sign in sign up
<<
Home , Abscess, Incision and drainage

8

ACOFP 55th Annual Convention & Scientific Seminars

Urgency vs. Emergency Procedure Pearls for the Family Physician

Lindsay Saleski, DO, MBA, FACOEP ACOFPFULL otSelOSUA;ECME FOR ACTMTIES

.._. �,_._,_.,..9""�1..-i__ ...... ,...,._..,� ...,_...,__ • ...... ,, 1... _.__,....�...... ,...... -._....,--� _aoc...���-...1 ..... ---·-_o.-..,... .. ,..,._'"'--h�fll.,_*9'1tr QI...,..,....,..,_ • ...,.. -.... 001 ...... *"OW 2 ,_.__ ,,•• __,.._...... -·-......

2 I I'' • .o,,s.,.,,.,..."..,..cf...-d...... ,...... '"... . ,0.:,...... , ....""- .... .c,.,..__.,.,...,-.IOWl_dh '" -- ... ·011,._,,...,-,NH ...... ,.._...... ,, __...... , -- ... •O.,o,t,.,...... �.----- ...... '? -- ... ,,.. ..,_ -- ...... 'w,.,...... ,w/CCIP .• . .,._.- ... __,, __,...... ,.� .,..�__,-­.. ,,_,,,,_ __ --,.,__ .... •YWl'IGl'-.C:...... ,,1;: ,,,_,,.,._.. __,.., _, ...... !IL DIICIOIORI! �tnOATIONAi. 0, IMS 0,. PIIIOOUCTI

,. ,,__....,of..,,...... ,.,iw_,.._ll• at�CME..-..,_.notlfldWlf�ol....._OMdo, ....,.,,a,,...,_.,.,.,.._..._ J •�-d�•�-.,..._.�n.,...,.,CII!..,�� 0l +.ntitCMl:� Jo'•----•... nt;,,:ta---; ...... , I -- -�""'"-11,,11 •1•1_.,_...... _...., .., ,._.. --- ....•. - ...... --- • ______...... , ______...... , ·-·-.... -··-- O ...... _ 1/17/201 18j

------17 ,_. __,__ 3/25/2018

Urgency vs. Emergency Procedure Pearls for the Family Physician Lindsay Tjiattas-Saleski DO, MBA, FACOEP Family Practice/Emergency Medicine

Outline

• Epistaxis • Patellar dislocation • Ear Foreign Body • Nursemaids Elbow • Nasal Foreign Body • • Septic Knee - Arthrocentesis • • Felon

1 3/25/2018

My nose has been bleeding… • 60 y.o. female with right sided nose bleed – Started last night, intermittent – Worse today and wouldn’t stop on its own so she came to the ED – Not on any anticoagulants – Takes Aspirin 81mg daily

Epistaxis • Most common in children under 10 and adults over 70 • Causes/Increased risk: – Digital trauma – Deviated septum – Dry air exposure – Rhinosinusitis – Neoplasia – Chemical irritants (nasal corticosteroids and/or drugs) – Chronic nasal cannula use – Coagulopathy • Clinical: H & P can usually identify the source

2 3/25/2018

Epistaxis

• Anterior vs. Posterior Bleed – Anterior bleed: Keisselbachs plexus = 90% of nose bleeds – Posterior bleed: Sphenopalantine artery • Attempt to visualize the bleed with a good light source • Posterior if: • Anterior attempts fail • Blood coming form both nares • Blood visualized in the posterior pharynx • Assessment: NSAIDS, Anticoagulants, Aspirin?

Treatment

• First steps… – Blow nose to rid it of clots – Lean forward, sniffing position, pinch nose with thumb and middle finger for 10-15 minutes – Neo-synephrine/oxymetazoline • Chemical cauterization – Silver nitrate stick (only if bleeding vessel visualized) • Thrombogenic foams and gels?

