4. 70
Thrush
94
71
Tinea
95
72
Tempromandibular
Joint
96
73
Tooth
Trauma
97
74
Upper
Respiratory
Tract
Infection
98
75
Urinary
Retention
100
76
Vaginal
Bleeding
101
77
Vaginitis
105
78
Vasovagal
Syncope
106
79
Vertigo
107
80
Weakness
109
81
Wry
Neck
(Torticollis)
111
82
Zipper
Caught
on
Penis
or
Chin
113
This
booklet
is
very
helpful
for
new
ED
Physicians
while
treating
the
patients,
and
can
avoid
those
steps
that
can
involve
them
in
medicolegal
problems.
The
material
in
this
booklet
is
taken
from
different
surgical
manuals
and
reference
books,
also
included
my
practical
experience
of
work
in
the
emergency
department
in
tertiary
referral
hospital.
I
need
your
opinion
and
suggestions.
DR
SHAHID
BASHIR
CHAUDHARY
MBBS
DTCD,FCCS
4
5. ABSCESS:
WHAT
TO
DO:
1. Simply
snip
open
the
cutaneous
roof
with
fine
scissor
or
an
inverted
#11
blade.
2. When
the
location
of
an
abscess
cavity
is
uncertain,
attempt
to
aspirate
it
with
a
#18
gauge
needle
after
preparing
the
area
with
Povidine
–iodine.
3. Anesthetize
the
area
with
regional
field
block
and
give
additional
anesthesia
like
I/V
paracetamol
1
gm.
4. Make
the
incision
at
the
most
dependent
area.
5. In
large
abscesses
insert
a
hemostat
in
to
the
cavity
to
break
up
any
loculated
collection
of
pus
and
irrigate
with
normal
saline,
put
packing
and
do
dressing,
6. The
patient
should
be
instructed
to
use
intermittent
warm
water
soaks.
7. Ask
for
dressing
after
two
days.
8. Discharge
the
patient
with
antibiotic
cover.
WHAT
NOT
TO
DO:
a. Do
not
incise
an
abscess
that
lies
close
to
major
vessel,
such
as
in
axilla,
groin
or
anticubital
space.
b. Do
not
treat
deep
infections
of
the
hands
as
simple
cutaneous
abscesses.
c. Routine
culture
is
not
indicated.
5
6. ANAL
FISSURE
Patient
complains
of
painful
rectal
bleeding
and
sometimes
constipation,
the
pain
occurs
with
and
immediately
after
defecation,
the
patient
is
relatively
comfortable
between
bowel
movements.
bleeding
with
defecation
is
usually
slight,
only
staining
the
toilet
tissue.
Mucus
discharge
may
increase
perineal
moisture
and
cause
itching.
Examination
of
anus
reveals
a
radial
tear
or
ulceration
of
the
posterior
midline
95%of
the
time.
WHAT
TO
DO:
1. Provide
topical
anesthesia
with
lidocain.
2. Advise
the
patient
to
take
soft
diet
and
use
a
glycerin
suppository
twice
daily
to
maintain
lubrication
of
the
anal
canal.
3. Instruct
the
patient
to
use
warm,
soothing
sitz
baths
after
each
painful
bowel
movement.
4. Prescribe
analgesia
if
needed.
5. Inform
the
patient
that
an
acute
superficial
fissure
will
take
about
one
month
to
heal
6. He
/she
should
follow
up
in
OPD.
WHAT
NOT
TO
DO:
a. Do
not
assume
that
a
lesion
located
outside
the
anterior-‐posterior
midline
saggital
plane
of
anus
is
an
anal
fissure
b. Do
not
confuse
a
sentinel
pile
with
a
heamorrhoidal
vein.
6
7. ANKLE
SPRAIN:
The
patient
inverted
the
foot
and
either
came
immediately
or
a
day
later
with
pain,
swelling
and
inability
to
walk,
there
is
tenderness
to
palpation
of
the
anterior
talofibularr
ligament.
WHAT
TO
DO:
1. Elevate
the
foot
and
apply
ice
for
15
minutes/hr
to
treat
the
reactive
inflammation
2. Palpate
the
prominence
on
the
lateral
foot
to
check
the
avulsion
of
peroneus
brevious
3. Palpate
the
fibula
on
the
lateral
leg
up
to
the
knee,
where
spiral
fracture
can
propagate
4. If
there
is
tenderness
and
patient
cannot
take
four
steps
in
the
ED,
obtain
x-‐rays
to
rule
out
a
fracture.
5. Immobilize
the
ankle
in
a
stirrup.
6. Anti-‐inflammatory
analgesics.
7. Follow
up
to
ortho
OPD/ED.
WHAT
NOT
TO
DO:
a. Don’t
rule
a
fracture
based
on
a
negative
x-‐rays.
b. Don’t
overlook
fractures
of
the
tarsal
navicular,
talus
or
os
trigonum,
all
visible
on
the
ankle
view.
7
8. BLACK
EYE
The
patient
has
received
blunt
trauma
to
the
eye,
most
often
from
a
fist,
a
fall,
or
a
car
accident
Family
and
friends
are
more
concerned
than
the
patient
about
the
appearance
of
the
eye.
There
may
be
associated
subconjuctival
hemorrhage,
but
the
remainder
of
the
eye
examination
should
be
negative.
WHAT
TO
DO:
1. Clarify
as
well
as
possible
the
specific
mechanism
of
injury.
2. Perform
a
complete
eye
exam
to
rule
out
a
retinal
detachment
or
dislocated
lens.
3. Fluorescein
stain
to
rule
out
corneal
abrasion.
4. Test
extra
ocular
eye
movements;
look
especially
for
diplopia
on
upward
gaze.
5. Check
sensations
over
the
infra
orbital
nerve
distribution.
6. Symmetrically
palpate
the
supra
and
infra
orbital
rims
as
well
as
zygoma.
7. If
there
is
any
suspicion
of
any
underlying
fracture,
obtain
x-‐rays
of
the
orbit.
8. If
significant
injury
is
discovered,
then
consult
with
an
ophthalmologist.
9. CT
scan
is
more
sensitive
and
can
visualize
subtle
fractures
of
the
orbit
and
small
amount
of
air.
10. When
there
is
significant
injury
,
reassure
the
patient
that
the
swelling
will
subside
with
in
12-‐24
hrs
8
9. 11. Give
inj.
paracetamol
1gm
i/v.
or
oral
paracetamol
1
gm.
12. Instruct
the
patient
to
follow
up
in
ophthalmology
clinic
WHAT
NOT
TO
DO:
a. Don’t
get
unnecessary
radiograph.
b. Minor
injuries
with
normal
eye
exams
and
no
palpable
deformities
do
not
require
X-‐rays.
c. Do
not
brush
off
bilateral
deep
peri
orbital
ecchymosis
(raccoon
eye),
especially
if
caused
by
head
trauma
remote
to
the
eye.
