EM #1 Flashcards
(293 cards)
1
Q
What is most common reason for people coming into ED?
A
lack of access to other providers
2
Q
What percent of patients come to the ED because of lack of access to other providers?
A
80%
3
Q
What GCS classifies a severe TBI?
A
under 9
4
Q
Who has the highest rate of mortality from TBI?
A
young (15-24yo) and old (over 65yo)
5
Q
What is the leading cause of TBI?
A
MVA (alcohol #2?)
6
Q
Who is at risk for TBI?
A
young/old low income unmarries ethnic minorities inner city residents men individuals w/substance abuse individuals w/ hx TBI
7
Q
What classifies moderate GCS?
A
9-12
8
Q
What classifies minor TBI?
A
13-15
9
Q
What is GCS?
A
15-point scale used to rate mental status and function (used to rate severity of brain injury and predict outcome)
10
Q
When should GCS be administered?
A
at triage and repeatedly during eval (any decrease is DANGER sign!)
11
Q
What are type of TBI primary injuries?
A
- 3 types of tissue deformation (compression, tensile, shear)
- mechanical injury to neurons/axons
- coup/countrecoup
- acceleration and deceleration
12
Q
What are secondary TBI injuries?
A
Minutes-days AFTER initial injury:
- microscopic/cellular
- cerebral arterial dilation
- hemorrhage
- cerebral edema/increased icp
13
Q
What are signs of basilar skull fracture?
A
- Battles sign (ecchymoisis of mastoid)
- Raccoon eyes (periorbital ecchymoses)
- CSF rhinorrhea
- hemotympanum
- vertigo
- decreased hearing
- 7th nerve palsy
14
Q
What are signs of patient NOT having significant intracranial injury?
A
- No HA
- No vomiting
- under 60
- no intoxication
- no memory problems
- no physical evidence of trauma above clavicles
- no seizure
15
Q
Who gets a CT?
A
-GCS under 15 2hrs after injury
-suspected skull fracture
-any signs of basilar skull fracture
-2 or more episodes of vomiting
-65 or older
-amnesia before/after impact
dangerous mechanism (pedestrian, ejected from vehicle, fall over 3ft/5 stairs)
-ANY neuro deficits
-Oral anticoag use
16
Q
What is a post-traumatic seizure?
A
- w/n first week after injury (most w/n first day)
- If happens, increases risk of post-traumatic epilepsy to 1/4 (resistant to typical anticonvulsant tx)
17
Q
When does post-concussion syndrome occur?
A
occurs even with mild TBI and occurs days-weeks after initial concussion
18
Q
What are sxs of post-concussion syndrome?
A
HA dizziness memory problems depression/anxiety difficulty concentrating sleep problems difficulty concentrating restlessness/irritability
19
Q
What are common areas of brain contussion?
A
orbitofrontal cortex, anterior temporal lobe, posterior portion of superior temporal gyrus
20
Q
What can brain contussion lead to?
A
herniation, midline shift, increased ICP
21
Q
What are cerebral contussions and intracerebral hemorrhage associated with?
A
subarachnoid hemorrhage
22
Q
What is a diffuse axonal injury?
A
acceleration/deceleration MOI where shear forces injure axons in white matter
23
Q
What is a common cause of diffuse axonal injury?
A
shaken baby syndrome
24
Q
Where does diffuse axonal injury commonly occur?
A
junction of grey and white matter
25
How do you classify diffuse axonal injury?
Mild- coma 6-24hrs, usually recover w/o sequelae
Moderate- Coma over 24hrs, wake up w/long-term sequela
Severe- prolonged coma, persistent vegitative state
26
How do you treat diffuse axonal injury?
supportive
27
What is the most common CT abnormality in patients with moderate/severe TBI?
subarachnoid hemorrhage
28
How does a subarachnoid hemorrhage present?
blood in CSF, headache (severe), photophobia, meningeal signs
29
What can subarachnoid hemorrhage lead to?
