Pain and Wound Management Flashcards
lecture only (134 cards)
1
Q
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
A
opioid use
2
Q
2 different pain scales
A
1-10
Wong-Baker Face
3
Q
Acute Pain Management Options
A
- NSAIDs - ibuprofen, naprozen, indomethacin, ketorolac
- acetaminophen
- ASA
- ketamine
- lidocaine
- Systemic opioids
4
Q
Mild to moderate pain
Smooth muscle origin: renal biliary colic
which pain tx?
A
NSAID
5
Q
- 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?
A
systemic opioids
6
Q
MC SE of non opiates?
one way to bypass it?
A
GI upset - take with food
use IV
7
Q
CI of ketaorolac
A
1st trimester of pregnancy - get hCG first
8
Q
topical analgesic agents?
A
- diclofenac
- ibuprofen
- ketoprofen
- lidocaine
- capsaicin
- methyl salicylate
9
Q
Variation in pain reduction is related to ?
but not ?
A
- age, initial pain severity, and previous or chronic exposure to opioids
- body mass or gender
10
Q
which opioid has the quickest onset and shortest duration?
A
fentanyl
11
Q
which opiate weakly inhibits the reuptake of norepinephrine and serotonin, producing a central opioid analgesic effect → can induce serotonin syndrome
A
Tramadol
12
Q
definition of addiction
A
misuse of a medication or drug to the detriment of the patient’s well-being.
13
Q
definition of dependence?
A
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
14
Q
RF for misuse?
A
concomitant mental health illness or previous drug or alcohol abuse, when prescribing opioids
15
Q
who to consider avoiding opioids in? (2)
mgmt for this?
A
- elderly
- naive to narcotics
home observation by a responsible adult
16
Q
Discharge instructions for those given opioids should include ?
A
- 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
17
Q
2 MC Local Anesthetics
A
Lidocaine, Bupivocaine
18
Q
routes for Lidocaine, Bupivocaine
A
topically, intradermally, subdermally, or infiltrated near peripheral nerve
19
Q
effects of EPI
A
increases the duration of anesthesia, helps to control wound bleeding, and slows the systemic absorption.
20
Q
avoid EPI in who?
A
- 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
21
Q
Topical anesthetics are used in three major situations:
A
- intact skin before dermal instrumentation
- applied to intact mucosa
- open skin for pain control or before wound repair.
22
Q
indications for nerve blocks
A
complicated lacerations, abscesses, fractures, debridement, and dislocations
23
Q
which anesthetics offer a longer duration of action?
which ones are significantly less cardiotoxic?
A
- bupivacaine, levobupivacaine, and ropivacaine
- levobupivacaine, and ropivacaine
24
Q
which type of block may not fully anesthetize the distal fingertip.
A
flexor tendon sheath block
25
what must you assess before performing a digital block?
Assess cap refill/sensation
26
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
27
what is not a recommended ED treatment for chronic pain?
Opioids
28
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)
28
MC complaints of patients who attempt to obtain opioids from the ED?
1. **back pain**
1. HA
1. extremity pain
1. dental pain
29
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”
30
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
31
how to eval lower back pain?
* **Neuro exam**, MSK
* XR
* If red flags→Sed rate, CRP, CBC, CMP, further imaging
32
mgmt for lower back pain
1. Restriction of activity
1. Analgesia, manipulation
- primary NSAIDS, naproxen ibuprofen
- Opioid: 3 day supply- not first line
- Muscle relaxers: maybe, Robaxin
1. PCP f/u, PT
1. Monitor symptoms for 4 to 6 weeks before embarking on further diagnostics
33
RF for lower back pain
1. Alcohol Abuse
1. DM
1. Renal Failure
1. Night Pain
1. 3rd Visit in last 20 days
1. IVDU
1. Fever w/o focus
1. Recent/Current Systemic Infection
1. Immunosuppression
1. Recent Spinal fx/Procedure
1. Incontinence or Retention
1. Indwelling Urinary Catheter
34
higher rates of infection:
DM, visible contamination, length greater than 5 cm, and non–head-and-neck
35
the density of the bacterial population is low on what parts of the body?
upper arms, legs, and torso.
