The following calculator is taken from the paper linked here; Derivation and Validation of a 10-year Risk Score for Symptomatic AAA. They used the UK Biobank to generate a risk score that predicted the risk of a clinical event from AAA so rupture/admission/surgery.
Friday 14 July 2023
Thursday 13 August 2020
Wednesday 29 April 2020
Tuesday 9 April 2019
What shall we do with medicine?
After we have won over all the scourge and pestilence, what is now the aim of medicine? Where to stop? Is its prime duty to keep people alive as long as possible? Is its charge to make people lead healthy lives or just to cure them when they are ill? Or is it but a service industry, to fulfil whatever fantasies its clients may frame for their bodies for instance, a facelift or cosmetic remodeling? Is developing an HIV vaccine the best thing we could put our funds into? Is the rate of human population growth healthy for this planet? Medicine has reached the point where Hippocrates, William Harvey and Lord Lister could only have dreamt of. What next?- Parikshit Sanyal
Monday 25 March 2019
Saturday 20 May 2017
Vinnie Jones advert for British Heart Foundation - Superb
If some geezer collapses infronta ya, what do you do?
Wednesday 17 May 2017
Lacerations in the ER Part 1: Before you stitch!
Here are my notes from the 'Advanced wound care' lecture, the last lecture before graduation. After just an hour with this prof I felt like I could handle any laceration that comes into the ER. Hopefully after this post you will feel a similar confidence:
History is important!
Before touching the wound, you should know exactly how it happened, when it happened and what instrument/surface cause the laceration. Its important because wounds heal differently and are devitalised in many different ways depending on these factors.
Location is relevant, the face heals better than the hands. Some areas are more mobile and better perfused.
Patient factors;
Patient factors will affect healing and can be important clues for risk of infection (diabetes), healing time etc.
Steroids slow healing, HIV doesnt affect wound healing, Keloids are common in afro-americans.
Find out the patient's Tetanus Status, you have probably heard about tetanus prone wounds, this is a myth. You can get tetanus from a corneal abrasion. Make you sure you find out about the primary series of vaccinations! no good giving a booster if someone hasn't had their primary series! this is a common situation with immigrants in our ER. Many people forget to ask! CDC advice
The key to good wound practice is IRRIGATION. rememeber: "the solution to pollution is dilution" Water is the best irrigant, you can use plain old tap water, its the volume that matters, taking the patient over to the tap you can supply much more water than a simple syringe from a saline bag. You will never completely eliminate the bacteria, it just needs to have a lower enough concentration so that colonies don't form (sample principle as the lab). Consider the environment, kid falls and hits head on table legvs kid who falls and hits head on road kerb. You need volume and pressure
Sensation:
The gold standard to test sensation is a 2 point discrimination (5mm apart for the hands), make sure there eyes are closed of course. A plastic surgeon can repair most nerves proximal to the DIP joint of the fingers, you will need them to fix any nerve injuries. From a malpractice point of view you need to perform the gold standard.
You can investigate tendon injuries in a variety of ways, a good way to test is to ask the patient to assume the position of function, you will spot any flexor injuries easily.
Position of function: arms raised to shoulder height, with hands pointing up and open chest position. imagine a policeman says "hands up!"
Flexor injuries you should call the surgeon. There is a small no mans land, the deep palmar lacerations. If the palm hurts when they move their hand then they have probably knicked the palmar sheath. With little pain you can probably leave this but a surgical referral is probably best.
Many extensor tendon injuries can be splinted and will heal well.
Remove foreign bodies. 90% of glass can be seen on X-ray
Use anaesthetic, local anaesthesia or nerve block. nerve blocks are very useful and with ultrasound very easy to perform (with practice). Use Lidocaine (short acting) or Bupivicaine (medium acting 8hours half life). Some areas are tender, for example the sole of the foot, do a nerve block!
Allergic reactions to lidocaine itself are impossible! (only to the preservatives used within, which are rare now). You can be almost 100% sure there will be no allergic reaction if you use single use vials or cardiac lidocaine.
There has never ever been a documented case of allergci reaction to cardiac lidocaine.
Most lidocaine reactions are just a vasovagal reaction to the needle ha.
When dealing with the face or kids, topical agents are great eg. Tetracaine. You can wack it on in triage.
Explore all Wounds!
Anaesthesia, Betadine on the neighbouring skin surface (not inside the wound). you are ready to suture!
SUMMARY:
History is important!
Before touching the wound, you should know exactly how it happened, when it happened and what instrument/surface cause the laceration. Its important because wounds heal differently and are devitalised in many different ways depending on these factors.
Location is relevant, the face heals better than the hands. Some areas are more mobile and better perfused.
Patient factors;
Patient factors will affect healing and can be important clues for risk of infection (diabetes), healing time etc.
Steroids slow healing, HIV doesnt affect wound healing, Keloids are common in afro-americans.
Find out the patient's Tetanus Status, you have probably heard about tetanus prone wounds, this is a myth. You can get tetanus from a corneal abrasion. Make you sure you find out about the primary series of vaccinations! no good giving a booster if someone hasn't had their primary series! this is a common situation with immigrants in our ER. Many people forget to ask! CDC advice
The key to good wound practice is IRRIGATION. rememeber: "the solution to pollution is dilution" Water is the best irrigant, you can use plain old tap water, its the volume that matters, taking the patient over to the tap you can supply much more water than a simple syringe from a saline bag. You will never completely eliminate the bacteria, it just needs to have a lower enough concentration so that colonies don't form (sample principle as the lab). Consider the environment, kid falls and hits head on table legvs kid who falls and hits head on road kerb. You need volume and pressure
Sensation:
The gold standard to test sensation is a 2 point discrimination (5mm apart for the hands), make sure there eyes are closed of course. A plastic surgeon can repair most nerves proximal to the DIP joint of the fingers, you will need them to fix any nerve injuries. From a malpractice point of view you need to perform the gold standard.
You can investigate tendon injuries in a variety of ways, a good way to test is to ask the patient to assume the position of function, you will spot any flexor injuries easily.
Position of function: arms raised to shoulder height, with hands pointing up and open chest position. imagine a policeman says "hands up!"
Flexor injuries you should call the surgeon. There is a small no mans land, the deep palmar lacerations. If the palm hurts when they move their hand then they have probably knicked the palmar sheath. With little pain you can probably leave this but a surgical referral is probably best.
Many extensor tendon injuries can be splinted and will heal well.
Remove foreign bodies. 90% of glass can be seen on X-ray
Use anaesthetic, local anaesthesia or nerve block. nerve blocks are very useful and with ultrasound very easy to perform (with practice). Use Lidocaine (short acting) or Bupivicaine (medium acting 8hours half life). Some areas are tender, for example the sole of the foot, do a nerve block!
Allergic reactions to lidocaine itself are impossible! (only to the preservatives used within, which are rare now). You can be almost 100% sure there will be no allergic reaction if you use single use vials or cardiac lidocaine.
There has never ever been a documented case of allergci reaction to cardiac lidocaine.
Most lidocaine reactions are just a vasovagal reaction to the needle ha.
When dealing with the face or kids, topical agents are great eg. Tetracaine. You can wack it on in triage.
Explore all Wounds!
Anaesthesia, Betadine on the neighbouring skin surface (not inside the wound). you are ready to suture!
SUMMARY:
- History of injury
- Location considerations
- Pateint factors
- Tetanus status
- Good neurovascular and functional exam
- Irrigation
- Anaesthesia
 |
| Get ready to stitch this guy up |
Subscribe to:
Posts (Atom)