The Washington Manual Internship Survival Guide (28 page)

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  History: Recent glycemic control (have insulin requirements been increasing in order to maintain the same level of plasma glucose?),
prior amputations or debridements, history of optic or renal dysfunction, or cardiac disease.

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  Physical examination: Obtain a thorough neurovascular exam including pulses, sensation, and motor function. Examine all wounds taking note of depth, purulence, necrotic tissue, exposed bone, and proximal extension. If peripheral pulses are absent or diminished, perform an ankle arm index (AAI) and consider vascular surgery consult (see “Ischemic Ulcer of the Lower Extremity” in the General Surgery section).

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  Workup: CBC, BMP, coagulation panel, ESR, and CRP. Obtain AP, lateral, and oblique views of the ankle
and
foot. Do not obtain an MRI prior to an orthopedic consult.

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  Treatment: Surgical management will vary based on the wound and can range from bedside debridement to limb amputation. Antimicrobial therapy should be based upon tissue or bone culture results when possible, but broad-spectrum agents (e.g., piperacillin/tazobactam or meropenem with or without vancomycin) should be started promptly for signs of hemodynamic compromise. Consider an infectious diseases consultation, as well as placement of a long-term venous access device if an extended course of intravenous antibiotics is anticipated.

Oncology Patients

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  The cancers that most commonly metastasize to the bone are breast, prostate, lung, thyroid, and renal cell carcinoma. Less common cancers are multiple myeloma, leukemia, lymphoma, and melanoma.

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  Any oncology patient with pain in an extremity or in the spine may have a bony metastasis and an impending fracture. The appropriate X-rays should be obtained, and an orthopedic consult should be called if a lesion is visualized. Impending fractures are important to recognize and treat early, because once the bone is fractured, fixation can become much more difficult.

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  Oncology patients with spinal metastases resulting in neurological compromise may do better with surgical decompression than with radiation alone. An orthopedic consult should be called for these patients.

Management of Postoperative Orthopedic Patients

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  Orthopedic patients are frequently admitted to a general medicine service postoperatively for significant medical comorbidities or unexpected medical complications.

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  Orthopedic procedures can result in significant blood loss, so labs should be carefully followed in the 48 hours following any surgery. Special attention should be given to the H/H, coags, and urine output. It is not unusual for the patient’s hematocrit to decrease over the 48 hours following a large orthopedic procedure as the patient may ooze into the surgical bed for several days. No heparin drips or therapeutic anticoagulation should be started without discussing it with the orthopedic team.

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  For all orthopedic patients, and especially patients with hip or pelvic pathology, there is a high risk of DVT. Unless they are at high risk for significant bleeding, patients should have TED hose and SCDs as well as prophylactic doses of heparin or LMWH. Patients at very high risk may be treated with warfarin postoperatively.

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  Aggressive physical therapy is necessary for postoperative recovery. All patients should have a physical therapy consult and orders to be out of bed tid unless otherwise specified by the orthopedic consultant. The orthopedic consultant will indicate the weight-bearing status of the affected extremity.

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  Orthopedic procedures can result in significant pain. Adequate pain control is important to allow postoperative mobilization and physical therapy.

OTOLARYNGOLOGY

Airway Emergencies

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Call a consult or the airway pager immediately for assistance!

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  Pertinent history: Note onset, duration, progression, and severity of stridor (the degree of stridor may not necessarily indicate the severity of obstruction). Does it occur with inspiration, expiration, or both? Are there voice changes? History of prior intubation, neck trauma, head and neck cancer/surgery, irradiation to the neck, or tracheostomy?