36
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
37
materials/general procedure for wound closure
* “Sterile” procedure: Gloves
* Remove Rings
* Cleaning: CHX or iodine
* Anesthesia: Local vs regional
* Irrigation
* Debridement
* FB removal
38
pros and cons of sutures
* Pros: strongest most accurate
* Cons: Most time consuming, needle stick risk
39
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
40
recommended suture size for scalp?
3-0 or 4-0
41
what suture size for face?
6-0
42
suture size for trunk & extremities?
4-0
43
suture size for digits
5-0
44
suture size for intraabdominal
2-0
45
how do you know how many ties to do for simple interrupted?
the number of knot ties should correspond to the suture size
46
Long linear wounds
Avoided in irregular wounds
Running stitch
47
* 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
48
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
49
* 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
50
* 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
51
* 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
52
The main disadvantage of the horizontal mattress stitch is ?
the skill required to place the suture to achieve wound eversion.
53
uses for staples?
* Speed and relative ease of use
* Least precision in wound approximation.
* **Linear, nonfacial lacerations.**
54
staples are Useful for what specific lacerations because does not require clipping and staples are easier to locate than sutures for removal.
scalp
55
* least reactive and most cost-effective of all wound closure devices.
* Their application is simple, painless, and rapid, and they also do not require formal removal.
* slough off when exposed to any tension or moisture.
* for very low-tension simple wounds or for closure of fragile skin subject to low tension, such as superficial skin tears - *little use in noncompliant patients* because they are so easy to remove.
Tapes/Steri Strips
56
Used in conjunction with a liquid adhesive adjunct, such as tincture of benzoin or Mastisol®, that is gently painted on either side of the wound edges and allowed to dry until tacky.
Tapes/Steri Strips
57
liquid monomers that polymerize into a stable bond when they come into contact with moisture
applied topically to the epidermis across the apposed wound edges, forming a strong bridge that holds the wound closed.
Dermabond
58
Dermabond usually sloughs off in how many days?
5 to 10 days as the skin renews itself
59
T/F: dermabond requires removal
F: it does not
60
The cyanoacrylate tissue adhesives are similar in strength to ?, but weaker than ?
* 4-0 poliglecaprone subcuticular sutures
* staples
61
dermabond should not be used alone for ______or for ____, such as over a moving joint.
* high-tension wounds
* wounds subjected to varying dynamic tension
62
how to approach face and scalp laceration
1. Cleanse, irrigate, and remove FB
1. Limit debridement of skin edges - excellent blood supply enables tissues to recover that may initially appear nonviable.
1. regional nerve blocks or topical anesthesia if local anesthetic infiltration would distort or hinder wound edge alignment
1. nonabsorbable monofilament suture for facial skin.
1. Rapidly absorbable suture and tissue adhesives are alternatives in selected locations and in some pts
63
what type of lacerations have a low incidence of postrepair infection, so primary closure can usually be done in wounds up to 24 hours after the injury, including most bite wounds.
Facial and scalp
64
what type of face/scalp lacerations yield the best cosmetic results
Forehead wounds that fall parallel to the lines of skin tension (and perpendicular to muscle fibers)
65
how to close scalp lacerations?
* surgical staples or simple interrupted percutaneous sutures using nonabsorbable monofilament or rapidly absorbable material
* Leave suture tails long, and use sutures of a color different than the hair for easy suture removal.
66
how to approach eyebrow laceration
* Do not clip or shave eyebrows - landmarks for wound edge reapproximation.
* Debridement of loose or nonviable skin should be minimal and, if necessary, done so that the remaining hairs preserve as much as possible of the original length, width, and curve of the eyebrow.
* Use care to align the hair margins.
* Use sutures that are a different color from the hair and leave long tails to facilitate removal.
67
how to approach forehead lacerations
* superficial - 6-0 nonabsorbable interrupted suture or tissue adhesive.