BITES
A
single
bite
may
contain
various
types
of
injury,
including
underlying
fractures
and
tendon
and
nerve
injuries,
not
all
of
which
are
immediately
WHAT
TO
DO:
1. Obtain
a
complete
history
including,
the
type
of
animal
that
bit,
whether
or
not
the
attack
was
provoked,
what
time
the
injury
occurred,
the
current
health
status
and
vaccination
record
of
the
animal
has
been
captured
and
is
being
held
for
observation,
report
the
bite
to
police
or
appropriate
local
authorizes.
2. Assess
the
wound
for
any
damage
to
deep
structures,
any
need
for
surgical
consultation
and
risk
of
infection.
3. Look
for
bone
and
joint
involvement
and
if
present.
9
10. 4. Obtain
appropriate
imaging
studies
(dog
bites
have
caused
open
depressed
fractures
in
small
children).
5. Examine
for
nerve
and
tendon
injury
and
be
aware
that
crush
and
puncture
wounds
as
well
as
bites
on
the
hands,
wrist,
and
feet,
are
at
higher
risk
for
development
of
infection
and
significant
complications
such
as
tenosynovitis,
septic
joints,
osteomylitis
and
sepsis.
6. If
tissue
damage
is
higher
then
take
opinion
of
surgery
and
orthopedic.
7. For
crush
wounds
and
contusions,
elevate
above
the
heart
and
apply
cold
packs.
8. If
the
wound
requires
debridement,
or
will
be
painful
to
clean
or
irrigate,
then
anesthetize
the
area.
9. If
there
is
already
sign
of
infection,
obtain
aerobic
and
anaerobic
cultures
of
pus.
10. Irrigate
the
wound
with
antiseptic
(10%povidine-‐iodine
solution,
dilated
1:10
in
normal
saline)
and
sharply
debride
any
debris
and
non
–viable
tissue.
11. Irrigate
the
wound,
using
a
20ml
syringe,
a
19
gauge
needle
or
an
irrigation
shield,
and
at
least
200ml
of
sterile
saline.
12. For
animal
bite
wounds
that
are
clean,
uninfected
lacerations
located
anywhere
other
than
the
hand
or
foot.
You
may
suture.
13. If
the
wound
is
infected
when
first
seen
.plan
either
a
delayed
repair
after
three
to
five
days
of
saline
dressings
or
secondary
wound
healing
with
out
closure.
14. Prescribe
antibiotics
for
seven
days.
15. Severe
infection
requires
hospitalization.
10
11. 16. With
human
bites,
animal
bites
that
are
punctured
or
located
on
he
hand,
wrist
or
foot,
or
bite
more
than
12
hours
old
,in
most
cases,
you
should
leave
the
wounds
open
and
apply
a
light
dressing
.
17. Wounds
should
also
be
left
open
on
debilitated
and
patients
with
diabetes,
alcoholism,
chronic
steroid
use,
organ
transplants,
vascular
insufficiency,
spleenectomy,
HIV
or
other
immnunocompromised
conditions,
18. Start
prophylactic
antibiotics
in
the
ED
on
these
wounds
and
in
patients
with
artificial
or
damaged
heart
valves
and
implanted
prosthetic
devices,
19. If
the
patient
has
had
no
tetanus
toxoid
in
the
past
5-‐10
years,
provide
prophylaxis.
20. Start
rapid
rabies
vaccination:
i. first
day
(0)
ii. third
day(3)
iii. seventh
day(7)
iv. Fourteenth
(14)
v. Twenty-‐eighth
(28)
21. Provide
hepatitis
prophylaxis
for
patients
who
have
been
bitten
by
known
carriers
of
hepatitis
B.
Administer
hepatitis
B
immunoglobulin
0.06ML/kg
i/m
at
the
time
of
injury
and
schedule
a
second
dose
in
30
days.
22. Follow
standard
guidelines
applicable
to
contaminated
needle
sticks.
23. Minimize
edema
of
hand
wound
by
splitting
and
elevation.
11
12. 24. Have
patient
returns
for
a
wound
check
in
two
days
or
sooner
if
there
is
any
sign
of
infections.
25. Explain
the
potential
for
serious
complication
such
as
septic
arthritis,
swollen
immobile,
tender
along
the
flexor
surface
painful
on
passive
extension
that
will
require
specially
consultation.
WHAT
NOT
TO
DO:
a. Do
not
overlook
a
puncture
wound.
b. Do
not
suture
debris,
non
–viable
tissue
or
a
bacteria
inoculation
into
a
wound.
c. Do
not
use
buried
absorbable
suture,
which
act
as
foreign
body
and
cause
a
reactive
inflammation
for
about
a
month
and
increase
the
risk
of
infection.
d. Do
not
routinely
suture
human
bites.
BLEEDING
AFTER
DENTAL
SURGRY
The
patient
had
an
extraction
or
other
dental
surgery
performed
earlier
in
the
day,
now
ha
excessive
bleeding
at
the
site
and
can
not
reach
his/her
dentist.
WHAT
TO
DO:
1. Ask
what
procedure
was
done
2. Inquire
about
antiplatelet
drugs,
like
aspirin.
3. H/O
previous
experience
of
bleeding
12
13. 4. Use
suction
and
saline
irrigation,
clear
any
packing
and
clot
from
the
bleeding
site.
5. Roll
a
2x2”
gauze
pad,
insert
it
over
the
bleeding
site.
6. If
the
site
is
still
bleeding
after
20
minutes
of
gauze
pressure
,inject
local
anesthetic,
7. If
this
does
not
stop
the
bleeding.
Pack
the
bleeding
site
with
Gel
foam.
8. An
arterial
bleeding
requires
ligation
with
figure
eight
stitch.
9. When
the
bleeding
stops,
remove
the
overlying
gauze.
10. Arrange
the
follow
up
for
dentist
WHAT
DO
NOT
DO:
a. Don’t
do
routine
lab
tests.
b. Don’t
use
tea
bags
as
a
gauze
BLUNT
SCROTAL
TRAUMA
Blunt
injuries
to
the
scrotum
usually
occur
in
patients
less
than
50
yrs.
Of
age
as
a
result
of
an
athletic
injury,
a
straddle
injury,
an
automobile
or
industrial
accident,
or
as
an
assault.
Patient
presents
with
various
degrees
of
pain,
ecchymosis
and
swelling.
WHAT
TO
DO:
1. Get
a
clear
history
of
the
exact
mechanism
of
the
trauma
and
the
point
of
maximum
impact.
2. Determine
if
there
was
any
bloody
penile
discharge
or
hematuria.b
13
14. 3. Gently
examine
the
external
genitalia
and
give
analgesia
according
to
pain
scale.
