PEM Source

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All posts with tag: "wound-management"

PEM Questions

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You are caring for a 20 kg child involved in an auto vs. bicycle accident who has several superficial lacerations requiring suturing. You calculated the maximum amount of 1% lidocaine with epinephrine that you can safely infiltrate for laceration repair. 

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You are repairing a large laceration extending from the occipital scalp over the top of the head and onto the forehead of a 5 year old 20 kg child. You have the parent and nurse place the child his head in a sink under tap water to irrigate the wound. You anesthetize the wound with a total of 14 mL of 1% lidocaine. You put on a surgical mask and nonsterile gloves. You use staples on the scalp, transitioning to 5-0 polyglactin irradiated suture for the forehead. 

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You are preparing to repair an upper lip laceration that crosses the vermillion border in a cooperative 15 year old girl who was bitten by the family dog. In order to reduce distension of the tissues which may result in poor vermillion border alignment and poor cosmesis, you decide to use a regional block for anesthesia. 

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(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 6 year old boy with a few days of episodes of crying and jaw clenching, decreased oral intake, and intermittent painful muscle spasms causing him to arch his neck and back. He cannot control or stop the spasms, but is otherwise alert. He visited a cousin’s farm 6 days ago where he played with a goat, drank unpasteurized milk, sustained a small laceration to his scalp that was allowed to heal on its own, and had a tick on him that was pulled off by his mother that evening. He is unimmunized by parent choice. He has received no medications and has no PMH. His temperature is 38.2, HR 140, RR 20, BP 130/65. O2 sat 97% on room air. [yop_poll id="126"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 11 year old left-hand dominant boy is brought in after accidentally sustaining an injury from a paint injection gun while helping his father on a project at home. The injury occurred 2 hours ago. On exam, he has a barely perceptible entrance puncture wound at the tip of his right index finger, no deformity or swelling, and a normal neurovascular exam. Radiographs are negative for fracture and his tetanus is up to date. [yop_poll id="117"]
(Click the link to comment and to vote - voting not working through email, sorry!) A child has a large galea aponeurotica laceration that is part of a scalp laceration. The provider sutured the scalp laceration but failed to close the galea. [yop_poll id="79"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5 year old was bitten by the family cat superficially on his right index finger, 3 days ago. He presents now with redness, warmth, and pain over the volar aspect of his index finger. [yop_poll id="31"]
(Click the link to comment and to vote - voting not working through email, sorry!) You have sutured a 2cm forhead laceration on a 4yo boy using 6-0 nylon sutures. [yop_poll id="15"]
Jellyfish en.wikipedia.org (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="10"]
A 10yo boy obtained a pet rat from a commercial pet store. Upon returning home, his new pet promptly bit him. 5 days later, he has fever, chills, severe headache, polyarthralgias, and a maculopapular rash with some petechiae that developed after 2 days of fever. What organism is the most likely cause for the boy’s symptoms? A. Staphylococcus aureus B. Group A Streptococcus pyogenes C. Eikenella corrodens D. Rabies virus E. Streptobacillus moniliformus
Which of the following wild animal exposures is the lowest risk for rabies?
  1. Skunk
  2. Coyote
  3. Raccoon
  4. Fox
  5. Rabbit
Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here

Tips and Tricks

First, highly recommend Dr. Brian Lin's site lacerationrepair.com (free) for all your wound management education and questions. Second, in a recent blog post, there was a review of an online laceration repair course, The Laceration Course (paid). Dr. Lin posted a pdf of a high yield laceration cheat sheet from that course. Below are some highlights...

Our approach to nail bed lacerations has evolved quite a bit over the last decade or two. The old teaching was that a significant subungual hematoma required removal of the nail to check for a nail bed laceration, and if present, painstaking suturing of the laceration with fine friable absorbable suture. Then, the nail plate or a substitute such as the foil from the suture packet needed to be placed in the nail fold to stent it open. Current state-of-the-art is much simpler! Simply trephinate significant subungual hematomas (e.g. > 50%, raising the nail, painful). If a nail bed laceration is to be repaired, tissue adhesive is an easier acceptable alternative to suturing. And there may not be a need to stent the nail fold unless there is direct injury to the nail fold itself. Check out this review from the experts.