* deep - close muscle layer to avoid noticeable defects, esp when facial muscles of expression are involved.
* muscle fascia - buried 5-0 absorbable suture; may be approximated with a buried subcuticular stitch.
* epidermal layer - 6-0 nonabsorbable sutures in a simple, interrupted fashion; with skin closure strips; or with tissue adhesive
68
how to approach eyelid laceration?
* Once integrity and function of the globe and orbital structures are verified, examine the lid for involvement of the canthi, the lacrimal system, or penetration through the tarsal plate or lid margin.
* 6-0 or 7-0 nonabsorbable monofilament for simple interrupted percutaneous sutures.
* Avoid deep penetration
* Do not use tissue adhesive near eye
69
Eyelid injuries within ? mm of the medial canthus are at risk for **canalicular laceration**, esp if associated with **medial wall blowout fractures**.
6 to 8
70
eyelid injuries that need referral to an ophthalmologist or oculoplastic specialist:
(1) injuries involving the inner surface of the lid
(2) wounds across lid margins
(3) injuries to the lacrimal duct
(4) wounds associated with ptosis
(5) injuries extending into the tarsal plate
71
The most important assessment of nasal lacerations?
determine their depth andthe involvement of the deeper tissue layers and septum
72
what type of nose laceration increases risk of infection?
Exposed cartilage or penetration through all tissue layers
73
With direct blunt trauma to the nose, assess for what type of fx and finding?
cribriform plate fracture with cerebrospinal fluid rhinorrhea
74
a hematoma develops between the cartilage and its protective mucoperichondrial layer and may produce complications such as
| nose lac
(1) permanent thickening of the septum, causing partial airway obstruction of the nasal passage;
(2) necrosis and subsequent erosion of the septum, resulting in communication between the nasal passageways
(3) septal erosion leading to a saddle-nose deformity.
75
how to close nose lac?
* Promptly close lacerations involving exposed cartilage.
* Preserve loose cartilage under the skin for future use.
* If extending through all tissue layers and involving the nostril - 5-0 nonabsorbable suture aligning skin at nasal canal entrance.
* gentle traction to align mucosa and cartilage layers.
* Close mucosal layer with 5-0 rapidly absorbable sutures.
* If cartilage suture needed - minimal 5-0 absorbable sutures for cartilage alignment.
* Reevaluate initial stitch at alar margin and tie.
* Suture remaining skin with 6-0 nonabsorbable material close to wound edges.
76
how to approach ear lac
* superficial - 6-0 nonabsorbable monofilament interrupted sutures.
* Cover any exposed cartilage to prevent subsequent infection - Do not remove crushed or loose pieces of cartilage under the skin
* Do not debride edges of auricular laceration - very little excess skin available to cover existing cartilage.
77
when would mucosal lip lcs may not need suturing?
isolated and the wound edges spontaneously approximate
78
how to approach lip lac
* Large or gaping - rapidly absorbable 5-0 suture
* Carefully place suture to include only mucosa with entrance 2-3 mm from the wound edges, and use care to evert the edges.
* Larger tissue bites can bunch the mucosa and pucker the outside skin.
79
how to approach lip Through-and-through lac that do not include the vermilion border
should be closed in layers
* Close mucosal layer with 5-0 rapidly absorbable suture, reirrigation
* approximate orbicularis oris muscle fascia with 4-0 or 5-0 absorbable suture material with a simple interrupted or horizontal mattress technique.
* repeat irrigation, suture skin with 6-0 nonabsorbable monofilament sutures in a simple interrupted fashion or tissue adhesive
80
Wounds that cross the vermilion border should be repaired by placing what type of suture?
first stitch with 6-0 nonabsorbable monofilament
* repair vermilion and skin with same 6-0 material, and repair mucosa and underlying muscle with 5-0 rapidly absorbable suture.
* useful technique: leave initial alignment suture untied and apply gentle traction on ends to help approximate and align the underlying tissue as the skin and vermilion are closed.
81
T/F: Small intraoral lacerations do not need routine repair and can be allowed to heal naturally
T
82
when is suture closure of intraoral lacerations indicated?
