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AFP Journal ReviewAFP Journal ReviewJanuary 1, 2009January 1, 2009
Cindi Hurley, MD MBAFebruary 12, 2009
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TopicsTopics
1. Principles of Casting & Splinting
2. Mgmt of Blood Sugar in Type 2 Diabetes
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Casting & Splinting Casting & Splinting ReviewReview
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Assess Need for Assess Need for ImmobilizationImmobilizationCasts & Splints serve to promote
healing, maintain bone alignment, decrease pain, protect the injury and compensate for weakness
Conditions that benefit from immobilization:
Fracture Inflammatory conditions
Sprains Deep lac repairs across joints
Tendon laceration Severe soft tissue injury
Reduced joint dislocations
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What’s the Difference? What’s the Difference? Both start with application of a
stockinette & paddingSplinting involves non–
circumferential application of a plaster or fiberglass support held in place by an elastic bandage
Casting involves circumferential application of plaster or
fiberglass
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Splint or Cast?Splint or Cast?
Must assess the stage & severity of the injury, potential for instability, risk of complications, and patient’s functional requirements
Splints used more often for simple or stable fractures, sprains, tendon injuries & other soft tissue injuries
Casting used for definitive and/or complex fractures
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Advantages of SplintingAdvantages of SplintingFaster & Easier to ApplyMay be static & prevent motion
or dynamic & allow controlled motion
Allows for natural swellingEasily removed to allow for
regular inspection
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Disadvantages of Disadvantages of SplintingSplintingAllow excessive motion at injury
siteInappropriate for definitive
treatment of unstable or potentially unstable fractures such as those requiring reduction, spiral fractures and dislocation fractures
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Advantages of CastingAdvantages of CastingMore effective immobilization
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Disadvantages of CastingDisadvantages of CastingTakes more time & skill to applyHigher risk of complications
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Complications of Splinting & Complications of Splinting & CastingCastingCompartment Syndrome
◦ Most serious complication◦ Increased pressure within a closed space,
compromises blood flow & tissue perfusion◦ If pt experiences severe swelling, worsening
pain, numbness or tingling , or dusky appearance ER
Heat InjuryPressure Sores and Skin Breakdown
◦ often caused by pressure from a wrinkled, unpadded or underpadded area over a bony prominence
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Complications, continuedComplications, continuedInfection
◦ Common with open wound◦ Moist, warm environment is ideal for
infectionIschemiaDermatitisJoint StiffnessNeurological Injury
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GuidelinesGuidelinesInspect the involved extremity and
document skin lesions, soft-tissue injuries, and neurovascular status beforehand
Protect the patient’s clothingProperly position the extremity
before, during & after application of materials
Properly pad bony prominences and high-pressure areas
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Guidelines, continuedGuidelines, continuedAvoid tension and wrinkles on
materialsUse the right temperature of water
– the hotter the water the faster the material sets and the greater the risk for heat injuries – use tepid water for plaster and room temp water for fiberglass
Do not dump water used on plaster down the sink – it will clog!
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VideosVideoshttp://intermed.med.uottawa.ca/
procedures/cast/
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Follow-Up Follow-Up Elevate the injured extremity to
decrease pain & swellingRefrain from getting the material wet Educate pt re: compartment
syndromeAvoid strong opioids so pain is not
masked that should prompt a doctor’s visit
Most require initial follow-up within 1 -2 weeks
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Management of Blood Management of Blood Glucose in Type 2 Glucose in Type 2 Diabetes MellitusDiabetes Mellitus
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Statistics on Type 2 Statistics on Type 2 DiabetesDiabetes6th cause of death in USLeading cause of kidney failureLeading cause of new blindness
in adultsMore than 20 million Americans
have T2DM, however 30% are undiagnosed
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We Need to Focus OnWe Need to Focus OnLifestyle ChangesManagement of Cardiovascular
Risk FactorsManagement of Blood Glucose
Levels
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Lifestyle ModificationsLifestyle ModificationsWeight loss goal of 7%
◦Reduces incidence of T2DM by 58% !!!
