pocket manual

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emm64
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304652
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pocket manual
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2015-07-01 08:27:50
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pocket manual
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  1. Preoperative Anesthesia Clearance packet should include
    • o Preoperative Labs printed ( CBC, BMP, PT/INR, UA, EKG, CXR, BHCG)
    • o Signed Consent
    • o Admission orders to A5C
    •  Admit to A5C
    •  NPO
    •  IV fluids as needed (LR, NS etc)
    •  Ancef 1g IVPB On call too OR (OCT OR)/Clindamycin 900 mg IVPB OCT OR
    •  Decadron 10 mg IVPB OCT OR
    •  Bilateral Sequential Compression Devices (SCD’s )OCT OR
    • o H&P in affinity
    • o Preop appointment request form
  2. Clearance for adult patients is limited by the following
    • o H&P – 30 days
    • o Labs – 90 days (T/S must be w/in 3days (?) for blood to be ready in Blood Bank)
    • o Consent – 30 days
    • o CXR – 6 months
  3. Clearance for pediatric patients expires in
    3 days
  4. ASA I patients can be cleared for surgery upon
    • review of pre-op packet
    • do not need to be seen and evaluated by the anesthesia team!)***
  5. JOW’s responsibility
    • OR Lineup:
    • Preoperative Anesthesia Clearance
    • o Manages all fracture patients, all in-patients, all consults received during the day
    • o Procedures: CRMMFs, sedations, procedures related to fracture patients
    •  Sets-up sedation procedures scheduled w/ other residents in Brev Room, ie Brev Clinic on wed
  6. o Pre-op studies:
    BMP, CBC, Coags (PT/PTT/INR), UA, T/S, CXR, EKG
  7. - Orders for OR
    • o Ancef 1 gram (Clindamycin 900 mg) IVPB in OR
    • o Decadron 10 mg IVPB in OR
    • o Bilateral SCD’s in OR
  8. Common Risks:
    Pain, swelling, bleeding, infection, numbness, paralysis of facial muscles, damage to adjacent structures, scar, need for further surgery or treatment,
  9. Admission Orders
    • ADC-VAN-DIML
    • Admit to, Diagnosis, Condition
    • Vitals, Allergies, Activities, Nursing instructions
    • Diet, I/O, Meds, Labs
  10. Maintenance Fluids Types:
    • LR, 0.9% NS, 0.45% NS, TKO, SLIV or HLIV
    • 4-2-1 Rule: 1st 10kg x4 + 2nd 10kg x2 + remaining kg x1= ?cc of IVF/hr
  11. Common Causes of Post-Op Fever
    • 1. Wind Atelectasis 1-2 WALK!, Pain meds, Pulm toilet, IS
    • 2. Water UTI (Foley) 3-5 Bactrim, D/C the foley!
    • 3. Walking Thrombophlebitis / DVT 3-5 BLE Compression, SQ Heparin
    • 4. Wound Infection 5-7 Cultures, check wounds, I&D
    • 5. Wonder Drug Medications Anytime *Diagnosis of exclusion.
  12. Regimen for (Total Daily Insulin)
    • TDI = 0.4 - 0.7 U / kg
    • split doses of 2/3 AM and 1/3 PM
    • Adjust patient’s hyperglycemic state
    • add TDI/30 per every increment of 50 mg/dl over 200. Another option is to use the ISS which can be “tightened” to accommodate for lesser then desired response to insulin.
  13. Hypertensive crisis:
    DBP > 120 mm Hg, SBP > 210 mm Hg
  14. Significant fetal risk drugs
    • Fosphenytoin
    • Phenobarbital
    • Phenytoin
    • Primidone
    • Valproic acid
    • Lithium
    • MAO inhibitors
    • HMG-CoA reductase inhibitors
    • Fluoroquinolones
    • Streptomycinl
    • Tetracyclines
    • Warfarin
    • Angiotensin-converting enzyme inhibitors
    • Angiotensin II–receptor antagonists
    • Misoprostol
    • Estrogens
    • Oral contraceptives
    • Pentobarbital
    • Phenobarbital
    • Isotretinoin
    • Leflunomide
    • Quinine
    • Tamoxifen
  15. Banana Bag
    • Order 3 days:
    • Rx: Add to 1st IVF bag in the a.m.:
    • Folate 1 mg
    • MgSO4 2 g
    • MVI 1amp
    • Thiamine 100mg
    • PRN Agitation:
    • Ativan 1 –2 mg po q 4-6h
    • Librium 50 – 75 mg po/IM q 4-6h
    • Need to check daily Mg+2 levels/ ‘Lytes
  16. Common Micro Odontogenic
    • most commonly isolated organisms include:
    • • Aerobic: streptococci (alpha, beta, and gamma),
    • • Anaerobic: streptococci (peptostreptococcus), Bacteroides (B. melaninogenicus, B. fragilis, and B. oralis), and staphylococci (S. aureus, S. epidermidis)
  17. Cavernous Sinusitis early signs
    • • Earliest sign: lateral gaze palsy 2/2 pressure on CN VI, since it is not covered by periosteum
    • • Other signs include: nausea, vomiting, diplopia, visual impairment, ophthalmoplegia, photophobia, papilledema.
