPEARANCE, SENSATION, HEALING TIME, SCARRING
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CAUSE
Scald by spill, flame, oil, grease APPEARANCE Blisters (easily unroofed); wet or waxy dry; variable color (patchy to cheesy white to red); does not blanch SENSATION Perceptive of pressure only HEALING TIME > 21 days SCARRING Severe (hypertrophic) risk of contracture |
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Burn Classifications: Full-thickness burn : CAUSE, APPEARANCE, SENSATION, HEALING TIME, SCARRING
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CAUSE
Scald by immersion, flame, steam, oil, grease, chemical, high-voltage electricity APPEARANCE Waxy white to leathery gray to charred and black; dry and inelastic; does not blanch with pressure (Destroyed hair follicles, sweat glands & nerves) Sensation Deep pressure only Healing Time Never if >2% TBSA Scarring High risk for contracture |
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Superficial thickness burn
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all that is involved is the dermis
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Superficial partial-thickness burn
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blister, not down to hair follicle
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Full thickness burn
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all the way down
white appearance |
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Deep partial-thickness burns
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wet
blister easily pulls away |
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Rule of 9s
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Each upper extremity 9%
Each lower extremity 18% Anterior or posterior trunk18% Head and neck 10% Hand 1% DOESN'T DESCRIBE CHILDREN VERY WELL |
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Early identification of burn severity: When to have ER care
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extensive burn, more than superficial burn, debilitated, immunocompromised, < 10 years or >50 years
If electrical burn (these burns can cause extensive internal injury with little injury to overlying skin (EKG, urine myoglobin, CK indicated) Fire related burns associated with smoke inhalation (CXR, ABGs, carboxyhemaglobin indicated) |
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Management and interventions - early: BURNS
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ABCs as indicated, consider O2
Fluid resuscitation as needed Flush chemicals for 2 hours Remove rings, watches distal to injury, clothes Pain management e.g. MS IV Avoid ice application Silvadene ung if not allergic, sterile dressing Tetanus prophylaxis as with lacerations |
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BURNS: Diagnostics
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CBC
Chem profile for electrolytes, BUN, creatinine, BS ABG, carboxyhemaglobin, CXR, and bronchoscopy if smoke inhalation likely u/a, urine myoglobin, and CPK levels if rhabdomyolysis a consideration EKG if electrical |
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BURNS: Management and interventions - late
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Care in tertiary center – late complications such as respiratory failure, sepsis, and multi organ failure
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What is the overall goal of burn management
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minimize complications
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How do we minimize complications in the management of burns
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Early mobilization
Grafts Escharectomy High protein, high caloric diet H2 blockers (Curling ulcer prevention) Pain control Wound cleaning, dressing Psychosocial support |
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What type of burns are included in "major burns"
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hands, face, eyes, ears, feet, genitalia; all inhalation injuries
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What is the treatment of major burns
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burn center
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What burns can be treated as outpatients?
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less than 15% partial thickness
less than 2% full thickness EXCLUDES electrical, inhalation, concurrent trauma |
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what burns need to be treated at inpatient medical floors
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15-25% partial thickness
<10% full thickness |
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BURNS: Economic, ethical, legal psychosocial, cultural, family considerations
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90% of survivors return to previous employment income level
Potentially devastating disfigurement with burns to face/perineum/hands/feet |
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BURNS: Health policy implications
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OSHA requirements of the posting of workplace hazards
School evacuation plans Community emergency plans for fires, explosions Building codes for electrical work completed |
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Define: Herpes Zoster
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an infection caused by the virus that is responsible for varicella (CHICKEN POX). Recurrence of the virus (HERPES ZOSTER) represents a reactivation of the dormant virus stored at the dorsal root ganglia (THATS WHY WHEN IT REACTIVATES ITS ALONG A DERMATOME) with advanced age or weakening of the immune system.
USUALLY STARTS OUT PAINFUL BEFORE A RASH ALONG DERMATOME DEMONSTRATES 10-20% overall with increased incidence in those with AIDS, malignancy, elders, and children who experienced varicella at <2mos |
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Herpes Zoster: PRIMARY PREVENTION
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If no previous hx varicella, vaccinate with a series of two immunizations for individuals >13 years.
