Lacerations module original

  • HPI
  • Time since injury:
      • <6 hrs
      • 6-24 hrs
      • >24 hrs
      • __
    • Location of laceration:
      • face,
      • ear,
      • hand, 
      • feet, 
      • leg, 
      • arm, 
      • chest, 
      • ear, 
      • lip, 
      • intra-oral, 
      • __
    • Pt denies bite as mechanism.
    • Pt denies bite as cause of laceration per pt,
      • bite by
        • human
        • animal
          • type of animal __
          • accessed for risk of rabies
            • given animal able to be observed, was acting normally, and was provoked, and animal not animal known to have rabies in US, will have pt observe animal and if animal exhibits abnormal behavior, pt to have animal euthanized for evaluation for rabies and pt to return to ED immediately for rabies post exposure prophylaxis. 
            • given animal of type that has been known to have rabies in US, will administer rabies post exposure prophylaxis. 
    • Risk factors for infection during healing:
      • DM,
      • difficulty for pt to follow up, 
      • immunocompromised, 
      • etoh abuse, 
      • __
    • Tetanus status:
      • within 5 years per pt
      • >5 years though pt states was fully immunized as child
      • unknown if ever immunized
      • knows was not immunized 
      • __
    • __
  • ((+))
    • [2] REVIEW OF SYSTEMS: 
      • [01] [2] Constitutional:
        • [01] no rigors
        • as noted in HPI
      • [01] [2] ENT: 
        • [01] no rhinorrhea, no otalgia, no sore throat
        • as noted in HPI
      • [01] [2] Ocular:
        • [01] no recent vision changes
        • as noted in HPI
      • [01] [2] Cardiac:
        • [01] no chest pain, 
        • [01] no palpitations
        • [01] no LE swelling
        • as noted in HPI
      • [01] [2] Pulmonary:
        • [01] no shortness of breath, 
        • [01] no new cough
        • as noted in HPI
      • [01] [2] GI:
        • [01] no abdominal pain, 
        • [01] no nausea, 
        • [01] no vomiting, 
        • [01] no dark tarry stool, no BRBPR
        • [01] no diarrhea
        • as noted in HPI
      • [01] [2] GU:
        • [01] no dysuria,
        • [01] no discharge
        • as noted in HPI
      • [01] [2] Neuro:
        • [01] no recent severe headache outside of normal headaches per patient,
        • [01] no recent ALOC.
        • as noted in HPI
      • [01] [2] MSK:
        •  no recent trauma
        • no focal weakness
        • [01] as noted in HPI
      • [01] [2] Psych:
        • [01] normal speech
        • as noted in HPI
      • [01] [2] Endo:
        • [01] no polyuria/polydipsia
        • as noted in HPI
    • [2] PMH/PSH/PSFH:
      • [01] [2] PMH:  
        • [01] medical history pertinent to chief complaint as noted in HPI
        • __
      • [01] [2] PSH:
        • [01]  surgical history pertinent to chief complaint as noted in HPI
        • __
      • [01] [2] SH: 
        • [01] no tob, 
        • [01] no daily etoh use, 
        • [01] no illicit drug use,
        • __
      • [01] [2] FH: 
        • [01] review and non-contributory to patient’s presenting complaint. 
    • [01] [3][1] EXAM:
      •  [2] VITALS: (overall impression of vital signs with repeat vitals in EMR as RNs re-access patient): 
        • [01] HR: 
          • [01] normal HR.
          • tachycardic
          • __
        • [01] BP: 
          • [01] normotensive. 
          • hypertensive
            • [01] (attempted to inform pt to advise to f/u with PMD). 
          • hypotensive.
          • __
        • [01] Pulse oximetry (O2 sat):
          • [01] no evidence of hypoxia 
          • hypoxic
          • __
        • [01] RR: 
          • [01] normal RR
          • tachypnic 
          • __
      • [2] PHYSICAL EXAM:
        • [01] [2] General:
          • [01] well nourished
          • no distress
          • mild distress
          • moderate distress
          • severe distress
        • [01] [2] HEENT:
          • [01] vision grossly intact. 