Dr. Rahul Patil describes using the suture packaging to create a sterile field / barrier in "Easy way of keeping hairs away while suturing ear lacerations" Indian J Plast Surg 2011;44(3):531

Hairtourniquet Wikimedia James Heilman Hair_Tourniquet_after Photos before & after release from Wikimedia Commons Hair tourniquets (and sometimes thread tourniquets) can occur on toes (most common), fingers, and more rarely the penis, clitoris, or uvula. Peak occurrence is at age 2-6 months, corresponding with maternal postpartum hair loss. Edema may progress to vascular compromise; ischemia and autoamputation have occurred. Tips for removal:
  • Magnifying loupes can be helpful
  • Consider topical anesthesia with EMLA or viscous lidocaine (avoid LET w/epinephrine so as to not confuse discoloration due to the tourniquet vs due to temporary epinephrine effect)
  • If definitely a hair, depilatory cream (eg Nair) can be applied for 3-10 minutes on unbroken skin; repeat once if not successful (the product can irritate skin, however)
  • AliEM describes use of a cutting needle to get under the hair and cut it https://www.aliem.com/2012/06/trick-of-trade-hair-tourniquet-release/
  • If the hair is too deep / not visualized, the cutting needle can still be used to lift the tissue and constricting band, and a scalpel then used to cut the hair and superficial layer of tissue
  • Severe tourniquets may require perpendicular cuts to the bone, best done at 3:00 and 9:00 positions
  • Look for improvement in swelling and color with release. If the hair cut deeply, it may be difficult to see if release is complete. At least one author has studied ultrasound for identification https://www.ncbi.nlm.nih.gov/pubmed/29341258.
  • Consult a urologist for deep penile tourniquets
  • Consider child abuse, particularly with genitalia involvement
Placing topical anesthetic (EMLA, LMX4) on skin abscesses may result in spontaneous drainage, precluding need for incision. If topical anesthetic doesn't result in spontaneous drainage, it at least provides some skin anesthesia prior to local anesthetic injection for incision and drainage procedure. In one published retrospective study, 26 of 110 patients with the topical anesthetic LMX4 placed had spontaneous drainage, 3 of whom required no further intervention: https://www.ncbi.nlm.nih.gov/pubmed/21129885
We all know the importance of lining up the two sides of a laceration that goes through the vermillion border of a lip laceration. Injecting lidocaine or swelling from the trauma itself can make this difficult. Use a skin marker to outline the the vermillion border on each side, making this easier. Vermillion border closing the gap This photo comes from this great tutorial on Closing the Gap For lip lacerations requiring repair beyond simple alignment, consult a plastic surgeon. Here is an interesting discussion on Plastic Surgery Key
Measure your fingernails to see which is closest to 1cm - now you will always have a 1cm "ruler" with which to measure lesions, lacerations, discolorations, etc. Measure nail  
For a forhead laceration, place gauze over patient's eye and hairline, cut a hole in center of a large tegaderm, peel and stick with the laceration positioned in the middle of the hole. Now you can use tissue adhesive to close the laceration without worrying about the adhesive running into the patient's eye, hair, or down the face.

Controversies

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 9 year old with a knee laceration IMG_1416 [poll id="51"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="41"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="39"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="36"]
You are about to incise and drain a relatively small simple abscess in a healthy child. (Click the link to comment and to vote - voting not working through email, sorry!) [poll id="17"]
You are seeing a 4 year old with a deep cheek laceration with irregular margins, under some tension. The parents express concerns about scarring, and they are also concerned that their child will definitely not be able to stay still for repair or for suture removal. Plastic surgery is unavailable, and the parents are amenable to having you repair the laceration with procedural sedation. Forheadlac (Source: Closing the Gap https://lacerationrepair.com) [poll id="14"]

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