Grand Rounds Recap - Minor Care Symposium - 9/23

Bites and Stings with Dr. Roche

Puncture Bites

  • Irrigation is the key for reduction of tetanus, rabies and infection
  • Have a low threshold for observing puncture bites
  • Ultrasound or XR for retained FB
  • IV Unasyn is the maintain for antibiotic therapy, elevate and get an early surgical consult if concerned

Rabies Prophylaxis

  • Rabies immune Globulin (RIG) needs to be injected locally multiple times at the site if there is any clinical suspicion. It can be diluted if you need to increased the volume
  • 4 dose rabies vaccine is given remotely from the site on days 0,3,7,14
  • Give rabies PEP for even suspected bat exposures, also consider for fox, skunk or raccoon exposures
  • Per Dr. Otten - the freezer is the easiest way to kill a trapped bat. And while you're in there grab the ice cream...

Hymenoptera (bee stings)

  • Remove Stinger to prevent prolonged poisoning exposure, symptomatic therapy with ice packs and NSAIDs

Tick Borne illnesses

 https://upload.wikimedia.org/wikipedia/commons/8/8e/Bullseye_Lyme_Disease_Rash.jpg

https://upload.wikimedia.org/wikipedia/commons/8/8e/Bullseye_Lyme_Disease_Rash.jpg

  • Can carry Rickettsia, spirochete, bacteria, viruses, toxins... they are dirty...
  • Rocky Mountain Spotted Fever
    • Petechial rash and fever are the most sensitive findings, find an endemic map and know your pre-test risk
  • Lyme
    • Fever
    • Erythema migrans
    • Bilateral facial palsy - must rule out lyme
    • Characteristic rash or facial palsy + Lyme endemic region = doxycycline

Cold Injuries with Dr. Roche

Spectrum of disease

  • Frostnip - Itching/burning sensation with no significant disease, wet vs dry warming
  • Chilblains (pernio) - similar vascular hypersensitivity with spasms in pre-disposed individual lasting for a week or longer
  • Raynauds - triphasic presentation of vasoconstrictive (white, cold extremities) to cyanotic phase (de-oxygenated tissue), return phase (hyperemic)
  • Popsicle Panniculitis - kiddos with focal cold exposure causes consolidated fat that resolves spontaneously

Frostbite

  • Direct crystal formation from tissue freezing is the main mechanism of frostbite, however thrombosis of vessels is contributory as a culminating process
  • Extracellular formation of crystals (slow) vs intra and extra-cellular freeze (fast)
  • Still considered 1st, 2nd (clear blisters), 3rd (hemorrhagic bullae) degree classifications
  • Consider systemic hypothermia in anyone with frostbite. Don't just stare at their fingers.
  • Circulating warm water re-warming is the preferred method for frostbite
    • Only rewarm if there is no chance of re-freezing
  • tPA and prostanoids? Special applications and the literature is controversial

Plastics Consult with Dr. Sparkman

  • 1st degree burns - Painful, red, blanching - NOT included in TBSA
  • 2nd degree
    • Superficial - into dermis but not through - superficial (papillary) dermis - painful and blanch with blisters
    • Deep - decreased pain, blistering
  • 3rd degree - no blisters, insensate, entire dermis

Home directions

  • 1st degree - keep moist
  • 2nd degree - with or wihout deroofing
    • Wash and dress the wound twice daily - use fragrant and perfume free
    • B+A dressings - apply the bacitracin for the adaptic first, decreases 

Referral to Dedicated Burns Center

  • Partial thickness > 10% TBSA
  • Face, hands, genitals or joints, inhalational injury (singed nasal hairs not specific for inhalational injury, but should raise your suspicion)

Dupuytren's Contractures

  • Fibroblastic proliferation causing fascial thickening
  • Ulnar side most affected
  • Painless, unnown cause but more in older, diabetic, northern European men (think Sven)
  • Early disease - splinting/stretching is controversial
  • Later disease (<30 degrees contracture) - fasciotomy (medical vs surgical) vs fasciectomy
 https://upload.wikimedia.org/wikipedia/commons/a/af/Pyogenic_granuloma_on_a_finger-1.jpg

https://upload.wikimedia.org/wikipedia/commons/a/af/Pyogenic_granuloma_on_a_finger-1.jpg

Pyogenic Granulolma

  • Benign vascular tumor of the skin / mucous membranes
  • Progress over weeks/months
  • Young demographic (2nd-3rd decades)
  • Friable surface
  • Treatment is shaving and electrocautery

Subungual Melanoma

  • 1-3% of melanomas
  • Brown/black streak that grow out with nail
  • 70% on great digit (thumb or 1st toe)

Sports Medicine with Dr. Kevin Burley

Strain - Muscle injury

 https://upload.wikimedia.org/wikipedia/commons/3/3b/Gray326.png

https://upload.wikimedia.org/wikipedia/commons/3/3b/Gray326.png

Sprain - Ligamentous injury

  • 1st degree - stretched but intact
  • 2nd degree - partial tear / subluxation
  • 3rd degree - complete rupture / avulsion

Shoulder Sprain Tips

  • Neck pain is shoulder pain and shoulder pain is neck pain - make sure to palpate and rotate all joints
  • Weighted view XR no longer recommended for shoulder films
  • If sending home in a sling - get out of the sling and do rotation exercises a few times daily

Bursitis

  • Overuse or traumatic injuries - warm, swollen with focal tenderness
  • 20% risk of septic bursitis, more common in DM, etOH, immunocompromised and need a diagnostic tap
  • Send home with compression wrap, ice, ROM exercises and NSAIDs as appropriate

Gamekeeper's Thumb

  • 30% avulsion fracture associated
  • 30 degree flexion at the MCP and apply valgus stress for laxity of the UCL
  • Failure to identify can cause utilization issues and osteoartritis down the line

Jersey Finger

  • Loss of DIP flexion - needs Hand Surgery follow up within 1 week for surgical repair

Lisfranc Fracture

  • There are no midfoot sprains until you have ruled out this fracture
  • Standing XRs revealing diasthesis is the standard imaging 

Helmet Removal

  • Anterior cspine stabilization
  • Remove the chin strap
  • Unscrew the mask and the helmet comes straight back
  • Keep the head up until the pads are off and the head ans shoulders can be lowered together

 https://upload.wikimedia.org/wikipedia/commons/a/a2/Dental_cavity2.jpg

https://upload.wikimedia.org/wikipedia/commons/a/a2/Dental_cavity2.jpg

Dental Emergencies with Dr. Bryant

Dental visits are up 60% over the past several years - you are not a DMD - but you can help these people

Pulpitis to Peri-apical Abscess

  • Cavity erodes through the enamel, dentin and into the pulp. It can be acute, acute on chronic or chronic. 
  • Continues to extend into the alveolar bone and the peri-apical space and forms an abscess which may be visualized through the gingiva

Who needs antibiotics?

  • Febrile, facial swelling, trismus, immunocompromised, signs of secondary swelling or systemic disease
  • Others... do NOT -  having teeth should not categorically mean you get antibiotics

But the PAIN

  • Offer a block - it is quick, easy and the best way of getting their pain to zero
  • Reduces the need for subsequent pain medications

Supraperiosteal block

  • Easiest for isolated tooth pain

Inferior Alveolar Block

  • Best for multiple mandibular teeth
  • Always consent for risk of IA injection, paresthesias, hematoma, etc