4. If
scrotal
swelling
is
not
too
severe,
try
to
palpate
and
assess
the
intrascrotal
anatomy.
5. Obtain
urinalysis
6. Do
digital
examination
of
the
prostate
and
obtain
urologic
consultation.
7. When
urologic
intervention
is
not
required,
provide
analgesia,
bed
rest,
scrotal
support,
a
cold
pack
and
urologic
follow
up.
WHAT
NOT
TO
DO:
a. Don’t
miss
testicular
torsion
which
can
be
associated
with
blunt
trauma.
b. Don’t
miss
the
rare
traumatic
testicular
dislocation
that
results
in
an
“empty
scrotum”.
BROKEN
TOE
The
patient
has
stubbed,
hyper
flexed,
hyper
extended,
hyper
abducted
or
dropped
a
weight
upon
a
toe.
Patients
present
with
a
pain,
ecchymosis,
and
decreased
range
of
motion
and
point
tenderness
and
there
may
or
may
not
be
any
deformity.
WHAT
TO
DO:
1. Examine
the
toe,
particularly
for
lacerations.
2. Relieve
the
pain
by
anti-‐inflammatory
analgesics.
3. Take
x-‐rays
to
look
fracture
entering
the
joint
space.
14
15. 4. Displaced
or
angulated
phalangeal
fracture
must
be
reduced
with
linear
traction
after
digital
block.
5. Splint
the
broken
toe
by
tapping
it
to
an
adjacent
non
effected
toe
,
padding
between
toes
with
gauze
and
using
half
inch
sticking
plaster.
6. Advise
the
patient
to
be
immobilized
by
using
clutches
or
wearing
hard
sole
shoe
and
elevate
the
toe
at
sleeping
time
and
put
ice
bar
on
the
pad.
7. Inform
the
patient
that
he/she
must
keep
the
padding
dry
between
toe
while
they
are
tapped
together
otherwise
skin
will
mace
and
break
down.
8. If
the
fracture
is
not
of
phalanx,
but
of
the
metatarsal,
construct
a
pad
for
the
sole
with
space
cut
to
the
foot.
9. Arrange
a
follow
up
for
the
orthopedic
OPD
with
in
one
week
WHAT
NOT
TO
DO:
a. Do
not
tape
together
with
out
keeping
pad
between
toes
wetness
and
Friction
will
maceration
will
b. Do
not
let
the
patient
overdo
the
ice,
which
should
not
be
applied
directly.
c. Don’t
overlook
the
possibility
of
acute
gouty
arthritis,
which
sometimes
follow
minor
trauma.
RIIB
RFACTURE:
It
is
due
falling
down
on
the
side
of
the
chest,
initial
chest
pain
may
subside
but
over
the
few
hours
or
days
pain
increases
and
patient
visits
the
ED
for
chest
pain,
15
16. there
is
point
tenderness
at
the
site
of
injury
and
occasionally
bony
crepitance
can
be
felt.
WHAT
TO
DO:
1. Examine
the
patient
for
possible
associated
injuries
2. Relieve
the
pain
and
compress
the
rib
medially
if
anterior
or
posterior
fracture
is
suspected,
3. Compress
the
rib
anterior
/posterior
if
the
fracture
is
suspected
laterally.
4. When
the
pain
occurs
at
the
suspected
fracture
site
with
indirect
stress,
this
is
clinical
evidence
of
fracture
and
document.
5. Obtain
a
history
of
chronic
pulmonary
problems
or
heavy
smoking.
6. Send
the
patient
for
PA/LAT
view
of
x-‐rays
chest
to
rule
out
pneumothorax,
hemothorax
or
evidence
of
pulmonary
contusion.
7. If
there
is
no
evidence
of
underlying
injury
and
there
is
clinical
and
radiological
evidence
of
rib
fracture,
call
surgical
team
or
arrange
appointment
for
Surgical
OPD
with
in
48
hours
and
discharge
the
patient
by
advising
potent
oral
analgesics.
8. Instruct
the
patient
on
the
intermittent
use
of
an
elastic
rib
belt
if
it
reduces
pain.
9. Ask
the
patient
about
the
importance
of
deep
breathing
and
coughing
to
help
prevent
pneumonia.
10. Advise
the
patient
rest
for
one
week
according
the
organization
policy.
11.
If
the
patient
is
compromised
and
have
cardiac
or
associated
respiratory
disease
and
the
patient
is
old
then
hospitalization
is
required.
16
17. WHAT
NOT
TO
DO:
a. Don’t
confuse
simple
rib
fracture
with
massive
blunt
trauma
to
the
chest.
b. Do
not
tape
ribs
or
use
continuous
strapping.
c. Do
not
assume
that
there
is
no
fracture
because
the
x-‐rays
are
negative,
Rib
fractures
is
often
not
apparent
on
x-‐rays,
especially
when
they
occur
on
cartilaginous
portion
of
the
rib.
BRUISES
The
patient
has
fallen
on
or
thrown
against
the
object
has
been
struck
at
a
site
with
the
point
of
tenderness
and
swelling.
Pain,
ecchymosis
and
hematoma.
On
Physical
examination
there
is
no
loss
of
function
of
muscles
and
tendons,
no
instability
of
bones
and
ligaments
and
no
crepitus
or
tenderness
produced
by
remote
stress.
WHAT
TO
DO:
1. Take
a
thorough
history
to
ascertain
the
mechanism
of
injury
and
perform
a
complete
examination
to
document
structural
integrity
and
bony
injury
2. Do
x-‐rays
if
you
suspect
possibility
of
bony
injury
or
foreign
body,
fractures
are
uncommon
after
a
direct
blow.
3. Explain
the
patient
that
swelling
will
be
at
peak
in
one
day
and
then
resolve
gradually.
17
18. 4. Giving
anti-‐inflammatory
drugs
and
prescribing
rest
of
effected
part,
immobilization,
elevation
and
ice
padding
reduce
the
swelling.
5. Explain
the
patient
late
migration
and
color
changes
of
ecchymosis.
6. A
large
intramuscular
hematoma
may
require
drainage
ororthopeadic
consultation.
7. Arrange
for
follow
up
in
surgical
OPD,
if
the
patient
returns
ED
with
increased
discomfort.
WHAT
NOT
TO
DO:
a. Do
not
apply
a
elastic
bandage
to
the
middle
of
limb
where
it
may
act
as
a
tourniquet.
b. Do
not
confuse
patient
with
instructions
for
application
of
heat
and
exercise
to
prevent
stiffness
and
atrophy,
concentrate
on
the
here
–and
–
now
therapy.
CELLULITIS
The
cardinal
sign
of
infection
(pain,
redness,
warmth,
and
swelling)
are
present.
Erysipelas
is
very
superficial
and
bright
red
with
indurate,
sharply
demarcated
borders.
