Beta Testing Featurality

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  • chest pain
  • Patient chest pain.
  • Age:
  • Patient’s age is
  • \ Assessment/Plan:
    • \ Evaluated appropriateness of wound for repair accessing the following aspects of the wound
      • \ Potential for underlying fracture
        • ED primary closure appropriate re fracture possibility
          • given radiographs not indicated given no hx c/f retained foreign body and wound exploration performed for FB.
          • Radiographs (interpreted in ED, formal read and call back mechanism for over-reads: obtained and no radio-opaque foreign body seen no fracture seen ((works to here))
      • \ Location
        • ED primary closure appropriate re location
          • given not at site of high risk of complications i.e. not on lacrimal duct, no on eyelid, no crossing vermillion boarder
          • crossing vermillion border but pt requests ED closure as opposed to waiting or f/u with specialist
      •  \ Type of wound
        • ED primary closure appropriate
          • wound with viable tissue that well approximates
          • not puncture wound,
            • ((which require minimal deep cleaning, no forced irrigation))
          • not human bite (pet pt)
          • bite from mammalian but on face and
            • repaired within 6 hrs with only required single layer closured w/o devitalized tissue
            • no underlying fracture
            • no systemic immono compromise.
    • \ Evaluation for damage to structures.
        • ED primary closure appropriate given no damage to structures requiring surgical repair
        • tendons intact
        • 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
        • neurologically intact
        • vascular intact
        • no avulsion requiring skin graft/complicated OR repair
      •   \ Timing
        •   ED primary closure appropriate given timing
          • given less than 6 hrs since injury per pt
          • 6 to 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.
      • \ Closure
        • Plan for closure by secondary intention given greater than 24 hrs.
        • Repaired indicated for primary closure in ED,
        • Assessment made w/ consideration of
          • of possible bony fracture
          • location that pt would benefit from specialist for repair in non ED setting
          • damage to structures requiring emergent operative repair
          • timing of wound occurance within window for repair
          • patient’s wishes (discussed risks/benefits of closure)
      • Laceration Repair Procedure:
        • anesthesia
          • local
          • nerve block
        • Laceration was cleaned with copious irrigation under pressure to remove contaminants. Devitalized tissue removed.
        • 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.
        •   \ Repaired using:
          • Method of closure:
            • suture type and number of suture
            • staples
            • dermabond
            • steristrip
        • No evidence of tendon injury on exploration of wound,
        • ointment placed on wound
          • bacitracin
          • triple abx preparation (neomycin, bacitracin, polymyxin)
          • Neosporin
          • Silvadene creme
          • mipirocin
          • ((not substantial evidence for any over another))
        • return precautions specific for infection d/w pt including redness, warmth, streaking, fevers, chills, wound coming apart, etc. Bandaged in ED. On re-evaluation, NVM intact after repair.
        • timing for return to MD for suture removal discussed with patient.
          • Face 5 days
          • Non high tensile area of body  7 to 10 days
          • high tensile area  10 to 14 days
      • \ Tetanus:
        • UTD,
        • not UTD and administered Tdap,
        • Tetanus IG (Hypertet indicated)
          • none or less than 3 doses of Td,
          • administered 250 u IM at dif site from Tdap
      • \ Antibiotics
        • Considered the following criteria in determining appropriate use of antibiotic:
          • comorbities of patient,
          • how wound was caused,
          • contamination of wound,
          • location of wound,
          • no overlying s/s of infection,
      • \ 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.
      • \ Fracture:
          •  given underlying fracture, presumed to be open fracture and as such abx administered based upon Gustillo-Anderson grading:
            • Grade I: Wound less than 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 greater than 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
      •  \ 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

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