3 3/25/2018

Anterior Nasal Packing

• Anterior – Anterior epistaxis balloons (Rapid Rhino) • Coated with cellulose that promotes platelet aggregation • Soak with water, insert along the nasal floor and inflate with air until bleeding ceases – Preformed nasal tampons or sponges (Merocel) • Coat with ointment, insert along the floor of the nasal cavity • Irrigate with 5ml NSS if does not expand within 30 seconds

Posterior Nasal Packing

• Failure to control hemorrhage suggests posterior bleeding • Septal  bilateral nasal packing ENT CONSULTATION • Posterior packing high complication rates – Pressure necrosis, hypoxia, , cardiac dysrhythmias • Posterior packing – Dual balloon catheter – 14-French Foley catheter • Anesthetize, place in nasal cavity until end visualized in posterior nasopharynx, inflate with 7cc of air, gently retract, tape catheter to cheek

4 3/25/2018

Posterior Nasal Packing

• 14F Foley

Disposition

• Anterior epistaxis: – Control hemorrhage and observe for 1 hour – Discharge with 48 hour ENT follow-up • Consider anticoagulant therapy changes • Antibiotic coverage for staphylococcal coverage if packing for > 48 hours – amoxicillin-clavulanic acid • Prophylactic • ENT or ED follow-up in 2 to 3 days for packing removal • Posterior epistaxis & packing  admit for monitoring

5 3/25/2018

My knee is deformed… • 40 y.o. male was standing by his car with the door open, when it began to roll – He pivoted to avoid getting hit by the door – Felt a “pop” in his knee & now unable to extend joint • 15 y.o. female gymnast was doing a back hand spring, came down on her right leg wrong – Obvious deformity – Has been unable to extend her knee – Has had previous episodes in the past

6 3/25/2018

Patellar Dislocation

• Overall incidence 7 per 100,000 per year (31 per 100,000 in patients aged 10-19) • 15-44 % of patient have recurrent lateral dislocation • Normally articulates in the groove between femoral condyles – Stabilizers = Vastus medialis, medial/lateral patellofemoral & patellotibial ligaments, medial retinaculum • Injury: – Varus force applied to a flexed knee or after forced contraction of flexed quads – Twisting injury to the extended knee • Patella displaces laterally over the lateral condyle

Treatment • Acute: – Flex at the hip – Hyperextend at the knee – Apply gentle force anteromedially to lateral patella edge – Severe hemarthrosis  sterile aspiration • Post Reduction Treatment – Immediate mobilization  Cast in extension for 6 weeks – Knee immobilizer, Crutches, Outpatient orthopedic follow-up

7 3/25/2018

What’s in your ear?

• 6 y.o. female presents to the office for a foreign body in the left ear – At school someone dared her to put a plastic bead in the ear

Foreign Body of the Ear

• Typically in children 6 years old and younger • Presentation: pain, pruritus, conductive hearing loss, & bleeding • Persistent foreign body  infection & granulation tissue • Batteries + moisture  liquefaction/pressure necrosis, low-voltage injury • Complications: – Trauma or laceration to the skin – Canal hematoma or bleeding – Development of otitis externa – Tympanic membrane perforation – Middle ear trauma

8 3/25/2018

Foreign body removal… • Irrigation – Least invasive method – Use for loosely wedged objects, small items, things next to the TM • Suction – Frazier suction catheter/Hognose – Place blunt or soft tip directly against the object and withdraw slowly • Manual – Position patient, lighting, assistance – Use the tool most appropriate to the foreign body…

9 3/25/2018

Foreign body removal… • Cyanoacrylate (Super glue) – Smooth, round, difficult to grasp objects – Apply a drop to the end of a wooden cotton tipped applicator and place against an object for 30 seconds – Better for adults – Complications: tip dries against the wall or glue drips in the canal • Insect Removal – Immobilize and/or kill with: mineral oil, lidocaine – Remove manually – If small parts remain, can Rx antibiotic drops and reattempt or send to ENT

• Do – Set a reasonable limit on the number of attempts you will make – Document hearing ability – Document abrasions to canal & if TM is intact – Make sure your patient will be able to tolerate the procedure • Don’t – Use a rigid instrument in a non-cooperative patient – Attempt to remove a bug without killing it first – Attempt to irrigate a canal with an item that will absorb the fluid and swell – Attempt to use bayonet forceps to remove a large object from a canal as you will only push it father in…