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HERPES ZOSTER: SECONDARY PREVENTION
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no screening as varicella is a clinical diagnosis
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HERPES ZOSTER: TERTIARY PREVENTION
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MANAGEMENT
Analgesics e.g. NSAIDs or Acetaminophen are not usually effective alone Gabapentin 300 – 1200mg qd tx pain and insomnia Lidocaine patches to site if intact skin (Lidoderm 5%) Narcotics as needed Median pain duration was 32.5 days (Drolet, et al, 2010) *NB: Treatment: If within2-3d: with moderate or severe pain, or >50years of age (up to 10 d if eye involvement [2011]) Acyclovir 800mg 5x/d x 7-10d or 10mg/kg IV q8h x 7d Famciclovir 500mg tid x 7d Valacylovir 1gm tid x 7d |
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HERPES ZOSTER: Symtomotology & Assessment
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Recurrence of herpes zoster (Shingles) follows that of original varicella infection:
Constitutional sx Malaise Fever HA Pain at site of rash occurs during Shingles only (itching with initial infection) REMEMBER A NERVE IS CARRYING THE VIRUS- NERVE PAIN Regional lymphadenopathy Rash follows pain by 3-5d (Ferri, 2013) Erythematous maculopapular rash (Shingles occurs most frequently on thorax) (PAPULE IS RAISED) Which evolve into vesicles of various sizes (Herpes simplex usually is characterized by homogenous sized vesicles) Then pustules by 3rd or 4th day Crusting which may last up to 3 weeks (Scarring may occur) FLAT--THEN RAISED---THEN VESICLES--THAN ERUPTS (IN VARIOUS STAGES) |
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Differentials for rash:
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Herpes simplex
Other viral rashes cellulitis |
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Differentials for localized pain in thorax:
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PE
Pleuritis Pericarditis Renal colic |
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*****HERPES ZOSTER: MANAGMENT
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Analgesics e.g. NSAIDs or Acetaminophen are not usually effective alone
Gabapentin 300 – 1200mg qd tx pain and insomnia (TAKES A AWHILE TO DEVELOP- START AT 300 mg PO DAILY AND BUILD UP TO 4 TIMES DAILY- MAKES YOU SLEEPY-HELPS WITH INSOMNIA) Lidocaine patches to site if intact skin (Lidoderm 5%)- COMPLETELY INTAKE SKIN Narcotics as needed (INITAL- LOW LEVEL NARCOTIC) Median pain duration was 32.5 days (Drolet, et al, 2010) *NB: Treatment: If within 2-3d: with moderate or severe pain, or >50 years of age (up to 10 d if eye involvement [2011])- GIVEN ANTIVIRAL AGENTS Acyclovir 800mg 5x/d x 7-10d or 10mg/kg IV q8h x 7d Famciclovir 500mg tid x 7d Valacylovir 1gm tid x 7d Coverage for possible Staph aureus or Strep pyogenes if secondary cellulitis Continue to evaluate for post herpetic neuralgia, the incidence of which increases with age (Ferri, 2013) |
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HERPES ZOSTER: Non-pharmacological & complimentary tx reactivation
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Wet compresses using Burrow’s solution or cool tap water 15-30min 5-10x/d provides local soothing and reduction of exudate
Consider hospitalization for disseminated disease, those not responding to traditional treatments for IV Acyclovir. Sympathetic block with intractable post-herpetic neuralgia. |
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Post-herpatic neuralgia: treatment
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Treatment by pharmacotherapy includes
anticonvulsants, antidepressants, topical lidocaine (lidoderm patch) high dose capsaicin (ON INTACT SKIN), and opioids either used individually or in combination (IF ON LONGER THAN MONTH GO TO PAIN SPECIALIST) |
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HERPES ZOSTER: Case management
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Pt/family psychosocial considerations
Contagious nature of exudate needs to be explained to family to avoid contact with immunocompromise or no hx of varicella especially if pregnant. Psychosocial/cultural considerations Pain expression and control are culturally and psychologically influenced. Consider stoicism in some patients and encourage pain management for improved function during infection. Economic/ethical/legal considerations Economic issue if post herpetic neuralgia continues and influences employment. |
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Scabies
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Often first noticed in hands where there are rashes and tracks of red linear papules.