Cellulitis
is
deeper,
involves
the
subcutaneous
connective
tissue
and
has
indistinctive
advancing
borders.
These
infections
are
preceded
by
minor
trauma
of
the
presence
of
foreign
body
and
are
most
common
in
those
patients
who
have
predisposing
factor
like
diabetes
mellitus,
DVT
and
lymphatic
drainage
obstruction,
they
may
be
18
19. associated
with
an
abscess
or
they
may
have
no
clear
–cut
origin.
The
patient
may
have
tender
lymphadenopathy
proximal
to
the
site
of
infection
and
may
or
may
not
have
signs
of
systemic
toxicity
(fever,
rigor
and
listlessness).
WHAT
TO
DO:
1. Look
for
possible
source
of
infection
and
remove
it.
2. Deride
and
cleans
any
wound,
remove
any
foreign
body
or
drain
any
abscess.
3. When
the
patient
is
very
sick
and
there
is
discoloration
of
the
limb,
get
medical
consultation
and
take
all
basic
investigation
(CBC,
BIO.
Culture),
and
X-‐rays
chest
and
limb.
4. Hospitalize
the
patient
through
surgical
team,
5. If
there
is
low
grade
fever
or
none
at
all
then
prescribe
third
generation
antibiotics
and
anti-‐inflammatory
analgesics.
6. Instruct
the
patient
to
keep
the
infected
part
at
rest
and
elevated
and
to
use
intermittent
warm
moist
compression.
7. Advise
the
patient
to
follow
up
in
ED
with
in
24-‐48
hour
WHAT
NOT
TO
DO:
a. Do
not
send
the
patient
home
if
there
is
suspicion
of
deep
facial
cellulites
or
the
patient
has
deep
infection
of
the
handed
even
the
patient
is
a
febrile
19
20. COLLAR
BONE
FRACTURE
(CLAVICLE)
The
patient
has
fallen
into
his
shoulder
or
out
stretched
arm
or
more
commonly
has
received
a
direct
blow
to
the
clavicle
and
now
present
with
the
pain
to
direct
palpation
over
the
clavicle
or
with
movement
of
arm
or
neck,
there
may
be
deformity
of
the
bone
with
the
swelling
and
ecchymosis.
An
infant
or
small
child
might
present
after
a
fall,
not
moving
arm
with
above
findings.
WHAT
TO
DO:
1. After
completing
the
musculoskeletal
examination,
evaluate
the
neurovascular
status
of
the
arm.
2. Fit
a
sling
or
clavicle
strap
that
comfortably
immobilizes
the
arm.
3. Prescribe
analgesics
like
ibuprofen
or
naproxen.
4. Obtain
x-‐rays
to
rule
out
other
injuries
and
document
the
fracture.
5. Arrange
for
orthopedic
follow
up
in
a
week
to
evaluate
heeling
and
begin
pendulum
exercise
of
the
shoulder
by
physiotherapy
or
advise
patient
by
you.
WHAT
NOT
TO
DO:
b. Do
not
apply
figure
of
eight
dressing
or
clavicle
strap
if
this
form
of
splitting
increases
patient’s
discomfort.
c. Do
not
leave
arm
immobilized
in
a
sling
for
more
than
week
,
this
can
result
in
loss
of
range
of
motion
or
frozen
shoulder,
therefore
instruct
patient
before
sending
home.
20
21.
CARPAL
TUNNEL
Patient
complains
of
pain
or
“pins
and
needle”
sensation
in
the
hand.
Onset
may
have
been
abrupt
or
gradual
but
the
problem
is
most
noticeable
upon
awaking
or
after
extended
use
of
the
hand.
The
sensations
may
be
bilateral,
may
include
pain
in
the
wrist
or
forearm
and
is
usually
ascribed
to
the
entire
hand
until
specific
physical
examination
localized
it
to
the
median
nerve
distribution.
More
established
cases
might
include
weakness
of
the
thumb
and
atrophy
of
the
thenaar
eminence.
Physical
examination
localizes
paresthesia
and
decreased
sensation
to
the
median
distribution
and
motor
weakness.
WHAT
TO
DO:
1. Perform
and
document
complete
examination,
sketching
the
area
of
decreased
sensation
and
grading
the
strength
of
the
hand.
2. Hold
the
wrist
flexed
at
90-‐degree
angle
for
60
seconds,
to
see
if
it
reproduces
symptoms,
this
is
known
as
PAHALEN’S
TEST
and
is
more
sensitive
and
more
specific.
3. Explain
the
nerve
–compression
etiology
to
the
patient
4. Call
surgical
team
or
arrange
evaluation
and
follow
up
referral.
5. Borderline
diagnosis
is
established
with
electromyography(EMG)
6. Early
surgical
intervention
is
indicated
when
there
is
pain
and
weakness.
21
22. 7. Anti-‐inflammatory
medication,
elevation
of
the
affected
hand,
ice,
immobilization
with
a
volar
splint
and
rest
may
all
help
to
reduce
symptoms.
WHAT
NOT
TO
DO:
a. Do
not
rule
out
thumb
weakness
just
because
the
thumb
can
touch
the
little
finger.
b. Do
not
diagnose
carpel
tunnel
syndrome
solely
on
the
basis
of
a
positive
Tinley’s
sign.
CYSTITIS
The
patient
complains
of
urinary
frequency
and
urgency,
internal
dysuria
and
supra
pubic
pain,
they
may
sometime
have
antecedent
trauma
in
females
(sexual
intercourse)
to
inoculate
the
bladder
and
there
may
be
blood
in
the
urine.
WHAT
TO
DO:
1. Take
urine
for
white
cells
and
if
possible
for
Gram
stain.
2. If
the
clinical
picture
is
clearly
that
of
an
uncomplicated
lower
UTI,
give
Ciprofloxacin
and
analgesics.
For
7days.
3. Instruct
the
patient
to
drink
plenty
of
water
4. If
there
is
external
dysuria,
vaginal
discharge,
odor,
itching
and
no
frequency
or
urgency
then
evaluate
for
vaginitis.
22
23. 5. If
the
dysuria
is
severe
then
prescribe
Phenazopyradine
(Pyridium)
200mg
tid
for
two
days
only
to
act
as
surface
anesthetic
in
the
bladder.
warn
the
patient
that
urine
will
stain
orange.
6. Arrange
follow
up
in
urology
department.
WHAT
NOT
TO
DO:
a. Do
not
undertake
urine
culture
for
every
lower
UTI
or
recent
onset
in
non
pregnant
,
b. Do
not
follow
the
single
dose
or
3
day
regimen
for
possible
upper
UTI.
c. Do
not
rely
upon
gross
inspection
of
urine
sample;
crystals
and
odor
usually
cause
cloudiness
usually
from
diet
or
medication.
d. Do
not
require
follow
up
visit
or
culture
therapy
unless
symptoms
persist
or
reoccur.