10 3/25/2018

Left Elbow Pain

• 2 year old female fell, running outside, chasing her sister • Mother lifted her up by her left hand • Patient has since refused to use her left arm • No TTP of the arm • Elbow X-ray ordered from triage

AP and Lateral X-rays

11 3/25/2018

Nursemaids Elbow

• Annular ligament displacement (radial head subluxation) • MC in children ages 1-4 years • Axial (longitudinal) traction to the forearm  elbow extension and pronation. – Subluxation of the radial head by partially tearing or entrapping the annular ligament between the radial head and capitellum • Clinical presentation: child not wanting to use the arm – No edema, ecchymosis or deformity – Pain with movement, not during palpation

Figure 98-3 Annular ligament displacement (nursemaid’s elbow). (Adapted from Kaplan RE, Lillis KA: Recurrent nursemaid’s elbow [annular ligament displacement] treatment via telephone. Pediatrics 110:171-174, 2002.)

12 3/25/2018

Supination-flexion (SF) reduction

• Monitor the radial head • Supinate and flex the elbow with gentle traction

Hyperpronation (HP)

• Monitor the radial head • Extend the arm and pronate the hand with gentle traction

13 3/25/2018

Comparison of Reduction Techniques • Comparison of success and pain levels of supination-flexion and hyperpronation maneuvers in childhood nursemaid's elbow cases: American Journal of Emergency Medicine 2013. Study compared the hyperpronation (HP) and the supination-flexion (SF) reduction techniques. – HP technique was found to be more successful – No significant difference in pain levels • Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: A systematic review and meta-analysis. American Journal of Emergency Medicine, 2017. – Hyperpronation was more effective and less painful

What in the world did you put in your nose? • 4 y.o. male presents with a foreign body in his left nares – Was playing outside, a yesterday, put something up his nose, told his mother today…

• 5 y.o. male with object in his right nares – Was dared to place a small white object up his nose…

14 3/25/2018

Nasal Foreign Body

• Children 1-5 years old • Nonorganic > Organic – Less often: adolescents, disabled • Most frequent objects: adults – Plastic Beads/Balls • Right side > Left Side – Plastic Toy Parts • Most commonly asymptomatic – Stones (witnessed or confessed to) – Paper • If symptomatic: • Increase in occurrences post – Mucopurulent/foul nasal odor Christmas, Easter, and Halloween – Epistaxis • Most Common Complications: – “Nasal sound to voice”/“mouth- – Epistaxis and breathing” – Pain/discomfort

Management

• Vasoconstriction! • Occlusive  Smooth and totally occlusive – Blow nose forcefully while occluding unaffected nostril – “Mothers Kiss”  oral positive pressure by parent while occluding unaffected nostril • Non-occlusive and in anterior portion of the nose – Rough surfaced items  forceps – Smooth/round  suction catheters, hooked probes, balloon tipped catheters • ENT Referral if: – Unable to visualize – Chronic or impacted FBs – Penetrating or hooked FBs

15 3/25/2018

Special Note: Button Batteries • Damage via electrical currents – Negative pole is most dangerous side • Septal perf in <4 hours – Severe burns in 2-2.5 hours – Black colored DC and necrosis bad • X-ray if you aren’t sure of the item!

I never saw the spider but…

• 22 y.o. female with left posterior thigh pain for 3 days – Possible ? – Applied alcohol and attempted to manipulate last night, had some drainage – Today it was bleeding and it “filled back up” – Developed surrounding

16 3/25/2018

Abscess

• Local superficial  necrosis, liquefaction, accumulation of leukocytes  walls off collection • Progression  liquefaction increases, abscess wall thins  rupture • Risk Factors – Breach in skin barrier: trauma, abrasions, shaving, insect bites, IV drug use – , Immunologic abnormalities • Bacterial Causes: – Cause depends on anatomic location  Oral/Rectal/Vulvovaginal – MRSA causes the majority in the US

Clinical Features

• Tender • Erythematous • Surrounding erythema • Fluctuant?? • Typically not associated w/systemic symptoms

17 3/25/2018

Procedure • Preparation – Consent & universal precautions – Position the patient, prepare w/antiseptic solution, sterile drape • Anesthesia – Dome - 25g needle, parallel to the skin – Field block • Incision – IDSA: is the recommended treatment for inflamed epidermoid , , abscesses – Needle aspiration – not adequate!

