MINOR PROCEDURES FOR ED/URGENT CARE

ELIZABETH BLUNT, RN, PHD, FNP -BC

COLLEEN STELLABOTTE, RN, MSN, FNP -BC

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Taser Removal

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Taser Facts Brand name

Electronic Control Weapon (ECW)

Acronym from a 20th century children’s book Thomas A. Swift Electric Rifle

Used to stun or incapacitate persons

Provides a safer less than lethal force option

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How Tasers Work

Interferes with the ability of the brain to communicate with the muscles.

Contacting the target on any body area leads to full incapacitation.

Fires 2 small darts that act as electrodes

Darts stay connected to the taser by thin conductive wires.

When 2 darts stick a 5 second electrical charge is released.

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Devices

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Devices

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How safe

Extensive review of literature reveals injuries are associated with the fall and not from the electrical impulse.

Do not cause cardiac arrhythmias when used appropriately and the exposure lasts for

Medical Considerations

Threshold to induce ventricular fibrillation in a normal heart is 10-50 joules.

Most tasers fire at 0.5 joules or less.

The most popular model fires at 0.3 joules, 30 times less than the threshold.

High risk populations

◦ Pregnant women

◦ Elderly persons

◦ Young children

◦ Visibly frail

◦ Heart disease

◦ Medical/mental crisis

◦ Persons under the influence of alcohol/drugs

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Assessment

Confirm taser is off and cartridge is disconnected from the device.

General survey of the patient addressing any serious injury from the fall.

Evaluate the anatomical location of barbs.

High risk zones Head Eyes

Ears Nose

Mouth Neck

Genital Spine

Hands, feet and joints

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Barb Removal

Universal precautions

Local anesthetic

Stabilize the skin surrounding the barb with your dominant using hemostats firmly grasp the barb with the “notch” facing up, jerk in a smooth quick motion

Visually examine the barb to ensure it is fully intact

Taser barb is considered a sharp, take all precautions to avoid accidental needle stick

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Barb Removal

Place barb in an appropriate container and return to law enforcement officer for evidence.

Cleanse wound with antiseptic and dress.

Up date tetanus immunization

Instruct patient on basic wound care and signs and symptoms of infection.

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Conclusion

Current medical literature does not support the need for routine laboratory studies, electrocardiograms or prolonged ED observation after electrical exposure from a Electrical Control Device in an otherwise asymptomatic awake and alert individual.

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ANIMAL BITE WOUNDS

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EPIDEMIOLOGY

Difficult to determine actual numbers because many are not reported

CDC reports that an average of 4.5 million bites per year

885,000 require medical attention

In 2006, 31,000 underwent reconstructive surgery

Children are the most frequent victims

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PRINCIPLES OF DISEASE

Bites are traumatic injuries that cause damage to skin, muscle, nerves, blood vessels, tendons, joints and bones

Wounds can be lacerations, contusions, scratches, tear or deep punctures

Contamination with oral flora makes local wound infection the principle treatment concern along with rabies and tetanus immunization status

Most US cities have animal bite reporting laws

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CLINICAL MANAGEMENT

Prevention and treatment of local bacterial infection and prevention, recognition and management of subsequent systemic illness

Initial assessment for life threatening injury

Meticulous exam and wound cleaning

Special attention to wounds that involve joint space penetration

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CLINICAL MANAGEMENT

Facial, hands, and perineum wounds can be problematic due to the close proximity of delicate structures

Image wounds if there is any suspicion of a foreign body

Primary closure for cosmetic and functional issues

Delayed primary closure is most successful

Tetanus and Rabies immunization evaluation

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HELICOPTER ACRONYM

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H History

E Examination

L Liberal cleansing

I Irrigation

C Closure & culture consideration

O Operative cleansing and closure

P Prophylactic or therapeutic antimicrobial use

T Tetanus immunization status

E Elevation

R Rabies risk

TETANUS PROPHYLAXIS

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RABIES PROPHYLAXIS

Rare disease in developed countries

Significant North American reservoirs of animal rabies exists in bats, skunks, raccoons and foxes.

