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Alan Keating, PA-CConyers, Georgia

Provide memory tools utilized in the rapid assessment and treatment of many of the common urgent care illnesses and injuries.

Emphasize the subtle signs and symptoms of these clinical presentations that can quickly lead to life threatening situations.

Provide multiple clinical pearls and review key clinical skills utilized in urgent care medicine assessment and treatment.

Teach techniques and provide hands on practice of the following skill areas: suturing, splinting, and casting emphasizing clinical “tricks of the trade.”

Utilize memory tools, discussions, and hands on techniques to reinforce the protocols learned.

What you see, you forget.

What you read, you remember.

But, what you DO… you LEARN.

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Procedure Fundamentals

Quick Reminders:The number one customer in a

pediatric case is the parent(s).

If the child starts talking to you, listen to them, even if you have no idea what they are saying!

Four A’s of Neurologic documentation: Alert, Active, Awake, and

Appropriate Response to…

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PenetratingBlock, X-Ray, Remove Don’t forget the antibiotics

Tetanus if over 5 years I.V. Cefzolin if fractured and orthopaedic

consultP.O. Cefalexin, TMP-SMX, or Doxycycline

In the Ear*** Quick look, 2% Lido Stat, then irrigation with warn water.

Dogs: 5% infection risk - tear wounds.Treatment – Amox/Clav. 875mg BID, pain control, and wound irrigation. These can be much worse due to other damage (fractures, vascular injury, deep muscle tears).

No. 1 Bacteria is Pasteurella canisNo. 2 is Staph. aureus

Cats: 80% infection rate - puncture wound.Treatment – Amox/Clav. 875mg BID,

pain control, and wound irrigation.No. 1 Bacteria is Pasteurella multiocidaNo. 2 is Staph. aureus

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Clear it with your attending

Prepare the patient

Feel the notch

Relax

Take your time

Volume: 2-4 cc Lidocaine – PLAIN

How deep?: Subcutaneously. Inject just on top of the tendon sheath and the infiltrate the digital nerves.

Effectiveness: Just as good as multiple sticks

Pain Level: About the same

Satisfaction: Patients – SameProviders - Better

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“Eventually all bleeding stops… one

way or another”

Blunt Trauma“Cheek just puffed out after I sneezed”

Lacerations Over SinusesFinger probe technique – Listen for eggshells

Lip Laceration - “Million dollar laceration”

Non X-Ray Mandible Fracture Exam

What is the facial injury imaging Gold Standard?

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Shapes:Cutting – Reverse & Conventional

Good for most skin & nailsTapered – Deep tissue and fascia

Curvature:

Nonabsorbable:Silk, NYLON, Polypropylene, Polyester fiber,

Polybutester, and Coated Polybutester

Natural Absorbable:Collagen, Plain surgical gut, Fast-absorbing

surgical gut, and Chromic surgical gut

Synthetic Absorbable:Polyglactin 910 (VICRYL), Polycaprolate

Poliglecaprone 25 (Monocryl), Polysorb,and Polydioxanone (PDSII)

Sutures: Only needles needed – PS-2 and P-3.Only suture needed – 6-0, 5-0, 4-0 Nylon

and 4-0 Vicryl, that’s it.

Anesthesia tips - Be nice and take your time:Hold the syringe to warm the lidocaine.Add 1cc bicarb for every 9cc of 1% lidocaine.

Use 2% or 0.5% bupivacaine for larger or complex lacerations.

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Suturing Dont’s:Perform a closure only if you are comfortableNo need to rush the anesthesia infusionRemember to pucker up the edges.Loose closure only of contaminated woundsLoose closure of the fascia layerIf it looks bad now, it will look worse later.External staples on the scalp works fine, unless…No “landing strips”Don’t forget to close the galea layer.

No internal sutures in the hand-EVER!

Suturing Do’s:Cut off rings Assess neurovascular status PRIOR to anesthesiaInfuse lidocaine inside the wound edgesIrrigate – A LOT! (towels)Approach at a 90 degree angle to the skinBrief use of finger tourniquet – “Squeeze trick”Listen for clicking when looking for FBTag the corners first, EXCEPT in a thin flapUse the “Over – Under” method

Reset your needle while holding the suture!

Basic Rules:1) ICE – Not necessary 2) Gentle Compression – first hour or two3) Elevate – first 24 hours for extremities4) Pool Rule – No Water, especially lakes!

Wound Care Rules:1) Antibiotic Rule – Always if contaminated2) Sensation Rule – Check often, fingers & toes3) Smother Rule – Only a gloss coat of topical 4) Dressing Rule – Change it daily, after shower

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The Fast and Furious World

of Urgent Care

Don’t fall asleep at the wheel!Watch out for the routine, don’t assume.Follow the same protocol for all.What do you need to note?

Driver, seat-belt, air-bag, impact, speed, other

Three most import X-raysCXR, C-spine, and pelvisClear off the board, BUT NOT THE COLLAR

What MUST you document?

Hoover Sign

Waddell Signs (HASSP)

Hip Rotation

Axial Loading

Skin Roll Test

SLR Distraction (“SLR/Heel” Test)

Pain Description

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P – Pain described, or on palpation

A – Alcohol

N – Neurological Deficit

D – Distracting Injury

A – Altered Mental Status

Most common joint to dislocate is the SHOULDER (Anterior 95%), then finger.