          • [01] hearing grossly intact.
          • __
        • [01] [2] Cardiovascular:
          • [01] no r/m/g
          • [01] no LE swelling
        • [01] [2] Pulmonary:
          • [01] Lungs CBTA,
          • [01] No respiratory distress, 
          • [01] Speaking comfortably in full sentences. 
          • I/E wheezing, 
          • rales, 
          • rhonchi, 
          • respiratory distress. 
          • __
        • [01] [2] GI:
          • [01] abd soft,
          • [01] abd non-tender in all 4 quadrants, 
          • TTP diffusely
          • TTP in RUQ
          • TTP in RLQ
        • [01] [2] Neuro:
          • [01] Normal LOC.
          • [01] No grossly focal neurological deficits. 
          • Somnolent though protecting airway
          • __
        • [01] [2] MSK:
          • [01] no deformities, 
          • [01] moving all extremities
          • Non-ambulatory. 
        • [01] [2] Pysch:
          • [01] Normal speech. 
          • [01] Demonstrates linear thinking. 
          • No SI/HI. 
          • Endorses SI
          • Endorses HI
          • Exam consistent with gravely disabled. 
          • No AH/VH. 
          • Agitated. 
          • Confused. 
          • __
  • [01] [2] Targeted exam to complaint:
    • location of laceration: [eyelid margin,lip,hands,feet,scalp,__;var_location]
    • size of laceration: [var:size-number] cm
    • nuero sensation intact at and distal to site of injury
    • vascular intact at and distal to site of injury
    • motor intact at and distal to site of injury  isolating areas around laceration and testing for strength
      • 5/5 throughout
      • 4/5 throughout
      • __
  • ((+))
    • [3][1] ED COURSE:
    • [2] Working Impression/Empiric Management:
      • __
    • [2] Diagnostically:
      • [1] Point of Care Testing:
        • Pregnancy Test
          • negative
          • __
        • POC gluc
          • wnl
          • __
        • POC Hg
          • wnl
          • __
        • iStat
          • no base deficit
          • __
        • lactate
          • wnl
          • __
      • EKG (as interpreted by prelim ED):
        • [01] Non-remarkable EKG. No evidence of ischemia. NSR, regular rate, normal intervals, no abnormal TWI, no ST elevation/depression.
        • Rate
          • [01] normal,
          • bradycardic,
          • tachycardic,
        • [1] ST-segment morphology:
          • [01] TWaves:
            • [01] No abnormal TWI,
            • Abnormal TWI,
            • Non-specific repolarization abnormalities,
            • No ST depression, ST depression,
            • No ST elevation, ST elevation but does not meet STEMI criteria, meets STEMI criteria and cath lab activated,
        • [1] [01] Comparison to prior:
          • [01] Unchanged when compared to prior,
          • Attempted but no old EKG available for comparison,
          • __
        • [1] [01] Summary to pt’s clinical condition:
          • Normal EKG – not suggestive any pathology elucidated on EKG, Non-specific repolarization abnormalities – no definitive evidence of active ischemia on EKG, Evidence on EKG concerning for active ischemia.
          • __
        • [1] Rhythm: 
          • Regularly regular: 
            • NSR,
            • Sinus tachycardia,
            • Sinus bradycardia,
          • Irregularly irregular:
            • Atrial fibrillation with normal ventricular rate,
            • Atrial fibrillation with RVR,
          • Regularly irregular:
            • tachycardic,
              • Atrial flutter with RVR,
            • bradycardic,
              • Heart block,
                • Type: __ 
        • Intervals:
          • Narrow QRS,
            • supraventricular:
              • irregular:
                • AVRT (considering pre-excitation, considering WPW, etc), 
                  • Tx: Procainamide (20-50mg/min until arrhythmia suppressed, hypotension, QRS duration >50%, or max 17mg/kg. Maintenance 1-mg/min. 
                  • Tx: Synchronized cardioversion.
                    • Per ACLS 120-200J.