All carnivores and omnivores are potential vectors

http://www.cdc.gov for updated information

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http://www.cdc.gov/http://www.cdc.gov/

RABIES PROPHYLAXIS

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Condition of animal at time of attack Treatment of exposed person

Healthy and available for 10 day

observation

No treatment unless animal

develops rabies

Rabid, suspected rabid, or escaped RIG and HDCV

DOG AND CAT BITES

RABIES PROPHYLAXIS

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Animal species Condition of animal

at time of attack

Treatment of

exposed person

Wild

Skunk, bat, fox,

raccoon, bobcat,

and other

carnivores

Regard as rabid RIG and HDCV

Bites from squirrels, hamsters, guinea pigs, gerbils,

chipmunks, rats, mice, rabbits and hares almost never call

for rabies prophylaxis. Consult local public health officials.

RABIES IMMUNOGLOBULIN (RIG)

20 IU/kg of body weight

If anatomically feasible up to half the dose should be infiltrated around the wound and the rest administered in the gluteal area

RIG should not be administered in the same syringe or into the same anatomic site as the vaccine because RIG may partially suppress active production of antibody

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RABIES VACCINE (HDCV)

HDCV 1 ml IM deltoid area on

Day 0

Day 3

Day 7

Day 14

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ANTIMICROBIAL TREATMENT

All puncture wounds

Bites involving hands, feet, face, or genital area

Moderate or severe wounds

All wounds in immunocompromised patients

Bite wounds with signs of infection

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PROPHYLACTIC ANTIBIOTICS

Refer to the Sanford Guide to Antimicrobial Therapy or other source for specific bites

Overall initial therapy for most bites and those not allergic to penicillin is Amoxicillin-Clavulanate

Alternative combinations vary with specific animals

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BATS

•Most recent human rabies has been caused by bats

•Contact with bats increases suspicion of rabies exposure

•Consult local health department and CDC

•Rabies is not transmitted by bat guano, urine or blood

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DOG BITE

5-6 % become infected

Pastaurella and anaerobes most common microorganism

Capnocytophaga canimorsus rare but fulminant bacteremia following a dog bite

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CAT BITES

60 -80 % become infected

Narrow sharp teeth increase the susceptibility to deliver infectious agents through puncture wounds

Pastaurella Multocida most common microorganism

Cat scratch disease 7-12 days after bite or scratch

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HUMAN BITES

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HUMAN BITE WOUNDS AND CLOSED FIST INJURIES (CFI)

Associated with a high incidence of infection, approximately 60%, especially with hand injuries

Polymicrobial, staph and strept species

Eikenella Corrodens common bacteria

If blood involved hep B and HIV prophylaxis may be warranted

CDC post exposure prophylaxis 24 hour hot line, 1-888-448-4911 for consultation

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FERRET BITES

3rd most popular pet in the US

Usually attack face and neck

Little is known about the bacteriology of ferret bites

CDC recommends management strategy similar to that for other domestic animals, 10 day observation.

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DOMESTIC HERBIVORES

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HORSES AND PIGS

Pigs and horses can inflict serious injury with their powerful jaws and grinding teeth

Usually require careful debridement and exploration

High risk of infection

Polymicrobial

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RODENT BITES

Usually trivial

No rabies

Rat bite fever- 2 similar febrile illnesses diagnosis confirmed by blood culture for streptobacillus moniliformis or spirillum minus rare

Hantavirus is also rare transmission

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OPHTHALMOLOGY Anatomy

◦ External ◦ Lid

◦ Eyelashes

◦ Internal ◦ Cornea

◦ Conjunctiva

◦ Iris

◦ Limbus

◦ Sclera

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OPHTHALMOLOGIC EVALUATION

History ◦ Traumatic

◦ Atraumatic

◦ Red Flags

◦ Pain

◦ Visual disturbance

◦ Vital sign of the eye

◦ Visual acuity – Snellen chart pt stands 20 ft from chart

Hand held 13 inches

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OPHTHALMOSCOPE

Filter dial

◦ Large, medium small

◦ Half light

◦ Red free

◦ Slit beam

◦ Blue light

Focusing wheel

◦ Positive focuses objects that are close

◦ Negative wheel focuses objects that are far away

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SLIT LAMP Illumination system

