Michael Abraham, MD

• Attending Physician, Department of Emergency Medicine, Upper
• Chesapeake Medical Center, Bel Air, MD, USA

Consultation is required because of the rarity of inferior shoulder dislocations womens health yeast infections discount femara 2.5mg free shipping, the difficulty of reduction menstrual when to see a doctor purchase femara from india, the high incidence of associated injuries menopause weight loss 2.5mg femara amex, and the need to operate to repair the associated injuries triple negative breast cancer buy generic femara 2.5mg on line. The shoulder joint is usually unstable and may not remain articulated once reduced menstruation 3 weeks post dc buy femara 2.5mg mastercard. In rare instances women's health center upper east side buy cheapest femara, buttonholing of the joint capsule will prevent closed reduction and require an open reduction. Step two is the reduction of the anterior shoulder dislocation Reichman Section06 p0775-p0970. Successful shoulder reduction can be sensed as a shift or "clunk" in the shoulder joint. The normal contour of the shoulder is restored and patients often report marked improvement in their pain. A simple test to evaluate the success of the reduced joint is to have the patient touch their contralateral ear or shoulder with the hand of the affected limb. The patient should have a thorough examination to evaluate the extremity for vascular and/or neurologic compromise. It is important to immobilize the shoulder to prevent further external rotation or abduction of the reduced shoulder by the patient. There is some evidence suggesting that postreduction radiographs may be unnecessary, especially if atraumatic. Axial traction (straight arrows) is applied and maintained on the dislocated extremity while it is simultaneously hyperadducted (curved arrows). The two-step maneuver has several advantages over using the tractioncountertraction technique. This includes requiring a single person, using a single reduction attempt, possibly using less sedation, and not requiring a trip to the Operating Room for the reduction. It is necessary to have the patient awake, alert, oriented, and to have the pain adequately controlled before discharge. The patient should be discharged with adequate pain control and follow-up care by an Orthopedic Surgeon. Control pain during the acute inflammatory response period using oral nonsteroidal anti-inflammatory drugs supplemented with narcotics as needed for 2 to 3 days. Arrange Orthopedic follow-up within 24 hours for anterior shoulder dislocations complicated by fractures or soft tissue injuries beyond ligamentous strain. Follow-up within 5 to 7 days is generally sufficient for uncomplicated anterior shoulder reductions. It found that the duration of immobilization had no effect on the incidence of recurrence. Patients under 20 years of age should be immobilized for 3 weeks and then begin active range-of-motion exercises. Patients age 20 to 40 years should be immobilized for 1 to 2 weeks and begin active range-of-motion exercises 5 days after reduction. Step one involves pushing the lateral aspect of the distal humerus while pulling on the medial condyle to convert the inferior dislocation into an anterior dislocation. One study showed that 86% of shoulder dislocations had rotator cuff tears diagnosed by arthroscopy an average of 7 months after the dislocation. Complications are discussed with respect to both the initial injury and the reduction. They include fractures, displacement of fracture fragments, rotator cuff tears, vascular injury, neurologic injury, recurrence of the dislocation, hemarthroses, and the inability to reduce the shoulder. The most common vessel injured during a dislocation and forceful reduction is the axillary artery. Arterial injuries can present with a decreased radial pulse, an axillary mass, an axillary bruit, or lateral chest wall bruising. Postreduction radiographs will identify fractures initially missed or new ones associated with the reduction. Fractures of the humerus and coracoid process are rare and almost always associated with traumatic anterior shoulder dislocations. Anterior shoulder dislocations with humeral fractures have a 45% incidence of nerve injury, with the axillary nerve being injured in up to 36% of cases. Many of the reduction techniques use significant force and may displace a fracture fragment. The displacement of fracture fragments may make reduction difficult or impossible. Brachial plexus injuries are much more common in posterior and inferior shoulder dislocations. Injuries to the artery should raise suspicion for a brachial plexus injury because the brachial plexus surrounds the axillary artery. Patients who have had multiple shoulder dislocations are generally easier to reduce using nonanalgesic manipulation techniques. The orthopedic literature suggests that three shoulder dislocations in a single extremity indicate the need for surgical repair. Patients older than 60 years of age will return to the Emergency Department within 24 to 48 hours with a tense, swollen, and painful shoulder. Posterior shoulder dislocation Inferior shoulder dislocation Small number of patients and unreliable results. Significant or complete disruption of ligamentous structures or soft tissue interposition will not allow the humeral head to remain in the glenoid cavity. There are three different types of dislocation, each with different mechanisms of injury and risks of associated injuries. The diagnosis of a shoulder dislocation is generally uncomplicated given the history and patient presentation. Orthopedic Surgeons may need to be involved with the acute care of a dislocated shoulder. They should be involved in the initial reduction care of all posterior and inferior dislocations because of the rarity of these shoulder dislocations, the difficulty of reduction, the high incidence of associated injuries, and the need to operate to repair the associated injuries. Patients should be thoroughly evaluated before and after any closed reduction attempt for neurologic, vascular, soft tissue, or bony injury. Patients should be instructed on proper aftercare and provided with adequate oral analgesia. This can be accomplished with nonsteroidal anti-inflammatory drugs supplemented with narcotic analgesics. All patients discharged from the Emergency Department should follow-up with an Orthopedic Surgeon within 1 day to 1 week, depending on the associated injuries and the patient age. Bonz J, Tinloy B: Emergency department