ERTHYEMATOUS BASE- CLEAR CENTER- LINEAR WEB SPACES ARE CLASSIC WET SPACES ARE CLASSIC (BELT AREA) Seen in web spaces between fingers, knees, elbows, penis, beltline, scapula Itching is worse at night (classic sign) Symptoms may appear 4-6 weeks after exposure!! |
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***Scabies: Treatment
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Instruct:
Occurs in all social, cultural, economic groups. Spreads quickly in crowded conditions where there is frequent skin-to-skin contact between people (household, hospitals, child-care centers and nursing homes). Sharing clothes, towels, and bedding can also spread scabies. Pets get a different mite infection (mange). Permethrin (Elimite, Acticin) 5% HS - apply over all the body, from your neck down to between toes, (include under nails and groin) and leave the medication on for at least 8-14 hours. ***do not put on face**** All members of family treated at same time. NB: Not studied in children <2months Wash all clothing, blankets, towels used in previous 2 days etc in HOT water (>140F) and HOT dryer Those items that cannot be washed need to be placed in an air-tight bag for 2 weeks. Itching may continue for 2-3 weeks and doesn't indicate lack of effective treatment Antihistamines are usually helpful for pruritis For scabies: Permethrin topical 5% to FROM NECK DOWN at HS with removal in 8 – 14 hours Overall Permethrin not used for children < 2 months May be used in pregnant women – Category B |
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Pediculosis
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Lice in scalp hair, nits are firmly attached to hair.
Permethrin topical 1% used to hair and scalp – removed after 10 min |
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Atopic dermatitis
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Papular eczematous dermatitis with redness and scaling, vesicular lesions.
DARK RED SCALY DRY DISTRIBUTION HAPPENS A LOT WITH PEOPLE WITH ASTHMA AND ALLERGIES Rx: Cutaneous hydration, Glucocoticoids possible, Avoidance of irritants (FRAGRANCE IN SOAPS/LAUNDRY SHEETS COMMON) ALSO HELPS SOAK IN WARM TUB, NO SOAP. GET PRUNEY, LATER UP ON THICK NON FRAGRANCE CREAM (NOT RUNNY LOTION) |
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Tinea Corporis
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AKA RING WORM
Flat spot with central brown area or hypopigmentation CENTER IS A LITTLE LIGHTER THAN THE REST OUTER AREA IS A LITTLE MORE RAISED Rx: Topical imidazoles TOPICAL AGENTS BEST FOR SKIN LESIONS BECAUSE YOU AVOID SYSTEMIC EFFECTS |
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Contact dermatitis
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CAN BE FROM POISON IVY OR WHATEVER
Erythema ,dryness, and vesicles are seen. Rx: Topical glucocorticoids (FOR HANDS NEED GLOVES), Avoidance of irritants IF HANDS ASK ABOUT GENITALIA (COULD DEVELOP CELLULITIS IF SCRATCH) |
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Halo nevus
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A preexisting nevus develops a surrounding rim of hypo pigmentation that may indicate it will fade over next few months.