Bio microscope

Basic goals ◦ r/o globe rupture, corneal abrasion,

ulcerations, and foreign bodies

◦ Provides superior magnification

◦ Tangential lighting assists in the diagnosis of uveitis and iritis

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EYE PRESSURES Indications

◦Eye pain

◦Eye trauma

10-21 mmHg normal

Numerous tools

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Tonopen

Anesthetize the eye

Apply latex cover

Calibrate unit if not already done (every 24 hours)

Press activation switch, “====“ appears indicating ok to test

Probe is held like a pen, briefly and lightly touched to the cornea

Do 4 times

After 4 valid readings a final beep will sound and display an averaged measurement

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Tonopen

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CHEMICAL BURNS

Serious damage arises from strong basic and acidic compounds

Severity is related to type of substance, volume, concentration, duration and mechanism

Treatment goals- aggressive early management and close long term monitoring

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Chemicals

Acidic

◦ Battery acid (e.g., sulfuric acid)

◦ Bleach (e.g., sulfurous acid)

◦ Glass polish (e.g., hydrofluoric; behaves like alkali)

◦ Vinegar (e.g., acetic acid)

◦ Chromic acid (brown discoloration of conjunctiva)

◦ Nitric acid (yellow discoloration of conjunctiva

Alkaline

◦ Cleaning products (e.g., ammonia)

◦ Fertilizers (e.g., ammonia)

◦ Drain cleaners (e.g., lye)

◦ Cement, plaster, mortar (e.g., lime)

◦ Airbag rupture (e.g., sodium hydroxide)

◦ Fireworks (e.g., magnesium hydroxide)

◦ Potash (e.g., potassium hydroxide)

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MANAGEMENT

Remove offending agent

Irrigation

◦ Must contact ocular surface to be effective

◦ 1-2 liters

◦ Morgan lens

Test ph

Rx artificial tears

Pain management

Close ophthalmologic follow up

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EYE FOREIGN BODY REMOVAL

Topical anesthetic

Measure visual acuity

Inspect cornea

If fb is visualized attempt removal with a moistened cotton-tip applicator

If successful, fluorescein stain and inspect

Evert upper lid to rule out pre-tarsal fb

If unsuccessful refer to ophthalmology

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EVERTING EYELID

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FLUOROSCEIN STAINING

Recommended for any red eye

Procedure ◦ Grasp non-orange end

◦ Apply 1 drop of saline

◦ Gently place inside the lower lid

◦ Instruct pt to blink

◦ Use a wood lamp, blue filter on s slit lamp or a penlight with a blue filter

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FLU0ROSCEIN STAINING

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RING REMOVAL Remove all rings before edema !!!!

Methods ◦ Lubrication

◦ String method

◦ Cut

Consider anesthesia

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RING CUTTER

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STRING METHOD

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Wrap a Penrose drain circumferentially proximal to distal

20-25 in piece of string

Pass string under ring

Wrap proximal to distal not allowing any skin to protrude

Grasp proximal end, turn clockwise

FISHHOOK REMOVAL

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The Problem is …….

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Fishhooks

Variety of shapes and sizes

Barb is a projection extending backward from the point of the hook.

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Fish Hook Removal Several methods for successful removal

Strategy depends primarily on the depth of the hook

Caution to be taken for removal of a hook with multiple barbs

Anesthetize the area either locally or by a digital block depending on location

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Simple Retrograde Technique Press skin over tip of hook to disengage barb while apply pressure downward on shank

Back the hook out of the skin

Most simple but least effective

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String Pull Method

Variation of retrograde technique

String is wrapped around the bend of the hook where

it enters the skin

End of the shank is depressed with one hand to disengage

the barb.

