but, what you do… you learn.€¦ · teach techniques and provide hands on practice of the...
Post on 10-Jun-2020
1 Views
Preview:
TRANSCRIPT
3/2/2014
1
Alan Keating, PA-CConyers, Georgia
Provide memory tools utilized in the rapid assessment and treatment of many of the common urgent care illnesses and injuries.
Emphasize the subtle signs and symptoms of these clinical presentations that can quickly lead to life threatening situations.
Provide multiple clinical pearls and review key clinical skills utilized in urgent care medicine assessment and treatment.
Teach techniques and provide hands on practice of the following skill areas: suturing, splinting, and casting emphasizing clinical “tricks of the trade.”
Utilize memory tools, discussions, and hands on techniques to reinforce the protocols learned.
What you see, you forget.
What you read, you remember.
But, what you DO… you LEARN.
3/2/2014
2
Procedure Fundamentals
Quick Reminders:The number one customer in a
pediatric case is the parent(s).
If the child starts talking to you, listen to them, even if you have no idea what they are saying!
Four A’s of Neurologic documentation: Alert, Active, Awake, and
Appropriate Response to…
3/2/2014
3
PenetratingBlock, X-Ray, Remove Don’t forget the antibiotics
Tetanus if over 5 years I.V. Cefzolin if fractured and orthopaedic
consultP.O. Cefalexin, TMP-SMX, or Doxycycline
In the Ear*** Quick look, 2% Lido Stat, then irrigation with warn water.
Dogs: 5% infection risk - tear wounds.Treatment – Amox/Clav. 875mg BID, pain control, and wound irrigation. These can be much worse due to other damage (fractures, vascular injury, deep muscle tears).
No. 1 Bacteria is Pasteurella canisNo. 2 is Staph. aureus
Cats: 80% infection rate - puncture wound.Treatment – Amox/Clav. 875mg BID,
pain control, and wound irrigation.No. 1 Bacteria is Pasteurella multiocidaNo. 2 is Staph. aureus
3/2/2014
4
Clear it with your attending
Prepare the patient
Feel the notch
Relax
Take your time
Volume: 2-4 cc Lidocaine – PLAIN
How deep?: Subcutaneously. Inject just on top of the tendon sheath and the infiltrate the digital nerves.
Effectiveness: Just as good as multiple sticks
Pain Level: About the same
Satisfaction: Patients – SameProviders - Better
3/2/2014
5
“Eventually all bleeding stops… one
way or another”
Blunt Trauma“Cheek just puffed out after I sneezed”
Lacerations Over SinusesFinger probe technique – Listen for eggshells
Lip Laceration - “Million dollar laceration”
Non X-Ray Mandible Fracture Exam
What is the facial injury imaging Gold Standard?
3/2/2014
6
3/2/2014
7
3/2/2014
8
Shapes:Cutting – Reverse & Conventional
Good for most skin & nailsTapered – Deep tissue and fascia
Curvature:
Nonabsorbable:Silk, NYLON, Polypropylene, Polyester fiber,
Polybutester, and Coated Polybutester
Natural Absorbable:Collagen, Plain surgical gut, Fast-absorbing
surgical gut, and Chromic surgical gut
Synthetic Absorbable:Polyglactin 910 (VICRYL), Polycaprolate
Poliglecaprone 25 (Monocryl), Polysorb,and Polydioxanone (PDSII)
Sutures: Only needles needed – PS-2 and P-3.Only suture needed – 6-0, 5-0, 4-0 Nylon
and 4-0 Vicryl, that’s it.
Anesthesia tips - Be nice and take your time:Hold the syringe to warm the lidocaine.Add 1cc bicarb for every 9cc of 1% lidocaine.
Use 2% or 0.5% bupivacaine for larger or complex lacerations.
3/2/2014
9
Suturing Dont’s:Perform a closure only if you are comfortableNo need to rush the anesthesia infusionRemember to pucker up the edges.Loose closure only of contaminated woundsLoose closure of the fascia layerIf it looks bad now, it will look worse later.External staples on the scalp works fine, unless…No “landing strips”Don’t forget to close the galea layer.
No internal sutures in the hand-EVER!
Suturing Do’s:Cut off rings Assess neurovascular status PRIOR to anesthesiaInfuse lidocaine inside the wound edgesIrrigate – A LOT! (towels)Approach at a 90 degree angle to the skinBrief use of finger tourniquet – “Squeeze trick”Listen for clicking when looking for FBTag the corners first, EXCEPT in a thin flapUse the “Over – Under” method
Reset your needle while holding the suture!
Basic Rules:1) ICE – Not necessary 2) Gentle Compression – first hour or two3) Elevate – first 24 hours for extremities4) Pool Rule – No Water, especially lakes!
Wound Care Rules:1) Antibiotic Rule – Always if contaminated2) Sensation Rule – Check often, fingers & toes3) Smother Rule – Only a gloss coat of topical 4) Dressing Rule – Change it daily, after shower
3/2/2014
10
The Fast and Furious World
of Urgent Care
Don’t fall asleep at the wheel!Watch out for the routine, don’t assume.Follow the same protocol for all.What do you need to note?
Driver, seat-belt, air-bag, impact, speed, other
Three most import X-raysCXR, C-spine, and pelvisClear off the board, BUT NOT THE COLLAR
What MUST you document?
Hoover Sign
Waddell Signs (HASSP)
Hip Rotation
Axial Loading
Skin Roll Test
SLR Distraction (“SLR/Heel” Test)
Pain Description
3/2/2014
11
P – Pain described, or on palpation
A – Alcohol
N – Neurological Deficit
D – Distracting Injury
A – Altered Mental Status
Most common joint to dislocate is the SHOULDER (Anterior 95%), then finger.