evaluation and treatment of the shoulder and humerus. Ballesteros R, Benavente P, Bonsfills N, et al: Bilateral anterior dislocation of the shoulder: review of seventy cases and proposal of a new etiologicalmechanical classification. Becker B, Cheim A, Youssefian A, et al: Sonographic measurement of glenoid to humeral head distance in normal and dislocated shoulders in the emergency department. Lahham S, Becker B, Chiem A, et al: Pilot study to determine accuracy of posterior approach ultrasound for shoulder dislocation by novice sonographers. Kanji A, Atkinson P, Fraser J, et al: Delays to initial reduction attempt are associated with higher failure rates in anterior shoulder dislocation: a retrospective analysis of factor affecting reduction failure. Musmeci E, Gaspari D, Sandri A, et al: Bilateral luxatio erecta humeri associated with a unilateral brachial plexus and bilateral rotator cuff injuries: a case report. Verhaegen F, Smets I, Bosquet M, et al: Chronic anterior shoulder dislocation: aspects of current management and potential complications. Breslin K, Boniface K, Cohen J: Ultrasound-guided intra-articular lidocaine block for reduction of anterior shoulder dislocation in the pediatric emergency department. Moharari R, Khademhosseini P, Espandar R, et al: Intra-articular lidocaine versus intravenous meperidine/diazepam in anterior shoulder dislocation: a randomised clinical trial. Blake R, Hoffman J: Emergency department evaluation and treatment of the shoulder and humerus. Reid S, Liu M, Ortega H: Anterior shoulder dislocations in pediatric patients: are routine prereduction radiographs necessary Hendey G, Chally M, Stewart V: Selective radiography in 100 patients with suspected shoulder dislocation. Emond M, Le Sage N, Lavoie A, et al: Refinement of the Quebec decision rule for radiography in shoulder dislocation. Hendey G, Kinlaw K: Clinically significant abnormalities in postreduction radiographs after anterior shoulder dislocation. Gottlieb M, Nakitende D, Krass L, et al: Frequency of fractures identified on post-reduction radiographs after shoulder dislocation. Blaivas M, Adhikari S, Lander L: A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department. Kaya M, Eksert S, Akay S, et al: Interscalene or suprascapular block in a patient with shoulder dislocation. Garnavos C: Technical note: modifications and improvement of the Milch technique for the reduction of anterior dislocation of the shoulder without premedication. Marinelli M, de Palma L: the external rotation method for reduction of acute anterior shoulder dislocations. Amar E, Maman E, Khashan M, et al: Milch versus Stimson technique for nonsedated reduction of anterior shoulder dislocation: a prospective randomized trial and analysis of factors affecting success. Baykal B, Sener S, Turkan H: Scapular manipulation technique for reduction of traumatic anterior shoulder dislocations: experiences of an academic emergency department. Milch H: the treatment of recent dislocations and fractures-dislocations of the shoulder. Milch H: Pulsion-traction in the reduction of dislocations or fracture dislocations of the humerus. Johnson G, Hulse W, Mcgowan A: the Milch technique for reduction of anterior shoulder dislocations in an accident and emergency department. Dudkiewicz I, Arzi H, Salai M, et al: Patients education of a self-reduction technique for anterior glenohumeral dislocation of shoulder. Yuen M, Yap P, Chan Y, et al: An easy method to reduce anterior shoulder dislocation: the Spaso technique. Cunningham N: A new drug free technique for reducing anterior shoulder dislocations. Lacy K, Cooke C, Cooke P, et al: Low-cost alternative external rotation shoulder brace and review of treatment in acute shoulder dislocations. Schiebel M, Kike A, Nikulka C, et al: How long should acute anterior dislocations of the shoulder be immobilized in external rotation Itoi E, Hatakeyama Y, Kido T, et al: A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. Hersche O, Gerber C: Iatrogenic displacement of fracture-dislocations of the shoulder. Garcia R, Ponsky T, Brody F, et al: Bilateral luxatio erecta complicated by venous thrombosis. Chalidis B, Sachinis N, Dimitriou C, et al: Has the management of shoulder dislocation changed over time Ceroni D, Sadri H, Leuenberger A: Radiologic evaluation of anterior dislocation of the shoulder. Ceroni D, Sadri H, Leuenberger A: Anteroinferior shoulder dislocation: an auto-reduction method without analgesia. Boss A, Holzach P, Matter P: A new self-repositioning technique for fresh, anterior-lower shoulder dislocation. Stafylakis D, Abrassart S, Hoffmeyer P: Reducing a shoulder dislocation without sweating. Boss A, Holzach P, Matter P: Analgesic-free self-reduction of acute shoulder dislocation. Aldebeyan S, Aoude A, Van Lancker H: Traumatic posterior shoulder dislocation with a large engaging Hill-Sachs lesion: splinting technique. Connolly S, Ritchie D, Sinopidis C, et al: Irreducible anterior dislocation of the shoulder due to soft tissue interposition of subscapularis tendon. The annular ligament slips between the capitellum and the head of the radius impeding supination of the arm. The patient will present with the arm held in slight flexion and pronation, usually in not much distress, and not using the affected arm. The distal humerus consists of the extraarticular medial and lateral epicondyles which are diverging columns separated by the intraarticular trochlea and capitellum. The articular surfaces of the trochlea extend from the coronoid fossa anteriorly to the olecranon fossa posteriorly. The anterior and posterior fossae provide space for the coronoid and olecranon, respectively, at the extremes of motion. The capitellum is a spherical structure that articulates with the concave radial head. The prominent medial epicondyle protects the ulnar nerve which travels in its posterior sulcus. The annular ligament and radial collateral ligament hold the radial head in position. The annular ligament allows the radial head to rotate under it during pronation and supination. The radius and ulna may be slightly lateral or medial in posterior elbow dislocations in addition to being posteriorly displaced. The presence of a fracture of the radial head or coronoid process may frequently render any attempt at reduction unstable and will usually require an open reduction. One particular type of dislocation pertains primarily to the pediatric population. It is rarely seen after age 7 and represents 20% of upper extremity injuries in children.

