Topical anesthestics can be applied in 3 major situations: On () skin prior to dermal instrumentation On () mucosa On () skin for pain control or prior to wound repair.

Intact skin Intact mucosa Open skin

Lecture 13: Pain + Wound Management Flashcards by Billie Roberts

() is the MC presenting symptom to the ED

PAIN

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The two ways we rate pain are via the () scale or () faces

1-10 scale
Wong-baker faces

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Systemic opioids are used when pain is severe and ()

Severe nociceptive pain

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Almost all NSAIDs should be used with caution in () dysfunction

Renal dysfunction

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Almost all NSAIDs cause:
* () upset
* () dysfunction
* Cannot be used in () dysfunction
* ()spasm

GI upset
Platelet dysfunction
Cannot be used in renal dysfunction
Bronchospasms

Exception: ASA has no bronchospasm

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Once you give an initial dose of an opioid, you should then () it to effect

Titrate to effect

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Fentanyl is especially useful in opioid-tolerant breakthrough pain in () patients

Cancer

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Tramadol is risky because it can contribute to () syndrome

Serotonin syndrome

It is a weak NE and 5-HT reuptake inhibitor

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() describes misuse of a medication to the detriment of a patient’s well being.

() describes that abrupt cessation of a medication with cause acute withdrawal symptoms.

Addiction
Dependence

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Generally, never take tylenol or advil within () hrs of an opioid combined with tylenol or advil.

6 hours

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The MC source of misused Rx opioids in adolescents comes from…

Parent’s medicine cabinet

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Epinephrine injections are avoided in patients with () vascular injuries

Digital

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Topical anesthestics can be applied in 3 major situations:

On () skin prior to dermal instrumentation
On () mucosa
On () skin for pain control or prior to wound repair.

Intact skin
Intact mucosa
Open skin

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Nerve blocks are used in place of subdermal injections of large volumes because they do not () the wound.

Distort

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Peripheral nerve blocks take about () minutes for a lido injection and () minutes for a bupivacaine injection.

10-20 for lido
15-30 for bupi

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T/F: A flexor tendon sheath will fully anesthetize the distal fingertip

False

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Chronic pain lasts either () months or more, beyond reasonable time for an injury to heal, or () months beyond the usual course of an acute disease.

3 months
More than 1 month past the usual healing time for an acute disease

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T/F: Opioids are highly recommended for ED treatment of chronic pain.

False

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Should you write drug-seeking behavior in a chart?

No. List actual facts not opinions

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Lower back pain in the ED is managed primarily with (drug) and (lifestyle) and a 3-day supply of (drug)

NSAIDs, like naproxen or advil
Restriction of activity
3 day supply of opioid (Not first-line)

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Wounds greater than () cm and located in () vascular areas are more likely to be infected.

Longer than 5 cm and in LESS vascular areas are more likely to be infected.

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Nonabsorbale sutures retain strength for () days and must be removed. (name some of the non-absorbable ones)

60 days.
Silk, nylon, prolene

You should use these on the Outermost layer!!!

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What size sutures does the scalp use? what about face?

3 or 4 for scalp
6-0 for face

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In simple interrupted sutures, you should aim to do () ties relative to suture size

Same ties as suture size (i.e. 4 ties for a 4-0)

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Running stitches are specifically not used in (shaped) wounds

Irregular wounds

Buried dermal sutures should not be placed in what layer of skin?

Adipose tissue

what kinds of skin is vertical sutures good for

Thin/lax skin (like the shin)

Horizontal sutures require less stitching, but the main DISadvantage is that they are ()

Very difficult to do

What wound closure device is the LEAST reactive and most cost-effective?

Adhesive tape | Aka steristrips

T/F: A patient needs to come back to get dermabond removed.

False. Sloughs off on its own after 5-10 days.

Why is debridement generally avoided on the face/scalp?

Because it is so vascularized, it generally heals itself well.

Forehead wounds that fall () to the lines of skin tension, () to muscle fibers yield the best cosmetic results.

Parallel to skin tension, perpendicular to muscle fibers

**Forehead** muscle fascia should be closed via ()-0 suture, whereas the epidermal layer should be closed via ()-0 suture.

5-0 for muscle, 6-0 for epidermal

These 5 kinds of eye injuries should be referred to ophtho instead: * Involves the () surface of the eyelid * Wounds that go across () margins * Injuries to the lacrimal () * Wounds with associated () * Injuries that extend into the () plate

* Inner surface of eyelid * Wounds going across lid margins * Injuries to the lacrimal duct * Wounds with associated PTOSIS * Injuries extending into the TARSAL plate

Eyelid injuries within 6-8mm of the () are at risk of canalicular laceration.

Medial canthus

The **most important assessment of nasal lacerations** is to determine their () and involvement of ()

* Depth * Deeper tissue layers and septum

A septal hematoma of the nose can produce 3 major complications: * Permanent () of the septum * Necrosis and () of the septum * Septal erosion leading to a () deformity

* Permanent thickening * Erosion * Saddle Nose Deformity

Besides checking the nose in direct blunt trauma, you must check the cribiform plate to see if there is any () rhinorrhea

CSF rhinorrhea

For superficial lacerations to the nasal skin, you should use a (size) (abs/non-abs) monofilament simple interrupted stitch. For anything deeper, you use (size)

* 6-0 Non-absorbable * 5-0 absorbable for deeper | Since its at the skin surface. ## Footnote Same for ears pretty much, just use 6-0 non-absorbable

Mucosal lip lacerations do NOT need sutures if they are () and the wound edges sponatenously ()

Isolated with spontaneous approximation | Otherwise, big gaping wounds need absorbable 5-0.