I & D Setup

18 3/25/2018

I & D • Incision – Follow skin creases or natural folds – No. 11 or 15 blade, nick skin over fluctuant area – Linear incision for total length of the abscess – Probe for loculations with hemostat • Packing – Keeps incision open, not meant to absorb all drainage – Pack loosely (1/4” or 1/2” gauze) • IDSA: and culture of from carbuncles and abscesses are recommended, but treatment without these studies is reasonable in typical cases (strong, moderate).

Antibiotics?

• Simple abscess  I & D alone is curative • Antibiotic treatment if: – Extensive disease (multiple sites) – Cellulitis – of systemic illness – or comorbid conditions – Lesions unresponsive to I&D • Antibiotic choice – MRSA: , TMP-SMX, – Strep coverage: clindamycin alone, TMP-SMX with β-lactam

19 3/25/2018

Evidence… • Antibiotics? – Talan, DA et al. Subgroup analysis of antibiotic treatment for skin abscesses. Ann Emerg Med. 2018 Jan;71(1):21-30. doi: – Daum, R.S., et al, A Placebo-Controlled Trial Of Antibiotics For Smaller Skin Abscesses. N Engl J Med 376(26):2545, June 29, 2017 • Packing? – O’Malley, GF et al. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med. 2009 May;16(5):470-3. – Kessler, DO et al. Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department. Pediatr Emerg Care. 2012 Jun;28(6):514-7.

Follow-up

• Simple abscess: Re-evaluate in 48 hours • Complex abscess: Cellulitis, hand and face wounds • Packing changes: – Oral medication/local anesthesia – Moisten packing with saline prior to removal – Frequency of packing changes is clinically guided… • Consider specific patient needs: diabetic patients or those with impaired healing capacity – Home care nurse – Hospital admission – Wound care or surgical follow-up

20 3/25/2018

My knee is swollen and hot…

• 60 y.o. male with right knee pain & swelling for 1 day – Knee is warm and difficult to bend – No known trauma – Denies associated & chills – Has a history of gout in his ankles

Septic Joint… • Exam: Hot, red, swollen joint with decreased ROM Septic joint until proven otherwise! • Urgent treatment prevents joint destruction • Diagnosis is CLINICAL and supported by diagnostic tests • MC Cause = hematogenous spread • Bacteria: Staphylococcus, , N. gonorrhoeae, – Non-gonococcal (80%) – DM, RA, prosthetic joint, HIV, Age > 80, skin ulceration/infection – Gonococcal – HIV, IVDA, age <40

21 3/25/2018

Diagnostic Workup..

• Labs • Joint fluid – Erythrocyte sedimentation rate – Gram stain – C-reactive protein – Leukocyte count with differential – Uric acid level – Wet prep for crystals – Serum WBC count – Culture – Procalcitonin levels – Glucose – Blood cultures – Protein – LDH

Arthrocentesis of the Knee

• Cleanse large area with providone- iodine solution • Anesthetize the skin with 25-27g needle • Use large bore needle 18-20g and 50-60cc syringe • Enter joint space medially or laterally • Fully extend leg, relax quad • Needle posterior to patella and horizontally towards joint space

22 3/25/2018

Synovial Fluid Analysis

• Positive Gram Stain for Bacteria – Found in <50% of patients with septic arthritis • WBC Count – >50,000 WBC/mm or >90% PMNs • 56% sensitive and 90% specific for – >25,000 WBC/mm in patient with risk factors, hot joint & systemic sx • 73% sensitive and 77% specific for septic arthritis – >2,000 WBC/mm or 90% PMNs and crystals • Joints can have gout + septic arthritis • WBC count <6000 in 10% of infected joints – 10,000 WBC/mm to 80,000 WBC/mm • Young patient, sexually active, mono-articular pain • Positive culture in <50% of infected joints