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  Pertinent physical exam: Cardinal sign of upper airway obstruction is
stridor secondary to turbulent airflow
. Inspiratory stridor usually indicates partial obstruction above the vocal cords (i.e., trauma/fractures, foreign bodies, hematomas, edema). Expiratory stridor usually indicates obstruction at or below the vocal cords. Biphasic stridor suggests partial obstruction at the level of the vocal cords. Other signs of respiratory distress may include restlessness, suprasternal/subcostal retractions, and hoarseness (which usually denotes laryngeal pathology). A muffled or “hot potato” voice suggests supraglottic involvement, such as obstruction due
to an abscess or angioedema. Coughing or choking may be due to vocal cord paralysis, aspiration, reflux, or an anatomic abnormality (laryngeal cleft or TE fistula).

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  Workup: In a true airway emergency, workup is deferred until a stable airway is established. In a less emergent setting, diagnostics include arterial blood gas, CBC, CXR, soft tissue airway films (may demonstrate supraglottic edema or subcutaneous emphysema), CT scan of the neck, and C-spine films in cases of trauma.

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  Treatment:

•  Cool humidified air helps to thin secretions and prevent crust formation. Use a face mask or face tent rather than nasal cannula if possible.

•  Oxygen per nasal cannula, face mask, face tent, or nonrebreather may be beneficial regardless of measured oxygen saturations.

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Systemic corticosteroids
may be used if edema is suspected. Dexamethasone 10 mg and methylprednisolone 125 mg are most commonly used as acute treatment, with methylprednisolone having a somewhat faster onset.

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Nebulized racemic epinephrine
works quickly, acting as a topical vasoconstrictor; however, it is short acting, and there may be a rebound effect once it dissipates. In addition, it can cause acute elevations in blood pressure which can be problematic in some patients. If there is a lack of improvement with epinephrine, one must be concerned about a fixed structural obstruction.

•  Heliox refers to an 80%:20% helium–oxygen mixture. It relies on decreased density of helium to transport oxygen past the obstructive site. Usually used as a temporizing measure.

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  Clinical pearls:

•  Nasopharyngeal airway (nasal trumpet) is beneficial for patients with oropharyngeal obstruction but normal respiratory drive. It provides support to the airway at the soft palate and base of the tongue.

•  Likewise, an oropharyngeal airway may treat ventilatory obstruction due to a relaxed tongue. It is not well tolerated in fully conscious patients.

•  Transoral intubation is the standard for airway control. Contraindications include C-spine fractures and some types of laryngeal or tracheal trauma. The laryngeal mask airway (LMA) is another option for emergent airway control,
especially as a temporizing measure. Use of this device is becoming more widespread and has the advantage of being placed without direct laryngoscopy. Endotracheal tubes can also be passed through some types of LMAs.

•  Consultation is advised when a difficult intubation is anticipated (and a fiberoptic intubation would be preferred), for airway distress refractory to medical interventions, or when exam of the upper airway is indicated (i.e., rule out vocal cord paralysis, neoplasm, foreign body).

•  While pulse oximetry should be monitored in a patient with airway concerns, note that saturations may stay above 95% until complete airway obstruction or respiratory exhaustion occurs. The pulmonary reserve for many patients is low and they may crash very rapidly despite initially stable pulse ox readings. Do not let pulse oximeter readings override clinical examination of a stridulous patient.

Tracheostomy

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  Indications/workup:

•  The optimal timing for a tracheostomy is controversial; however, it is accepted that earlier intervention has beneficial effects for critically ill patients. Evaluation of the patient at 7 to 10 days after intubation is appropriate to assess for likelihood of extubation. If long-term intubation is probable, then a tracheostomy is justified. In some patients with neuromuscular disorders or severe neurologic injury in which long-term ventilatory support is anticipated, earlier tracheostomy may be indicated.

•  Workup for tracheostomy includes physical examination, evaluation of coagulation (PT/PTT, bleeding time, or PFA-100), peak airway pressures, and patient’s expected prognosis.

▪  Patients on anticoagulation (including ASA) are at higher risk of both intraoperative and postoperative hemorrhage. Reverse or discontinue anticoagulation, if possible.