Quick Exam: they can not touch opposite side.Complications: Repeat dislocations.

What is needed most in a shoulder reduction?

Pain medication, sedation, & PATIENCE!

Treatment (other joints): Block first, X-Ray, Reverse the mechanism

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Preparing (Helpful Hints):Choose the right material size – 2”, 3”, 4”Need: Splint roll, ACE Wrap, water, & towelPeel and cut backREALLY dry it out

Applying (Do’s and Don’ts):DO Place in position of comfort… UsuallyDO Roll back the ends and move endsDON’T squeeze the corners – Ankles & ElbowsDON’T stretch the ACE, just roll it

90 Degrees at the ankle – a MUST!*

Upper Extremity:Volar or Short ArmUlnar GutterThumb SpikaSugar TongLong Arm/Hanging Long Arm

Lower Extremity:Short LegLong LegCadillac – (Short leg and sugar tong combo)

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Basic Rules:1) ICE, ICE, Baby!... - But gently2) Elevate, Elevate, Elevate - ABOVE the heart3) ACE RE-Wrap Rule - DON’T STRECH IT!4) Weight Baring - There is no weight baring

Crutch Training Rules:1) Pink Flamingo Rule – draw the bad leg up2) Lead Off Rule - Crutch first, foot second3) Stairs Rule – NO up or down stairs, ever!4) Backwards Rule – There is no backwards

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Honing Your Skills

Assessment (NOM)First- Neurovascular

Second – Open versus Closed

Third – Mechanism of Injury

Description (TOAD)T ype – Spiral, transverse, comminutedO pen vs. ClosedA ngulation – Degrees of angulationD isplacement – Percentage

Six Most Commonly Missed Fractures

Hand – Assume that it is fractured

Scaphoid – “Snuff Box” tenderness

Radial Head – Positive Posterior Fat Pad

Cervical – PANDA Neck Criteria

Calcaneous – Bohler’s Angle/Assess Spine

Salter-Harris – Most Common is Type II of the wrist (50%)

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Upper Extremity:Short ArmThumb SpikaClam Shoveler – Boxer’s FractureLong Arm/Hanging Long Arm

Lower Extremity:Short LegLong Leg – slight bend at kneeCylinder

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Preparing (Helpful Hints):Choose the right material size – 3” or 4”Need: Cast roll, stockinet, cast padding, waterREALLY shake off the water

Applying (Do’s and Don’ts):DO over extend the stockingDO Roll back the ends, AFTER one pass DON’T over pad, even distribution of paddingDON’T Pinch (Fingers and toes)

Extra PAD on the heel– a MUST!

Basic Rules:1) ICE, ICE, Mayby... – Not as important2) Elevate, Elevate, Elevate – first two weeks3) Pool Rule – No Water, especially lakes!4) Weight Baring – It depends

Cast Care Rules:1) Itching Rule – NOTHING goes in the cast!2) Wiggle Rule – Keep wiggling fingers and toes3) Swelling Rule – Split cast If swelling continues 4) CRPS Rule – REMOVE cast if present!

Kids VS. Cuts

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…You’ve got to have a game plan!

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What are the primary bugs?Chlamydia, Gonorrhea, and Trichomoniasis

What are the symptoms?

3D’s - Dysurea, Discharge, DiscomfortSx’s are not as severe in Chlamydia versus GCSx’s tend to be asymptomatic in women longerEducate, educate, educate…

Treat all infections and all partners

Why is fever important?

What is the treatment?Trichomoniasis –

Metronidazole 500mg BID X 7 days,or 2 gram X 1 dose OR…Tinidazole 2 gram x1

Gonorrhea – “The Love Dart…”Ceftriaxone 250 mg IM X once ALWAYS. you can add Cefpodoxime 400 mg po x once.

Chlamydia – “…and a Z chaser”Azithromycin 1 gram PO X once.OR, Doxycycline 100 mg po BID for 7 days.

Bates, Barbara, A Guide to Physical Examination and History Taking, Fifth Edition, J.B. Lippincott Company, Philadelphia, PA, 1991.

Cannon B, Chan L, Rowlinson JS, Baker M, Clancy M (2010). Digital anaesthesia: one injection or two? Emergency medicine journal: EMJ, 27 (7), 533-6 PMID.

Gilbert, David, N., et. al., The Sanford Guide to Antimicrobial Therapy 2010, 40th Edition, Antimicrobial Therapy, Inc., Sperryville, VA, 2010.

Jauch, Edward C, et. al., Acute Management of Stroke, MedScape Online, Jul 10, 2012.

Lai, Stephen Y, et. al., Sutures and Needles, Medscape Online, June 3, 2013.Kirkcaldy, Robert, New Treatment Guidelines for Gonorrhea: Antibiotic

Change, Online CDC Expert Commentary, 08/13/2012.Purvis, John, M. Engaging with Younger Patients, AAOS Now, May 2009.Sarwark, John F., Put Pediatric Patients and Parents in the Picture, AAOS

Bulletin, April 2004.Staff author, Diseases Characterized by Urethritis and Cervicitis, CDC Report,

April 12, 2007Staff author, Joint dislocation, Wikipedia, 18 March 2012.

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Game Time!