Increased ICP due to blockage of CSF outflow at 3rd and 4th ventricles
30
What is a slow/venous bleed of bridging veins?
subdural hematoma
31
Who is at risk of getting subdural hematomas?
people with cerebral atrophy (elderly, alcoholics)
32
How do subdural hematomas appear on CT scan?
Concave, CRESENT-shaped
33
Are subdural hematomas acute or chronic?
Can be both!
34
What is the initial clinical presentation of someone with an epidural hematoma?
brief LOC followed by a lucid period
35
Which artery is the source of bleeding?
Middle meningeal artery (from temporal blow to head)
36
How do epidural hematomas appear on CT?
Football shaped
37
What are late findings in someone with an epidural hematoma?
fixed, dilated pupil on ipsilateral side with contralateral hemiparesis
38
What is a type A brain herniation?
Subfacial (cingulate) herniation
39
What is a type B brain herniation?
Uncal herniation
40
What is a type C brain herniation?
downward
41
What is type D brain herniation?
External herniation
42
What is type E herniation?
Tonsillar herniation
43
What are the 3 types of brain herniation that are caused by focal, ipsilateral space-occupying lesions (tumor, hemorrhage)?
A, B, E
44
What is the definition of ICP?
volume of brain, volume of CSF, volume of blood, volume of mass lesion (all NON-COMPRESSIBLE!)
45
How do you calculate CCP?
MAP- ICP
46
When is CCP critical?
50-70
47
How do you adjust CCP?
Increase MAP (IVP, pressors) or Decrease ICP (osmotic diuresis, HOB elevation, burr holes, hyperventilation)
48
What is one of the most common pre-hospital procedures?
spine immobilization
49
Who is at risk for C-spine injuries?
- 80 percent cervical fractures in males
- 25 percent involve alcohol
- Elderly (osteoporosis)
- Other (RA, downs, chronic steroids)
50
Where does the cord that controls motor movement cross?
Medulla
51
Where does the cord that controls pain/temp cross?
At level in spinal cord
52
Where does the cord that controls vibration/proprioception cross?
Medulla
53
Where is the most common location to injure ones spine?
Cervical (55 percent)
54
What are primary spine injuries?
frature, dislocation, tearing ligament, disruption of discs
55
What are characteristics secondary spine injuries?
- minutes to hours after injury
| - AVOID HYPOTENSION!
56
How do you dx a cord injury?
MRI
57
Hhow do you treat a cord syndrome?
dexamethasone
58
What is MOI of central cord syndrome?
forced hyper-flexion of neck
59
How does central cord syndrome present?
- muscle weakness (more in upper extremity)
- lose pain and temp sensation in cape-like distribution
- proprioception/vibration intact
60
What is the prognosis for central cord syndrome?
Will probably recover fine
61
What is MOI of Anterior Cord Syndrome?
hyperextension of neck (ex: MVA, vascular injury, vertebral compression fracture)
62
Who is anterior cord syndrome more common in?
elderly
63
How does anterior cord syndrome present?
- weakness and loss of pain/temp on both sides distal to lesion
- vibration/proprioception intact
64
What is prognosis for anterior cord syndrome?
not great
65
What is MOI of Brown-Sequard syndrome
Penetrating injury (stabbing) that paralyzes half of cord
66
How does Brown-Sequard syndrome present?
- Loss of strength strength and proprioception/vibration on same side of injury
- loss of pain/temp on opposite side
67
What is NEXUS?
Criterion for when NOT to get C-spine xray
68
What are criteris in NEXUS? (5)
- No posterior midline cervical spine tenderness
- No evidence of intoxication
- Normal level of alertness
- No neuro deficits
- No painful distracting injury
69
What is next step if meet all NEXUS criteria?
ok to remove collage, no imaging needed
70
What is next step if yes to at least ONE of NEXUS criteria?
