9:00 "Wound Care" by Dr. Michael Greenberg

Wounds account for 8 millions ED visits per year, 9% of all ER visits. 20% of all malpractice suites in EM.

Most common causes:

1. retained FBs
2. missed tendon injuries
3. wound infections

High risk wounds:

Location:

• Hand, foot, joints
• Scalp or face
• Any weird place that needs special attention: scrotum, perineum, eyelid, inner canthus, etc.

Configuration:

• Puncture, linear, stellate

Mechanism:

• Crush object causing lac
• High pressure injection wounds
• Most glass-caused wounds
• Unusual animal bites
• Wringer injury

High-pressure injection injuries:

• Occupational
• Get deep in a tissue
• Limb-threatening
• Potentially devastating
• Fluids in the wound: oil, paint, river water, molten metal, etc.
• Referral is a must

High-risk patients:

• DM
• Age >50 yo
• Chronic alcoholism
• Immunocompromised: HIV, steroids, chemotherapy
• PVD
• Prosthetic cardiac valve
• Asplenia
• "Special" patients: VIPs, occupation, etc.

Objectives for each wound:

• Identify high risk wounds
• Preserve viable tissue
• Restore tissue and continuity and function
• Avoid infection
• Minimize scar formation
• Avoid getting sued

Pearls:

• No wound MUST be closed!
• When in doubt, leave it open
• Too many sutures are a curse
• Look for FB – 38% are overlooked on initial exam

Glass FB:

• clinical exam is not sufficient
• soft tissue glass shows up on X-ray most of the time
• when in doubt, do not close the wound and refer for follow up

Wood FB cannot be seen on x-rays well, but are well seen on US. Echogenic rim is seen well on US.

Approach to Wound Care:

ABCs

Relevant H&P

History:

• Allergies
• Tetanus status
• Mechanism, contamination, FB
• Other associated injuries
• Occupation
• Handedness

Physical exam:

• Control local bleeding
• Expose patient and look for other wounds
• Evaluate and document distal neurovascular function
• Motor function – passive and active
• 2 point sensation
• Describe the wound – location, length, width
• Consider imaging

Topical anesthesia:

Use field block for anesthesia whenever possible

Forceful irrigation

Use wound scrubbing when appropriate

Avoid betadine solution for cleaning the wound

Explore the wound with gloved fingers, hemostats, etc.

Wound debridement:

Removal of FB, bacteria, devitalized tissue

Creates sharp edges which are easier to repair

Results in more cosmetically accepted scar

Aftercare:

Check tetanus status

Pre-printed wound instructions

Wound check in 24-48 hours or 72 hours: hand wounds, bites, heavily contaminated, wounds requiring Abx

Pt must understand the signs of infection – write it down: red, tender, swollen, pus, etc.

Abrasions:

• Look for underlying injuries

Puncture wounds:

• Remember the vector
• It's a worse wound than a laceration
• Never close a puncture wound

Contusions:

• Myositis ossificans

Closing remarks:

• Always suspect the worst
• Assume tendon injury
• Evaluate and document NV and tendon function distal to the injury
• Explore the wound
• Look for FB
• Use consultants judiciously
• Be thorough
• Extend the wound
• Debride when necessary
• Evert skin edges
• Arrange followup/wound recheck
• Document everything

10:00 am "Weapons of Mass Destruction: Part I" by Dr. Michael Greenberg

Chemical weapons

Chemicals used in military operations to kill, injure, or incapacitate.

1994 Sarin gas in Japan

Nerve agents: Tabun, Sarin, Soman, VX

• Most toxic of the chemical agents
• Penetrate skin, eyes, inhalation
• Causes LOC, seizures, apnea, death
• Dx is clinical: cholinergic toxidrome
• Secretions: saliva, tears, runny nose, secretions in airways, in GI tract, sweating

Vesicants: Mustard, Lewisite

Industrial chemical: Phosgene, Chlorine, Ammonia, Cyanide

Riot Control Agents: Mace, Pepper spray

Nerve agent treatment:

• ABC
• Antidotes:
  1. Atropine – antagonizes muscarinic effects, dries secretions, relaxes smooth muscles, can be given IV, IM, ET – from 2 to 20 mg (max dose)
  2. 2-PAMCI – Pralidoxime chloride – remove nerve agent from AchE in absence of aging, 1 gr slowly in IV infusion, no effect on muscarinic sites, helps on nicotinic sites
  3. Diazepam – decreases seizure activity, give to severely affected as prophylaxis

Great website for nerve agent treatment: https://chemm.nlm.nih.gov/

Vesicants (blister agents):

Sulfur mustard

Lewisite

Liquid

Latent period b/w exposure and symptoms

Similar to radiation – systemic toxicity, damages DNA and causes cell death

Mild conjunctivitis, skin injury – bullae and coagulation necrosis

Can destroy airway if inhaled

Lewisite:

Immediate symptoms, severe

Tissue necrosis, pseudomembranes

Increased capillary permeability

Antidote: BAL

Phosgene:

Industrial chemical

Toxic to lungs by inhalation

Irritates eyes, nose, airway, laryngospasm

Non-cardiogenic pulmonary edema

Treatment: non-specific, symptomatic

Ammonia:

Anhydrous ammonia

pH>;>12

Irritating, corrosive, causes necrosis and severe pain

Eyes, lungs, skin, GI tract

Management:

Remove from exposure, decontaminate

Symptomatic

Riot control agents:

Irritants to eyes, skin, lungs

11:00 am "The Toxicology Consult" by Dr. Maricel Dela Cruz

• question to start: how long after toxic APAP ingestion does NAC still prevent hepatic injury w 100% success?
  • if given with 8 hours of ingestion, will have 100% successful reversal of hepatic injury
• brief history lesson
  • 2001 standard tox number created - 1-800-222-1222
    • area code based, call from landline
  • our tox answering service - 1-800-24-toxic
• another question: ASA toxicity acid-base disturbance
  • mixed respiratory alkalosis and metabolic acidosis
  • uncouples oxidative phosphorylation and stimulates respiratory drive
• calling tox
  • good info to have ready
    • patient demographics
    • route of exposure
      • oral
      • dermal
      • inhalation
      • IM/IV/intradermal
    • accidental or intentional
    • signs or symptoms of withdrawal
    • time of ingestion (or best estimate)
    • extended vs immediate release
    • exact strength (or best estimate)
    • always helpful to count remaining pills and when bottle was filled if actual bottle is available
    • clinical picture
      • neuro - mental status, reflexes, clonus
      • eyes - pupils, nystagmus
      • lethargy
      • GI - peristalsis, bowel sounds
      • skin - dry or wet
      • mucous membranes
      • GU - bladder retention, incontinence
• another question: what mushroom can cause hepatotoxicity
  • amatoxin
• toxidromes
  • anticholinergic
    • mad as hatter - AMS
    • blind as a bat - mydriasis
    • red as a beet - flushed skin
    • hot as a hare - hyperthermia
    • dry as a bone - dry skin
  • cholinergic
    • muscarinic and nicotinic
    • DUMBELLS
      • fluid from every orifice
      • bradycardia
      • miosis
  • sedative hypnotics/ ethanol
    • decr BP, hypothermia, variable pupil size
  • opioids
    • decreased BP, pulse rate, respiratory rate, temperature
    • depressed mental status
    • pupil constriction (miosis)
    • hyporeflexia
  • sympathomimetics
    • increased BP, HR, RR
    • pupil dilation (mydriasis)
    • hyperpyrexia
    • rhabdo
    • seizures
  • withdrawals
    • sedative hypnotics/ ethanol withdrawal
      • opposite of the toxidrome (generally)
      • increased BP, HR, RR, temp
      • calculate a CIWA score
    • opioid withdrawal
      • increased BP, HR, RR
      • anxious
      • diarrhea
      • diaphoresis
      • piloerection (goosebumps)
      • yawning
      • calculate a COWS score
      • COMHAR
        • program to start suboxone from ED
        • talk to social worker
      • supportive treatment
        • zofran, pain meds (ideally non opioid), clonidine, octreotide can help with abdominal cramps, benzos
      • cocaine washout syndrome
        • coined by Drs. Roberts and Greenberg
        • depleted catecholamines/adrenergic NTs due to prolonged stimulant use
        • mild hypotension, bradycardia
        • depression, difficulty concentrating
        • treatment
          • supportive care
          • don't get too crazy about the blood pressure as long as well perfused and saturating well
  • vital signs
    • hypotension - BBs, CCBs, TCAs, nitros, ARBs, ACE-I's, opioids, EtOH, iron, sedative hypnotics
    • HTN - cocaine, PCP, caffeine, sympathomimetics
    • bradycardia - BBs, CCBs, opioids, digoxin, clonidine, baclofen, GHB, organophosphates
    • tachycardia - anticholinergics, TCAs, antipsychotics, ethanol/sedative withdrawal, thyroid hormone, PCP, sympathomimetics, methylxanthines (e.g., theophylline, caffeine)
    • bradypnea - opioids, alpha-2 agonists, botulin toxin, GHB, ethanol, neuromuscular blockers, organophosphates, sedative hypnotics
    • tachypnea - cyanide, sympathomimetics, salicylates, methylxanthines, nicotine, pulmonary irritants
    • hyperthermia - anticholinergics, herbicides, malignant hyperthermia, monoamine oxidase
    • hypothermia - alpha 2 blockers, CO, ethanol, GHB, hypoglycemics, opioids, thiamine deficiency
  • diagnostics
    • EKG
      • QRS < 120 msec
      • QTc < 500 msec (or 1/2 RR interval)
    • labs
      • AST/ALT (especially for APAP)
    • drug levels (if available)
  • quality measures - every patient gets these evaluations
    • risk of opioid misuse/ overuse
    • HCG test
    • EKG intervals (cardiac toxicity)
    • eval for PAP toxicity
      • always get APAP level in any intentional ingestion/ suicide attempt
    • eval for toxic alcohol poisoning
      • may be done with history
    • eval for salicylate poisoning
      • get level if indicated and repeat within 4 hours

The information on these pages is provided for general information only and should not be used for diagnosis or treatment, or as a substitute for consultation with a physician or health care professional. If you have specific questions or concerns about your health, you should consult your health care professional.

The images being used are for illustrative purposes only; any person depicted is a model.

 
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