One pill can kill!

These medicines could potentially be fatal in a single dose to a 10kg toddler

• Benzocaine
• Camphor
• Chloroquine
• Clonidine
• Cyclic antidepressants
• Diphenoxylate/atropine (Lomotil)
• LIndane
• Methadone (and other opioids)
• Methyl salicylate (oil of wintergreen)
• Oral hypoglycemics
• Quinidine
• Propranolol
• Theophylline
• Thioridizine
• Verapamil

Suturing and tetanus prophylaxis

Suturing Guidelines

For Uncontaminated, Uncomplicated Lacerations

LET (Lidocaine-Epinephrine-Tetracaine)

- Works in ~ 30 minutes

- Use only on broken skin (won’t work on intact skin)

- Don’t use on mucous membranes (risk of toxicity)

- CAUTION with fingertips, toes, penis, nose, or pinna b/c of epi

EMLA (Eutectic Mixture of Local Anesthetic)
ELA-max
Use only on intact skin (NOT on lacerations!)

ELA-max works in 30 minutes, EMLA takes an hour

OK to use on areas of distal circulation because no epi

Lidocaine

1% lidocaine = 10 mg/ml
2% lidocaine =  20 mg/ml

Max dose - lidocaine WITH epi = 7 mg/kg (up to 280 mg)

Max dose - lidocaine WITHOUT epi = 4 mg/kg (up to 280 mg)

w/ epi DO NOT use on fingertips, toes, penis, nose, pinna

To buffer with bicarb: 1:10 solution with 8.4% sodium bicarbonate
(9ml of lidocaine + 1ml bicarb)

Location	Percutaneous (Skin)	Deep (Dermal)	Days to removal (percutaneous only)
Scalp	Staples or 5-0/4-0 Prolene/Ethilon	4-0 Vicryl/Chromic Gut	7-10
Ear	6-0 Prolene/Ethilon – SEE NOTE*		5-7
Eyelid	7-0/6-0 Prolene/Ethilon.  If low on lid, consult Ophtho.		5-7
Eyebrow	6-0/5-0 Prolene/Ethilon	5-0 Vicryl/Chromic Gut	5-7
Nose	6-0 Prolene/Ethilon - SEE NOTE*	5-0 Vicryl/Chromic Gut	5-7
Lip	6-0 Prolene/Ethilon	5-0 Vicryl/Chromic Gut	5-7
Oral mucosa	---	4-0 or 5-0 Vicryl/Chromic Gut	---
Tongue	Suture if significant step-off or through and through laceration
Other face/ forehead	6-0 Prolene/Ethilon – SEE NOTE*	5-0 Vicryl/Chromic Gut	4-5
Trunk	5-0/4-0 Prolene/Ethilon	3-0 Vicryl/Chromic Gut	8-10 (Chest/Abd) 12-14 (Back)
Extremities	6-0/5-0/4-0 Prolene/Ethilon	4-0 Vicryl/ Chromic Gut	8-10
Hand	6-0/5-0 Chromic	5-0 Vicryl/ Chromic Gut	8-10; 10-12 (tip)
Extensor tendon	Refer to plastic surgeon
Foot/sole	4-0/3-0 Prolene/Ethilon	4-0 Vicryl/ Chromic Gut	12-14
Vagina	---	4-0 Vicryl/Chromic Gut	---
Scrotum	---	5-0 Vicryl/Chromic Gut	---
Penis	5-0 Prolene/Chromic	---	7

*Consider use of Fast Absorbing Gut (5-0/6-0) on Ear, Eyelid, Eyebrow, Nose, Lip and Face if anticipated difficulty with suture removal (Note: follow up still required for wound evaluation)

NOTE:  If cartilage involved, strongly consider plastic surgery consult.  Always treat with antibiotics

NOTE:  If human/animal bite, cleanse, dress, treat with antibiotics, and follow-up with Plastics.  If tendons are involved, start antibiotics and consult Plastics.  See ‘Bugs and Drugs’ section (page 63-64) for specific treatment guidelines.

Tetanus administration

Immunization history	Dirty, Tetanus prone:  >6 hrs since injury; stellate or avulsion injury; missile, crush, burn, frostbite; >1 cm deep; devitalized /contaminated.		Clean, Non-tetanus prone: ≤6 hours since injury; linear injury; sharp surface (glass, knife); ≤1 cm deep; No devitalized or contaminants
	TdaP (Adacel)	TIG	TdaP (Adacel)	TIG
Unknown or <3 doses	Yes	Yes	Yes	No
3 or more doses	No, unless >5 yrs since booster	No	No, unless >10 yrs since booster	No

Overview of Acute Scrotal/Testicular Pain

History & Physical Exam

• Pain? Acute onset suggests torsion, epididymitis, or torsion of the appendix testis/epididymis
• Trauma?
• Change in size? Valsalva = hydrocele
• Sexually active? Epididymitis in adolescents
• Difficulty voiding? Think mass, cord lesion, UTI
• Flank pain or hematuria? Referred pain from a kidney stone
• Abdominal pain, nausea/vomiting? Torsion
• Setting the stage
• Get a chaperone if you or patient are uncomfortable
• Have the patient stand if possible
• If you suspect a varicocele examine the patient supine as well
• Respect the patient’s privacy!
• Don’t forget to examine the;
• Inguinal folds
• Penis and urethra
• Pubic hair
• Testicular position (left is lower)
• Testicular lie

Testicular torsion

• Surgical emergency!
• The testicle twists on the spermatic cord
• Venous compression then…
• Edema of testicle and cord then…
• Arterial occlusion then…
• 1/4000 males < age 25
• Bimodal -  neonatal and puberty
• 65% between ages 12-18 years
• Likely due to increasing testicle volume
• Bell clapper deformityTestis is not fixed to the tunica vaginalis posteriorly and it is free to rotate and is at increased risk of torsion.Incidence is approximately 1/125 and usually present bilaterally.
  
