By Q. Kirk. Asbury College.

In this therapy safe 50 mg imitrex, wounds are managed topically with daily application of cerium nitrate–silver sulfadiazine for a week buy generic imitrex 25mg on-line. Patients then undergo surgery on limited areas of their body and return at weekly interval for further excision and autografting discount 50 mg imitrex amex. The wounds that are left nonexcised after every operative session are treated with daily application of the same topical agent until complete wound closure has been achieved. In any pragmatic approach, certain patients may not fit in the protocol. In these circumstances, an individual approach needs to be implemented to provide a good outcome. Good examples include the following: Non-life-threatening burns in patients with important associated medical conditions. Medical conditions need to be addressed first to decrease the morbidity and mortality of surgery Large superficial burns with small full-thickness patches are best treated as superficial burns and full-thickness areas addressed last when the rest of the burns are healed. Patients who experience extreme pain not controlled with analgesic regi- mens may benefit from early excision and grafting to decrease daily cleansing. Small deep–partial and full-thickness burns in patients who continue work- ing and attending school are best treated conservatively and operated on as out patients procedures. Burns to the hands and feet benefit from an aggressive approach to permit the patient’s early social and work reintegration PREPARATION FOR SURGERY Burn surgery requires commitment and cooperation from the whole burn team. Treatment of massive burns is an enterprise that matches the complexity of open- heart surgery or any other major surgical procedures based on the interaction of a multidisciplinary team. It should be only attempted in major tertiary hospital facilities where the whole spectrum of specialization is available. Even though burn wound excision and grafting may seem to the novice as a simple and easy surgical procedure, a profound understanding of the burn pathophysiology, dy- namics of wounds, critical care, and wound healing is necessary to perform suc- cessful operations. Burn wound excision, either immediate/early or delayed should be considered an elective procedure and prepared and managed as such. Only emergency surgi- cal airway access and escharotomy and fasciotomy should be undertaken without formal and proper evaluation. Experienced burn anesthetists and burn surgeons only should perform burn wound excision, since minor errors may lead result in the death of patients. Anesthetic Evaluation Destruction of skin by thermal injury disrupts the vital functions of the largest organ in the body and results in a systemic inflammatory response that alters function in virtually all organ systems. All changes that occur during the resuscitation phase and postresuscitation phase should be noted and taken into account to provide safe anesthesia. Treatment of burn patients must compensate for loss of these func- tions, until the wounds are covered and healed.

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In the presence of hypovolemia generic 50 mg imitrex free shipping, hemodynamically significant beat-to-beat alterations in myocardial preload can result from phasic changes in venous return caused by changes of intrathoracic pressure during the respiratory cycle purchase 25 mg imitrex with visa. These changes in preload result in beat-to- beat variation in ejection volume and buy cheap imitrex 25mg on line, thus, systolic blood pressure. The relation- ship between respiratory-related changes in intrathoracic pressure and systolic blood pressure variation have been studied and quantitated to some extent for positive pressure ventilation. The relationship is more complex for spontaneous ventilation and has not been quantitated. Systolic pressure variation during sponta- neous ventilation can increase with changes other than decreased preload such as increased respiratory effort or increased airway resistance. Still, hypovolemia can reduce preload to the point that changes in venous return during the respiratory cycle are enough to alter stroke volume noticeably, resulting in increased systolic pressure variation. When other causes are ruled out, respiratory variation in sys- tolic blood pressure can, thus, be used as one of several imperfect indicators of hypovolemia that needs to be corrected. Transfusions There is no general agreement regarding the point at which transfusion may be indicated for burn patients. As a rule, currently accepted guidelines support transfusion almost always when the hemoglobin concentration falls below 6 g/100 ml but rarely when the hemoglobin concentration is 10 g/100 ml or greater. In the past, hemoglobin concentration has been maintained at 10 g/100 ml or higher in patients with significant burns. Several centers now recommend lower- ing the acceptable hemoglobin concentration in order to reduce exposure to blood products and to conserve the resource. There are few objective data on the optimal man- agement strategy for blood transfusion during burn wound excision. At present the most logical approach is to assess the needs of each patient individually and continually through the perioperative period. If preload is opti- mized as described earlier, then oxygen-carrying capacity can be increased as needed depending on the presence of acidosis or problems with oxygen delivery. Demonstration of acidosis, decreased mixed venous oxygen content, or evidence of myocardial ischemia despite adequate preload and blood pressure suggests a need for more oxygen-carrying capacity. During excision of extensive burn wounds, patients will require transfusion of large amounts of blood, often an exchange volume or more. Massive blood Anesthesia 129 transfusions are associated with a variety of complications, which can be mini- mized but not entirely avoided by careful practice.