Disposition – Admit to the Hospital • Non-Gonococcal Septic Arthritis – Antibiotics Vancomycin plus a 3rd-generation cephalosporin – Consult orthopedics if aspiration positive for infection • Gonococcal Septic Arthritis – Synovial fluid cultures often negative (20-25% yield an organism ID) – Can culture pharynx, urethra, cervix, rectum – Treat despite negative initial results – Antibiotics – 3rd generation cephalosporin – Possible daily joint aspiration, washout typically not necessary • Crystal Induced Arthropathy – Indomethacin 50mg – Colchicine 0.6mg

23 3/25/2018

My finger tip is swollen…

• 40 y.o. male presents with right hand index finger pain and swelling – Onset 2 days ago when he got a in his finger while washing dishes – Splinter was removed at a clinic yesterday & had a tetanus shot – Worse pain and swelling today

Felon

• Infection of the pulp of the distal finger with S. aureus – Trauma  bacterial invasion – Thorn, splinter, “finger stick felon” • Anatomy: fibrous septa from volar skin to periosteum – Closed- space infection • Clinical Presentation – gradual onset pain, swelling, erythema • Complications: , septic arthritis, flexor tenosynovitis

24 3/25/2018

Incision & Drainage • Early infection – elevation, oral antibiotics, warm compresses • Abscess development – I&D – Digital nerve block – Tourniquet – Lateral incision – Blunt dissection with hemostat – Gauze placement for 24-48 hours

– Culture wound Ambrose, Gina et al. Figure 37.30. Incision and Drainage. Roberts and • Hedges’ Clinical Procedures in Emergency Medicine and Acute Antibiotics Care. Chapter 37, 738-773.e4

Felon I & D

25 3/25/2018

What happened to my ?

• 73 y.o. female with right hand, thumb pain – Mild erythema at nail-bed • Treated with Keflex and warm compresses • Returned 4 days later with fluctuance and worsening swelling as shown

Paronychia

• Localized superficial infection involving the nail fold • Due to insult to fingernail and cuticle • Clinically: Swelling, tenderness, erythema  fluctuance – Cellulitis  abscess  extension to overlying nail (eponychia) • Cause: – Adults: or streptococci – Children: Pseudomonas, gram-negative bacilli, and anaerobes • Treatment: – Early  oral antibiotics, warm compresses – Late  I&D – Chronic  albicans

26 3/25/2018

Paronychia Treatment

• Early cellulitis phase: – Warm soaks, elevation, PO antibiotics (/cephalexin) • Abscess formation: – Soak – Digital block – No. 11 scalpel blade, scissors, or a 21- to 23-gauge needle  parallel to Figure 50-55 Drainage of paronychia. A, Eponychial fold is the nail and under the eponychium elevated from the nail for a simple paronychium. B, Lateral nail – Irrigate is removed if pus tracks under it. A small eponychial incision – Packing may be necessary. C, Proximal nail is removed if pus tracks under it. Two incisions are needed to remove the proximal nail. • Antibiotic coverage (From Moran GJ, Talan DA: Hand . Emerg Med Clin North Am 11:601, 1993.)

END

27 3/25/2018

Patellar Dislocation

• Phillips, Barry. Recurrent Dislocations. Campbell's Operative Orthopaedics, Chapter 47, 2346-2404.e7 • Patellar Dislocation. Burton JH, Fortuna TJ. Joints and Bursae. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. p1864 • Hopkins, Christy. Knee and Lower Leg Injuries. Emergency Medicine, 84, 731- 744.e1 Copyright © 2013, 2008 by Saunders. • Jain, Neel MD et al. A Treatment Algorithm for Primary Patellar Dislocations. Sports Health. 2011 Mar; 3(2): 170–174. • Davenport, Moira MD et al. Reduction of Patellar Dislocation Technique. https://emedicine.medscape.com/article/109263-technique#c2

Reference - Felon

• Tannan, Shruti MD et al. Diagnosis and Management of the Acute Felon: Evidence- Based Review. Journal of Hand , 2012-12-01, Volume 37, Issue 12, Pages 2603-2604, Copyright © 2012 American Society for Surgery of the Hand • Ambrose, Gina et al. Figure 37.30. Incision and Drainage. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. Chapter 37, 738-773.e4

28 3/25/2018

References Septic Arthritis

• Burton JH, Fortuna TJ. Joints and Bursae. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.vcom.idm.oclc.org/content.aspx ?bookid=1658§ionid=109447778. Accessed March 11, 2018.