C-spine xray or CT
71
What are the 3 views to get for C-spine imaging?
- long AP
- lateral
- mouth
72
What must a lateral c-spine xray include?
T1
73
What happens if injury at C4?
loss of spontaneous breathing
74
What happens if injury at C5?
loss of shoulder shrug
75
What happens if injury at C6?
loss of flexion at elbows/triceps reflex
76
What happens if injury at C7?
loss of extension at elbow/triceps reflex
77
What happens if injury at C8/T1?
Loss of flexion in fingers
78
What happens in injury at T1/T2?
loss of intercostal muscle and abd muscle use
79
Which xray view shows 70 percent of abnormalities?
lateral neck
80
Which xray view do you use to see spinous processes are in straight line?
Long AP view
81
Which xray view do you use to see lateral margins of C1 and C2?
open mouth
82
Which xray view do you use to see contour lines and vertebral bodies?
lateral neck
83
Which xray view do you use to see distance between odontoid peg and lateral masses?
open mouth
84
Which xray view do you use to see the distances between spinous processes?
long AP view
85
Which xray view do you use to see intervertebral disc space?
lateral neck
86
Which xray view do you use to see prevertebral soft tissues?
lateral neck
87
Do normal xrays r/o significant cord injury?
Nope (always use clinical judgement!)
88
What is a Jefferson fracture?
C1
89
What is MOI of Jefferson fracture?
axial loading (diving)
90
What is an odontoid fracture?
C2 (more than half of a all C2 fractures)
91
What are sxs of Jefferson and odontoid fractures?
may have few sxs because no spinal cord injury, but both very unstable!
92
What is a hangmans fracture?
C2
93
What is MOI of hangmans fractures?
Forced hyperextension of neck (Falls, MVA, hanging)
94
What is a clay shovelers fracture?
stable fracture of spinous process (no neuro problems)
95
What is a burst compression fracture?
Involves posterior half of vertebrae (may result in retropulsed fragments that can impinge on spinal cord and cause neuro damage)
96
What are S/S of Cauda Equina syndrome?
- bowel/bladder dysfunction
- decreased rectal tone
- saddle anesthesia
- decreased lower extremity DTRs
- sciatica
97
What percent of ED visits are for people over 65?
25 percent
98
What are factors in geriatric ED medicine?
- longer stays
- multiple medical problems
- polypharm
- vague/atypical sxs
99
What are cardiovascular changes in elderly? (5)
- Decreased HR, CO, EF
- Impaired ventricular compliance
- Thickening valves
- Decreased response to sympathetic stimuli
- Increased prevalence of CAD, CHF
100
What are pulm changes in elderly? (6)
- Decreased lung compliance, increased CW stiffness
- Decreased strength/endurance of resp. muscles
- Decreased vital capacity, expiratory flow
- Decreased mucocilliary clearance mechanisms
- Increased sensitivity to narcotic-induced resp. depression
- Increased incidence of small airway closure
101
What are renal changes in elderly? (6)
- decreased GFR
- Decreased renal mass, blood flow, permeability
- Decreased ability to concentrate urine (decreases ability to conserve H2O)
- Dysregulation of renin-angiotensin system
- Impaired Vit D metabolism
- Decreased thirst mechanism
102
What are GI changes in elderly? (4)
- Impaired swallowing
- Impaired GI mucosal protection
- Decreased GI motility and absorption
- Impaired hepatic drug clearance
103
What are MSK changes in elderly? (2)
- Decreased muscle mass
| - Decreased bone density
104
What are intergumentary changes in elderly? (4)
- Decreased subcutaneous fat, loss of elastic collagen
- Decreased glandular function
- Skin thin and fragile
- Increase benign/malignant skin changes
105
What are neuro changes in elderly? (5)
- Neuronal loss
- Increased stroke risk
- Cerebral atrophy
- Impaired memory and cognition
- Impaired sensory function
106
What are come complications of falls in elderly?