              •  regular: 
                • AVNRT (considering supraventricular tachycardia), 
                  • Tx: Adenosine 6mg IV push,
                    • Refractory, therefore second dose 12mg IV push 
                  • Synchronized cardioverson.
                    • 100 J
                    • per ACLS for narrow regular 50-100J
          • Wide QRS,
            •  bradycardic:
              •  low junctional escape/ventricular origin,
            • tachycardic:
              •  regular:
                •  stable,
                  •  Amiodarone 150mg IV / 10 min
                    •  Refractory, repeated PRN recurrence of VT. 
                    •  Maintenance 1mg/min x 6 hrs.
                  •  Procainamide (20-50mg/min until arrhythmia suppressed, hypotension, QRS duration >50%, or max 17mg/kg. Maintenance 1-mg/min. 
                  • synchronized cardioversion
                    •  100 J (per ACLS)
                •  unstable:
                  •  with pulse. Therefore Unstable Ventricular Tachycardia with Pulse. 
                    •  Synchronized cardioversion (per ACLS 100J).
                •  pulseless. Therefore pulseless ventricular tachycardia. ACLS initiated: [1] (CPR. Defibrillation 200 J Biphasic. Epi 1mg. Continuation of ACLS.) 
      • [2] Laboratory Results Reviewed
        • [01] Analysis/Interpretation:
          • [2] CBC:
            • [01] No significant unexpected anemia.
            • [01] No significant leukocytosis. 
            • __
          • [2] BMP:
            • No significant pathologic electrolyte derangements.
            • __
          • [2] LFTs/lipase:
            • No laboratory evidence of hepato-biliary pathology.
            • __
          • [2] UA:
            • Not consistent with urinary tract infection.   
            • Urine Cx sent with follow mechanism in place
            • Equivocal for infection
              • Empirically treated.
              • UCx sent with f/u mechanism in place
              • __
            • [2] CK __
            • [2] EtOH level __
            • [1] Ingestion labs (acetaminophen, ASA) __
            • __
          • [2] Troponin 
            • undetectable
            • <99th percentile
            • >99th percentile but under cut off for positive
            • positive
            •  __
          • [2] Delta troponin
            • undetectable
            • <99th percentile
            • >99th percentile but under cut off for positive
            • positive
            •  __
          • __
      • [2] Radiographically:
        • [2] CXR:
          • [01] Normal study: no tracheal deviation, non-widened mediastenum, normal cardiac boarder, no pleural effusion, no air under diaphragm, no focal consolidation, no PTX, no gross bony abnormalities.
          •  Pulmonary edema,
          •  Cardiomegaly,
          •  lobar opacity,
          • diffuse radio-opacities
          • pneumothorax
            • on right
            • on left
            • mediastenium midline
            • __
            • (This is an ED prelim radiographic interpretation in order to increase chance of finding obvious emergent pathology which can be intervened upon and to minimize delay in care secondary to delay of radiology to be able to provide formal reads. Given these studies require board certified radiologists to review and formal reads are beyond the scope of Emergency Medicine, institutional protocol in place which will alert current care team/patient for over-reads/changes/critical reads).
        • [2] PXR:
          • no evidence of pelvic fracture
          • __
        • [2] XR extremity
          • __
        • [2] Advanced Imaging:
          • CT head:
            • __
          • CT c-spine
            • __
          • CT chest
            • PE protocol
            • angio
            • __
          • CT a/p
            • w/ contrast
            • non-con
            • __
          • CT of extremity 
            • __
    • [3] Therapeutically: __
        • __
  • [01] [2] Assessment/Plan: 
    • [01] [2] Evaluated appropriateness of wound for repair accessing the following aspects of the wound
      • [2] Potential for underlying fracture
        • [01] ED primary closure appropriate re fracture possibility
          • [01] given 
            • Radiographs not indicated given no hx c/f retained foreign body and wound exploration performed for FB.