Exercise goal of 150 minutes per week ◦(30 mins/day x 5 days/week)
TLC much more effective than Metformin in reducing blood glucose & HbA1C
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Mgmt of Cardiovascular Mgmt of Cardiovascular Disease Risk FactorsDisease Risk FactorsInterventions to manage blood
pressure, cholesterol and microalbuminuria have been shown to decrease mortality
Use ASA if T2DM and ◦Have existing CAD◦Have RFs for CAD◦Are over 40 yo
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Mgmt of Cardiovascular Mgmt of Cardiovascular RF’sRF’sUse Statins if T2DM and
- have existing CAD- they are older than 40 with at least one CAD RF
Use ACE or ARBs if T2DM and ◦Micro- or macroalbuminuria
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Management of Blood Management of Blood GlucoseGlucoseOral AgentsOral AgentsBiguanidesSulfonylureasNon-SulfonylureasAlpha Glucosidase InhibitorsAmylin AnaloguesIncretin EnhancersIncretin MimeticsThiazolidinediones (TZDs)
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BiguanidesBiguanidesExamples: Metformin (Glucophage) Mechanism: decreases hepatic
glucose production and intestinal glucose absorption; and to a lesser extent, increases insulin sensitivity of peripheral cells
SA’s: nausea, diarrhea, flatulenceCaution: RI (d/c if Cr > 1.4), using IV
dyeCost: $20-30/month if genericNote: 1) only hypoglycemic agent
shown to reduce mortality 2) approved for children > 10 yo
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Insulin Secretatogues: Insulin Secretatogues: SulfonylureasSulfonylureasExamples: Glyburide, Glipizide,
Amaryl Mechanism: incease insulin
secretion from the pancreatic islet beta cell by closing K+ channels
SA’s: hypoglycemia, wt gainCost: $50/month
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Insulin Secretatogues: Insulin Secretatogues: Non-sulfonylureasNon-sulfonylureasExamples: Starlix, Prandin Mechanism: stimulates
pancreatic islet beta cell insulin release
SA’s: hypoglycemia Cost: $175/month
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Alpha Glucosidase InhibitorsAlpha Glucosidase Inhibitors
Examples: Acarbose (Precose), Miglitol (Glyset)
Mechanism: acts at the brush border in the small intestine to delay glucose absorption
SA’s: flatulence, abdominal pain, diarrhea
Cost: $80-$90/monthNote: Shown to decrease CV
events
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Amylin AnaloguesAmylin AnaloguesExamples: Pramlintide (Symlin) Mechanism: exact mechanism of
action unknown; decreases postprandial plasma glucose rise, suppresses glucagon secretion, slows gastric emptying
SA’s: nausea, vomiting, anorexia, headache, diarrhea
Caution: Severe hypoglycemia can occur, especially with co-administration of insulin
Cost: $150-$250/month
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Incretin EnhancersIncretin EnhancersExamples: Januvia, Onglyza Mechanism: slows incretin
metabolism, increasing insulin synthesis/release, decreasing glucagon levels
SA’s: nausea & vomitingCaution: adjust dosage in pts
with RICost: $180/month
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Incretin MimeticsIncretin MimeticsExamples: Byetta Mechanism: enhances insulin secretion
in response to elevated plasma glucose levels
SA’s: nausea & vomiting, diarrhea, dizziness
Caution: not recommended in pts with Cr Cl < 30
Cost: $250/monthTidbit: derived from a compound found
in the saliva of the Gila monster, a large lizard native to the southwestern US
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Thiazolidinediones (TZDs)Thiazolidinediones (TZDs)Examples: Actos & Avandia Mechanism: increases insulin
sensitivity in peripheral tissue, and to a lesser extent, decreases hepatic glucose production
SA’s: wt gain, fluid retentionCaution: liver dz, pregnancy, HF,
association between Avandia and CV events
Cost: $150/month
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Goal for Blood GlucoseGoal for Blood GlucoseMaintain as close to normal as
possible without causing hypoglycemia
ADA recommends A1C < 7%In relatively well-controlled DM,
home monitoring has not been associated with significant improvement in A1C levels
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Rapid Acting Insulin Rapid Acting Insulin
1. Lispro (Humalog), Aspart (Novolog) onset: 5-15 minutes peak: 1-2 hours duration: 4-5 hours
2. Regular (Humulin R) onset: 30-60 minutes peak : 2-4 hours duration: 8-10 hours note: inject 30 minutes before meal
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Intermediate-Acting Intermediate-Acting InsulinInsulinNPH (Humulin N) onset: 1-2 hours peak: 4-8 hours duration: 10-20 hours
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Long-Acting InsulinLong-Acting InsulinGlargine (Lantus) onset: 1-2 hours peak: relatively flat duration: 20-24 hours dosing: start at 10 units per
day, titrate at 2 units per day q 3 days
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ReferencesBoyd A, Benjamin H, Chad A.
Principles of Casting and Splinting. American Family Physician. Jan 1, 2009.
Ripsin C, Randall U. Management of Blood Glucose in Type 2 Diabetes Mellitus. American Family Physician. Jan 1, 2009.