DIGITAL
BLOCK
It
is
necessary
to
provide
complete
anesthesia
when
treating
most
fingertip
injuries,
many
techniques
for
performing
nerve
block
have
been
described,
as
the
following
is
the
one
that
is
both
effective
and
rapid
in
onset.
This
type
of
digital
block
will
only
provide
anesthesia
distal
to
the
inter
phalangeal
joint,
but
this
is
most
often
the
site
that
demands
a
nerve
block.
WHAT
TO
DO:
23
24. 1. Cleans
the
finger
and
paint
the
area
with
Povidine-‐
iodine
(Betadine)
solution.
2. Using
a
27-‐gauge
needle,
slowly
inject
1%lidocain
midway
between
the
dorsal
and
palmer
surface
of
the
finger
at
the
mid
point
of
the
middle
phalanx.
3. Inject
straight
in
along
the
side
of
the
periosteum,
then
pull
with
out
removing
the
needle
from
the
skin
and
fan
the
needle
dorsally.
4. Advance
the
needle
dorsally
and
inject
again
5. Advance
the
needle
and
inject
the
lidocain
in
the
vicinity
of
the
digital
neurovascular
bundle.
6. With
each
injection,
instill
enough
lidocain
to
produce
visible
soft
tissue
swelling.
7. Repeat
this
procedure
on
the
opposite
side
of
the
finger
8. With
painful
crush
injury
or
when
the
pain
will
be
prolonged,
substitute
bupivicain
for
lidocain.
WHAT
NOT
TO
DO:
a. Do
not
use
lidocain
with
epinephrine,
The
digital
arteries
that
can
spasm
and
provide
prolonged
anesthesia,
ischemia
of
the
fingertip
and
potentially
necrosis.
24
25. EPIDIDYMITIS.
An
adult
male
complains
of
dull
to
severe
scrotal
pain
developing
over
a
period
of
hours
to
day
and
radiating
to
the
ipsilateral
lower
abdomen
or
flank,
there
may
be
history
of
recent
urethritis,
prostitis
or
prostectomy,
straining
with
lifting
heavy
object
or
sexual
activity
with
full
bladder.
There
may
be
fever,
nausea
or
urinary
urgency
or
frequency
.The
epididymitis,
is
tender
swollen,
warm
and
difficult
to
separate
from
the
firm,
non
tender
testicles.
Increasing
inflammation
can
extend
up
to
the
spermatic
cord
and
fill
the
entire
scrotum,
making
examination
more
difficult
as
well
as
produces
frank
prostatitis
or
cystitis.
The
rectal
exam
therefore
may
reveal
a
very
tender,
boggy
prostitis.
WHAT
TO
DO:
1. Ascertain
that
testicles
are
normal
in
position
and
perfusion.
2. Doppler
ultrasound
may
help
pick
up
a
drop
off
in
arterial
flow
from
splenic
cord
to
testicle.
3. Palpate
and
auscultate
the
scrotum
to
rule
out
hernia.
4. Prescribe
antibiotics
and
call
surgical
tem
if
the
patient
is
having
sever
pain
5. Give
strong
analgesics
6. Advise
2-‐3
days
strict
bed
rest,
with
the
scrotum
elevated
and
urologic
follow
up.
WHAT
NOT
TO
DO:
a) Do
not
miss
testicular
torsion
25
26. b) Don’t
wait
more
than
4
hours
other
wise
chance
of
developing
ischemia
is
present,
FINGER
DISLOCATION
The
patient
has
jammed
his
finger,
causing
hyperextension
injury
that
forces
the
middle
phalanx
dorsally
and
proximally
out
of
articulation
with
the
distal
end
of
the
proximal
phalanx.
An
obvious
deformity
will
be
seen;
there
should
be
no
sensory
or
vascular
compromise.
WHAT
TO
DO:
1. X-‐Rays
shaft
of
finger.
2. If
the
patient
is
having
considerable
delay
and
the
orthopedic
team
is
busy
then
give
digital
block.
3. To
reduce
the
joint,
do
not
pull
on
the
fingertip,
instead,
push
the
base
of
the
middle
phalanx
distally,
using
your
thumb
until
it
slides
smoothly
into
its
natural
anatomical
position.
4. Test
the
finger
by
extending
his
finger
at
the
proximal
inter
phalangeal
joint.
5. Post
reduction
x-‐rays
should
be
taken
“chip
fracture”
may
represent
tendon
or
ligament
avulsions.
6. Splint
in
extension
for
3-‐4
days.
7. Inform
the
patient
that
joint
swelling
and
stiffness
may
be
present
for
months
after
the
initial
injury.
26
27. 8. Remind
the
patient
to
keep
the
injured
finger
elevated.
9. Recommend
the
ice
application
for
next
24
hours,
and
analgesics
FINGER
TIP
DRESSING
To
provide
a
complete
non-‐adherent
compression
dressing
for
an
injured
finger
tip,
a
first
cut
out
an
L
–shaped
segment
from
a
tip
of
polyurethane
or
oil-‐
emulsion
(Adaptec)
gauze.
Cover
the
gauze
with
antibiotic
ointment
to
provide
occlusion
and
prevent
adhesion.
WHAT
TO
DO:
1. Place
the
tip
of
the
finger
over
the
short
leg
of
the
gauze
and
then
fold
it
over
the
top
of
the
finger
2. Take
the
long
leg
of
the
gauze
and
wrap
it
around
the
tip
of
the
finger.
3. For
absorption
and
compression,
a
fluff
cotton
gauze
pad
and
apply
it
over
the
end
of
the
finger.
4. Cover
with
roller
or
tube
gauze
and
secure
with
adhesive
tape.
WHAT
NOT
TO
DO:
• Do
not
place
tight
circumferential
wraps
of
the
tape
around
the
finger,
27
28. FINGER
TIP
AVULSION
Mechanism
of
injury
can
be
knife,
a
meat
slicer,
closing
door
or
spinning
fan
blades
or
turning
gears.
Depending
upon
the
angle
of
amputation,
varying
degree
of
tissue
loss
will
occur
from
the
volar
pad,
or
finger
tip.
WHAT
TO
DO:
1. X-‐ray
of
the
crush
injury
caused
by
high
speed
mechanical
instrument.
2. Consider
tetanus
prophylaxis.
3. Perform
a
digital
block
to
obtain
complete
anesthesia.
4. Thoroughly
debride
and
irrigate
the
wound.
5. When
active
bleeding
is
present
,
provide
a
bloodless
field
by
wrapping
the
finger
from
the
tip
proximally.
6. On
a
less
than
one
square
centimeter
full
thickness
tissue
loss
,
apply
a
simple
non
adherent
dressing
with
gentle
compression.