* when wounds are large enough to trap food particles
* a tissue flap that interferes with chewing
83
For intraoral lacs, include only the mucosa in the suture because ?
an external pucker may be created if underlying muscle is ensnared in suture loop
84
if there is significant skin tension on the face/cheek, place _____ _____ sutures, and ensure that *what structure* is not caught in the suture?
intradermal absorbable
parotid duct
85
if the parotid duct is affected from the lac, what is the next step?
operative repair
86
how to repair full-thickness cheek laceration?
**repaired in layers**
1. start with intraoral mucosa
2. Once mucosa closed, reirrigate before closure of subcutaneous layer w/ 5-0 absorbable suture
3. close skin w/ 6-0 nonabsorbable suture, tissue adhesive, or adhesive strips
87
face lac f/u based on where their sutures are?
* Scalp - 14 d
* forehead, external ear, or lips - 5 d
* eyelid, nose, or face - 3-5 d
* Intranasal packing - 1-2 d
88
when should Arms and Hands lac be sutured to avoid the risk of infection?
< 12 h after injury
89
suture removal day for arm and hand lac?
* Wrist forearm hand: 5
* Arms: 4
* Tendon injury: can repair if possible-refer to hand surgeon
90
what is a Subungal hematoma?
Disruption of blood vessels of nail bed w/o fx of nail = accumulation of blood under nail
91
A subungual hematoma that covers >50% is treated with ?
**trephination of nail plate** - heated paper clip, electric nail drill, hand-held electrocautery, 18-gauge needle, or #11 scalpel
allows decompression and drainage of the hematoma
92
indication for nail removal after nail bed injury?
only if there is associated partial nail avulsion or surrounding nail fold disruption
93
time goal to repair foot/leg wounds?
6 hr is acceptable if primary closure is felt beneficial
consider delayed primary closure in cases of delayed presentation or heavy contamination
94
when to remove foot/leg sutures?
10-14 days
95
how to approach FB soft tissue wounds?
* weigh RvB of leaving FB in place vs harm of attempting to remove it
* Not all need to be removed, and not all that require removal must be extracted in the ED
96
indications to remove FB soft tissue?
1. potential for later infection, toxicity
1. injury
1. functional problems
97
how to determine what closure to use for FB soft tissue wounds?
* FB removed + good blood supply - primary closure
* otherwise, delayed primary closure is preferred
98
how to remove superficial FB (needle)
1. make incision at one end to expose and grasp it with a hemostat.
1. US probe can be used to locate the long axis of FB
1. incision made at end closest to skin, grasp FB with forceps and remove with traction in direction of long axis.
99
how to remove deep FB (needle)
1. **perpendicular incision** to the needle at its **midpoint**, where it can be clamped with a hemostat
1. pushed out of entrance of original wound.
100
what type of FBs may disintegrate with being pulled out of the puncture wound with forceps?
what type of FB is this best with?
* wood splinters and organic spines (e.g., cactus, sea urchin, and fish)
* wood-solid FB
101
technique that can make locating wood fragments easier to precisely locate?
create an elliptical incision around puncture wound and extract the fragment in a block of tissue
102
technique useful for deeply penetrated and larger fishhooks?
**advance-and-cut technique**
_traumatizes and contaminates tissue_, but effective method in the ED if barb has nearly or already penetrated the surface of the skin.
103
which technique is nearly always successful in removing fishhooks?
incision
104
2 major benefits to enlarging puncture wounds containing foreign bodies.
| fishhook
1. wound is more easily inspected for additional FB
1. wound tract is more easily irrigated through a larger opening
*the incising scalpel can easily injure tendons, nerves, and vessels*
105
MC organism in most soft tissue infections from puncture wounds?
**s. aureus (MC),** staph, strep
106
MC pathogen isolated from plantar puncture wound–related osteomyelitis, esp if through rubber sole of an athletic shoe
pseudomonas
107
imaging for puncture wounds?
