Wounds and Lacerations: Emergency Care and Closure (4th Edition)

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Cope's Early Diagnosis of the Acute Abdomen Silen, Early Diagnosis of the Acute Abdomen -If you have not read it during med school, pick it up during your surgery block from the library. Make sure it is the newest addition where they emphatically recommend pain meds for abd pain pts and it is written by a surgeon. This is a perfect introductory text for residents. Covers Trauma from A to Z in a easy to read format. Trauma, Seventh Edition -The be-all end-all of trauma management.

Geared towards the surgeon so be prepared to skim. It is written by and for EM docs, so no boring crap, just the important stuff we need to know. Common Hand Injuries by Carter years old and still the best hand book out there.

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You need to know the hand; this book is the way to learn. It even has cartoons. Out of print forever, it has just been released in a 2nd edition as an ebook. Carter still has them beat. Toxicology Secrets, 1e -Hate to recommend review books, but this series keeps coming through. This book has gone out of print, so Steve Smith who is super-kind has decided to give away the full text for free.

Electrocardiography in Emergency Medicine -Until Dr.


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Smith's book returns to print, this incredible work edited by the master, Amal Mattu, is the one I recommend. Critical Care Ultrasonography, 2nd edition -This book will take your ultrasound skills to the next level to be able to optimally manage the critically ill patient. Minor Emergencies: Expert Consult — Online and Print, 3e -Covers all the emergencies that need to be treated but don't need to come in by ambulance, ie. Basically everything you will see on a fast track shift. Of course our patients call ambulances for back pain for the past 7 years, but that is another story.

Sapira's Art and Science of Bedside Diagnosis -this is your medical school physical diagnosis class taken to the next level. All the skills and tricks of the old time docs who could diagnose without the benefit of labs and x-rays of course they did not have the benefit of any useful treatment one they diagnosed, sort of reminds me of the neuro folks.

I keep going back to this one to learn new skills as I get more comfortable with the old ones. Auerbach's Wilderness Medicine, 2-Volume Set, 7e -If you are interested in wilderness and expedition medicine, save up for this book. An Introduction to Clinical Emergency Medicine -How about a book to recommend to rotating med students. Should be required reading during an EM residency. Principles and Practice of Intensive Care Monitoring -Unfortunately out of print; but this is the bible of monitoring technology.

Diagnostic Bronchoscopy: A Teaching Manual -This book taught me how to bronch; good luck finding it though. We may delete without a full, true name. Your Job i. Most reacted comment. Hottest comment thread. Recent comment authors.

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Eric M Barach, M. What's Your Job? George Douros. Hi George thanks for the ED reference. It is important to examine each patient for septal hematoma, because it can cause pressure necrosis and deformity from collapse of the nasal septum saddle-nose deformity if untreated see section on Septal Hematoma. Likewise, any clear fluid from the nose may indicate CSF rhinorrhea and should prompt evaluation for skull cribriform plate fractures.

Unfortunately, testing for glucose in suspected CSF fluid is not enough to differentiate CSF from other nasal discharge. Anesthesia is best obtained by gentle injection of small amounts without epinephrine through or gauge needles. Nasal blocks are possible but difficult to obtain, and are best referred to the consultant if required for larger injury.

Gaping wounds can have one or two deep sutures with or absorbable suture to reduce surface tension. Deep sutures also are helpful to support the healing scar after surface sutures are removed as tape may not always stick. Nostril injuries often affect skin, cartilage, and mucosa, but usually only the skin requires repair.

The skin edges must be realigned carefully to avoid a notched appearance afterward. The alar rim suture can be the first suture placed to ensure good re-approximation and, like the vermillion border, can be left untied to ease deep suture placement. Nostril cartilage usually is well approximated with skin closure alone but does require complete skin coverage to avoid chronic chondritis. Thus, mucosal surfaces should be repaired with absorbable suture when needed to cover exposed cartilage. Usually, moving the tissue back into place before repair is initiated will show if mucosal defects are likely to be present after skin repair.

Due to their recessed nature, it may be easier technically to place mucosal sutures first during repair.

After repair, wounds usually can be covered just with a bandage or left open with a thin antibiotic ointment layer. Sutures should be removed in days to reduce stitch marks, but unfortunately, nasal skin can be too oily to make secondary support by suture tape effective in many cases. Patients should be made aware of efforts to balance risk of stitch marking and scar widening. Deep Structure Injury. Nasal Fracture. That, combined with the exposed location of the nose and the relative lack of soft tissue that can act as a means to dissipate the force of a blow, make the nasal bone prone to fracture.

The proximal nasal bones connect with the nasal process of the frontal bone and are much stronger than the more distal part. Alcohol abuse in combination with the above increases risk for fracture; thus, one should consider intoxicated patients with facial trauma at higher risk for facial fractures.

Simple fractures involve only the nasal bones, whereas complex fractures also involve other facial bones i. Simple nasal fractures are some of the few fractures for which x-rays are not indicated in the ED.

Wounds and Lacerations: Emergency Care and Closure by Alexander T. Trott

These usually are lateral fractures arising from direct trauma. The diagnosis is primarily clinical based on crepitus, pain and tenderness, epistaxis, nasal obstruction, ecchymosis, and deformity. Most patients accept this and are satisfied with otolaryngologist follow-up in days when swelling has subsided. In some cases the physician still may end up ordering nasal films to placate the patient or family.

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The first step in treatment is to control any bleeding that may be coming from the nose. If unsuccessful, anterior packing is the next step. Inability to control bleeding may indicate complex nasal fracture, and otolaryngologist consultation is indicated. Most EPs will not attempt reduction of nasal fracture in the ED as the perception of a deformity is based largely upon the degree of edema that is present around the site of injury. In some cases, the patient may present early enough that swelling has not yet occurred but deformity is obvious.

In this case, if experienced with reduction, one may use cocaine- or tetracaine-soaked pledgets for anesthesia and perform closed reduction by exerting a quick firm pressure toward the midline with the thumbs. Complex fractures involve other bones than just the nasal bones. Clinical features of complex fractures that may be hidden by swelling include: widened intercanthal distance greater than 40 mm is diagnostic , changes in visual acuity, enophthalmos posterior displacement of the globe from medial rectus entrapment , abnormal glabellar angle, and displacement of the medial canthal ligament causing shift of the eyelid apparatus laterally.

Other clinical clues are: CSF rhinorrhea see next section ; excessive tearing indicating tear duct injury ; and disrupted olfactory function, which can be difficult to detect in the ED. It is important to realize that suspicion of additional facial fractures is an indication for imaging in the ED. Facial CT is the test of choice with both axial and coronal sections preferred to fully define identified fractures. When being discharged from the ED, the patient should be given follow-up with the otolaryngologist, plastic surgeon, or oro-maxillofacial surgeon within days to allow swelling to resolve.

Patients can be instructed that if they have no deformity or problems breathing through their noses once swelling is gone, they may not need further treatment.


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Adequate analgesics and, in some cases, nasal decongestants also may be given.