The treatment of choice continues to be removing the entire system followed by the administration of parenteral antibiotic agents breast cancer volleyball socks order cheapest femara and femara. Vancomycin is frequently used as an empiric agent when cultures are still pending given its good coverage against coagulase-negative staphylococci and methicillin-resistant S menstruation 15 days apart purchase genuine femara on line. Empiric gram-negative and fungal coverage may be necessary in the immunocompromised patient menstruation in islam 2.5 mg femara with mastercard. Patients are advised to use the opposite ear when using a cell phone and not stay near antitheft devices or metal detectors long women's health big book of yoga pdf discount 2.5mg femara with amex. Inappropriate shocks have been documented through electronic article surveillance systems breast cancer vaccine cleveland clinic best 2.5 mg femara. Studies have deemed it safe for patients to walk through these systems if they avoid lingering around these devices menopause after 60 generic femara 2.5mg without prescription. Obtain routine laboratory tests, including a complete blood count and differential. Wound cultures and Gram stains may be helpful in differentiating an infection Reichman Section3 p0301-p0474. The components include the portable computer/ monitor/power source (1), the wearable vest (2), the charger and Bluetooth transmitter (3), and the wearable case for the around the neck or waist (4). The vest (1), electrode belt or defibrillator (2), heart sensors (3), monitor connection cable (4), vibration box (5), and defibrillator therapy pads (6). Troubleshooting and programming should be performed in conjunction with consulting an Electrophysiologist. Patients presenting with cardiopulmonary arrest may require the device to be deactivated and external defibrillation performed. The device can demonstrate problems associated with lead displacement or fracture. Raviele A, Gasparini G (for the Italian Endotak Investigator Group): Italian multicenter clinical experience with endocardial defibrillation: acute and long-term results in 307 patients. Gradaus R, Bocker D, Dorszewski A, et al: Fractally coated defibrillation electrodes is an improvement in defibrillation threshold possible Dorwarth U, Frey B, Dugas M, et al: Transvenous defibrillation leads: high incidence of failure during long-term follow-up. Guinand A, Noble S, Frei A, et al: Extra-cardiac stimulators: what do cardiologists need to know Abd-Elsayed A, Grandhi R, Sachdeva H: Lack of electrical interference between spinal cord stimulators and other implanted electrical pulse devices. Stunder D, Seckler T, Joosten S, et al: In vivo study of electromagnetic interference with pacemakers caused by everyday electric and magnetic fields. Napp A, Joosten S, Stunder D, et al: Electromagnetic interference with implantable cardioverter-defibrillators at power frequency: an in vivo study. Binggeli C, Rickli H, Ammann P, et al: Induction ovens and electromagnetic interference: what is the risk for patients with implantable cardioverter defibrillators An axial pump uses a propeller in a pipe and transmits rotational energy without a change in the direction of blood. A centrifugal pump uses an impeller and pushes the blood and directs it tangentially. When the head pressure increases, most of the rotational energy transmitted by the pump is "wasted" generating pressure. This means that small variations in head pump pressures are associated with large variations in flow. The clinical significance of this hydrodynamic behavior is increased flow pulsatility and afterload sensitivity in patients with centrifugal pumps. In the context of relative or absolute hypovolemia, the patient is more likely to suffer suction phenomena or the contact of the inflow cannula and the left ventricular endocardium. Therapeutic options include cardiac transplantation, mechanical circulatory support, and palliative care. Cardiac transplantation is limited by donor availability and recipient eligibility. They have advanced in recent years as a superior alternative to medical therapy in patients who are not eligible for transplantation. A compact centrifugal-flow device with an integrated inflow cannula designed for intrapericardial placement. The device incorporates a bearing-less design with magnetic and hydrodynamic levitation of the internal impeller. An axial-flow device that requires bearing support of the internal impeller and is implanted outside the pericardium in a preperitoneal (pump) pocket. The impeller is supported by hydrodynamic and magnetic mechanisms that are friction free. The degree of left ventricular dysfunction, preexisting right ventricular dysfunction, and progressive right ventricular dysfunction may contribute to the appearance of a low-flow state and congestion. Aortic insufficiency may lead to ineffective cardiac output and heart failure symptomatology. The patient is subject to right to left shunting in the context of low leftsided filling pressures with an untreated patent foramen ovale. It serves as a user interface by displaying advisory alarms, battery status, flow, hazard alarms, power, pulsatility parameters, and speed. Pump speed is measured in rpm and is the only variable that can be programmed by the operator. Trends in flow are clinically useful, but absolute values do not accurately represent the cardiac output. The increase in intracavitary pressure during ventricular systole causes a decrease in total head pressure with a consequent increase in flow. Place the Doppler probe over the brachial artery and auscultate the brachial pulse. Slowly deflate the cuff in 2 to 3 mmHg/sec increments, allowing the reestablishment of flow. Focus the physical examination on detecting congestion, hypoperfusion, and neurologic deficits. Evaluate the driveline exit site to assess for signs of inflammation or infection. Evaluate the system controller for signs of burns, deterioration, immersion, or other signs of wearing. Electrocardiogram evaluation may disclose atrial fibrillation, which has been associated with an increased risk of ischemic stroke and ventricular tachycardia in patients who present with nonspecific symptoms. Renal function increases in renal failure from hypoperfusion and/or renal congestion due to right ventricular failure. The parasternal long axis is useful to evaluate for aortic valve opening, left ventricular