• Presentation
• Abrupt onset of pain <12 hours
• Associated N/V, lower abdominal pain
• In a retrospective review only 8% had pain prior to this episode (Kadish, 1998)
  
• Exam
• Edema of scrotum
• Testis – tender and slightly elevated, may have a horizontal lie
• Cremaster reflex is absent
• Torsion is ideally a clinical diagnosis
• If suspected tell your Attending and call Urology ASAP
• Ultrasound
• Sensitivity 69-100%
• Specificity 77-100%
• Nuclear medicine scans are very sensitive and specific – but not readily available
• Surgery
• If viable – detorsion of affected testis and fixation (orchiopexy) of both testis

§                    Viability rates

Within 4-6 hours 100%

12-24 hours 20%

>24 hours 0%

• Sequelae
• Males may have increased risk of infertility even when viable de-torsed testis is left in scrotum because of immune-mediated injury to contralateral testis
• Other studies have failed to show that anti-sperm antibodies are present
• Intermittent torsion
• 80% have bell clapper deformity
• Pain is brief and resolves quickly (minutes)
• Eaton et al, 26% had nausea and vomiting, 21% pain awakened patient from sleep
• Neonatal torsion
• A topic that could have its own talk
• Many cases occur in utero

Torsion of the appendix testis and appendix epididymis

• Vestigial structures
• Appendix testis: Müllerian system
• Appendix epididymis: Wolfian system
• They torse easily
• Boys 7-12 years of age
• Pain is usually less severe
• The ‘blue dot sign’ is the pathognomonic physical finding
• Due to infarction/necrosis of the appendix
• A reactive hydrocele may also be seen
• Diagnosis
• Usually clinical if you see a ‘blue dot sign’
• Get an Ultrasound in cases where you can’t r/o torsion
• Management
• Analgesics
• Rest
• Scrotal support
• The pain typically resolves in 5-10 days

Epididymitis

• Etiology
• Sexually active? Chlamydia, gonorrhea, E.coli, viruses
• Prepubertal? Viruses, E. coli, mycoplasma
• Presentation
• Pain and swelling localized to the epididymis
• Testis has a normal lie
• 50% have scrotal edema
• The scrotum is sometimes red
• Cremaster reflex is present
• Positive ‘Prehn sign’ (not reliable)
• Patient may have dysuria
• The work-up
• Clinical exam
• Ultrasound
• Urinalysis
• Obtain in ALL patients with suspected epididymitis
• STD testing
• Get gc/chlamydia DNA of urine if sexually active
• Syphilis and HIV testing
• Prepubertal boys
• Antibiotics are NOT always indicated
• Treat if.. Pyuria >3-5 wbc, positive U/C, or underlying UTI risk factors  - TMP/SMX or Cephalexin for 10 days
• Teenagers (Pro-Tip: think about STDs)
• Ceftriaxone 250mg IM x1 then doxycyline 100mg bid x10 days
• For enterics AND negative STD…
• 10 days of ofloxacin 300mg bid or levofloxacin 500mg qday
• Tx also includes rest, NSAIDs, and scrotal elevation

Day 8 Leaderboard

As Day 8 of the #PEMTwitterTriviaContest dawns there is a logjam at the top of the Leaderboard with a deadlock in 2nd place. Other competitors - there is still plenty of time to make your move.

1. @MarlinaLovett
2. @Bedingaj and @paulbunchmd
3. @GreggKottyan

Close behind are @ziggy7652, @dbailey4, @7hillsandariver, @AnotherLynLee, @preetir85, @TarekAlsaied

Prognotic factors in sickle cell disease

Three prognostic factors have been associated with worse outcome in sickle cell disease:
1.) Dactylitis in infants younger than age 1 year
2.) Hemoglobin level less than 7 g/L
3.) Leukocytosis in the absence of infection


These worse outcomes include death, risk of stroke, high pain rate, recurrent acute chest syndrome.


Check out the article here: http://www.nejm.org/doi/full/10.1056/NEJM200001133420203

Hyphemas are bad

A hyphema is a collection of blood in the anterior chamber and is usually the result of trauma. The eyeball is compressed, and the anterior ciliary body tears, leading to bleeding.


The grades are estimated by volume of the anterior chamber
I: <1/3
II: 1/3 to 1/2
III: >1/2
IV: complete

The higher the grade, the greater the risk for re-bleeding. Ophtho may consider hospitalizing a grade II-III, elevated intraocular pressure, patients with sickle cell disease, or in social situations where close outpatient follow up isn't assured. A grade IV hyphema means that the entire anterior chamber is full of blood, and is also known as an 'eight-ball hyphema.'


Generally hyphemas are managed conservatively with close follow-up. The success of treatment, as judged by the recovery of visual acuity, is good in approximately 75% of patients.

• 80% of those with grade I regain visual acuity of 20/40 or better
• 60% of those with a grade III regain visual acuity of 20/40 or better
• 35% of those with a grade 4 hyphema have good visual results

Treat with rest, unilateral patch/shield, acetaminophen (but not ibuprofen), and elevating the head of the bed. Other therapies are controversial, and are at the discretion of the Ophthalmologist.