XR, US
108
mgmt for Uncomplicated clean punctures presenting < 6 hours after injury?
superficial wound cleansing and tetanus prophylaxis
109
difference in suing low-pressure vs high-pressure irrigation for puncture wounds?
Low-pressure: assist in surface cleansing and can see entrance site; will not penetrate puncture tract
High-pressure: might penetrate tract; has no proven benefit, theoretically could force foreign matter and bacteria deeper into surrounding tissue
110
what two mgmts have no affect in reducing infection/no proven benefit for puncture wounds?
* Soaking of wound in antiseptic solution
* Debridement or coring
111
high-risk puncture wounds that require pt to receive abx?
1. plantar punctures
1. punctures due to bites
1. punctures with heavy contamination
112
prophylatic abx for puncture wounds?
* 1st gen cephalo
* augmentin
* FQ
* alt: bactrim/tetracylcine + ticarcillin/ceftazidime/cefepime
113
abx for plantar puncture wounds?
cipro
114
available postexposure prophylasis for needle sticks?
available for hep B and HIV, but **not for hep C**
115
Despite an initial appearance that suggests only a minor injury the history of _____ use alone should prompt immediate consultation with a hand surgeon.
high-pressure injection device
116
what intervention to avoid in for high pressure finger wounds as it could further increase pressure in finger compartments?
digital block
117
The risk of subsequent amputation is reduced if surgical debridement is performed within ? hours of the injury, especially in cases of organic solvents.
6
118
approach to wound care involving animal bites?
1. careful examination, aggressive irrigation and debridement
2. imaging if retained FB
3. **avoid primary closure** in immunodef and higher-risk wounds
119
which type of animal bite is more prone for infection, cat or dog?
cat - sharper teef
120
organism causing infection from cat bite?
Pasteurella multocida
121
abx for animal bites?
1. **augmentin** - dog, cat, human
1. PCN V/ampicillin - cat
1. doxy/cefuroxime - cat
2. clinda + FQ - dog
**avoid** Cephalexin, dicloxacillin, erythromycin, or clindamycin
122
what type of injury is suggestive of a human bite?
closed-fist injury
123
mgmt for human bite wounds?
1. avoid primary closure
2. keflex or augmentin
3. established infections: unasyn, cefoxitin, zoysn
124
mgmt for rodent bites?
* IV PCN x 5-7 d, then oral PCN x 7 d
* Alt: Doxycycline or tetracycline
125
two pathogenic causes of rate-bite fever?
1. Streptobacillus moniliformis (MC North America)
1. Spirillum minus/minor (MC Asia)
126
pathogenic cause of freshwater fish bites?
**Aeromonas**, streptococci, and staphylococci
127
mgmt for fish bites
Freshwater - FQ or Bactrim
Saltwater: cover **Vibrio** - FQ or doxy
128
what animals are considered to be high risk for rabies and is recommended postexposure prophylaxis with immunoglobulin and vaccine if exposed to these animals?
skunk
raccoons
foxes
bats
129
when to administer tetanus-dipheria (Td)?
* incomplete vaccinations
* with tetanus-prone wounds and >5 yrs from last vax
* with any wounds >10 yrs from vax
* if ≥7 y/o
130
how to I&D abscess?
1. prep area with povidone-iodine solution, use sterile drape
2. administer anesthesia over abscess, then deeper until resistance of wall of abscess cavity is overcome. distend abscess with lidocaine
3. use No. 11 or 15 blde to incise
4. squeeze
5. hemostat into the abscess cavity, opening and closing the jaws to break up loculations.
6. Irrigation of cavity with saline followed by packing with gauze ribbon
131
alternatives to packing for abscesses?
placing a catheter, or tying in a rubber drain after placing two small stab incisions, using a small forceps to reach into one incision, coming out the other, and pulling the drain back through the track before making a knot.
132
pt ed and mgmt for abscess?
* warm compresses 3x/day.
* f/u 2-3 days
* Maintain catheter or replace packing if cavity is still draining at follow-up
133
when would abx not be indicated for post-abscess care?
healthy immunocompetent, abscess drainage copmleted after procedure, mild disease