- TBI
- C-spine injury
- Fracture
- hematoma
- intra-abd injury
- lacerations
107
What are risk factors for falls in elderly?
- hx falls
- increased age
- female
- cognitive impairment
- dizziness/balance problems
- peripheral neuropathy
- hx stroke
- psychotropic drugs
- arthritis
- orthostatic hypotension
- vision impairment
- PD
- DM
- Etoh use
- trip hazards in home
108
do elderly patient having an MI always have chest pain?
no
109
What are risk factors for serious disease in elderly?
```
Temp over 103
RR over 30
WBC over 11k
HR over 120
positive CXR
```
110
What are common causes of delirium?
- infection
- hypoxia
- metabolic (Na, glu)
- CVA
- polypharm
- substance abuse/withdrawal
- med SE
111
What percent of all ED visits are due to adverse drugs effects in patients over 65?
11%
112
What are reasons geriatric patients are more susceptible to med SE?
- changes in drug metabolism/kidney function
| - increased risk drug-drug reaction
113
What are some high risk drugs for geriatric patients?
- anticholinergics
- insulin
- sulfonylureas
- warfarin
- digoxin
- benzos
- diphenhydramine/antihistamine
- opioids
- antipsychotics
114
What is the most common type of burn?
thermal burn
115
When should you suspect myocardial depression in a burn patient?
Burn over 40 percent of TBSA
116
What temperature causes a thermal burn?
over 115 degreed F
117
What is the severity of a burn based on?
depth, extent, location
118
What is the outermost layer of skin called?
epidermis
119
What is the layer of skin that contains capillaries/nerves/hair follicles?
dermis
120
What layer of skin is a layer of adipose tissue and connective tissue?
hypodermis
121
When should you re-eval burn depth?
24-72 hrs
122
Who/when should you definitely re-eval burn depth in?
- under 5, over 55
- volar surface of arms
- medial thighs
- perineum
- ears
- esp. thin skin!
123
What type of burn has red, dry painful skin with NO blistering?
superficial burns
124
Do superficial burns blanch with pressure?
yas
125
What layer of skin is involved with superficial burns?
epidermis only
126
How long does it take for superficial burns to heal?
heals w/n 4-7 days w/o scarring
127
What type of burn is red, moist, painful and HAS BLISTERS?
superficial partial thickness
128
What layers of skin are involved in superficial partial thickness?
epidermis and extends into dermis
129
Does skin blanch in superficial partial burns?
yas
130
How long does it take superficial partial burns to heal, and is there scarring?
heals w/n 14-21 days w/o scarring
131
What type of burn is the skin white/yellow and pressure can be felt but no overt pain?
deep partial thickness
132
Is blanching present in deep partial thickness burns?
nope
133
What other sensation is lost with deep partial thickness burn?
2-point discrimination
134
How long does it take deep partial thickness burns to heal and is there scarring?
healing 21 days- 3 months, scarring common
135
What type of burn presents as charred, black-pale and waxy white, leathery and is PAINLESS?
full thickness burns
136
How long does it take full thickness burns to heal?
will NOT heal spontanesouly, need skin graft
137
What layers of skin are involved in a 4th degree burn?
extends into deeper tissue (fat, bone, muscle)
may require amputation
138
When is total body surface area used to describe the extent of a burn injury?
only for burns more severe than superficial
139
What percent of a persons body is their head and neck?
9 percent
140
What percent of a persons body is their entire chest and abdomen?
18 percent
141
What percent of a persons body is their back and butt?
18 percent
142
What percent of a persons body is one entire arm (front and back?
9 percent
143
What percent of a persons body is one entire leg (front and back)?
18 percent
144
What can you use to estimate 1 percent of BSA?
A persons hand (including fingers)
145
What can be used to better estimate BSA in children as their head size relative to body?
Lund-Bowder diagram
146
What burn locations make burns more serious?