▪  Patients with high peak airway pressures (numbers vary, but typically over 40 to 45 cm H
₂
O) are at higher risk for ventilatory complications due to leakage of air around the tracheostomy tube at high pressures and the need for excessive cuff pressures to maintain a seal.

▪  Prognosis is a key component of discussion with the family regarding the purposes of a tracheostomy. Assistance with long ventilator weans is an appropriate indication, as is palliation of airway obstruction in end-of-life situations.

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Two types of tracheostomy may be performed:
open surgical tracheostomy
(performed in the operating room) or
bedside percutaneous dilational tracheostomy
(PDT). PDT avoids transporting a critically ill patient out of the ICU but may be prone to complications in some patients (e.g., obese or prior neck surgery). The choice of procedure is dependent on patient characteristics, as well as the experience and preference of the surgeon.

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  Types of tracheostomy tubes: Tubes come in metal or plastic varieties. Shiley and Portex brand tubes are plastic and come with or without cuffs. Cuffs are necessary when ventilatory support is needed and are always used as the initial tracheostomy tube. Jackson tubes are metal and are not cuffed. After the tracheostomy, the tube is kept undisturbed for 3 to 7 days to allow for formation of a well-healed tract. At this point, the original tube is changed to either a similar cuffed tube or to a cuffless tube (if ventilatory support is not required).

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  Post-tracheostomy care: ENT will perform the first tracheostomy tube change after 3 to 7 days to ensure a well-healed tract has formed. Further trach changes can be performed by nursing staff on the floors or by the patient/family after discharge. Frequent cleaning or changing of the inner cannula is recommended to prevent obstruction by crusting (typically at least tid). A patient with a tracheostomy should always wear a high-humidity trach collar to thin secretions and have bedside suction catheters available.
All patients should have a spare trach in the room and should also have their obturator secured to the foot of the bed where it is easily accessible
. The obturator is the metal or plastic inner piece that facilitates reinsertion of the trach. Nurses and physicians caring for these patients should know its location and have immediate access to it.

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  Dislodged tracheostomy tube: If the trach tube comes out, first assess the stability of the patient.

•  If in respiratory distress or with stridor, call the ENT consult or emergency airway pager immediately for assistance. You may reinsert the tube with the aid of the obturator (which will be secured at the bedside as noted above) and resecure the collar to prevent further dislodgement. If this is not possible or unsuccessful and the patient is decompensating, transoral endotracheal intubation is an option for most patients. The exception is a patient with previous laryngeal surgery who may have difficult transoral access (or no access in the case of a patient after a total laryngectomy).

•  If the patient is stable and comfortable, you may attempt to reinsert the tracheostomy tube as noted above. Using a small Kelly clamp to retract the skin, along with a bright
light source, may give a better view of the tract. Occasionally, passing the trach tube over a Foley catheter or nasogastric tube will do the trick.

•  If the patient is stridulous, talking, or breathing through the nose or mouth with the trach tube in place, it is likely in a false tract. If in proper position, most of the expired airflow should emanate through the tracheostomy tube and not the nose/mouth. Thus, you may feel for airflow through the tube. Also, passage of a tracheal suction catheter into the trachea via the tube should always elicit a cough and is a standard way of confirming proper tube placement. Removing the tube and reattempting with the methods above will usually allow for correct placement. If difficulty persists, call the ENT consult pager for assistance.

Epistaxis

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  May be considered emergent, urgent, or routine based on volume of blood loss, hemodynamic stability, airway compromise, and whether the patient is currently bleeding. Be clear in defining the urgency of the consult when calling to elicit the appropriate rapidity of response.

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  Pertinent history: Trauma (digital or facial)? Anticoagulant medications? Systemic diseases with bleeding diatheses (e.g., hemophilia, liver disease, von Willebrand disease, hereditary hemorrhagic telangiectasia)? Local nasal inflammation (e.g., rhinosinusitis, allergic rhinitis, digital trauma, foreign body)? Does the patient use nasally administered medications or nasal cannula oxygen?