References Ear Foreign Body

• Buttaravoli, Philip MD et al. Foreign Body, Ear. Minor Emergencies. Chapter 28, p108-112. Third Edition. Copyright © 2012 by Saunders, an imprint of Elsevier Inc. • Brown KD, Banuchi V, Selesnick SH. Chapter 47. Diseases of the External Ear. In: Lalwani AK. eds. CURRENT Diagnosis&Treatment in Otolaryngology—Head&Neck Surgery, 3e New York, NY: McGraw-Hill; 2012. http://accessmedicine.mhmedical.com.vcom.idm.oclc.org/content.aspx?bookid=386§ionid=39944089. Accessed March 22, 2018. • Rivello, Ralph. Otolaryngologic Procedures. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care, Chapter 63, 1338-1383.e2. Copyright © 2019 by Elsevier, Inc.

29 3/25/2018

Nose FB References

• Claudet I, Salanne S, Debuisson C, et al. [Nasal foreign body in infants]. Arch Pediatr 2009; 16:1245. • Figueiredo RR, Azevedo AA, Kós AO, Tomita S. Nasal foreign bodies: description of types and complications in 420 cases. Braz J Otorhinolaryngol 2006; 72:18. • Watanabe K, Hatano GY, Aoki H, Okubo K. The necessity of simple X-ray examination: a case report of button battery migration into the nasal cavity. Pediatr Emerg Care 2013; 29:209. • Oh H, Min HJ, Yang HS, Kim KS. Is Radiologic Evaluation Necessary to Find out Foreign Bodies in Nasal Cavity? J Craniofac Surg 2016; 27:e62.

References: Abscess

• Kalyanakrishnan, Ramakrishnan, MD et al. Skin and Soft Tissue Infections. Am Fam Physician. 2015 Sep 15;92(6):474-483 • Stevens, Dennis et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases, Volume 59, Issue 2, 15 July 2014, Pages e10– e52, July 15th 2014. • Mason, Jessica MD and Schmitz, Gillian MD. Annals of Emergency Medicine – A Pain in the Abscess. EMRAP. January 2018 Written Summary. • Ambrose, Gina and Berlin, Donald. Incision and Drainage. Roberts and Hedges’ Clinical Porcedures in Emergency Medicine and Acute Care. Chapter 37, 738-773. Seventh Edition. Copyright © 2019 by Elsevier, Inc.

30 3/25/2018

Nursemaids Elbow References • Gunaydin, Y MD et al. Comparison of success and pain levels of supination-flexion and hyper-pronation maneuvers in childhood nursemaid's elbow cases. American Journal of Emergency Medicine, 2013-07-01, Volume 31, Issue 7, Pages 1078-1081, Copyright © 2013 Elsevier Inc. • Bexkens, Rens MD et al. Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: A systematic review and meta-analysis. American Journal of Emergency Medicine, 2017-01-01, Volume 35, Issue 1, Pages 159-163, Copyright © 2016 Elsevier Inc. • Buttaravoli, Philip MD and Leffler, Stephen MD. Annular Ligament Displacement, Radial Head Subluxation: (Nursemaid’s Elbow) Download PDF. Minor Emergencies. Third Edition. Chapter 98, 379-382. Copyright © 2012 by Saunders, an imprint of Elsevier Inc. • Fleisher, G and Ludwig, S et al. Annular Ligament Displacement (Radial Head Subluxation). Textbook of Pediatric Emergency Medicine. p1574-1575.

31