Pain and Wound Management Flashcards
lecture only
Appropriate tx of acute severe pain should not be withheld for fear of facilitating drug misuse; rather, ____ should be but one of many options considered in pain management
opioid use
2 different pain scales
1-10
Wong-Baker Face
Acute Pain Management Options
- NSAIDs - ibuprofen, naprozen, indomethacin, ketorolac
- acetaminophen
- ASA
- ketamine
- lidocaine
- Systemic opioids
Mild to moderate pain
Smooth muscle origin: renal biliary colic
which pain tx?
NSAID
- severe nociceptive pain (damage to body tissue, fracture, visceral pain)
- have little if any role in managing acute neuropathic pain or acute pain flares linked to chronic pain states
which pain tx?
systemic opioids
MC SE of non opiates?
one way to bypass it?
GI upset - take with food
use IV
CI of ketaorolac
1st trimester of pregnancy - get hCG first
topical analgesic agents?
- diclofenac
- ibuprofen
- ketoprofen
- lidocaine
- capsaicin
- methyl salicylate
Variation in pain reduction is related to ?
but not ?
- age, initial pain severity, and previous or chronic exposure to opioids
- body mass or gender
which opioid has the quickest onset and shortest duration?
fentanyl
which opiate weakly inhibits the reuptake of norepinephrine and serotonin, producing a central opioid analgesic effect → can induce serotonin syndrome
Tramadol
definition of addiction
misuse of a medication or drug to the detriment of the patient’s well-being.
definition of dependence?
abrupt cessation of a medication will result in acute withdrawal symptoms.
Dependence on opioids requires regular daily usage for 4 to 6 weeks in most patients
RF for misuse?
concomitant mental health illness or previous drug or alcohol abuse, when prescribing opioids
who to consider avoiding opioids in? (2)
mgmt for this?
- elderly
- naive to narcotics
home observation by a responsible adult
Discharge instructions for those given opioids should include ?
- instructions to avoid making important decisions while medicated
- avoid driving, operating machinery, climbing or working from heights,
- treatment of constipation
- avoid acetaminophen or ibuprofen within 6 hrs of an opioid
- secure opioid prescriptions
2 MC Local Anesthetics
Lidocaine, Bupivocaine
routes for Lidocaine, Bupivocaine
topically, intradermally, subdermally, or infiltrated near peripheral nerve
effects of EPI
increases the duration of anesthesia, helps to control wound bleeding, and slows the systemic absorption.
avoid EPI in who?
- suspected digital vascular injury
- in patients with vascular disease - Raynaud’s or Berger’s disease
- other conditions in which end-arterial vascular supply is problematic
Topical anesthetics are used in three major situations:
- intact skin before dermal instrumentation
- applied to intact mucosa
- open skin for pain control or before wound repair.
indications for nerve blocks
complicated lacerations, abscesses, fractures, debridement, and dislocations
which anesthetics offer a longer duration of action?
which ones are significantly less cardiotoxic?
- bupivacaine, levobupivacaine, and ropivacaine
- levobupivacaine, and ropivacaine
which type of block may not fully anesthetize the distal fingertip.
flexor tendon sheath block
what must you assess before performing a digital block?
Assess cap refill/sensation
definition of chronic pain
3 months, pain that persists beyond the reasonable time for an injury to heal, or pain that persists 1 month beyond the usual course of an acute disease
what is not a recommended ED treatment for chronic pain?
Opioids
possible signs of drug seeking behavior
- Personal h/o illicit drug and alc abuse
- hx given may be factual or fraudulent
- may be demanding, intimidating, or flattering
- complain of panic disorder or drug withdrawal sx and request BZD
- “Allergy” to lower tiered pain meds (NSAIDS, tramadol)
MC complaints of patients who attempt to obtain opioids from the ED?
- back pain
- HA
- extremity pain
- dental pain
mgmt for drug seeking behavior
- refuse the controlled substance, consider the need for alternative medication or treatment, and refer for drug counseling. Escort
- State facts in chart, not “drug seeking behavior”
aberrant drug-related behavior
- forges/alters Rx
- sells controlled substances
- uses aliases to receive opioids
- current illicit drug use
- factitious illness, requests opioids
- conceals multiple physicians prescribing opioids
- abusive when refused
- conceals multiple ED visits for opioids
how to eval lower back pain?
- Neuro exam, MSK
- XR
- If red flags→Sed rate, CRP, CBC, CMP, further imaging
mgmt for lower back pain
- Restriction of activity
- Analgesia, manipulation
- primary NSAIDS, naproxen ibuprofen
- Opioid: 3 day supply- not first line
- Muscle relaxers: maybe, Robaxin - PCP f/u, PT
- Monitor symptoms for 4 to 6 weeks before embarking on further diagnostics
RF for lower back pain
- Alcohol Abuse
- DM
- Renal Failure
- Night Pain
- 3rd Visit in last 20 days
- IVDU
- Fever w/o focus
- Recent/Current Systemic Infection
- Immunosuppression
- Recent Spinal fx/Procedure
- Incontinence or Retention
- Indwelling Urinary Catheter
higher rates of infection:
DM, visible contamination, length greater than 5 cm, and non–head-and-neck
the density of the bacterial population is low on what parts of the body?
upper arms, legs, and torso.
Wounds located on highly vascular areas, such as the ____ or _____, are less likely to be infected than wounds located in less vascular areas
face or scalp
materials/general procedure for wound closure
- “Sterile” procedure: Gloves
- Remove Rings
- Cleaning: CHX or iodine
- Anesthesia: Local vs regional
- Irrigation
- Debridement
- FB removal
pros and cons of sutures
- Pros: strongest most accurate
- Cons: Most time consuming, needle stick risk
difference between absorbable vs nonabsorbale sutures?
- Absorbable: < 60 days, does not need to be removed, intradermal, subcuticular, mucosa - surgical gut chromic gut, polygalactin, collagen derived
- Nonabsorbable: retain strength 60 days, need removed - silk nylon prolene polyester, outermost layer
recommended suture size for scalp?
3-0 or 4-0
what suture size for face?
6-0
suture size for trunk & extremities?
4-0
suture size for digits
5-0
suture size for intraabdominal
2-0
how do you know how many ties to do for simple interrupted?
the number of knot ties should correspond to the suture size
Long linear wounds
Avoided in irregular wounds
Running stitch
- reduce tension on the wound and to close dead spaces
- requires judgment because the benefits for nongaping small wounds are unproven
- presence may increase the risk of infection in contaminated wounds
Buried Dermal
for buried dermal do not suture through what tissue to approximate wound edges? why?
- adipose
- won’t hold tension
- unnecessary in clean surgical cases and only promote infection in contaminated wounds
- results in fairly good wound approximation, often without requiring any percutaneous sutures.
- The second knot is tied with the tails cut short so as to remain buried.
Cutaneous subcuticular
- advantages of deep and percutaneous sutures—closure of gaping wound edges with excellent wound edge eversion.
- useful in very thin or lax skin and in areas where the deep SQ tissues are too fragile to be used for anchoring tension-reducing sutures (e.g., over the shin).
- may result in excessive tension on the more superficial skin edges → reduces blood supply to the skin = necrosis of wound margins
Vertical mattress
- Angled flaps of skin, can be used as initial step
- reduces tension at wound edges and reduces potential for subsequent local necrosis.
- can close a wound with fewer individual stitches because each stitch encases more tissue than other technique
Horizontal mattress
The main disadvantage of the horizontal mattress stitch is ?
the skill required to place the suture to achieve wound eversion.