7. Where
there
is
greater
than
one
square
centimeter
of
full
thickness
skin
loss
there
are
three
options
that
may
be
followed.
i. Simply
apply
the
same
non
adherent
dressing
used
for
smaller
wound
ii. Call
the
surgical
team,
if
the
avulsed
piece
of
tissue
is
available
to
convert
it
into
modified
full
thickness
graft
and
suture
it
in
place.
iii. With
the
large
area
of
tissue
loss
that
has
thoughrly
cleaned,
debrided
and
where
the
avulsed
portion
has
been
lost
or
destroyed,
consider
a
thin
split
–thickness
skin
graft
on
the
site.
28
29. 8. In
infants
and
young
children,
finger
tip
amputation
can
be
sutured
back
on
in
their
place
as
a
composite
graft,
9. When
the
loss
of
soft
tissue
has
been
sufficient
to
expose
bone,
simple
grafting
will
be
unsuccessful;
therefore
plastic
surgery
consultation
is
required.
10. Apply
a
protective
four-‐prong
splint
for
comfort.
11. Advise
a
course
of
antibiotics
for
3-‐5
days
and
analgesics.
WHAT
NOT
TO
DO:
a) Do
not
apply
a
graft
directly
over
the
bone
or
over
a
devitalized
or
contaminated
bed.
b) Do
not
attempt
to
stop
wound
bleeding
by
cautery
or
ligature.
FISH
HOOK
REMOVAL
The
patient
has
been
snagged
with
a
fishhook
and
arrives
with
it
embedded
in
his
skin.
WHAT
TO
DO:
1. Cleanse
the
hook
and
puncture
wound
2. Provide
tetanus
prophylaxis
3. Give
1%
local
anesthesia.
4. For
hooks
lodged
superficially,
first
try
the
simple
“retrograde
“
technique.
Push
the
back
along
the
entrance
pathway
while
applying
29
30. gentle
downward
pressure
in
the
shank.
if
the
hook
does
not
come
out
,
an
18
gauge
needle
may
be
inserted
in
to
puncture
hole
and
use
miniature
scalpel
blade
.Manipulate
the
hook
in
to
position
so
you
can
cut
bands
of
connective
tissue
barb
and
release
it
5. For
more
deep
imbedded
hooks
.call
the
surgical
team
WHAT
NOT
TO
DO:
a) Do
not
try
to
remove
multiple
hooks
or
fishing
lur
.
b) Do
not
attempt
to
use
the
:string”
technique
if
the
hook
is
near
the
patient’s
eye.
FOREIGN
BODY
BENEATH
NAIL
The
patient
complains
of
paint
chip
or
silver
under
the
nail.
Often
he
has
unsuccessfully
attempted
to
remove
the
foreign
body,
which
will
be
visible
beneath
the
nail.
WHAT
TO
DO
:(Paint
Chip)
1. With
out
anesthesia,
remove
the
overlying
nail
by
shaving
it
off
with
a
#15
scalpel
blade.
2. Cleanse
remaining
debris
with
normal
saline
and
trim
the
nail
edges
smooth
with
scissors.
3. Provide
tetanus
prophylaxis
if
necessary
and
then
dress
the
area
with
antibiotics
ointment.
4. Do
the
bandage.
30
31. WHAT
TO
DO
(SILVER)
1. If
the
patient
is
cooperative
and
can
tolerate
some
discomfort,
crave
through
the
nail
down
to
the
perimeter
of
silver
with
#11
blade
until
the
overlying
nails
falls
away.
2. For
a
more
extensive
excision
of
nail
wedge,
you
will
need
to
perform
a
digital
block.
3. Slide
small
Mayo
or
iris
scissors
between
the
nail
and
nail
bed
on
both
sides
of
the
silver
and
cut
out
the
overlying
wedge
of
nail.
4. Cleans
any
remaining
debris
with
normal
saline
and
trim
the
fingernail
until
the
corners
are
smooth.
5. Give
inj
Tetanus
toxoid.
6. Dress
with
antibiotic
ointment
and
bandage
7. Advise
to
redress
after
2
–
3
days.
WHAT
NOT
TO
DO:
a) Do
not
run
tip
of
the
scissors
into
the
nail
bed
while
sliding
it
under
the
fingernail.
GANGLION
CYST
The
patient
is
concerned
about
the
rubbery,
rounded
swelling
emerging
from
the
general
are
of
a
tendon
sheath
or
the
wrist
and
hand
.It
may
have
appeared
abruptly,
been
present
for
years,
or
fluctuated,
suddenly
resolving
and
gradually
and
returning
in
pretty
much
the
same
place,
There
is
usually
little
tenderness,
inflammation
or
interference
with
function.
31
32. WHAT
TO
DO:
1. Under
take
a
thorough
history
and
physical
exam
of
the
hand
to
ascertain
that
everything
else
is
normal.
2. X-‐rays
are
of
no
value
unless
there
is
some
question
of
bony
pathology.
3. Explain
the
patient
that
this
is
a
fluid
filled
cyst.
Spontaneously
arising
from
bursa
or
tendon
sheath
and
posing
no
particular
danger.
4. Treatment
option
include
i. Draining
the
contents
of
the
cyst
with
an
18gauge
needle
to
reduce
its
size
ii. Injecting
corticosteroid
i/m
5. Follow
the
wishes
of
the
patient.
6. Recurrence
chances
are
present
even
with
surgical
excision
MINOR
IMPLEMENT
INJURIES
A
sharp
metal
object
such
as
a
needle,
heavy
wire,
nail
or
fork
is
driven
into
or
through
a
patient
‘s
extremity.
In
some
instances,
the
patient
may
arrive
with
a
large
object
attached.
WHAT
TO
DO:
1. If
implant
is
acting
like
a
lever
and
causing
pain
with
movement
,
either
immediately
pull
the
extremity
off
the
sharp
object
or
quickly
cut
through
it
to
release
the
patient,
it
can
be
cut
with
orthopedic
cutter.
32
33. 2. Obtain
x-‐rays
when
pain
and
further
damage
from
a
leveraged
object
is
not
a
problem.
3. Examine
the
extremity
for
possible
neurovascular
or
tendon
injury.
4. If
surgical
debridement
is
anticipated
after
removal
of
the
object
,
then
infiltration
of
an
anesthetic
should
be
provided
prior
to
removal.
5. Objects
with
small
barbs
such
as
crochet
needle
and
fish
spines
,
can
be
removed
by
first
anesthetizing
the
area
and
the
applying
firm
traction
until
the
barb
is
revealed
through
puncture
wound.
6. After
removal
of
the
impaled
object
,te
wound
should
be
appropriately
debrided
and
irrigated
7. Tetanus
toxoid
is
given
WHAT
NOT
TO
DO:
b) Do
not
send
a
patient
to
x-‐rays
with
a
leveraged
impaled.
