ER/Acute Care Pearls

Question 1

What is the second most common joint in the body to dislocate?

Answer 1

shoulder

Question 2

How is the arm positioned with a shoulder dislocation?

Answer 2

arm is moved away from the body (abducted) & externally rotated

Question 3

What is the re-dislocation rate in young athletes?

Answer 3

up to 90%

Question 4

Which type of shoulder dislocation is most common?

(it is also the easiest to put back in place)

Answer 4

anterior

Question 5

Which shoulder reduction technique is good for the elderly?

Answer 5

external rotation technique

Question 6

Which shoulder reduction technique might be best for people without a significant amount of muscle mass?

Answer 6

scapular rotational maneuver

Question 7

Which shoulder reduction technique uses weights?

Answer 7

Stimson’s technique

Question 8

Which shoulder reduciton technique requires 2 people & is commonly employed for muscular patients/dislocated for long periods?

Answer 8

tractoin counter-traction

Question 9

What should be done following shoulder reduction?

Answer 9

shoulder should be immobilized in a sling (2-4 weeks)

post reduction films

circulatory & sensatory status should be reassessed (axillary nerve)

Question 10

With shoulder dislocations, older patients are at an increased risk for what?

Answer 10

adhesive capsulitis

(frozen shoulder)

Question 11

Typical population/age group for nursemaid’s elbow

Answer 11

usually under 5 years old

Question 12

What is the classic mechanism for a nursemaid’s elbow?

Answer 12

sudden pull on a young child’s arm

parent swings child around

Question 13

What is the reduction method for nursemaid’s elbow?

Answer 13

with clinician’s thumb over the radial head & the other hand holding the child’s hand, the forearm is supinated & flexed then pronated & flexed

telltale ‘click’ signifies reduction

Question 14

When should a child exhibit spontaneous & full movement after reduction of a nursemaid’s elbow?

Answer 14

within 10-15 minutes

Question 15

What is the most commonly dislocated joint in the body?

Answer 15

PIP joint of finger

Question 16

What is the hallmark of a dislocated finger?

Answer 16

deformity

Question 17

Finger dislocations are usually ______

Answer 17

dorsal

Question 18

With a finger dislocation, what do we want to confirm?

Answer 18

tendon function

Question 19

What is the rule rather than the exception with ankle dislocations?

Answer 19

associated fractures

Question 20

What is a principle concer with ankle dislocations?

Answer 20

neurovascular injury

Question 21

With ankle dislocations, tented skin may be subject to what?

Answer 21

ischemic necrosis

Question 22

What are the primary goals of treatment with ankle dislocations?

Answer 22

immediate reduction of the joint

and

relief of neurovascular stress

Question 23

What are some ways to attempt to remove nasal foreign bodies?

Answer 23

patient may “blow their nose” while blocking opposite nostril

“mother’s kiss” technique

Question 24

Attempts at removing nasal foreign bodies can cause?

Answer 24

airway hazards (by pusing the FB into the pharynx)

consult ENT before complications are created

Question 25

Is sedation encouraged or discouraged with nasal foreign bodies?

Answer 25

discouraged it can increase complications by reducing the gag & cough reflexes

Question 26

Can the tempanic membrane be damaged by pushing an ear foreign body further in the canal when attempting to remove it?

Answer 26

yes

Question 27

What are the keys to a successful removal of an ear foreign body?

Answer 27

adequate visualization appropriate equipment a cooperative patient skilled clinician

Question 28

What are some methods for ear foreign body removal?

Answer 28

irrigation with water grasping with forceps cerumen loop right-angle needle suction catheter

Question 29

inflammation fo the nail fold can be acute or chronic

Answer 29

paronychia

Question 30

What does a paronychia usually result from?

Answer 30

mild trauma nail biting

Question 31

What is the usual bacterial agent that causes paronychias?

Answer 31

*S. aureus*

Question 32

In rare cases, paronychias may be accompanied by what?

Answer 32

fever & painful glands at axilla

Question 33

What is the treatment of choice for an ingrown toenail? What is required for this?

Answer 33

wedge resection digital block is REQUIRED

Question 34

What is the most common agent causing skin abscesses? What is increasing?

Answer 34

most common: *S. aureus* increasing: MRSA

Question 35

collection of blood between teh nail bed & the fingernail

Answer 35

subungal hematoma

Question 36

What type of fracture is often associated with a subungal hematoma?

Answer 36

distal phalanx tuft fracture

Question 37

What is the treatment for subungal hematomas?

Answer 37

nail trephination (with cautery stick) reduces pain & may save the nail

Question 38

Stages of wound healing: immediate to 2-5 days hemostasis vasodilation, phagocytosis

Answer 38

inflammatory phase

Question 39

Stages of wound healing: 2 days to 3 weeks angiogenesis, collagen deposition, granulation tissue formation, epithelialization, wound contraction

Answer 39

proliferative phase

Question 40

Stages of wound healing: 3 weeks to 2 years new collagen forms which increases tensile strength to wounds scare tissue is only 80% as strong as original tissue

Answer 40

remodeling phase

Question 41

wound edges are approximated at or close to the time of injury typically allows for the best cosmetic result to follow best performed on wounds that are "clean" & uncomplicated

Answer 41

primary intention

Question 42

wound is not surgically closed allowed to heal on own through granulation & re-epithelialization often allowed for abscesses, fight bites, or "dirty" wounds may be chose as closure method for wounds \> 12 hrs old

Answer 42

secondary intention

Question 43

delayed primary closure or secondary suture wound intentially left open for 1 to several days & then surgically closed often done to allow tissue edema to reduce often chosen for wounds with likely chance of infection

Answer 43

tertiary intention

Question 44

With topical anesthesia, what is the "key to success"?

Answer 44

blanching

Question 45

What are the desired effects of conscious sedation?

Answer 45

relaxation & cooperation patient maintains protective airway purposeful responses to verbal or tactile commands safe return to baseline & ambulatory discharge

Question 46

What are some undesirable effects of conscious sedation?

Answer 46

deep & non-arousable state decreased respiration & dyspnea/apnea airway obstruction hypotension & bradycardia agitation/non-cooperative

Question 47

What are some comonly used medications for conscious sedation? What side effect do they all have the potential to produce?

Answer 47

benzos, narcotics, dissociative agents, hypnotics all can produce respiratory depression