            • [01] Radiographs (interpreted in ED, formal read and call back mechanism for over-reads: obtained and no radio-opaque foreign body seen no fracture seen
      • [01] [2] Location
        • [01] ED primary closure appropriate re location
          • [01] given not on eyelid,
          • [01] given not at lacrimal duct on eye,
          • [01] not on lip crossing vermillion border,
            • on lip crossing vermillion border but pt request ED to repair rather than wait for specialist and ED repair made every attempt approximate vermillion border, 
            • __
      • [01]  [2] Type of wound 
        •  [01] ED primary closure appropriate re: wound type
          • [01] given sufficiently small and with sufficient viable tissue for approximation, skin graft not required, no large avulsion, not extensively large that would require operative closure
            • [01] not puncture wound,
              • ((which require minimal deep cleaning, no forced irrigation))
            • [01] not bite from human, 
              • ((leave open))
            • bite from mammalian but on face and
              • [01] repaired within 6 hrs
              • [01] repair only required single layer closured w/o devitalized tissue
              • [01] no underlying fracture
              • [01] no systemic immono compromise. 
      • [01] [2] Evaluation for damage to structures.
        • [01] ED primary closure appropriate given no damage to structures requiring surgical repair
          • [01] given no injury to structure requiring operative repair.
          • [01] given no tendons intact
          • [01] tendons not intact though able to be reconnected by suture in ED, pt given prompt follow up for re-eval, consideration of operative revision verses continued outpatient follow up
            • [01] neurologically intact
            • [01] vascular intact
            • [01] not avulsion to extent that would require skin graft or complicated closure in OR
      • [01] [2] Timing
        •  [01] ED primary closure appropriate given timing
          • [01] given less than 6 hrs since injury per pt
          • 6 – 24 hrs 
            • on face will repair given pt’s desire for cosmesis and highly vascularized area reducing risk of infection. 
            • repair deferred given on hands/feet, dirty wound, risks of infection (likely resulting in even worse cosmesis) outweigh benefits fo cosmesis from repair at this time.
        • Plan for closure by secondary intention given >24 hrs.
        • __
        • [01] [2] [2] Repaired indicated for primary closure in ED
          • [01] given meets criteria for benefits outweighing risks for primary closure in ED 
            • [01] given assessment in regards to 
              • [01] consideration of possible bony fracture
              • [01] not in location that pt would benefit from specialist for repair in non ED setting
              • [01] no damage to structures requiring emergent operative repair
              • [01] timing of wound occurance within window for repair
              • [01] patient’s wishes (discussed risks/benefits of closure)
              • __
        • [01] Laceration Repair Procedure:
            • [01] anesthesia utilized was
              • local injection
              • nerve block.
            • [01] Laceration was cleaned with copious irrigation under pressure to remove contaminants. Devitalized tissue removed. 
            • [01] Explored wound in a clean, bloodless field with good lighting and explored (which was not limited by pain), no retained foreign body was found. Laceration repaired with good approximation of wound edges. Hemostatic after repair.
            • [01]  [2] Repaired using:
              • Method of closure:
                • suture __
                • staples
                • dermabond
                • steristrip
              • Number of sutures: __
            • [01] Given proxmity of laceration to potential tendon, every effort made to evaluate for possible neuro-vascular-tendon injury. Motor-neuro-vascular exam intact after to procedure. No evidence of tendon injury on exploration of wound.
            • Covered in ointment
              • bacitracin
              • triple abx preparation (neomycin, bacitracin, polymyxin)
              • Neosporin
              • Silvadene creme
              • mipirocin
              • ((not substantial evidence for any over another)
            • Bandaged
            • [01] Return precautions specific for infection d/w pt including redness, warmth, streaking, fevers, chills, wound coming apart, etc. 
            • [01] Timing for return to MD for suture removal discussed with patient.
              • Face – 5 days
              • Non-high tensile area of body – 7-10 days
              • high tensile area – 10-14 days
              • __
    • [01] [2] Tetanus:
      • UTD
      • not UTD and administered
      • required IG Hypertet 250 u IM, administered at different site from TDap given no hx of full 3 doses of Td
        • Informed pt that needs f/u Tdap at 1 mo and 1 yr.