WILL FADE NOT IMPORTANT |
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Candidiasis
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Red moist glistening plaques extend to just beyond the limits of opposing skin folds. Advancing border is sharply defined – with ‘satellite lesions’
MEATY BEEFY RED SHARPLY DEFINED BORDERS WITH SATELLITE LESIONS UNDER WOMEN'S BREAST COMMON AREA Rx: Nystatin powder, Ketoconazole cream. |
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Paronychia
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Superficial infection of the skin around the nail at the cuticle and nail bed. Localized redness and swelling
Rx: Soaks, Incision and Drainage (I&D) SOAK UNTIL REALLY SOFT AND RUN EDGE OF HOOK OF NAIL CLIPPER AROUND CUTICLE TO GET HANGNAIL BACK IN LINE UNTIL YOU CAN CLIP IT – if mild, treat with topical e.g. bacitracin topical 500u/g tid If moderate, add oral Dicloxacillin, Cephalexin (TREATING STAPH OR STREP) -BC OFTEN CAUSED BY BITING HANGNAIL) |
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Basal Cell Carcinoma
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Irregular oval mass (papule) with the surface becoming multilobular. Superficiual telangiectasias are seen; may be pearly white or a firm lesion
NOT ROUND AND SMALL, DIVETS, IRREGULAR, SEVERAL DIFFERENT AREAS OF HEIGHT. Rx: Needs bx. Electrodessication and curettage, excision (98% effective) |
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Squamous cell carcinoma
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Ranges from in situ to metastatic. Similar to lesions such as actinic keratosis
Smooth, dull red, firm, dome shaped, sharply defined nodule with a potentially crusted center – can be from mouth, plantar feet. Rx: Surgical excision, radiation. CAN LOOK A LOT OF DIFFERENT WAYS |
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Melanoma
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Up to 20% are metastatic; 99% of in situ cases are not recurrent.
Various appearances: Raised, brown to black and rapidly appearing, growing papules which may suggest a vascular lesion and may have focal hemorrhage. (RED, WHITE, OR BLACK) Rx: Wide surgical excision, elective regional node dissection, chemotherapy |
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Lyme disease
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Erythema migrans involving spontaneously fading central erythema leaving light blue surface.
Ring remains flat, blanches with pressure, does not desquamate and the erythema migrans border may be slightly raised. Rx: Doxycycline, Amoxicillin. |
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Stevens Johnson Syndrome
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Erythematous papules, purpuric maculae widespread on the trunk are seen. Small vesicles on macules are seen.
Rx: Discontinuation of causative drug, hydration, steroids, intensive care often required. DIFFERENTIAL WOULD BE MENINGITIS SULFA ALLERGY IS A COMMON CAUSE FOR THE REACTION |
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Impetigo
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Thin roofed bullae,flat honey colored crusts are seen.
WITHIN A BEARD IS CLASSIC Highly contagious!! Rx: Topical anti-staph agents e.g. mupirocin or fusidic acide may be effective and used prior to consideration of starting po agent IT IS A STAPH INFECTION (CAN BE MRSA) |
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Cellulitis
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Characterized by erythema, edema and pain (usually an extemety). Vesicles, blisters may be seen.
Rx: Augmentin, but consider MRSA coverage with Vancomycin |
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Meningitis manifestation Rash
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Diffuse erythematous maculopapular rash becoming petechial found upper limbs, trunk and face.
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Rubeola
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Erythematous, nonpruritic, maculopapular rash is seen spreading on the trunk. Brownish discoloration of skin may occur later.
STARTS AS LIKE A CAN OF RED PAINT BEING POURED OVER HEAD AND DOWN TO TRUNK (ALL RED AND THEN MEASLES FORMATION) Rx: supportive, symptom based. Vitamin A for severe measles. |
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Varicella zoster
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Thin walled clear umbilicated vesicle and simultaneous presence of other lesions (vesicles, pustules, crusts).
VARYING STAGES Rx: Supportive care if low risk, immunocompromised, Otherwise consider Acyclovir (WITHIN 3 DAYS, MODERATE OR SEVERE, OR OVER 50 YEARS OLD) |
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Scarlet fever
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Diffuse blanchable erythema on face spreading to trunks, circumoral pallor: and paper texture to skin; accentuation of linear erythema in skin folds.
Rx: Treat underlying group A Beta hemalytic streptococcus infection |
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NB: Should be able to describe lesion by ABCDE method if not able to diagnose immediately
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DISCRETE
GROUPED CONFLUENT LINEAR- DERMATOME ANNULAR POLYCYSTIC GENERALIZED- VARICELLA ZOSTER FORM |
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Non-palp lesions
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PALPABLE
NONPALPABLE FLUID FILLED |