filling, left ventricular function, pericardial effusion, and right ventricle function. Low flow ventricular function and provide information on the inflow cannula position. The inflow cannula position is considered normal when aligned with the left ventricle inflow tract. Algorithms for the evaluation of left ventricle filling pressures and detailed guidelines for echocardiographic evaluation have previously been published and are beyond the scope of the Emergency Physician. Suspect incomplete unloading if the left ventricle is dilated and the atrioventricular valve is opening. The Heart Mate device driveline consists of three pairs of cables covered by a metallic shield. The energy will be drained from the pump, causing a voltage drop and alarms if there is a loss of integrity to the wires and any wire contacts the metallic shield while the device is connected to a grounded wire on the power base unit. A large right ventricle and a small left ventricle is seen in pulmonary hypertension, right heart strain, and right-sided myocardial infarctions. Correct any acidosis, correct hypoxemia, consider inotropes, and evaluate for a myocardial infarction. Small right and left ventricles suggest hypovolemia, gastrointestinal bleeds, and sepsis. Stasis of blood may lead to thrombus formation in the noncoronary cusp and may extend, causing obstruction of coronary arteries with subsequent ischemia. This may present as an acute coronary syndrome or ventricular tachycardia, or may embolize, causing ischemic complications. Follow diagnostic and therapeutic guidelines for the treatment of a pulmonary embolism. Avoid elevated peripheral vascular resistance, high positive end-expiratory pressure, hypercarbia, and hypoxia, which worsen right ventricular function. It is associated with the absence of elevated left atrial/pulmonary capillary wedge pressure > 18 mmHg, tamponade, ventricular arrhythmias, or pneumothorax. Right ventricular failure is severe if it requires a right ventricular assist device. Right ventricular failure is considered mild if two of the following four criteria are met: central venous pressure > 18 mmHg or mean right atrial pressure > 18 mmHg, cardiac index < 2. Late right ventricular failure may be more difficult to diagnose, and a high index of suspicion is important to avoid underdiagnoses. Right ventricular failure may manifest as progressive dyspnea, ventricular arrhythmias, or frequent hospitalizations. The clinical presentation ranges from nonspecific symptoms to cardiovascular collapse. Factors that may impact the tolerance of ventricular arrhythmias include significant pulmonary hypertension with elevated pulmonary vascular resistance. Some have related the tolerance to ventricular arrhythmias to the capacity of withstanding Fontan circulation. Factors related to the increased gastrointestinal bleeding include therapeutic anticoagulation, platelet antiaggregation, continuous flow physiology that is related to acquired von Willebrand disease, and arteriovenous malformation in the gastrointestinal tract. It is important to inquire about current anticoagulation and antiplatelet regimens. The patient with recurrent gastrointestinal bleeding may have their anticoagulation discontinued. Have a low threshold for admission to the hospital given the presence of concomitant comorbidities. Aggressive anticoagulation reversal is discouraged given the high risk of thrombotic events in the absence of upper gastrointestinal bleeding with hematemesis or hemodynamic instability. Nasal arteriovenous malformations are extremely common in this patient population. A history of bacteremia and device infection has been associated with increased risk of stroke. Percutaneous site infections affect 19% of the patients and are associated with increased mortality. Careful inspection of the driveline insertion site for any evidence of cellulitis or drainage is mandatory. Aggarwal A, Kurien S, Coyle L, et al: Evaluation and management of emergencies in patients with mechanical circulatory support devices. Robertson J, Long B, Koyfman A: the emergency management of ventricular assist devices. Moazami N, Fukamachi K, Kobayashi M, et al: Axial and centrifugal continuous-flow rotary pumps: a translation from pump mechanics to clinical practice. Imura T, Kinugawa K, Kinoshita O, et al: Reversible decline in pulmonary function during left ventricular assist device therapy. Ozmete O, Bali C, Ergenoglu P, et al: Resuscitation experience in a patient with left ventricular assist device. Yuzefpolskaya M, Uriel N, Flannery M, et al: Advanced cardiac life support algorithm for the management of the hospitalized unresponsive patient on continuous flow left ventricular assist device support outside the intensive care unit. It is attached posteriorly to the thoracic vertebral column, esophagus, bronchi, and aorta. The pericardial cavity is a potential space between the visceral and parietal layers of the pericardium. It normally contains up to 50 mL of fluid that acts as a lubricant to the motion of the heart. The estimated causes and relative frequencies of pericardial effusions are listed in Table 48-1. This space can become quite large over time in several chronic conditions and contain pericardial effusions up to 2 L without signs of cardiac tamponade. This results in an increase in fluid pressure surrounding the heart and possible cardiac tamponade. Cardiac tamponade can be caused acutely by accumulation of pericardial fluid ranging from 60 to 200 mL. The initial physiologic strategies of compensation include an increase in the systemic venous pressure, catecholamine release, and tachycardia. Small increases in the fluid amount will generate significant and increasing pressure on the heart chambers once the ability of the pericardial space to distend and accommodate more fluid is overwhelmed. Venous filling of the right heart is drastically impaired as the pericardial pressure rises. Left ventricular filling becomes compromised from the lack of flow from the right ventricle and the bulging inward of the interventricular septum. Cardiac perfusion eventually decreases, the heart contractibility is progressively impaired, and the patient becomes hypotensive. A progressive decline in cardiac output occurs as pericardial fluid accumulates and intrapericardial pressure increases. This is followed by the equilibration of the right atrial and intrapericardial pressures.