    • Antibiotics
      • Considered the following criteria in determining appropriate use of antibiotic:
        • [01] comorbities of patient, 
        • [01] how wound was caused, 
        • [01] contamination of wound, 
        • [01] location of wound, 
        • [01] no overlying s/s of infection, 
        • __
      • [01] [2] No antibiotics administered given no suspected underlying fracture, routine abx not indicated, patient not significantly immunocompromised, wound not caused by bite, wound in well vasculized area of body, no s/s of overlying infection of wound on this evaluation. 
      • [2] Fracture: 
        •  given underlying fracture, presumed to be open fracture and as such abx administered based upon Gustillo-Anderson grading:
          • Grade I: Wound <1cm, Little soft tissue injury or crush injury, Moderately clean puncture site, Infection risk 0-12%
            • Grade I Fracture:
              • Cefazolin (Ancef) 2g IV three times daily
              • ((OR))
              • Ciprofloxacin 400mg IV BID
                • ((avoided in pediatrics))
          • Grade II: Laceration >1cm, No extensive soft tissue damage, but slight or moderate crush injury, Moderate contamination, Infection risk 2-12%
            • Cefazolin (Ancef) 2g IV three times daily
            • ((OR))
            • Ciprofloxacin 400mg IV BID
              • (avoid in pediatrics)
            • Added Gentamicin 300 mg (1-1.7mg/kg) IV the Grade I regemin
          • Grade III: Extensive damage to soft tissue, including neurovascular structures and muscle, High degree of contamination, Infection risk 5-50%
            • Further subcategorized:
              • III A: Fracture covered by soft tissue (Infection risk 5-10%)
              • III B: Loss of soft tissue and evidence of bone stripping (Infection risk 10-50%)
              • III C: Any fracture with an associated arterial injury that requires surgical repair (Infection risk 25-50%)
              • Additional Considerations: Fracture with non-communicating overlying wound, Additional sites of injury found in 40-80% of cases, Nerve, vascular, muscular, and/or ligamentous injury
            • Cefazolin (Ancef) 2g IV three times daily
            • ((OR))
            • Ciprofloxacin 400mg IV BID
              • (avoid in pediatrics)
            • Added Gentamicin 300 mg (1-1.7mg/kg) IV the Grade I regemin
          • Given concern for clostridium given
            • through plantar aspect of shoe,
            • highly contaminated with soil
            • will administer  Pipericillin/Tazobactam (Zosyn) 4.5g (80mg/kg) IV three times daily
    • [01] Wound is hemostatic, NVM intact after repair.
    • [01]  [2] DDx includes but in not limited to (pt does not meet reasonable likelihood/consistency with the dx to warrant additional pursuit of these entities (risks outweigh benefits of non-indicating testing):
        • tendon laceration, loss of permanent function
        • vascular injury, risk for loss of limb
        • tetanus
        • wound infection
        • __
      • [2] __
  • ((+))
    • [01] [3] Re-evaluation:
      • [2] On thorough re-evaluation, after patient was observed on telemetric monitoring, patient remains hemodynamically stable, normal vital signs, with clear sensorium, repeat cardio-pulmonary-abdominal exam benign, is ambulatory, has no new development of pain, pain is well-controlled and is amenable to discharge after observation period in the ED.
      • [2] Neurologically Intact.  Patient has normal speech, clear sensorium, exhibits linear thinking, able to articulate plan for aftercare, and exhibits normal fine motor skills.
      • [2] Abdominal Benign. Repeat abdominal exam  did not reveal any tenderness in any of the four quadrants. No rebound their guarding. patient  tolerated PO fluids and food to the emergency department without any recurrence of abdominal pain or vomiting.
      • [2] Respiratory status
        • No signs of respiratory distress on exam, able to speak in full sentences without dyspnea. Respiratory related vital signs reassuring and suggestive of improvement.
        • Improved respiratory exam compared to prior.
        • Unchanged respiratory status compared to prior.
          • __
          • Worsening respiratory status compared to prior.
      • [2] Clinically Sober.
        • Patient demonstrates clinical sobriety.