The other hand gives a quick pull on the string

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Needle Cover Technique

◦ Requires dexterity

◦ 18g needle is inserted into the entrance wound along side of the shank

◦ Needle follows the hook until the lumen covers the barb

◦ The hook and needle are withdrawn from the wound as a unit

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Advance & Cut Technique Useful for deep penetration and large hooks

Tip is advanced through the skin

Once exposed tip and barb are cut with wire cutters

The remaining part is rotated back out of the wound

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Incision Technique

Modified needle cover technique

Used for hooks embedded in dermis or in delicate areas

Enlarge of wound with a #11 scalpel, follow the bend of the hook until the barb is disengaged from the tissue

Withdraw hook through the wound

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Arthrocentesis &

Joint Injection

The Basics

Arthrocentesis

Aspiration of fluid from a joint space

May be diagnostic or therapeutic

Generally presents few complications

Joint injection may occur after fluid removal or may be performed as a separate procedure

Indications

Diagnosis of non-traumatic joint disease

Relief of pain ◦Removal of effusion ◦Local infiltration of medication

Diagnosis of bony or ligament injury

Establishment of intra-articular fracture

Obtain fluid for culture & cell study

Contraindication Absolute

◦Overlying infection

◦Cellulitis

◦Abscess

◦Suspected bacteremia

◦Steroid injection – Septic joint

Relative ◦Recent fracture

◦Osteoporosis

◦Anticoagulants

◦Bleeding disorders

Requirements

Always ensure complete H&P before procedure

X-Rays?

Check for allergies

Previous joint aspirations or injections?

Informed consent

Decisions

Aspirate?

Inject?

Both?

Fluid Analysis Observation

Chemical Analysis

Microscopic Study

Bacterial Culture

Serologic Study

Polarized Light Microscope

Synovial Fluid Analysis Fluid grossly assessed as clear, turbid or bloody

Most important to distinguish between inflammatory and infectious causes

“Normal” synovial fluid is ◦ Straw, clear enough to read newspaper

◦ Flows freely – consistency of motor oil

◦ Gives positive string test

String Test Simple test for fluid viscosity

Viscosity correlates with hyaluronate

Inflammation degrades hyaluronate which becomes lowers viscosity

Measure fluid “string” from falling drop of gloved finger

“Normal” fluid = 5-10cm string

Inflammation = short string or multiple drops

Specimen Collection Cell count and cytology – lavender top tube (EDTA)

Chemistries, serology and viscosity – red top tube ( no additive)

Crystals – green top tube(sodium heparin) or immediate visualization under microscope

Specimen Collection

GC – culture medium, low oxygen level

Culture – appropriate medium

Synovial Fluid Analysis

Indicator

Normal

Inflammatory

Infectious

Gross

Appearance

Clear

Transparent

Yellow

Clear-slightly turbid

Yellow

Cloudy

String Sign

Normal

Diminished

Diminished

WBC/mm3

50% positive

Crystals

Negative

Positive

Negative

Common Joint Injection Sites

Knee*

Hip

Ankle

Shoulder* ◦Glenohumeral joint

◦Acromioclavicular joint

Elbow* ◦Lateral epicondyle

◦Medial epicondyle

Hand and Wrist ◦Thumb*

◦Trigger finger*

◦wrist

Steroid Injection and Doses

Preparation

Large Joint

Small Joint

Triamcinolone hexacetonide 20mg 2-6mg

Triamcinolone acetonide 20mg 2-6mg

Prednisolone terbutate 25mg 2.5-7.5mg

Betamethasone sodium

Phosphate/acetate

1ml 0.25-0.5ml

Methylprednisolone 35mg 3.5-10.5mg

Triamcinolone diacetate 20mg 2-6mg

Prednisone acetate 30mg 3-9mg

Frequency of Injection

6 to 12 weeks between injection

No more than 3 times per year for large or weight bearing joints

Inject no more than 3 separate joints per month

Equipment

Sterile gloves

Skin prep ◦ Iodine & alcohol

Sterile 4x4’s

Sterile towels

Vapor coolant

1% or 2% lidocaine

Non lock syringes ◦ 2ml, 10ml, 30ml

Needles ◦ 18, 22, 25 gauge

Hemostat

3-way stopcock

Specimen equipment

Steroid injection

Sterile dressing

Stop Cock

Procedure

Thorough H & P

Position patient optimally ◦Knee – fully extended with relaxed quadriceps

◦Elbow – flexed 90 degrees, forearm pronated, palm flat on table

Spend time to find anatomical landmarks!!!!!!