A #11 scalpel blade is used to make a stab incision in the skin and subcutaneous tissues pregnancy joint pain femara 2.5mg low price. A mosquito hemostat can be used to grasp the vein and hold it open while the tubing is inserted menopause upset stomach purchase 2.5 mg femara overnight delivery. For small veins menstruation red tent buy generic femara 2.5mg, a vein pick or 18 gauge needle with the tip bent can be used to hold open the vein women's health clinic tampa fl discount femara online master card. Palpate the posterior aspect of the vein after inserting the intravenous tubing for penetration of the catheter menopause cures generic 2.5 mg femara with visa. The catheter must be removed if it penetrates through the posterior wall of the vein womens health group tulsa ok generic femara 2.5 mg with mastercard. Release the proximal suture and allow the intravenous fluid to flow into the vein if the tubing has not penetrated the posterior wall of the vein. Gently advance the catheter 2 to 3 mm or withdraw it 2 to 3 mm and observe the fluid for flow. Insert the intravenous tubing through the stab incision and pull it through the skin incision. This technique will insert the catheter as if cannulating a peripheral vein (Chapters 59 and 61). This method is very quick, provides a more secure cannulation, and potentially decreases the chance of infection. The advantage of this method is that the catheter goes through the skin, which will stabilize the catheter and prevent it from becoming dislodged. If the intravenous tubing was inserted as above, the skin incision will be sutured closed and the tubing will exit the incision. Some feel this may allow access of bacteria through the wound and into the underlying vein. Secure the cutdown more permanently if the patient survives the episode for which a venous cutdown was performed. Apply antibacterial ointment to the incision, the sutures, and the site where the catheter exits the skin. The knowledge of the local anatomy and the technical aspects of the various cutdown techniques may avoid arterial, venous, and nerve injury. The other complications may be reduced by removal of the catheter within 12 hours after placement. The skin incision is closed in a cadaver (A) and covered with a clear dressing (B). Phlebitis, an inflammation of the vein, usually results from prolonged catheterization. It may be seen within hours of catheter placement to 18 days after the removal of the catheter. The strength of the correlation was attributed to a previous unrelated study that found Staphylococcus aureus on almost all catheter tips in patients with phlebitis as opposed to catheter tips in patients without phlebitis. These cases of phlebitis all resolved without the use of antibiotics suggesting an inflammatory, rather than infectious, process to be the more likely etiology. Moran et al cultured 89 cutdown sites and observed that the pathogenic species causing infection were S. They did not find a correlation between infection and phlebitis and postulated that phlebitis was due to irritation of the vein wall by the catheter. Collins et al studied polyethylene catheters and found a 2% bacteremia rate and a 1% death rate from Pseudomonas species in debilitated patients. Sterile technique is encouraged with this procedure to minimize complications related to infection. If learned properly, it can be lifesaving in the critically ill or injured patient. It is imperative to understand the relevant local anatomy and identify the clinical landmarks before this procedure is performed. Strict adherence to sterile technique and the early removal of the catheter will decrease the rate of infection and other complications. American College of Surgeons: Advanced Trauma Life Support for Doctors: Student Course Manual, 8th ed. The catheter is looped around the great toe, for an ankle cutdown, and secured with gauze or elastic wrap. Aggressive and forceful dissection without an understanding of the anatomy or the procedure will increase the incidence of complications. Venous spasm, which causes nonuniform acceptance of the intravenous extension tubing, may also occur. The vascular collapse that may accompany severe dehydration or a cardiac arrest can be profound and delay administration of essential therapies. Pediatric patients present a challenge due to the small size of their peripheral veins and the increased subcutaneous tissue. This is usually performed when other methods of venous access are unavailable or have failed. He referred to the medullary cavity as a "noncollapsible vein" that can be used for obtaining rapid vascular access. The saphenous venous cutdown technique was developed and gained popularity as an alternative method for obtaining vascular access when attempts at peripheral vein cannulation failed. This procedure was more widely deployed in the care of pediatric patients due to the increased difficulty of obtaining vascular access in profoundly ill children. It pierces the cortex and divides into ascending and descending branches that further divide into arterioles and then capillaries. Venous drainage from the capillaries into the medullary venous sinusoids, located at the proximal and distal portions of the long bone, flows into the central venous channel located in the shaft of the long bone. In the adult, it is easier to penetrate the cortex of the medial malleolus than the thicker cortex of the proximal tibia. Under 300 mmHg of pressure, the sternum, proximal humerus, and proximal tibia have the following respective observed rates: 93, 70, and 30 mL/min. Do not use a bone that has had a previous orthopedic procedure, contains hardware, or may contain hardware. Other contraindications are an actual or possible compartment syndrome or vascular injury in an extremity. Spinal and standard hypodermic needles may break while being inserted and injure the Emergency Physician. This prevents injury to the underlying great vessels, heart, lung, and mediastinum. Alternate sites include the distal tibia, distal femur, proximal Reichman Section4 