          • speak non-slurred speech
          • is alert and oriented
          • ambulatory with steady gate
          • has fine motor intact
          • able to articulate plan for safe aftercare upon discharge from ED.
        • Unlikely initially unappreciated pathology on initial eval given patient has no new complaints and re-examination does not reveal any new abnormalities suggestive of previously undetected pathology.
        • Employed importance that patient not drive for remainder of day and to exercise extreme caution while around stairs, areas for potential falls, and to avoid areas with potential for being hit by car (street crossing, etc). Patient advised not to drink/use substances which alter mental status/cause sedation/impair judgement or reflexes (alcohol, illicit substances, prescription medications) if driving in general and advised to refrain from those substances in general. Patient advised to seek treatment for substance abuse.
        • Patient requests discharge, will oblige demonstration of capacity, sobriety, and no unevaluated pathology.
        • On re-evaluation, remains intoxicated. Hemodynamically stable. Will continue observation.
    • [01] [2] [2]  Diposition:  
      • home.  
        • Counseled patient on assessment, impression, plan.  Discussed disposition options with patient after counseling as above and included option for continued observation in medical setting however shared decision making yielded joint decision for disposition to home with self and family observation, prompt follow up with PCP, and return to ED precautions.  Counseled patient on complaint specific return precautions given that there are pathologies that, while sufficiently unlikely to warrant further investigation at this time, may develop/worsen after discharge.  Counseled that early in a disease progress, a work up can be falsely non-revealing of more significant pathology however this does not exclude the possibility of developing serious pathology.
      • __ observation.  
        • Indication: __
      • Admitted.  
        • __ level of care.  
        • __ service.
      • Sign out at change of shift to oncoming ED team
        • pending __
      •  [2] [2] Additional Notation:
        • Attempted shared decision making in discussion with patient/family to the extent that was possible.
        •  Counseling: patient/family educated on diagnostics, assessment, treatment plan. Patient/family amenable in an agreement with proposed plan. All questions answered and concerns addressed.
        •  Supervision:  discussed and obtained approval/confirmation of evaluation (history, exam, diagnostics) and plan (assessment, interventions, disposition) with ED attending physician __ 
    • [01] [2] [2] Supplemental Aspects of Care:
      • [01] [2] COUNSELING: To the extent that was possible, patient/family educated on diagnostics, assessment, treatment plan. Patient/family amendable and in agreement with plan. All questions and concerns answered and addressed.
      • [01] [2] Laceration Specific Counseling:
        • [01] [2] I discussed the possibility of residual foreign body with patient and that no matter how thorough the search it is still a possibility. I explained to return if patient notices signs of retained FB.
        • [01] [2] I also explained what to look for with regard to infection. The patient agreed to return with any increasing discharge, extending erythema, fever, nausea/vomiting or any other changes.
        • [01] [2] I also discussed the inevitability of scarring with the patient. They understand that all lacerations will leave a varying degree of scarring and optimal outcome/cosmetic appearance can never be guaranteed. They also understand the possibility of prompt revision by plastic surgery if desired.
        • [01] [2] Advised on follow up timing for suture removal.
      • [2] COUNSELING: Attempted to explain and obtain patient’s approval for plan however unable to do so secondary to patient’s condition and the requirement of emergent evaluation and interventions.
      • [2] SUPERVISION: Evaluation, assessment, plan, and disposition discussed with attending physician who approves and is in agreement with evaluation, assessment, plan, and disposition. 
        • Attending MD __ 
      • [01] [2] PROCEDURE NOTE REGARDING REPAIR OF LACERATION
        • [2] location of wound: __
        • [2] size of wound: __ cm
        • [2] complexity:
          • simple
          • intermediate
            • given requirement for 
              • debridement, 
              • multiple layers of sutures, 
              • complex stitches, 
            • complex
              • given requirement for 
                • debridement, 
                • multiple layers of sutures, 
                • complex stitches, 
      • [2] Of note, radiology over-read mechanism in place for formal reads on imaging will hospital call back mechanism in place

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