Soft Tissue Flashcards
This deck covers Chapters 52-57 in Rosens, compromising all of burns, wounds, bites, envenomations, and foreign bodies.
What are 5 indications for hospital admission for human bites of the hand?
- Infection at time of presentation
- Tendon/Joint/Bone violated
- Crush/Avulsion/Contaminated/FB
- High-risk patient (immunocompromised)
- Wound >24h old
- Social issues
List 5 features that indicate a snake is more likely to be venomous
- Triangular head
- Elliptical eyes
- Pits
- Fangs
- Single row anal plate
For the following bites, give “Yes/No” for suturing and prophylactic antibiotics:
- Dog
- Cat
- Human
- Hand
- Oral Mucosa
- Oral Mucosa through and through
Dog
- ABx: No except hand
- Sutures: Yes except hand
Cat
- ABx: Yes
- Sutures: No except face
Human
- ABx: Yes
- Sutures: No except face
Hand
- ABx: Yes
- Sutures: No
Oral Mucosa
- ABx: No
- Sutures: Yes
Oral Mucosa through and through
- ABx: Yes
- Sutures: Yes
What are the zones created in the pathophysiology of burns?
-
Zone of Coagulation
* Irreversible necrosis -
Zone of Stasis
* Fixable -
Zone of Hyperemia
* Recovery likely
Outline the mechanism of injury and management of a HF acid burn
Hydrofluoric Acid
- Causes coagulative and liquefactive necrosis
- Necrosis can lead to hyperkalemia
- F- binds Ca2+ and Mg2+
- Hypotension
- Long QTc
- Ventricular arrhythmia
Treatment
- Poison control
- Water/Saline irrigation
- Titrate treatment to pain-free status
- Calcium gluconate paste
- 3.5g in 150 mL lubricant, put in glove, wear glove
- Calcium gluconate locally SC or intra-arterially
- To ICU for monitoring
What are 6 indications for transfer to a burn unit?
Burn Unit
- Hands/Feet/Head/Genitalia/Joint
- Inhalational injury
- Non-thermal burn
- >10% TBSA
- Any 3rd degree burn
- Trauma + Burn
A lab worker presents following a macaque monkey bite. How do you manage this?
- Clean, irrigate wound
- ABx
- No sutures
- Tetanus prophylaxis if needed
- Monkey B virus prophylaxis
- Valacyclovir 1g TID x2 weeks
- Give if:
* Skin/Mucosal exposure to sick monkey
* Inadequately cleaned wound on scene
* Head/Neck/Torso bite
* Deep wound
* Needle-stick injury
* Basically anything….
List 5 strategies for managing an esophageal food bolus
- Carbonated beverage
- Glucagon
- Nitroglycerin
- Benzos
- Foley
- Bougie
- Endoscopy
- Wait
No real evidence for anything other than endoscopy
What is the mechanism of action of the toxin from a black widow spider? How do you manage this?
Lactrodectus mactans
- Neurotoxin - depletes ACh in presynapse
Symptoms
- Dull crampy pain
- Facial swelling
- HTN, sweating
- Weakness, speech issues
Treatment
- Symptomatic
- Wound care
- Ice pack to bite
- Poison control
- Benzos for cramps
- Antivenin if child, elderly, pregnant, or sick
- 1 vial over 15 min
How do you approach a choking infant?
Mild
- Allow them to cough
Severe
- 5 back blows then 5 chest compressions, repeat
Unconscious
- 30 chest compressions, check airway
- 2 breaths and 30 compressions, check airway
- 15:2 if two-person rescue
How does a scorpion sting (centruroides) present? Management?
Symptoms
- Immediate, severe pain
- Allodynia
- Systemically sympathomimetic
Treatment
- Symptomatic
- Wound care
- Ice pack to sting
- Poison control
- Benzos for cramps
- Atropine for bradycardia
- Alpha-blockers/NTG for HTN
- Antivenin if severe
Differentiate the various degrees of burns
- 1st Degree
- Pink, no blisters, dry
- Epidermis
- 2nd Degree (superficial)
- Pink, clear blisters, moist
- Superficial (papillary) dermis
- 2nd Degree (deep)
- Pink, hemorrhagic blisters, moist
- Deep (reticular) dermis
- 3rd Degree
- White, insensate, dry
- Subcutaneous fat
- 4th Degree
- Leathery, dry, insensate
- Bone/Tendon
Compare and contrast a pit viper and coral snake bite. How do you manage these?
Pit Viper (Viperidae)
- Hematologic toxin (Blocks coagulation)
- Immediate pain
- Swelling, bullae, compartment syndrome
- Die from shock, DIC
Coral Snake (Elapidae)
- Neurotoxin (Blocks AChR)
- Ptosis, Paresthesias, Slurred speech
- Weakness
- Die from respiratory failure
Treatment
- Supportive
- Send DIC b/w and crossmatch blood
- Wound care (clean, irrigate, Td, ABx if necessary)
- Tourniquet only if <30 min ago
- Antivenin for pit viper/coral snake
- Give 4 vials over 1 hr and R/A.