p0475-p0656. The bony landmarks for the proximal tibia are the tibial tuberosity and the flat anteromedial surface of the proximal tibia. The bony landmarks for the distal femur approach are the medial and lateral condyles of the femur and the patella. This site is used less often in adults because of the abundance of muscle and soft tissue structures but may be an excellent option in infants due to the small size of the tibia. Apply povidone iodine or chlorhexidine solution to the skin and allow it to dry if time permits. A significant reduction in the resistance to forward motion will be encountered when the cortex is penetrated and the needle enters the medullary canal. This will help prevent overpenetration into and through the cortex on the opposite side of the bone. The aspiration of more than 2 to 3 mL of blood may not be possible in cardiac arrest situations. Place a sterile dressing around the skin puncture site and apply pressure for 5 minutes. If the stylet-trocar is "stuck" and not easily removable, do not pull or try to forcefully remove it. It is spring loaded with a double safety mechanism to maximize caregiver and patient safety. The primary site is the proximal tibia approximately 2 cm medially and 1 cm proximally to the tibial tuberosity. The depth control prevents overpenetration through the back of the sternum and into the mediastinum. Downward pressure pushes the infusion tube through the sternal cortex and into the marrow cavity. This may not be possible because of poor circulation in patients with Reichman Section4 p0475-p0656. The ability of the fluid to flow without inducing soft tissue swelling can also be used to confirm proper placement. Ultrasonic visualization of flow within the medullary cavity using color flow Doppler can confirm correct placement, although physical examination as described above may be the most reliable method. Circumferential pressures of the involved extremity may be used for serial examination. Grasp the infusion tubing as close to the patient as possible with fingers or a clamp. Bleeding at the insertion site can be controlled with a sterile pressure dressing followed by cleansing the skin and a simple bandage. There have been cases of tibial fracture due to overpenetration of the cortex, although this is extremely rare. This may be due to a small marrow cavity, a fibrous marrow cavity, and/or the replacement of red marrow with yellow marrow. The procedure is technically straightforward and has been demonstrated to be successful in the hands of trained health care workers, including prehospital personnel. Hansen M, Meckler G, Spiro D, et al: Intraosseous line use, complications, and outcomes among a population-based cohort of children presenting to California hospitals. Cohen J, Duncan L, Triner W, et al: Comparison of computed tomography image quality using intravenous vs. Lewis P, Wright C: Saving the critically injured trauma patient: a retrospective analysis of 1000 uses of intraosseous access. Miller L, Philbeck T, Montez D, et al: A two-phase study of fluid administration measurement during intraosseous infusion. Hodge D, Delgado-Paredes C, Gleisher G: Intraosseous infusion flow rates in hypovolemic "pediatric" dogs. Johnson D, Dial J, Ard J, et al: Effects of intraosseous and intravenous administration of Hextend on time of administration and hemodynamics in a Swine model. Celik T, Ozturk C, Balta S, et al: A new route to life in patients with circulatory shock: intraosseous route. Petitpas F, Guenezan J, Vendeuvre T, et al: Use of intra-osseous access in adults: a systematic review. Johnson L, Kissoon N, Fiallos M, et al: Use of intraosseous blood to assess blood chemistries and hemoglobin during cardiopulmonary resuscitation with drug infusions. Ilicki J, Scholander J: Lidocaine can reduce the pain of intra-osseous fluid infusion. Helleman K, Kirpalani A, Lim R: A novel method of intraosseous infusion of adenosine for the treatment of supraventricular tachycardia in an infant. Landy C, Plancade D, Gagnon N, et al: Complication of intraosseous administration of systemic fibrinolysis for a massive pulmonary embolism with cardiac arrest. Massarwi M, Gat-Yablonski G, Shtaif B, et al: the efficiency of intraosseous human growth hormone administration: a feasibility pilot study in a rabbit model. Weiser G, Poppa E, Katz Y, et al: Intraosseous blood transfusion in infants with traumatic hemorrhagic shock. Launay F, Paut O, Katchburian M, et al: Leg amputation after intraosseous infusion in a 7-month-old infant: a case report. Fiallos M, Kissoon N, Abdelmoneim T, et al: Fat embolism with the use of intraosseous infusion during cardiopulmonary resuscitation. Umbilical vein catheterization is the preferred procedure for the infant in shock and in need of rapid resuscitation. Umbilical vessel catheterization can lead to serious complications and should be reserved for the patient in whom intraosseous or peripheral venous access cannot be rapidly secured. The umbilical arteries begin to constrict immediately after birth and can typically be cannulated during the first few days of life. It then passes through the ductus arteriosus to meet the oxygenated blood in the aorta. Pulmonary vascular resistance decreases dramatically as the infant takes its first breath. The ductus arteriosus closes within 24 to 48 hours due to the release of prostaglandins and increased blood oxygen tension. There are two thick-walled umbilical arteries that are significantly smaller in diameter than the umbilical vein. Some describe the umbilical cord as a "happy face" with the two arteries as the eyes and the vein as the mouth. A skilled Emergency Physician can sometimes perform this in neonates up to 7 days of age. It is the preferred procedure for the neonate in shock needing rapid administration of intravenous fluids, blood, or medications. They contain all the equipment required for catheter insertion but do not always include the actual catheter. Give parents the option to leave the room or look away as the procedure can be disconcerting to some.