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Pain in 11–18 tender points (Figure 3-5) months Bilateral involvement Occipital order 50mg imitrex with visa, lower cervical generic imitrex 25 mg without prescription, trapezius generic imitrex 25mg without prescription, supraspinatus, second rib, lateral epicondyle, gluteal, greater trochanter, knee FMS SHOULD BE DIFFERENTIATED FROM MYOFASCIAL PAIN SYNDROME AND CHRONIC FATIGUE SYNDROME Myofascial Pain Syndrome Local pain and tender points that resolves with local treatment, but may recur Fatigue, morning stiffness uncommon Chronic Fatigue Syndrome Disabling fatigue at least six months Preceded by a viral syndrome TREATMENT OF FMS Patient education and reassurance Nortriptyline—sleep disturbance RHEUMATOLOGY 125 NSAIDs and corticosteroids Combination therapy is effective Biofeedback, tender point injection Acupuncture, aerobic exercise Greater Trochanter FIGURE 3–5. Fibromyalgia: Location of Specific Tender Points COMPLEX REGIONAL PAIN DISORDER (CRPD) OTHER NAMES Sudeck’s atrophy Algodystrophy Shoulder hand syndrome RSD: Reflex Sympathetic Dystrophy 126 RHEUMATOLOGY CHARACTERISTICS Limb pain, swelling, and autonomic dysfunction Most commonly caused by minor or major trauma CLINICAL FEATURE Pain, deep burning exacerbated by movement – Allodynia—pain induced by a nonnoxious stimulus – Hyperalgesia—lower pain threshold and enhanced pain perception Local edema and vasomotor changes – Extremity is warm, red, and dry initially – Later becomes cool, mottled, and cyanotic Muscle weakness Dystrophic changes – Thin, shiny skin, brittle nails CLINICAL STAGES 1. Acute—few weeks–6 months – Pain, hypersensitivity, swelling, and vasomotor changes – Increased blood flow creating temperature and skin-color changes – Hyperhidrosis 2. Dystrophic—3–6 months – Persistent pain, disability, and atrophic skin changes – Decreased blood flow, decreased temperature – Hyperhidrosis 3. Atrophic – Atrophy and contractures – Skin glossy, cool, and dry RADIOGRAPHIC FINDINGS 1. Plain radiographs Sudeck’s atrophy—patchy osteopenia, ground-glass appearance 2. Three-phase bone scan First two phases are nonspecific, osteoporosis Third phase—abnormal, with enhanced uptake in the peri-articular structures TREATMENT 1. Immediate mobilization—Passive and active ROM, massage, contrast baths, TENS 2. Inflammation—Corticosteroids, initial dose 60–80 mg/day qid dosing for two weeks then gradual tapering the next two weeks 4. Cervical sympathetic ganglia block for the upper extremities, lumbar ganglion block for the lower extremities 5. Surgical sympathectomy—if block is beneficial but transient RHEUMATOLOGY 127 TABLE 3–9. Adults (Janig and Stanton Hicks, 1995) Children Adults Site Lower extremity Upper extremity Spontaneous pain Common Common Allodynia Most patients Most patients Sex ratio Female:male 4:1 Mixed Three-phase Mixed results: Used to rule out other Increased uptake in the third bone scan pathology phase of the affected extremity See decreased uptake of the extremity— decreased atrophic changes Occasionally normal Will have increased uptake normally secondary to bone growth Treatment Physical therapy alone Sympathetic blocks Noninvasive—TENS, Biofeedback Meds—Tricyclic antidepressant Blocks more common in the upper extremity Prognosis Good Poor SYMPATHETIC AND NONSYMPATHETIC CRPD Four tests used to determine if pain is sympathetically mediated; the first two are used more commonly. Sympathetic block with local anesthetic: Local anesthetic is injected at the stellate ganglion (upper extremity) or the lumbar par- avertebral ganglion (lower extremity). Guanethidine test: Injection of guanethidine into the extremity distal to a suprasystolic cuff. The test is posi- tive if the pain is reproduced after injection and is immediately relieved after cuff is released 3. Ischemia test: Inflation of the suprasystolic cuff decreases the pain TENDON DISORDERS DUPUYTREN’S CONTRACTURE: (Snider, 1997) (Figure 3–6) Fibrous contracture of the palmar fascia creating a flexion contracture at the MCP and PIP joints More common in white men ~50–70 years of age Associated with → epilepsy, pulmonary TB, alcoholism, diabetes mellitus 128 RHEUMATOLOGY Mechanism The palmar fascia is a continuation of the palmaris longus tendon attaching to the sides of the PIP and middle phalanges The fascia is connected to the skin, as it contracts and fibroses, the skin dimples Contraction of the fibrous bands into nodules and the fingers develop a flexion contracture Clinically Painless thickening of the palmar surface and underlying fascia Most commonly at the fourth and fifth digits Treatment Nonoperative—Trypsin, chymotrypsin, lidocaine injection follow by forceful extension rupturing the skin and fascia improving ROM Modalities—heating, stretching, ultrasound Surgical—fasciotomy, amputation Flexion contracture at the PIP and MCP joints of fourth and fifth digit Palmar surface Painless FIGURE 3–6. Rosemont, Illinois: American Academy of Orthopaedic Surgeons, 1997, with permission. Trigger Finger: With finger in extension, nodule is distal to the pulley. Rosemont, Illinois: American Academy of Orthopaedic Surgeons, 1997, with permission. RHEUMATOLOGY 129 Trauma to the flexor portion of the fingers pinching the flexor tendon within its synovial sheath Ligamentous sheath thickens and a nodule is formed within it When the finger is flexed, the nodule moves proximally, re-extension is prevented A locking sensation is felt or clicking when the nodule passes though the tendon sheath MALLET FINGER Most common extensor tendon injury (Snider, 1997) Rupture of the extensor tendon into the distal phalanx secondary to forceful flexion The DIP drops remains in a flexed position and cannot be extended actively Treatment: Splinting to immobilize the distal phalanx in hyperextension Acute—6 week Chronic—12 weeks Surgical: poor healing, volar subluxation, avulsion > one third of bone FIGURE 3–8. Mallet finger caused by: Top: Rupture of the extensor tendon at its insertion.

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