emed II exam 1 wound

emed II exam 1 wound

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– clean cut, very easy to suture –Produced by sharp objects, Low energy actiono Usually with straight edges, Little contamination, Typically heals well shearing
– something falls and causes a laceration- Crush the skin against underlying bone, High energy forces, Irregular edges, ragged, contusion, stellateDisruption of microvascular, Look for underlying injuryworry abt compartment syndr and open fx compresive forces
– Produce flap-like lacerations, Usually have surrounding devitalized tissue o Wound is much more susceptible to infection than shear forceTakes a large amount of force tension
Excoriations of the superficial layers of the skin, Doesn’t req repair, Most often contaminated- Usually no bleeding upon arrival, Irrigate/treat with bacitracinCan clean without anesthetizing – abx ointment/ sterile dressing to help reduce infxm abrasion
wound made by forcibly being torn/pulled away, Definite scar, More likely to be infected, Usually on digits, Repair unlikelydigital block is helpful with cleansing. DO NOT SCRUB can devitalize tissue- App of surgical clotting material >hemostasis avulsion
“hole” made by a sharp object, Frequently on plantar or palmar surfaces–Likely to get infected, Difficult to irrigate, DO NOT SUTURE puncture
what is the MC missed organism in a puncture wounds pseudomonas
Can involve characteristics of all types of wounds, Highly contaminated with bacteria- Must consider source when giving antibiotics, Shouldn’t be sutured unless necessary and if so done loosely EVERYTIME PATIENT GOES HOME WITH ANTIBIOTICS bites
Extremity bite that needs to be closed you do it loosely
Separation of the superficial layer of skin from the deeper layers often circumferential- Usually caused by machinery, Requires surgical/hand consult degloving
Usually occurs in elderly, Unrepairable –Usually requires dressings and wound care follow up- Put an antibiotic dressing on it and then give them follow up with wound care skin tear
what two conditions should you rule out with pressure ulcers (stage 3 and up) osteomyelitis and surrounding cellulitis
what anitbiotics would you give a patient with osteomyelitis or cellulitis vanc and zosyn
what are the 5 stages of wound healing (1) hemostasis (2) inflammation (3) epithelization (4) fibroplasia/ proliferation (5) maturation/ remodeling
– platelet activation, coagulation cascade initiated, fibrin clot production o Pts can be on meds to slow this down hemostasis
– Neutrophils and macrophages phagocytose dead tissue, foreign material and bacteriaPhysiologic debridement occurso Physiologic prevention of infectiono First 72 hours neutrophils are activeo Macrophages continue to work for 30 d inflammation
– Peaks at 24h after the injury lasts 48 hours aftero Cell division occurs in the stratum germinativumo Cells migrate across a closed traumatic wound to it impervious to waterProcess is impeded by eschar formation and surface debris, including hair epithelialization
what cells are active in first 72 hrs of inflammation neutrophils
how long do macrophages work in inflammation 30d
when does epithelialization occur peaks at 24 hr after the injury and lasts 48hr after
– New blood vessels bring life to new tissue, Begins within the first 72 hours peaks at 7-10 days, Brings the surrounding “pink” color to healingo As wound heals vascularity goes back to baseline at 30 days(patients with issues with this stage) angiogenesis
– Peaks at 7 days continues for 3 weeks–Balance of collagen synthesis and damaged collagen breakdown are in a tenuous balance between 7-10 dayso Wound dehiscence is most likely to occur during this critical time fibroplasia
– changes the appearance of the skin and accounts for the initial eversion of wound edges contraction
o is an individual process… no one heals alike(keloids)Sometimes sutures can cause even more keloids remodeling
why dont you fix a wound past 12h – DON’T FIX PAST 12H because they are more likely to get infected—open for 12 h already you don’t want to close them up because you could be closing in the bacteria it has been exposed to
how can you tell if a would/lac went into the joint capsule How to ensure this—fill up 100CC syringe with water and do knee injection on the opposite side of the lac and if it went into the joint capsule all of the water will come out the wound
what is the preferred method to control bleeding so you can do proper wound evaluation direct pressure
Local injection inhibits depolarization of the nerve membrane by blocking the influx of sodium ions and preventing propagation of the action potential anesthesia
anesthesia lasts 3-7 mins (sometimes longer) onset lasting 90mins-6hrs bupivacaine
anesthesia onset 2-5 mins lasting 1-2hours- Max 4.5mg/kg without epinephrine (fingers, toes, nose, penis, pinna)- Max 7mg/kg with epinephrine —causes less bleeding—typically what you useused mc in ED setting bc quick onset lidocaine