Alternatively pregnancy 37 weeks purchase femara 2.5mg with visa, apply the petroleum jelly in a wide circle surrounding the wound and create a valley for the tissue adhesive to fill if it runs pregnancy test eva order femara 2.5mg mastercard. It may become difficult to hold the wound edges together in a small space covered with petroleum jelly menopause how long does it last cheap femara online visa. The oil-based petroleum jelly may prevent adequate binding of the tissue adhesive if the jelly gets on the skin immediately adjacent to the wound women's health clinic pueblo co purchase femara now. A final technique to keep the wound adhesive from running is the use of an occlusive dressing menstrual vitamins buy discount femara 2.5 mg on-line. Make sure that the newly created hole in the center is large enough to include the entire laceration and some surrounding skin pregnancy stages week by week generic femara 2.5mg with visa. Remove the protective tape from the back of the dressing and apply it to the skin. Cover the entire precut hole and some of the surrounding dressing with the tissue adhesive. When removing the dressing be careful not to disturb the freshly adhered tissue adhesive. A useful technique is to pull apart the dressing from the center outward, stretching it away from the edge of the adhesive. This allows it to release from the tissue adhesive without causing the adhesive to peel. The use of an occlusive dressing for protection of nearby sensitive structures when using tissue adhesives. The result after the dressing has been removed reveals a well-circumscribed area of tissue adhesive. Tissue adhesive is applied to the twisted hair and apposed skin segment of the laceration. Do not wind the strands more than one turn to prevent increased tension and tissue necrosis. This technique may not produce as much hemostasis or wound eversion as tying a hair knot. The self-adherent mesh will hold the wound edges together and eliminates the need for manual apposition using fingers. This simplifies wound closure and gets the fingers out of the location of the wound. Tissue adhesives are most useful in the pediatric population, but this population has the greatest risk of movement. Children may pick at the edges of the newly formed adhesive covering and cause it to become dislodged prematurely. Tissue adhesive that has adhered and dried on uninvolved areas may be removed using petroleum jelly or topical petroleum-based antibiotic ointment. Apply the oil-based jelly or ointment to the dried tissue adhesive and let it stand for 30 minutes. Use acetone or nail polish remover pads to remove the tissue adhesive more quickly instead of waiting the time for the oil-based products to work. Do not attempt to pry open the eyelids or cut between the eyelid margins to separate the eyelids. Gently wipe the ointment and adhesive from the eyelids if the patient can open their eyelids. The Emergency Physician must choose the proper patient, the proper wound, and the appropriate wound location. These few things in association with the appropriate tissue adhesive application technique will avoid most complications. Tattooing of the scar can occur from the adhesive, a foreign body in the wound, or not cleansing the wound thoroughly. It will peel away within 5 to 10 days as new epithelial layers are formed below it. Instruct the patient to return immediately to the Emergency Department or to their primary care provider for any signs of a wound infection. High-viscosity tissue adhesive can be used routinely to prevent the adhesive from running and in children. This includes the use of anesthesia if appropriate, wound irrigation, wound debriding, wound undermining, wound exploration for foreign bodies, and the use of deep sutures to release tension. Wounds are repaired more quickly with tissue adhesives and often at a lower cost compared to suturing. Proper patient selection, proper wound selection, and proper wound preparation will minimize any complications. Al-Mubarak L, Al-Haddab M: Cutaneous wound closure materials: an overview and update. Cascarini L, Kumar A: Case of the month: honey I glued the kids: tissue adhesives are not the same as "superglue. Richter D, Stoff A, Ramakrishnan V, et al: A comparison of a new skin closure device and intradermal sutures in the closure of full-thickness surgical incisions. Any wound presenting with concerns for a poor outcome or an obvious likelihood of wound revision in the future should be evaluated and treated by a Plastic Surgeon when possible. The younger patient tends to heal more rapidly, while the older patient tends to have a more favorable cosmetic outcome with wound closure. Older patients have less overall elastic and subcutaneous tissue and more wrinkling, thus decreasing the tension on the healing wound and making scarring less noticeable. Suturing of asymmetrical, deep, or large wounds requires particular attention to the preexisting lines of minimal tension or lines of facial expression. Without properly addressing such preexistent anomalies, the cosmesis of wound repair can be grossly affected. With markedly less skin elasticity and subcutaneous fat, older patients will often experience more favorable cosmetic results from less complex wound closures. However, younger patients will benefit from more advanced wound closure techniques to properly close large or complicated wounds. Rotational and advancement flaps are frequently performed to make scarring less obvious when suturing across lines of tension. Consideration of wound outcome should be given to areas of the skin that are rich in sebaceous glands or simply hyperpigmented. Patients with underlying connective disease disorders or conditions with a high likelihood of concomitant vitamin deficiencies should also be scrutinized, as wound closure and healing may be compromised in such cases, resulting in highly variable and less predictable outcomes. The mechanism of injury, including environmental exposure to underlying tissue, should not be overlooked so that adequate debridement and preparation may be done prior to a complex wound closure. This allows the Emergency Physician to better visualize the anatomic layers of the skin. It can be difficult to determine a clear delineation between the anatomic layers of the skin when the wound was a result of a crush injury, shredding mechanism, or any circumstance resulting in uneven or macerated wound edges. Delineate the pigmented epidermis from the thicker underlying dermis, especially when