- circumferential burns
- burns covering joints
- burns involving face (eyes), hands, feet, genitalia/perineum
147
What defines a minor burn? (7)
- partial thickness under 10% BSA pts 10-50yo
- Partial thickness under 5% BSA under 5yo, over 50yo
- full thickness burns under 2% BSA w/o other injury
- may NOT involve face/hands//feet/perineum/genitalia
- may NOT cross joints
- may NOT be circumferential
148
Who gets referred to a burn center?
Basically anything other than a minor burn
149
What should you do immediately when treating minor burns?
Cool them!! with cool/room temp H2O
150
What do you clean minor burns with?
mild soap and H2O
151
What topical antibiotics do you use for minor burns?
- silver sulfadiazine (not under 2yo)
| - bacitracin, triple abx ointment, honey
152
What do you want to avoid when treating minor burns?
lanolin (increased itchiness)
153
What vaccine do you want to give burn victims?
tetanus
154
What do you use during the final phase of healing of a burn?
non-perfumed moisturizing cream
155
How soon should someone with a minor burn follow up?
in 24 hours, then in 1 week
156
What is the most common cause of death in burn victims?
smoke inhalation injury
157
What does smoke inhalation lead to?
rapid airway edema
158
What are signs of smoke inhalation injury?
- carbonaceous sputum
- singed facial/nasal hairs
- facial burns
- oropharyngeal edema
- voice changes
- assume injury if person confined in fire environment
159
What should you be concerned about with a burn that is over 15 percent BSA?
hypovolemia
160
What is the Parkland formula?
determines how much fluid to give to burn patients?
161
How do you calculate the parkland formula?
percent BSA + wt(kg) + 2cc
162
What is the timing of fluid resuscitation in burn patients?
half in first 8hrs, remaining over 16 hrs
163
What do you use to calculate how much fluid to give children?
Galveston formula
164
What should you monitor for while cooling a burn that is over 10 percent BSA?
hypothermia!
165
What lab do you want to order to check for muscle breakdown in burn patients?
CPK
166
What do you have to be mindful of with circumferential burns?
eschar
167
When should an eschartomy take place?
12-24 hrs after injury
168
What can an NTG trial for CP help with?
angia, esophageal spasm, cervical disc disease
169
A patient presents with central CP that worsens when supine and improves with sitting and leaning forward
pericarditis
170
What PE finding do you have with pericarditis?
friction rub
171
What is the most common cause of pericarditis?
viral (coxsackie)
172
What are other causes of pericarditis?
- uremia
- early post-MI (2nd-3rd day)
- neoplastic disease
- Dresselers syndrome (2-6 weeks post-MI)
- others (trauma, drug-induced, radiation, autoimmune)
173
What are the ECG findings in pericarditis?
diffuse ST-elevation (all leads except Avr and V1)
174
What imaging stusy do you have to do on all pericarditis patients to confrim resolution?
echo!
175
How do you treat pericarditis?
NSAIDS
176
What do you want to avoid with pericarditis?
anticoag! (potential risk to bleed into pericardium)
177
What are risk factors for a PE?
- STASIS
- cardiac d/o (afib, HF)
- hypercoagability (OCP, neoplasm, factor V leiden)
- trauma
- chemo
- smoking
178
What are the 3 sxs that most patients with PE have at least one of?
- tachypnea
- dyspnea
- pleuritic chest pain
179
What lab do you want to order for PE?
d-dimer! (sensitive, but not specific)
180
What is the initial imaging of choice for PE?
-Helical CT angiography
non-invasive, requires contrast
181
What is the definitive imaging test?
pulmonary angiography (invasive!)
182
How do you treat PE?
Full anticoag x3-6 months
183
What is the INR goal for pts with PE on coumadin?
2-3
184
Who has atypical presentations of STEMIs?
- elderly (fatigue, abd pain)
- women (right-sided pain)
- diabetes (painless MI)
185
What is the dose of aspirin you give someone with STEMO?
