By H. Dennis. California State University, Stanislaus.
If a uniform skin graft is desired buy 500mg tinidazole with amex, the surgeon can either discard the final part or stop the dermatome while maintaining its angle purchase 1000mg tinidazole free shipping. The thickness of the drum is then opened to maximum aperture and the dermatome is gently withdrawn, exposing the final part of the skin graft. Epinephrine-soaked (1:10,000) Telfa dress- ings are then applied to the surface of the donor site to allow good hemostasis. Specific Donor Sites Patients with minor burns present with many donor sites. Choice of donor site depends on graft requirements, anatomical location, extent of burn, patient’s char- acteristics, and patient’s preference. The most commonly used donor sites for small- and medium-sized burns are: Scalp Thigh Back The Small Burn 201 A B FIGURE6 Donor sites are infiltrated with normal saline with epinephrine 1/200,000 to promote hemostasis, provide enough tension to immobilize the skin, and produce an even surface. Powered dermatomes should be used to harvest the skin, which provide the best quality of skin by a reproducible means. Donor sites are infil- trated before harvest, which provide good blood loss control. Donor sites are then dressed with epinephrine-soaked Telfa dressings for 10 min. The Small Burn 203 The scalp provides the surgeon with the best quality of skin for burn surgery. The harvesting is practically painless and the donor site remains concealed pro- vided the hairline is not crossed. The scalp should be considered the first choice in infants and small children and when excision and grafting of face burns are considered. The following are some of the principles for successful harvesting of scalp donor sites: 1. Infiltrate the area to be harvested with 1:200,000 epinephrine solution. Provide enough tension to facilitate the harvest by achieving a flat surface. The head should be fixated by an assistant to allow control and good exposure 6.
An and chondroitin sulfate potentially offer some relief MRI is valuable in assessing the status of the knee lig- in subjective symptoms cheap tinidazole 300 mg otc. Glucosamine is thought to aments and menisci buy cheap tinidazole 1000 mg, but generally tends to underesti- stimulate chondrocyte and synoviocyte activity, and mate the degree of cartilage abnormalities seen at the chondroitin is thought to inhibit degradative enzymes time of arthroscopy (Khanna et al, 2001). The role of and prevent fibrin thrombi formation in periarticular the bone scan remains controversial: isolated articular tissues (Gosh, 1992; Bucci, 1994; Muller-Fassbender surface defects that do not penetrate subchondral bone et al, 1994). Recent studies indicate that pain, joint may not be identified by bone scan. Arthroscopy con- line tenderness, range of motion, and walking speed tinues to remain the gold standard for the diagnosis of may be improved with these medications (Barclay, articular cartilage injuries. Tsourounis, and McGart, 1998; DaCamara and The Outerbridge classification system (Outerbridge, Dowless, 1998). However, there are no clinical data 1961) was initially developed for macroscopic grad- showing that these oral agents affect the formation of ing of chondromalacia patellae and has since been cartilage (Tomford, 2000). A recent modifica- with high-molecular weight hyaluronans remains an tion by the International Cartilage Repair Society option despite the lack of well-controlled studies (ICRS) (Brittberg, 2000; Brittberg and Peterson, demonstrating efficacy. Suggested indications for referral to an orthopedic surgeon with expertise in cartilage NONSURGICAL MANAGEMENT restoration techniques are presented in Table 9-5. Acute motion loss Gross deformity Traditional methods for treatment of chondral lesions Acute neurovascular deficit include the judicious use of nonsteroidal anti-inflam- Mechanical symptoms (catching, locking, sensation of a loose body) matory drugs combined with activity modification. Failed nonsurgical management greater than 3 months in duration Oral chondroprotective agents such as glucosamine Repeated giving way or complaints of instability 50 SECTION 1 GENERAL CONSIDERATIONS IN SPORTS MEDICINE SURGICAL MANAGEMENT quality and volume of repair tissue (fibrocartilage) is variable. These procedures are used in low demand patients with larger lesions (>2 cm2) or in higher Various surgical modalities exist for the treatment of demand patients with smaller lesions (<2 cm2). The goals are to reduce symptoms, and abrasion arthroplasty for several reasons: (1) it is improve joint congruence by restoring the articular sur- less destructive to the subchondral bone because it cre- face with the most normal tissue (i. Postoperative rehabilitation PALLIATIVE consists of nonweight bearing for 6 to 8 weeks and may include continuous passive motion (CPM) to improve Arthroscopic debridement and lavage is used to the extent and quality of the repair tissue. As MSTs are remove degenerative debris, cytokines, and proteases low-cost and relatively low-morbidity procedures, they that may contribute to cartilage breakdown. It is ide- remain the mainstay for the initial management of ally indicated in the patient with defect area less than small chondral lesions.