* If stable stop.
* If not, give 4 more. Repeat until stable. - Maintenance = 2 vials q6h x3 once stable
How can you tell if a snake is poisonous by its colours?
- Red next to yellow, kill a fellow
- Red next to black, venom lack
But not reliable so don’t mess with snakes.
What are the indications for tetanus prophylaxis?
>10 years since vaccine/Unsure
- Td vaccine
5-10 years since vaccine
- None if clean
- Td vaccine if dirty
<5 years since vaccine
- None
Didn’t have primary series
- Td vaccine if clean
- Td + TIg if dirty
- TIg dose = 4 IU/kg (max 250 IU) IM
How do you manage a box jellyfish sting?
- Remove from water
- Remove stinger
- Heat/Vinegar to neutralize remaining stingers
- CCBs for tachydysrhythmia
- Antivenin
- Td prophylaxis
List 4 methods of heat transfer
- Conduction
- Convection
- Radiation
- Evaporation
- Respiration (listed in some)
List 4 risk factors for infection by Capnocytophagia carnimorus
- Asplenia
- Alcoholic liver disease
- Lung disease
- Steroids
- Causes gangrene at site and overwhelming sepsis
- Adrenal hemorrhage
- Mortality = 30%
List 5 factors that determine the rate of heat transfer
- Heat capacity of agent
- Temperature of agent
- Duration of contact
- Conductivity of local tissues
- Transfer coefficient
List 5 discharge instructions relevant to wound care
- Elevate
- Clean/Dry
- Analgesia
- Immobilize until sutures out
- Signs of infection
- Suture removal time
What are the toxic doses of lidocaine/bupivacaine with and without epi?
- Lidocaine w/ = 7 mg/kg
- Lidocaine w/o = 5 mg/kg
- Bupivacaine w/ = 3 mg/kg
- Bupivacaine w/o = 2.5 mg/kg
Outline the rule of 9’s in adults. What changes are made for children?
Adults
- 9% head
- 9% each arm
- 18% chest
- 18% back
- 1% genitalia
- 18% each leg
Children
- 18% head
- 9% each arm
- 18% chest
- 18% back
- 14% each leg
- Difference is no % for genitalia and head is bigger
List the types of local anesthetics. Give 2 examples of each.
Amide (have two i’s)
- Procainamide
- Lidocaine
- Bupivacaine
- Ropivacaine
Esters (more likely to have allergy)
- Tetracaine
- Cocaine
- Procaine
List 10 indications for antibiotic prophylaxis for lacerations
- Human
- Cat
- Dog (hand)
- Thru buccal
- Nose
- Ear
- Foot puncture
- Open fracture
- Exposed joint/tendon
- Crush
- Contaminated
- Immunocompromised
List 5 indications for intubation in a burn victim
- Hypoxia
- Hypoventilation
- Low GCS
- Stridor
- Soot around face
- Can’t handle secretions
- Fatiguing
List 8 risk factors for wound infection
- Location (leg > arm > feet > chest > back > face > scalp)
- Delay to clean/present >8h
- Contaminated
- Crush
- Human/Cat Bite
- GSW
- Anesthesia with epinephrine
- Repair type (Suture > Staples > Tape)
- Immunocompromised (DM, Cancer, HIV, Transplant)
- Elderly
- Cirrhosis
List 3 venomous families of snakes
- Viperidae (vipers)
- Elapidae (coral snakes)
- Crotalidae (rattlesnakes)
- Hydrophilidae (sea snakes)
- Colubridae
List and describe 2 formulas for fluid resuscitation in burns
Parklard
4 cc/kg/TBSA
- Ringer’s Lactate
- ½ over 8h (time from burn)
- ½ over 16h
Galveston
5000 mL/m2 * %Burned + 2000 mL/m2
- RL + Albumin 12.5g/L + D5 PRN
- ½ over 8h (time from burn)
- ½ over 16h
Target U/O 1-2 cc/kg
List 6 complications of esophageal foreign body
- Obstruction
- Airway compromise
- Erosion
- Perforation
- Migration
- Mediastinitis
- Stricture
- Fistula
- Abscess
- Spondylodiskitis
What is the mechanism of action of the toxin from a brown recluse spider? How do you manage this?
Laxosceles reclusa
- Sphingomyelinase D toxin - local tissue destruction
Symptoms
- Bleb with a red ring at the bite site
- Fever, petechiae, N/V
- Hemolysis, Thrombocytopenia
- Pulmonary edema, Renal failure
Treatment
- Symptomatic
- Wound care
- Poison control
- Dapsone for local wound