160-325mg
186
What is the ECG criteria for STEMI?
- Over 2mm ST elevation precordial leads
| - Over 1mm ST elevation limb leads in 2 adjacent leads
187
What do you give for pain during STEMI?
- NTG (0.4mg SL q5min up to 3 doses)-- avoid if SBP under 90
- Morphine sulfate
- BB
188
What labs do you want to order serially with STEMI?
- CK-MB
- troponins
- INT/PTT
189
What are the 3 different reperfusion strategies for tx of STEMI?
- PCI (requires facility available)
- fibrinolytic
- facilitate PCI
190
What is the ideal "door to balloon" time for PCI?
90 min
191
What is the goal time for keeping ischemic time undeR?
120 min
192
How soon do you want to initiate fibrinolytic therapy?
w/n 30min
193
What are contraindications for fibrinolytic therapy?
- hx hemorrhage
- prior stroke w/n 1 yr
- internal bleeding
- recent head trauma
- recent surgery (w/n 3 wks)
- over 65yo
194
What is a Type A aortic dissection?
dissection starts at aortic arch, proximal to L subclavian
195
What is a Type B aortic dissection?
dissection starts proximal to descending aorta beyond subclavian
196
What are sxs of aortic dissection?
- CP radiating to back
- HTN usually present
- sometimes femoral bruits
197
What urgent imaging do you want to get in ED?
multiplanar CT (need low threshold)
198
What is ASAP tx for aortic dissection?
Lower dat BP! (goal is SBP 100-110)
199
What do you use to lower BP in aortic dissection?
BB initial drug of choice (IV labetolol, esmolol)
200
What does a Type A aortic dissection need for tx?
urgent surgery
201
What does Type B aortic dissection need for tx?
surgery or medical rx (if not surgical candidate)
202
What is the major difference between NSTEMI and UA
NSTEMI has elevated cardiac markers because cell necrosis has started, UA does not
203
What are S/S of UA/NSTEMI?
sxs AT REST
204
What is the dx criteria for an NSTEMI?
at least one value over 99th percentile
205
What does the ECG look like for NSTEMI/UA?
ST depression, T-wave inversion
206
What are risk factors for an adverse event from UA/NSTEMI?
- over 65
- 2 or more CHD risk factors
- coronary stenosis
- 2 or more angina episodes w/n 24 hrs
- ASA use in 7 days
- elevated cardiac biomarkers
207
What should you do if you suspect someone is having UA/NSTEMI but exam is unremarkable, 1st biomarkers unremarkable and no ECG changes?
continue to monitor and do serial ECG's and cardiac markers
208
What should all patients be put on post NSTEMI/UA?
ASA!
209
What is a complication of pericarditis?
cardiac tamponade!
210
What are S/S of cardiac tamponade?
- marked elevation of LV/RV diastolic pressures
- soft heart sounds
- MARKED DECREASE CO
- pulsus paradoxus
211
What is pulsus paradoxus?
systolic BP drops over 10mmHg w/inspiration
212
How does cardiac tamponade appear on CXR?
cardiomegaly
213
How does cardiac tamponade appear on ECG?
low voltage/amplitude (due to effusion blocking electricity)
214
How do you dx cardaic tamponade?
Echo!
215
How do you treat cardiac tamponade?
pericardiocentesis (subxiphoid approach)
Send fluids to cytology
216
What are causes of acute pulmonary edema?
- Acute MI/severe ischemia
- progression of heart failure (acute deterioration)
- acute volume overload of LV (MR, etc. )
217
What are precipitating factors to acute pulmonary edema?
- discontinuation of meds
- excessive Na intake
- tachy arrhythmia
- intercurrent infection
- MI
218
How do you dx acute pulmonary edema?
-BNP
| CXR (lungs with vascular redistribution-- "BUTTERFLY PATTERN" of alveolar edema
219
How do you treat acute pulmonary edema?