Procedure

Aseptic technique ◦ Clip thick hair

◦ Area thoroughly scrubbed

◦ Bactericidal agent x 3

◦ Medial to lateral aspect in circular motion

◦ Allow to dry between scrubs

◦ Clean area with alcohol

◦ Sterile gloves and equipment

Procedure Anesthesia for Site

◦ Vapor coolant

◦ 1% or 2% Lidocaine (rapid onset; 1-2 hrs) OR Bupivacaine (5 minutes; 2-4 hrs) OR Diphenhydramine OR Ice

Procedure

Identify Landmarks!!

Use larges practical needle ◦18 gauge aspiration

◦25 gauge for injection

Use appropriate syringe ◦30cc or 60cc for aspiration

Insert needle, pull back on plunger, enter joint space

Procedure

Withdraw all fluid

Use hemostat or stopcock to change syringe

Assess fluid and transfer into container ◦ Cell count, culture, slide, string test

If injecting – change syringe and inject

Withdraw needle and apply dressing

Potential Complications

Infection ◦Introduction ◦Masking with steroid

Steroid arthropathy

Post injection inflammation

(steroid flare – 12-48 hours)

Potential Complications

Bleeding and blood vessel trauma

Peri-articular complications ◦Tendon rupture

◦Soft tissue atrophy

Systemic responses ◦Elevated BS

◦Peripheral flushing

Follow-Up Band-Aid

Rest, Ice, Elevation, Compression

Limited weight bearing for 48 hours

Consider knee immobilizer

NSAID or other analgesic

Instructions for signs of infection

Conclusions

When performed correctly, arthrocentesis is a relatively safe procedure that is used to obtain valuable diagnostic information and provide therapy for acute joint disease. The key to success is strict adherence to sterile technique, observance of anatomic landmarks and proper preparation of synovial fluid for examination.

Musculoskeletal Injuries Extremity X-Rays

Splinting

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MUSCULOSKETAL EVALUATION History!!!!!

Traumatic vs atraumatic

Mechanism of injury

Physical Exam

Diagnostics ◦ X-ray

◦ CT

◦ MRI

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CLASSIFICATION OF SPRAINS/STRAINS

Sprain- injury to the ligament that connects a bone to another

Strain-injury to the muscle fibers and to other fibers that attach to the muscle. ◦ 1ST DEGREE

◦ 2ND DEGREE

◦ 3RD DEGREE

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OTTAWA ANKLE RULES

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TYPES OF FRACTURES

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RADIOLOGY

HAND

WRIST

ELBOW

KNEE

ANKLE

FOOT

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MANAGEMENT

P – Protect from further injury.

R – Restrict activity.

I – Apply Ice.

C – Apply Compression.

E – Elevate the injured area

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SPLINT INDICATIONS Sprain/strains

Fractures

Lacerations

Inflammatory processes

Infection/cellulitis

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SPLINT MATERIAL Pre-formed

Plaster

Fiberglass

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SPLINTING Upper extremity

◦ Volar

◦ Long posterior

◦ Sugar tong

◦ Thumb Spica

◦ Ulna gutter

◦ Finger splint

Lower extremity ◦ Knee immobilizer

◦ Posterior leg

◦ Long

◦ Short

◦ Stirrup

◦ Cam boot

◦ Hard shoe

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VOLAR

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SUGAR TONG

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THUMB SPICA

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ANKLE STIRRUP

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POSTERIOR LEG

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KNEE IMMOBILIZER

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ANKLE AND FOOT

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COMPLICATIONS

Ischemia

Heat injury –plaster

Pressure sores

Infection

Dermatitis

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Let’s Splint

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