Lip laceration suture techniques are decided by the () border.

Vermilion border

Lip lacs that do NOT include the vermilion border should be closed in ().

Layers

The order in which you close a lip lac WITHOUT vermilion border inclusion: 1. Mucosal layer: (size) (abs/non-abs) 2. Orbicularis oris muscle fascia with (size) (abs/non-abs) via simple int or horizontal mat 3. Skin with (size) (abs/non-abs)

* Mucosal: 5-0 absorbable * Muscle fascia: 4-0 or 5-0 absorbable * Skin 6-0 NON-absorbable

The process in which you suture lip lacs WITH vermilion border involvement: 1. First stitch must repair vermilion border via (size) (abs/non-abs) suture to align edges **precisely** 2. Repair vermilion + skin with (size) (abs/non-abs) 3. Repair mucosa + muscle with (size) (abs/non-abs)

1. 6-0 nonabsorbable for first stitch 2. Vermilion + skin with 6-0 nonabsorbable 3. Mucosa + muscle with 5-0 absorbable

Intraoral lacerations only need closure if they are large enough to () or have a tissue flap that interferes with ()

* Trap food * Interferes with chewing

An intraoral suture uses (size) (abs/non-abs)

4-0 absorbable | Drip some 1% lido in their wound first

Most cheek/facial lacs can be repaired via 6-0 non-abs or dermabond and stuff. However, if the () duct is injured, operative repair is indicated.

Parotid duct

In a full-thickness cheek lac, you want to repair the wound in ()

Layers

Scalp sutures/staples should be removed after () days

14 days

Forehead, external ear, or lip sutures should be removed after () days

5 days

Eyelid, nose, or face sutures should be removed after () days

3-5 days

Intranasal packing should be removed after () days

1-2 days

Generally, the wrist, forearm, and hand should use (size) sutures, while the arm should use (size) sutures.

* Wrist/forearm/hand: 5-0 * Arm: 4-0

An upper extremity wound is generally more prone to infection if it is sutured more than () hours after the injury occurred.

> 12 hrs post injury

The mainstay of treating a subungal hematoma is via...

Trephination of the nail plate | Stabbing a hole in the nail via scalpel or cautery

You should only remove a nail if there is associated partial () or surrounding () disruption

* Associated partial nail avulsion * Surrounding nail bed disruption

Generally, foot and leg wounds use (size) sutures and are removed after (0 days.

* 4-0 sutures * 10-14 days.

T/F: You should remove all foreign bodies within soft tissue

False. Weigh risk vs benefit

Any splinter parallel to skin surface should be removed along its () axis

Long

The technique to remove deep fishhooks is...

Advance-and-cut

For normal fishhooks, the most successful technique is...

Incision technique | Make wound entrance bigger

The MC organism seen in puncture wounds

Staph aureus

The MC organism in plantar puncture wounds that resulted in osteomyelitis

Pseudomonas

ABX prophylaxis is indicated in puncture wounds that are (location), due to a (), or with heavy ()

* Plantar located * Due to a bite * Heavy contamination

ABX prophylaxis for a established infected puncture wound are (), () or (). If it is a plantar puncture, you must use ()

* Normal infected wound: First-gen cephalo, augmentin, or FQ. * Plantar: Ciprofloxacin (anti-pseudomonal FQ) | F/u in 48 hrs!

For needle sticks, you can get Post-exposure prophylaxis for () and (), but not ()

* HIV and Hep B * You're out of luck for Hep C

In high pressure wounds, it is recommended to avoid (), which can increase pressure in the finger compartments. Ideally, you should do surgical () within 6 hours to reduce the risk of subsequent ()

* Avoid digital nerve blocks * Do surgical debridement * Reduces risk of amputation

# Bites The current practice is to () primary wound closure in patients with systemic immunodeficiencies and higher-risk wounds

AVOID PRIMARY WOUND CLOSURE | Suturing showed higher infection rate. Re-eval in 24-48 hrs! ## Footnote You just debride and clean

The MC organism within dog and cat bites is...

Pasteurella Multocida

ABX are indicated in bite wounds: * all (animal) bites * Bites in () hosts * (animal) bites that puncture * hand wounds * Any injury that will undergo surgical repair

* All cat bites * Immunocompromised hosts * Dog bites that puncture | Use augmentin. ## Footnote Pen V or ampicillin works for Pasteurella infections too

In PCN-allergic pts, the abx for a cat bite is () or (). For a dog bite, it is () + ()

* Cat bite: doxy or cefuroxime * Dog bite: clinda + FQ

What is worse, a human bite or a cat/dog bite?

A human bite

What is one of the MC ways you can get a human bite equivalent injury?

Closed-fist injury | Punching their mouth

There is a very specific G- rod that is present in human bites known as (E)

Eikenella corrodens

The initial ABX for a human bite is:

Cephalexin | Augmentin alternative. ## Footnote You should give to every human bite unless its extremely superficial.

The only place where you SHOULD do primary wound closure on a human bite is...

Face

The treatment for a rodent is IV () followed by oral ()

1. IV PCN for 5-7 days 2. Oral PCN for 7 more days

Freshwater fish bites can contain (bacteria), which saltwater can contain (bacteria) ABX for freshwater bites is: ABX for saltwater bites is:

* Freshwater = aeromonas = FQ or bactrim * Saltwater = Vibrio = FQ or doxy | Salty docks vibrate, Fresh arrows are trimmed

Rabies MC comes from () in the US

BATS

Tetanus guidelines

* No tetanus vaccination or Ig if minor wound with complete vaccination hx. * Tdap + Ig is for incomplete hx and contaminated wound

After draining an abscess, your patient should follow up in () days

2-3 days