Great debate still exists regarding intubation in patients with suspected inhalation injury 1000 mg tinidazole free shipping. If early evidence of upper airway edema is present order 300mg tinidazole fast delivery, then early intubation is mandatory since airway edema increases over 12–18 h. Prophylactic intubation without a good indication should not be done, because intubation may otherwise increase pulmonary complications in burn patients. Early extubation should be performed in all patients (within 48–72 h), as soon as an air leak is detected around the tube cuff. Other patients who benefit from early intubation and extubation (after 48–72 h) are those with severe life-threatening burns. Controlling the upper airway by means of early intubation makes resuscitation much easier. The patients, however, should be extubated when resuscitation is over, in order to prevent the development of airway complications and acute respiratory distress syndrome (ARDS). All patients with positive findings at bronchoscopy or with a suggestive history should be placed in an inhalation injury protocol. The nebulization of various substances and different respiratory therapy maneuvers have proved bene- ficial in the prevention of progression to tracheobronchitis, pulmonary edema, ARDS, and bronchopneumonia. The protocol is universal, and can be applied to patients with any sort of burn. Although the inhalation injury protocol is very effective in preventing the development of ARDS, some patients with inhalation injury do develop the whole picture of ARDS. Patients often have severe systemic inflammatory response syndrome (SIRS), and receive substantial second-hit insults from surgically in- duced bacteremia, sepsis, and repetitive hypovolemia. The strategy for managing General Treatment 41 TABLE 3 Inhalation Injury Protocol 1. Titrate high-flow humidified oxygen to maintain arterial oxygen saturation 90% 2. Nebulize 500 units of heparin with 3 ml normal saline every 4 h for 7 days 7.
Any lower extremity involvement ured and immediate ophthalmology consult is c cheap 500 mg tinidazole. The size of the hyphema should be noted purchase 1000 mg tinidazole otc, the carefully looked for is a septal hematoma, which is a eye shielded, and immediate ophthalmology consult red-blue, bulging mass on the nasal septum. Fluoroscein staining may reveal a positive Seidel sign, EAR INJURY a washing away and streaking of fluoroscein as aque- ous humor leaks out of the globe. The eye should be An auricular hematoma is a subperichondral accumu- shielded, intraocular pressure measurements avoided, lation of blood following blunt trauma. Treatment involves drainage of the because of a sudden increase in intraocular pressure. Treatment is the same as that of an acute emergency, must be recognized so that proper intraocular foreign body or corneal laceration. Most will be caused by RETROBULBAR HEMORRHAGE either blunt or noise induced trauma and greater than Usually occurs after trauma and presents with acute 90% will heal spontaneously. Antibiotics (either sys- proptosis, pain, swelling, and limitation of extraocu- temic or topical) are typically not necessary for lar muscle (EOM) movement. Those that are caused by “orbital compartment syndrome” and irreversible penetrating trauma should be promptly referred to an vision loss can occur within 1 h. ORBITAL RIM FRACTURE ABDOMINAL/PELVIC INJURY Usually a result of blunt trauma with examination revealing periorbital bony tenderness, crepitus, or Although potentially serious and even life-threaten- paresthesias in the distribution of the infraorbital ing, most abdominal injuries can be managed nonop- nerve, as well as limitation of EOM movement if there eratively with close observation. Athletes should be sent for radi- generally result from either rapid deceleration, direct ographic evaluation, with treatment depending on the blunt trauma to the abdomen, or indirect trauma from extent of injury. The importance of these injuries to the FP lies in erally involves identification of nasal fractures, con- excluding associated intra-abdominal injuries, with trol of epistaxis, or treatment of septal hematomas. Treatment includes ice, analgesics, inadequate in excluding significant intra-abdominal nasal decongestants, and avoidance of further injury. CHAPTER 4 FIELD-SIDE EMERGENCIES 17 SPLENIC/HEPATIC INJURY In terms of fracture care, the FP must always ascertain The spleen and liver comprise the two most common the mechanism of injury and never assume that the organs injured in blunt abdominal trauma. Always check be left or right upper quadrant and/or shoulder pain the neurovascular status of the affected body part respectively, as well as signs of hypotension if bleed- distal to the fracture site.