can you use a higher dose of lidocaine w/ or without epinephrine with epinephrine
where do you use cation w/ epi fingers, toes, nose, penis, pinna
– When using lidocaine patient will feel intense burning this sometimes can be minimized by buffering with ____ to raise pH and decrease onset sodium bicarb
o requires a solid knowledge of anatomy. Allows for no distortion of anatomy of wound, greater area of anesthetized, and fewer injections. May have risk for compartment syndrome. Can also be used for fractures and dislocations regional/digital blocks
anesthesia injection causes increased anatomical deformity local injection
Reduces risk of infection—High pressure with water/saline, Use a safe guard—contaminated wounds until al visible debris is removed. Make sure you can visualize wound on bloodless field irrigation
Dead tissue may increase the risk of infection and delay healing–this removes FB matter, bacteria and dead tissue creating sharper edges for repair- Elliptical excision is most effective – Surgical consults will be requires for large debridement debridement
Shown to reduce infection? Wear sterile gloves, Sterilize intact skin and then sterile draping- Maintain the integrity of the sterile environment sterile technique
– Any type of sutures, staples, dermabond, wound adhesive, steri strips- pt has to coe in w/ in 12 hrs, best outcomes w/in 4, key to clean wound out with well everted edges, may or may not require abx primary closure
where is the only place you use staples in the ED setting scalp
o type and size dependent on location. Absorbable usually left for under the skin or in mucosal area. 6.0-5.0 are left for the face. 5.0-4.0 are left for extremities nut under high tension. 4.0-3.0 are left for high tension areas sutures
suture size left for the face 6.0-5.0
suture size left for extremities not under high tension 5.0-4.0
suture size left for high tension areas 4.0 -3.0
– Wound cleansing then closure if no infection after 4-5 days left open with wet dressingo Not used frequently in the ER because of poor follow upo MUST MAKE SURE THEY HAVE FOLLOW UP or are going to the ORo Usually done to improve cosmetics delayed primary closure or tetiary closure
Wound cleansed & allowed to heal w/out repair (dog and cat bites)o wounds present after window of opp has closedo wounds heavily contaminated w bact or debris that is unable to be removedo much larger scaro used to decr infxn secondary intention wound closure
sutures have the lowest infection rate and most commonly used nylon and polypropylene
sutures – are absorbable and used to close underlying skin layers and mucus membranes vicryl sutures
What is the time for healing/recovery of restoration from efforts of anesthetic and surgery 3-4 weeks
What is the time for healing/recovery of regaining full tone of peri-articular ligaments (around the joint/risk of dislocation) 12-16 weeks
What is the time for healing/recovery of restoration of general tone and vitality up to 6 months
What is the time for healing/recovery of complete healing of scar both deep and superficial up to 9 months
how many days later do you remove face sutures 5 days
how many days later do you remove scalp sutures 7-10 days
how many days later do you remove scalp staples 5-7 days
Image studies, May primarily close, Try to remove. DON’T DIG- Obtain a post procedure xray- Give proper follow up if unable to remove and possible antibiotics soft tissue foreign body
what is the antibiotic of choice for pasteurella (dog bite) augmentin
pt is bit by a human, what is the mc organism and method of treatment staph/strep, tx w/ augmentin
pt is bit by a rats, mice, squirrel, gerbil, what is the mc organism and method of treatment streptobacillus moiliformis, tx w/ augmentin
pt is bit by livestock, what is the mc organism and method of treatment brucella, leptospira, francisella tularensis –augmentin or specific agent for disease
pt is bit by bat/monkey/dog/skunk/raccoon/fox/bat what is the mc organism and method of treatment rabies, give rabies immune globulie and vaccine
pt is bit by monkey, what is the mc organism and method of treatment herpes b virus, acyclovir or valcyclovir
pt is bit by freshwater fish, what is the mc organism and method of treatment aermonas, staph, strep, tx w/ flouroquinolone or bactrim
pt is bit by a saltwater fish, what is the mc organism and method of treatment vibrio, staph, strep, tx w/ doxycycline +/- flouroquinolone
What are the treatment options for a cat bite augmentin or cefitin or doxy
what are the treatment options for a human bite mild: augmentinmod/severe: amp-sulbactam or ticaracillin/calvulanic acid or piper/tazo pcn allergic: cipro/bactrim + clinda
what are the treatment options for a dog bite augmentin or if pcn allergic clinda+cipro, kids clinda and bactrim

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