This
creates
further
pain
and
possible
injury
with
movement.
c) Do
not
try
to
hand
–saw
off
a
board
to
an
impaled
object.
IMPETIGO
Streptococcal
lesion
consists
of
irregular
or
somewhat
circular
red,
oozing,
erosions,
often
covered
with
a
yellow
=brown
crust.
Smaller
erythmatous
macular
or
vesicopustular
areas
may
surround
these.
Streptococcal
lesion
present
as
bullae
that
are
quickly
replaced
by
a
thin
shiny
crust
over
a
erythmatous
base.
33
34. WHAT
TO
DO:
1. Prescribe
mupiricin
2%ointment
(Bactoban)
to
rash
TID
.for
three
days.
2. Tell
parents
of
small
children
to
clean
crust
with
warm
soapy
compresses
before
applying
the
antibiotic
ointment.
3. For
repeatedly
visiting
cases
to
ED
add
a
10
days
coarse
of
Erythromycin
or
penicillin
VK
(250mg
qid)
or
intramuscular
injection
of
benzathine
penicillin
(600,000
units
i/m
for
children
and
younger,
1.2
million
units
for
children
over
7
years).
4. For
suspected
staphylococcus
infection
use
dicloxacillin
250mg
qid
in
place
of
penicillin
or
prescribe
erythromycin
or
cefadroxil.
WHAT
NOT
TO
DO:
a) Do
not
routinely
culture
these
lesions.
JAW
DISLOCATION
The
patient’s
jaw
is
“out”
and
will
not
close,
usually
following
a
yawn
,
or
perhaps
after
laughing
,
a
dental
extraction
,
jaw
trauma
or
a
dystonic
drug
reaction
.
The
patient
has
difficulty
speaking
and
may
have
severe
pain
anterior
to
the
ear.
A
depression
can
be
seen
or
felt
in
the
particular
area
and
the
jaw
may
appear
prominent.
WHAT
TO
DO:
1. If
there
was
a
no
trauma
(and
especially
if
the
patient
is
chronic
dislocator)
proceed
directly
to
attempt
reduction.
34
35. 2. If
there
is
any
possibility
of
associated
fracture
then
take
x-‐rays.
3. Have
the
patient
sit
on
a
low
stool,
his
back
and
head
braced
against
something
firm
–
either
against
the
wall,
facing
you,
or
with
the
back
of
his
head
braced
against
your
body,
facing
away
from
you.
4. With
gloved
hands,
wrap
your
thumbs
in
gauze,
seat
them
upon
the
lower
molars,
grasp
both
sides
of
the
mandible,
lock
your
elbows,
and
bending
from
the
waist.
Exert
slow
steady
pressure
down
and
posterior.
The
mandible
should
be
at
or
below
the
level
of
your
forearm.
5. In
bilateral
dislocation,
attempt
to
reduce
one
side
at
a
time.
6. Reassess
with
x-‐rays.
7. After
reducing
apply
soft
collar.
8. Prescribe
analgesics
9. If
reduction
cannot
be
obtained
using
above
technique,
then
consider
admission
for
reduction
under
GA.
WHAT
NOT
TO
DO:
b) Try
not
to
get
your
thumb
bitten
when
the
jaw
snaps
back
in
to
position.
c) Do
not
put
pressure
on
oral
prosthesis
that
could
cause
them
to
break.
d) Do
not
try
to
force
the
patient’s
jaw.
LOW
BACK
PAIN
Suddenly
or
gradually
after
lifting,
bending,
or
other
movement
the
patient
develops
a
steady
pain
in
one
r
both
sides
of
the
lower
back.
At
times
this
pain
35
36. can
be
severe
and
incapacitating.
It
usually
better
on
lying
down
,
worse
with
movement,
and
perhaps
radiates
around
the
abdomen
or
down
the
thigh
,
but
no
farther.
WHAT
TO
DO:
1. Perform
a
complete
history
and
physical
examination
of
the
abdomen,
back,
and
legs.
looking
for
alternative
causes
for
the
back
pain,
2. Consider
plain
x-‐rays
of
the
lumbosacral
spine
of
those
who
have
suffered
from
severe
pain
and
difficulty
in
bending.
3. Order
and
ESR
on
patients
with
history
of
cancer
or
I/V
drug
abuse
or
sign
and
symptoms
of
underlying
disease.
4. For
point
tenderness
over
a
sacroiliac
joint
with
no
neurologic
findings
to
suggest
nerve
root
compression,
refer
to
neurosurgery
team.
5. Advise
injection
Voltran50
mg
+Injection
Dexamethasone
8
mg
both
together
IM.
6. If
there
is
acute
trauma
with
in
one
hour,
advise
inj.
Methylprednisolone.
7. Prescribe
ice
to
the
acutely
injured
area,
20
minutes
/hour
for
first
day.
8. Arrange
appointment
for
neurosurgery
OPD.
9. Teach
them
to
avoid
twisting
and
bending
when
lifting
and
show
them
how
to
lift
with
back
vertical,
using
thigh
muscles
and
holding
heavy
objects
close
to
the
chest
to
avoid
re-‐
injury.
WHAT
NOT
TO
DO:
a) Don’t
be
eager
to
use
narcotics
pain
medications.
b) Do
not
apply
lumber
traction.
36
37. MINOR
HEAD
TRAUMA
A
patient
is
brought
in
the
emergency
department
after
suffering
a
blow
to
the
head,
there
may
or
may
nor
be
laceration,
scalp
hematoma,
headache,
transient
sleeplessness
and
or
nausea
but
there
was
no
loss
of
consciousness
or
amnesia
for
the
injury
or
preceding
events,
seizure.
Neurological
changes
or
disorientation.
WHAT
TO
DO:
1. Take
the
history
and
ascertain
why
the
patient
was
injured.
2. Perform
and
record
physical
examination
of
the
head,
looking
for
signs
of
skull
fracture.
3. Perform
and
record
a
neurological
examination
with
special
attention
to
mental
status,
cranial
nerves
and
deep
tendon
reflex
to
all
four
limbs.
4. If
the
history
or
physical
examination
suggests
there
is
clinical
evidence
of
intracranial
injury
,
then
call
surgical/neuro
team.
5. Criteria
for
obtaining
CT
Scan
includes
i. Documented
loss
of
consciousness
ii. Amnesia
iii. CSF
leakage
from
nose
or
ear
iv. Blood
behind
the
tympanic
membrane
or
over
the
mastoid
(Battle’s
sign)
v. Stupor
vi. Coma
vii. Any
focal
neurological
sign.
37
38. 6. If
there
is
no
clinical
indication
for
CT
Scan
or
skull
x-‐rays,
explain
to
the
patient
and
concerned
family
and
friends.
Many
patients
expect
x-‐rays,
but
gladly
forego
them
once
you
explain
they
are
of
little
value.