- Keep SaO2 over 91 (means over 60 Po2)
- morphine sulfate (venodilator)
- IV diuretics
- nitrates
220
IS afib usually seen with or without an underlying cario/pulm pathology?
with cardio/pulm pathology!!
221
How long do you need to have afib before thromboemboli is a risk?
48-72hrs!
222
How do you treat someone who is stable with afib acutely?
rate control is first priority (IV diltiazem or BB (esmolol))
223
What should you do if someone has been in afib for more than 48 hours?
FULL ANTICOAG x3 weeks
224
How do you treat chronic/recurrent afib?
1. Rhythm control
or
2. Rate control + anticoag
225
What are different ways to cardiovert?
1. DC cardioversion
| 2. Ibutilide (IV agent for rapid convertion)-- monitor continuous ECG for 4 hours
226
When do you need to treat a HTN emergency by lowering bp w/n few hours? (3)
- asymptomatic pt w/BP over 220/120
- High BP (200/100) w/optic disc edema or progressive target organ (kidneys/heart) complications
- perioperative htn
227
What warrants substantial BP decrease w/n 1 hr? (3)
- Hypertensive encephalopathy (HA, confusion, altered MS)
- Hypertensive nephropathy (Hematuria, proteinuria)
- Malignant HTN (enceph and neph and papilledema)
228
At what BP do you want to lower BP during an ischemic stroke?
over 200/100 (not if below)
229
How do you treat htn emergencies?
Lower BP to no more than 25 percent w/n 2hrs, then more gradual (2-6 hrs)
230
What happens with excessive BP reduction?
coronary, cerebral, renal ischemia
231
When is the one exception that you want to aggressively lower BP as fast as possible?
acute aortic dissection
232
What are some meds you can use to lower BP during a htn emergency?
Nicardipine, Clevipine, IV NTG, labetolol, esmolol, diuretics
233
What is the pathology behing aortic aneurysms?
atherosclerosis, cystic something necrosis
234
Where do most aortic aneurysms take place?
75 percent below renal arteries
235
What is PE finding with aortic aneurysms?
pulsatile, non-tender mass
236
Who should get screened for aortic aneurysms?
Male smokers over 60yo with at least one of following:
- FH AAA
- PRESENCE OF PAD/ATHEROSCLEROSIS
- presence of peripheral artery aneurysms
237
What is the risk of rupture of aortic aneurysms?
Under 5cm- 1-2 percent over 5yrs
| Over 5cm- 20-40 percent over 5yrs
238
What is the tx for aortic aneurysms?
- operative excision for rapidly expanding or symptomatic
| - Endovascular placement of stent/graft for non-surgical candidates
239
Who should get surgery for their AAA?
- anyone symptomatic
| - If asymptomatic: always surgery if over 6.5cm, probable surgery if over 5cm
240
Who is the chance of shoulder re-dislocation high in?
young ppl, athletes
241
What shoulder reduction technique would you want to use on an elderly person?
external rotation technique
242
What shoulder reduction technique uses weights, and takes time?
Stimson's technique
243
Which shoulder reduction technique requires 2 ppl?
traction counter-traction
244
Who is traction counter-traction reduction good to do on?
-muscular pts and ppl with dislocation for long-time
245
What is the scapular rotational maneuver good for?
muscular patients
246
Following reduction, how long should a shoulder be immobilized for?
2-4 weeks
247
What do you need to be careful of in the elderly when immobilizing their shoulder after reduction?
adhesive capsulitis/frozen shoulder
248
What do you need to check following shoulder reduction?
- circulator and sensory status (axillary nerve)
| - post-reduction xrays
249
Should pts with shoulder dislocation go for ortho f/u?
ALWAYS!
250
What do you need to consider when a patient presents with a laceration?
possible deep structures involvement (tendons, nerves, bones, glands)
251
What are the 3 stages of laceration healing?