multilayer wound closures are required, as suturing may then become unnecessarily complicated and affect the overall integrity of the wound closure. Most wounds heal with a surprisingly pleasing cosmetic transformation from their initial presentations. It is not uncommon for some wounds to present complications during the healing period as well as to produce an undesirable scar. A systematic approach to wound management serves to help in deciding how to close complicated wounds, reduce the risk for infection, and minimize less favorable outcomes. Wound management in the Emergency Department includes an assessment of the mechanism and conditions that were present at the time of injury. Initially, one must address the concerns of the patient, family members, or friends with a concise explanation of how the wound will be treated and what can be anticipated for aftercare. It is recommended that verbal wound care instructions be offered once wound closure is completed, in addition to giving the patient written discharge instructions. Most patients expect cosmetic and functional perfection as an ultimate result after their wounds are treated and the healing process is completed. These expectations are often not clearly expressed during the evaluation and treatment in the Emergency Department. The Emergency Physician must openly explain and discuss the fact that virtually no wound heals without a scar following wound closure. Treatment is rendered to offer the best possible functional and esthetic outcome while reducing the risk of potential soft tissue infection. An overall plan of wound site preparation and closure will be needed to provide the greatest likelihood of a pleasing cosmetic Reichman Section07 p0971-p1174. Single-layer closures and excessively large suture materials are the greatest causes of residual scar tissue. Depending on the presentation of the tissue defect, more than one wound closure technique may be used to adequately close a wound. Using more than one technique will help remove underlying tension and allow better approximation of the epidermis. With the help of specific camouflage techniques used in closing the epidermis, irregularly shaped wounds can heal with less obtrusive scarring. Familiarity with a few of these techniques and their application will allow the Emergency Physician to comfortably close the more challenging wounds encountered with expectantly more favorable cosmetic prognoses. These kits tend to be expensive and occasionally have a limited amount of equipment. It also allows the kits to contain a wide variety of instruments for multiple situations. The fingers can also be placed through the finger holes, but this is not as efficient when closing a wound. It produces a small puncture wound in the subcutaneous tissues and does not penetrate the skin surface. The Emergency Physician will most certainly prefer a skin hook to forceps with proper instruction and experience. They should not be used to cut suture material as this rapidly dulls and nicks the blades. They can be used to close circular, square, elliptical, or asymmetrical skin defects. Advanced wound closure techniques are beneficial when there is a need to reduce skin tension and contracture, which are likely to result in hypertrophic scar formation. This is often encountered with facial wounds in proximity to the eyelids, eyebrows, canthi, nasolabial folds, or lip borders. These techniques allow the initial shape of the wound to be altered such that there is reduced tension on the wound edges, which may then be closed simply. This can happen when a wound must be elongated to create parallel lines and to decrease the tension on the wound edges. Elongation of a wound may bring it into proximity of other anatomic positions or landmarks, thus further complicating the healing process. If not planned well, excessively large defects may result, making it more likely that the scar will require later revision. Particular attention must be given to crush injuries with devitalized or contaminated tissues. Severely contaminated wounds, including those with prolonged exposure, generally are at greater risk of infection with multilayer closures. Do not perform these techniques if the patient is at risk for poor wound healing. Careful wound assessment may result in a decision to use simple approximation of the wound edges with close follow-up for ongoing wound care. Contraindications to complex wound closures will at times be reliant on temporal factors, such as the need to close a wound prior to the patient receiving surgical intervention for more life-threatening injuries. There must be a commonsense approach in deciding how to close more challenging wounds in the Emergency Department. Apply the drapes so that the wound may be approached easily from different angles and without the risk of contaminating the site or any of the materials being used. Therefore, it is important to note that the best way to avoid wound infections is to employ and maintain consistency with sterile procedures throughout the wound repair. The reason for changing the orientation of a wound is to create a more functionally and cosmetically pleasing scar. The Z-plasty has been described as a basic technique for scar revision, although its application also proves useful to lengthen and reorient wounds. The Z-plasty should not be used for wounds from burn injuries where normal skin is not present. It also breaks up a linear scar into an accordionlike scar that has some degree of elasticity. The Z-plasty is generally described to redirect a wound occurring across a flexion crease, over a joint, or on the face. The undermining and separation of the two triangular flaps lengthens the wound and allows it to be reoriented perpendicularly to the original location. The risks include poor healing, wound dehiscence, bleeding, pain, a worse scar, infection, loss of the tissue, and the need for further surgery. Alternatives to advanced wound closure include wet-to-dry dressings and allowing the wound to granulate or follow-up with a Plastic Surgeon for closure or a skin graft. Discuss the presence of a visible scar after the repair which may require subsequent revision. Place the patient in a position of comfort that is equally comfortable for the Emergency Physician. This should allow for appropriate stretcher or seat height, lighting, and maneuverability so that physical obstacles are not a complicating variable during the wound repair.

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