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Trauma and Procedures

Links

• local: Corneal Abrasion & Foreign Body, Orthopedics, Concussion, Heat-Related Illness, Skin Sores and Ulcers (debriding), Trapped Zipper, Warts

Animal Bites

• asplenic patients: sickle cell, surgery: very susceptible to c. canimorsus (cat and dog), rapidly fatal.
• 3. P. multocida: cat bites, some dog. Oxacillin for prophylaxis.

Rabies

• if animal unavailable — standard rabies procedures
• if available and unvaccinated: animal control will sacrifice and test. Usual protocol says to delay postexposure prophylaxis until animal tests positive -- personally the potential delay makes me nervous.

Cervical spine series

• Cervical Spine Radiographs in the Trauma Patient - January 15 1999 - AAFP
• Cervical spine fractures

Misc

• 20% false-negative rate for plain film studies?
• Any pt w/ 1 spinal fx needs entire spine series

Views/Interpretation

• initial films cervical collar
• need lateral (7 vertebrae + C7-T1 junction), AP, Odontoid
• if inadequate, try swimmer's view (one arm over head). If still inad, repeat or CT

Parameters

Cold Injury and Frostbite

• frostbite not affected by wind chill, exposure must be < -2 to -3 C
• worse at high altitudes for same exposure
• treat with rapid rewarming in circulating water from 90-108 F (eg. body temperature water)

Cutting

Anesthesia

injection

• start at margin of lesion and extend distally
• reverse direction and extend proximally
• consider mixing xylocain with ‘nutricane’, a base neutralizing solution mix 1:5 with xylocaine to reduce sting

topical

• TAC gel (tetracaine, adrenaline, cocaine)
• LAT gel (lidocaine 4%, adrenaline 1:2000, tetracaine .5%
• apply then check for anesthesia q10 minutes for 30 minutes

Misc

• punch biopsy:limit to under 4 mm punch, else do elliptical excision
• undermining: 3 cm required to get 1 cm relaxation (3:1). Do just at dermal/fat junction, nerves run through fat.
• recover from a V incision
  • pull on subdermis then cut straight down
  • place suture while tugging subdermis inwards to get ‘flask’ type placement.

Dermabond

A Practical Guide to Dermabond - March 1, 2000 - AFP

• maximum strength in 2.5 minutes
• strength similar to that of 7-day old healed tissue
• can replace 5-0 sutures on face,extremity or torso; really sub-q sutures on deeper sites or sites with stress. Consider splint immobilization in high mobility areas.
• can wipe away with dry gauze within first 10 seconds of application
• if need to remove, put petroleum jelly or antibiotic ointment on for 30 minutes (patients must be instructed to avoid antibiotic ointment)
• don't drip on wound, squeeze vial until drop appears at end, then allow suction to retract it
• edge eversion does not appear to be very important
• apply light layer, hold for 30 seconds, then apply two more layers in oval. Later layers take longer to dry. Fanning does not help.
• wound irrigation key, oral antibiotic if suggestion infection
• hemostasis critical: pressure or 1:1000 topical epi solution. Fluid will increase heat reaction, make use much harder
• no baths until 7-10 days (will wash off top skin and adhesive)
• if gets in wound may produce foreign-body reaction
• non-toxic to eye, if lids glued apply lots of ophthalmic ointment

Hand Trauma

• test thenar group by oppose thumb and 5th fingers
• test adductor pollicis by see if thumb IP flex when grip paper (Froment's sign)
• don't repair flexor tendor injuries, consult hand surgeon
• extensor tendon with horizontal mattress 5-0 nylon
• nail bed laceration: remove nail and repair (?)

Lacerations: Special

Nail and Nailbed

• suture nail margins with fast absorbing gut
• if remove nail, keep nail bed open with an foil splint or nail body

Tongue

• small study suggests no differece between suture and not
• suture for significant through and through lesions, or where a part of tongue may be lost

Fish Hooks

• Fishhook Removal - June 1, 2001 - American Family Physician is a very complete review.
• The "string technique" is probably best suited to smaller hooks with partial implantation.
• If hook is reasonably close to a complete in and out arc probably best to anesthetize, push out, cut and retract.
• Don't mess around with dinky wire cutters. Have a serious bolt cutter in the office that will slice smoothly through a serious hook.
• If multiple barbs along the hook see the article above.
• Tetanus, soaks, etc.

Foreign Bodies

• FB in Foot: Removal via anesthetic ejection -- inject lidocaine beneath foreign body, use fluid pressure to force upwards and eject. May need to enlarge opening.
• eye: see Corneal Abrasion & Foreign Body
• nasal
  • occlude opposite nares, have pt do valsalva and then blow sharply. If young the occlude nares and use ambu-bag to generate force or have parent blow into child's mouth
• ear/nasal
  • apply strong bonding glue to tip cotton-tipped applicator, touch to fb for 15-20 seconds
  • cockroach: apply lidocaine solution into canal, cockroach will back out

Nail Splinter

1. soak in lukewarm water 15-20 minutes to soften nail
2. anesthesize
3. shave nail over splinter with No 15 blade (proximal to distal nailfold)

Preps

• betadine prep must extend well beyond perimeter of undraped field.
• don’t use fenestrated drapes — fields are way too large.
• always use two drapes: one on patient, one for work

Sebaceous cyst

• make ellipse over pore (don't remove ellipse from cyst)
• use ellipse for traction while removing the cyst with dissection

Stings and Poisons

• hymenoptera: poultice of baking soda or salt

Suture Care and Duration

time (assuming a deep vicryl layer)

• face: 5.0-6.0 vicryl and 6.0 nylon: 3-5 days with steristrips
• scalp: 7 days
• neck: 7-10 days
• upper extremity: 7-9 days
• trunk: 8-10 days
• lower extremities: 10-30 days (longer with smoking, obesity)

Tegaderm dressing to wound for 1st six hours

Scalp wounds: apply pressure by patient lying on head