1. Inflammatory phase
2. Proliferative phase
3. Remodeling phase
252
Which stage of healing has granulation, contractions, and epithelization?
proliferative phase
253
Which stage of healing has new collagen which increases tensile strength?
remodeling phase
254
How strong is scar tissue compared to the original tissue?
80 percent as strong
255
Which stage of healing involves hemostasis and baceteria/debris phagocytosis?
Inflammatory phase
256
What do you want to know in pts PMH when they have a laceration?
Immunization status! (Td/tdap)
257
What is primary intention wound closure?
Wound edges are approximated at time of injury
allows for best cosmetic result
258
When is primary intention a good option for wound closure?
clean, uncomplicated wounds
259
What is secondary intention wound closure?
Wound is NOT surgically closed
allowed to heal on own through granulation and re-epiphelization
may be chosen as closure method for wounds over 1hrs old
260
What is tertiary intention?
- delayed primary or secondary closure
| - wound intentionally left open for 1-several days and then surgically closed
261
Why do you use tertiary intention?
to allow tissue edema to reduce (orthopedic injuries)
also done with wounds with likely chance of infection (incision post-ruptured appendix)
262
What do all topical anesthetics have?
vasocontriction
263
What is the "ket to success" in terms of topical anesthetic?
blanching
264
What do you use to clean lacerations?
-saline, sur-clens, chlorohexate, butsomething
265
How do you remove grease from laceration?
bacitracin/polysporin ointment
266
How do you deal with dusky or "ragged" wound edges?
debride and trim to decrease change of necrotic tissue
267
When are staples a good closure choice for a laceration?
Fast and easy, good for NON-COSMETIC areas (head, extremities)
268
What are some tips to laceration closure on limbs?
- immobilize below/above
- temp. tourniquet during repair
- carefule w/anterior shin laceration (Esp. elderly)
- careful with tension in pre-tibial lacerations
269
When do you want to use abx for lacerations?
-animal bites (esp. cats), fight bites
270
What abx do you want to use for bite lacerations?
augmentin
271
How long until suture removal?
4-14 days
272
When is it controversial to close laceration?
Under 6 hours, over 12 hours
273
What is often associated with subungal hematoma?
distal phalanx tuft fracture
274
How do you treat subungal hematoma?
nail trephination
275
When do you do nail trephination for hematoma?
- ALWAYS if over 50 percent of nail
| - also helps with pain
276
What is conscious sedation?
pharm agents used to depress patients LOC while they still maintain their own patent airway and airway reflexes
277
What are commonly used agents in conscious sedation?
benzos, narcotics, hypnotics, dissociative agents
278
What do you want to monitor when patient is conciouslly sedated?
- continuous pulse ox
- BP
- cardiac monitor
279
What is the most common pathogen of abscesses?
S. aureus
280
Where do you want to incise an abscess?
at the apex or site of drainage
281
How long should incised abcess be kept dressed?
24-72 hrs and then recheck, re-irrigate
282
Who is paronchia more common in?
smokers
283
What is the most common pathogen in paronychia?
S. aureus
284
How do you treat paronychia?
abx (dicloxacillin, bactrim/doxy/clinda if MRSA)
285
What is not effective in the treatment of paronychia?
topical abx
286
What type of dislocation are ankle dislocations usually?
POSTERIOR
287
What is the primary concern in ankle dislocations?
neurovascular compromise (can lead to permanent nerve damge, tissue necrosis)
288
What is tx of ankle dislocation?
IMMEDIATE REDUCTION and immediate ortho consult
289
What is typically associated with ankle dislocations?
fractures!
290
What is the most commonly dislocated joint in the body?
PIP of finger
291
What should always be done in the eval of finger injuries?
xray!
292
Do you want to do xray before or after finger reduction?
BEFORE usually (unless long time to get xray)
293
When is sedation discouraged in FB removal?
nasal FB removal