Quick Exam: they can not touch opposite side.Complications: Repeat dislocations.
What is needed most in a shoulder reduction?
Pain medication, sedation, & PATIENCE!
Treatment (other joints): Block first, X-Ray, Reverse the mechanism
3/2/2014
12
Preparing (Helpful Hints):Choose the right material size – 2”, 3”, 4”Need: Splint roll, ACE Wrap, water, & towelPeel and cut backREALLY dry it out
Applying (Do’s and Don’ts):DO Place in position of comfort… UsuallyDO Roll back the ends and move endsDON’T squeeze the corners – Ankles & ElbowsDON’T stretch the ACE, just roll it
90 Degrees at the ankle – a MUST!*
Upper Extremity:Volar or Short ArmUlnar GutterThumb SpikaSugar TongLong Arm/Hanging Long Arm
Lower Extremity:Short LegLong LegCadillac – (Short leg and sugar tong combo)
3/2/2014
13
Basic Rules:1) ICE, ICE, Baby!... - But gently2) Elevate, Elevate, Elevate - ABOVE the heart3) ACE RE-Wrap Rule - DON’T STRECH IT!4) Weight Baring - There is no weight baring
Crutch Training Rules:1) Pink Flamingo Rule – draw the bad leg up2) Lead Off Rule - Crutch first, foot second3) Stairs Rule – NO up or down stairs, ever!4) Backwards Rule – There is no backwards
3/2/2014
14
3/2/2014
15
Honing Your Skills
Assessment (NOM)First- Neurovascular
Second – Open versus Closed
Third – Mechanism of Injury
Description (TOAD)T ype – Spiral, transverse, comminutedO pen vs. ClosedA ngulation – Degrees of angulationD isplacement – Percentage
Six Most Commonly Missed Fractures
Hand – Assume that it is fractured
Scaphoid – “Snuff Box” tenderness
Radial Head – Positive Posterior Fat Pad
Cervical – PANDA Neck Criteria
Calcaneous – Bohler’s Angle/Assess Spine
Salter-Harris – Most Common is Type II of the wrist (50%)
3/2/2014
16
3/2/2014
17
3/2/2014
18
3/2/2014
19
3/2/2014
20
Upper Extremity:Short ArmThumb SpikaClam Shoveler – Boxer’s FractureLong Arm/Hanging Long Arm
Lower Extremity:Short LegLong Leg – slight bend at kneeCylinder
3/2/2014
21
Preparing (Helpful Hints):Choose the right material size – 3” or 4”Need: Cast roll, stockinet, cast padding, waterREALLY shake off the water
Applying (Do’s and Don’ts):DO over extend the stockingDO Roll back the ends, AFTER one pass DON’T over pad, even distribution of paddingDON’T Pinch (Fingers and toes)
Extra PAD on the heel– a MUST!
Basic Rules:1) ICE, ICE, Mayby... – Not as important2) Elevate, Elevate, Elevate – first two weeks3) Pool Rule – No Water, especially lakes!4) Weight Baring – It depends
Cast Care Rules:1) Itching Rule – NOTHING goes in the cast!2) Wiggle Rule – Keep wiggling fingers and toes3) Swelling Rule – Split cast If swelling continues 4) CRPS Rule – REMOVE cast if present!
Kids VS. Cuts
3/2/2014
22
…You’ve got to have a game plan!
3/2/2014
23
What are the primary bugs?Chlamydia, Gonorrhea, and Trichomoniasis
What are the symptoms?
3D’s - Dysurea, Discharge, DiscomfortSx’s are not as severe in Chlamydia versus GCSx’s tend to be asymptomatic in women longerEducate, educate, educate…
Treat all infections and all partners
Why is fever important?
What is the treatment?Trichomoniasis –
Metronidazole 500mg BID X 7 days,or 2 gram X 1 dose OR…Tinidazole 2 gram x1
Gonorrhea – “The Love Dart…”Ceftriaxone 250 mg IM X once ALWAYS. you can add Cefpodoxime 400 mg po x once.
Chlamydia – “…and a Z chaser”Azithromycin 1 gram PO X once.OR, Doxycycline 100 mg po BID for 7 days.
Bates, Barbara, A Guide to Physical Examination and History Taking, Fifth Edition, J.B. Lippincott Company, Philadelphia, PA, 1991.
Cannon B, Chan L, Rowlinson JS, Baker M, Clancy M (2010). Digital anaesthesia: one injection or two? Emergency medicine journal: EMJ, 27 (7), 533-6 PMID.
Gilbert, David, N., et. al., The Sanford Guide to Antimicrobial Therapy 2010, 40th Edition, Antimicrobial Therapy, Inc., Sperryville, VA, 2010.
Jauch, Edward C, et. al., Acute Management of Stroke, MedScape Online, Jul 10, 2012.
Lai, Stephen Y, et. al., Sutures and Needles, Medscape Online, June 3, 2013.Kirkcaldy, Robert, New Treatment Guidelines for Gonorrhea: Antibiotic
Change, Online CDC Expert Commentary, 08/13/2012.Purvis, John, M. Engaging with Younger Patients, AAOS Now, May 2009.Sarwark, John F., Put Pediatric Patients and Parents in the Picture, AAOS
Bulletin, April 2004.Staff author, Diseases Characterized by Urethritis and Cervicitis, CDC Report,
April 12, 2007Staff author, Joint dislocation, Wikipedia, 18 March 2012.
3/2/2014
24
Game Time!
top related