7. Make
sure
that
family
understood
and
are
given
written
instructions
that
i. Any
abnormal
behavior
ii. Increasing
drowsiness
iii. Difficulty
in
arousing
the
patient
iv. Headache
v. Neck
stiffness.
vi. Vomiting
vii. visual
problem
viii. Weakness
ix. Seizures
are
signals
to
return
to
the
ED.
WHAT
NOT
TO
DO:
a) Do
not
skip
on
the
neurological
examination
or
its
documentation.
b) Do
not
be
reassured
by
negative
skull
films,
which
do
not
rule
out
intracranial
bleeding
or
edema.
38
39. MUSCLE
STRAINS
AND
TEARS.
Strains
occur
during
or
after
a
vigorous
over
stretching
of
a
muscle
bundle
that
leads
to
an
insidious
development
of
pain
and
tightness
that
is
worse
with
use
and
better
with
rest.
Tear
of
the
muscle
belly
tend
to
be
partial,
with
sudden
onset
pain
and
partial
loss
of
function.
Often
a
tear
occurs
with
considerable
bleeding
that
can
lead
to
remarkable
hematomas
causing
swelling
at
the
site
and
dissecting
along
tissue
planes
to
create
e
ecchymosis
at
a
distant.
Complete
tears
are
more
likely
in
the
tendinous
part
of
the
muscle,
WHAT
TO
DO:
1. Obtain
a
history
of
mechanism
of
injury.
2. A
complete
tear
of
a
muscle
merits
orthopedic
consultation.
3. For
muscle
strain,
provide
soft
splint,
analgesics
and
instruct
the
patient
to
apply
warm
moist
compresses
for
comfort.
4. For
muscle
tear,
construct
a
loose
splint
to
immobilize
the
injured
part
and
instruct
the
patient
in
rest,
elevation
and
ice.
NAIL
ROOT
DISLOCATION.
The
patient
has
caught
his/her
finger
in
the
car
door,
or
dropped
a
heavy
object,
like
a
cane
of
vegetable
on
a
bare
toe,
with
the
edge
of
the
cane
striking
the
base
of
the
toenail
and
causing
a
painful
deformity.
The
base
of
the
nail
will
be
found
resting
above
the
eponychium
instead
of
its
normal
anatomical
position
beneath.
39
40. WHAT
TO
DO:
1. Take
an
x-‐rays
to
rule
out
an
underlying
fracture
2. Anesthetize
the
area
using
digital
block.
3. Lift
the
base
of
the
nail
off
the
eponychium
and
thoroughly
cleanse
and
inspect
the
nail
bed.
4. Minimally
debride
loose
cuticular
tissue
and
test
for
a
possible
avulsion
of
the
extensor
tendon.
5. If
bleeding
is
the
problem,
then
establish
a
bloodless
field
using
a
tourniquet
6. Repair
any
nailed
laceration
with
a
fine
absorbable
suture
like
a
7-‐0
or
6-‐0
Vicryl.
7. Reinsert
the
root
of
the
nail
under
the
eponychium.
8. Reduce
any
underlying
fracture.
9. If
the
nail
tends
to
drift
out
from
under
the
eponychium.
it
can
be
sutured
in
place
with
two
4-‐0
nylon.
10. Any
non
absorbable
sutures
should
be
removed
after
one
week.
11. Provide
Tetanus
Prophylaxis
12. Follow
up
should
be
provided
in
3-‐5
days
either
in
surgical
OPD
or
ED.
13. Advise
analgesics
and
antibiotics
WHAT
NOT
TO
DO:
a) Do
not
ignore
the
nail
root
dislocation
and
simply
provide
a
fingertip
dressing.
b) Do
not
debride
any
position
of
the
nail
bed,
sterile
matrix
or
germinal
matrix.
40
41. NAILBED
LACERATION
The
patient
has
either
cut
into
his
nail
bed
with
a
sharp
edge
or
crushed
his
finger.
With
shearing
forces,
the
nail
may
be
avulsed
from
the
nail
bed
to
varying
degrees
and
there
may
be
an
underlying
bony
deformity.
WHAT
TO
DO:
1. Provide
appropriate
tetanus
prophylaxis.
2. Obtain
x-‐rays
of
any
crush
injury
or
any
injury
caused
machinery.
3. Perform
digital
block.
4. Remove
the
nail
surrounding
the
laceration
to
allow
for
suturing
the
laceration
closed
i. Use
straight
hemostat
to
separate
the
nail
from
the
nail
bed.
ii. Use
the
scissors
to
cut
away
the
surrounding
nail
or
remove
the
entire
nail
intact
for
re-‐insertion.
After
the
nail
bed
is
repaired.
iii. Cleanse
the
wound
with
saline
and
suture
accurately
with
a
fine
absorbable
sutuer6-‐0
or
7-‐0.
iv. Apply
a
non-‐adherent
dressing
and
antibiotics
antiseptic
ointment
and
plan
to
change
the
dressing
after
the
24
hours.
5. When
a
crush
injury
results
in
open
hemorrhage
from
under
the
fingernail;
,
the
nail
must
be
completely
elevated
to
allow
proper
inspection
of
the
damage
to
the
nail
bed.
6. Apply
a
fingertip
dressing.
WHAT
NOT
TO
DO:
a) Do
not
use
non
absorbable
suture
41
42. b) Neither
does
nor
attempts
to
suture
a
nail
bed
laceration
through
the
nail.
c) Do
not
do
any
more
than
minimal
debridement
of
the
nail
bed
and
its
surrounding
structures.
NECK
(CERVICAL)
STRAIN.
The
patient
may
arrive
directly
from
a
car
accident,
arrives
the
following
day
or
long
after.
The
injury
occurs
when
the
neck
is
subjected
to
sudden
extension
and
flexion,
possibly
injuring
inter
vertebral
joints
and
ligaments,
cervical
muscles,
or
even
nerve
roots,
as
with
other
strain
and
sprains,
the
stiffness
and
pain
may
tend
to
peak
on
the
day
following
the
injury.
WHAT
TO
DO:
1. Obtain
a
detailed
history
to
determine
the
mechanism
and
severity
of
the
injury.
2. Examine
the
patient
for
involuntary
splinting,
point
tenderness
over
the
spinous
processes
of
the
cervical
vertebrae,
cervical
muscle
spasm
or
tenderness
and
for
strength,
sensation
and
reflexes
in
the
arm.
3. Take
the
x-‐rays
lateral
view
of
cervical
spine.
If
necessary
then
AP
view
and
open
mouth
view
of
odontoid
can
also
be
obtained.
4. To
evaluate
the
head
trauma
ask
the
history
of
loss
of
consciousness.
5. If
there
is
no
evidence
e
of
injury
then
explain
the
Patient
that
stiffness
and
pain
will
relieve
with
in
24
hours
to
3-‐4
days.
42