  18. • Commonly used antibiotics in OMFS:
    •  Penicillins
    • Pen GK 2 – 4 Million Units IVPB q 6 h
    • Pen VK 500 mg PO q 6 h x 7 – 10 days
    • Amoxicillin
    • Unasyn
    •  Cephalosporins
    • Ancef 1 – 2 g IVPB q 6 h
    • Alternatives: Cefotaxime, Cefoxime, Ceftazidime
    •  Clindamycin:
    • 900 mg IVPB q 6 – 8 h
    • 150 – 300 mg PO q 6 h x 7 – 10 days
    •  Metronidazole
    • 500 mg IVPB q 6 h
    •  Other: Aminoglycosides, Erythromycin
  19. Wound Closure
    • a. Deep layers: remove dead-space, avoid excessive layering
    • i. Absorbable sutures, 3-0 or 4-0; Vicryl, Dexon
    • b. Skin, Mucosa: align key anatomy; evert margin; tension-free
    • i. Skin: 5-0 or 6-0
    • 1. Prolene, Nylon: non-absorbable, remove in 4-6days
    • 2. Fast Gut: absorbable, can be used, but may compromise esthetics
    • a. Remember: the suture is degraded by a localized inflammatory reaction, which may hinder healing/esthetics
    • 3. Dressing/cover: Dermabond vs triple abx ointment vs gauze
    • ii. Mucosa: 4-0 chromic
  20. Splinting: General Guidelines
    • • allow some tooth movement.
    • • until teeth are minimally mobile or treatment fails.
    • • Types: 0.016 multistrand ortho wire, Composite bridge, acrylic, Essig’s splints
    • • *Erich arch bars (EAB’s) – the gold standard of LAC
  21. IMMEDIATE CRMMF INDICATED: These pts MUST be wired on-call, No Exceptions !
    • • Unstable Airway or Fracture
    • • Infected Mandible Fracture
    • • Mandibular Fx 2/2 a GSW
    • • LeFort Fracture
    • • Bleeding
    • • A mandibular fx with an extensive laceration
  22. INDICATIONS FOR CLOSED REDUCTION
    • • Nondisplaced favorable fracture
    • • Grossly comminuted fractures
    • • Fractures exposed by significant loss of overlying soft tissue
    • • Edentulous mandible fractures
    • • Mandibular fractures in children with developing dentitions
    • • Condylar fractures
  23. INDICATIONS FOR OPEN REDUCTION
    • • Displaced unfavorable fracture lines
    • • Complex or multiple fractures and/or displaced bilateral condylar fractures
    • • Edentulous fractures with severe displacement of the fracture fragments
    • • Malunion or fibrous union
    • • Systemic problems that may contraindicate MMF, ie uncontrolled seizures, acute psychosis.
    • • *Any fracture unable to adequately be managed by closed techniques
  24. 3 meds (anticipating CRMMF):
    • 1. An antibiotic
    • Pen VK
    • • Elixir 250/5ml, 10 ml PO Q6H x 7 - 10 days (300 - 450 ml)
    • • Tabs 500 mg 1 tab PO Q6H x 7 - 10 days (28 - 40 tabs)
    •  Clindamycin
    • • Elixir 75 mg/5 ml; 20 ml PO Q6H x 7 - 10 days ( 600 – 850 ml )
    • • Tabs 300 mg 1 tab PO Q6H x 7 - 10 days (21 - 30 tabs)
    •  Keflex
    • • Elixir 250/5 ml, 10 ml PO Q8H x 7 - 10 days (300 - 450 ml)
    • • Tabs 500 mg 1 tab PO q6h x 7 - 10 days
    • 2. An Rx for pain control
    •  Tylenol w/codeine elixir 12/120/5 ml 15 ml PO Q6H PRN pain (300 ml)
    •  Norco 5/325 1 tab Po q6H PRN pain,
    • 3. Peridex 0.12 % 15 ml PO sw/spit TID
  25. ZMC ARTICULATIONS
    • • Frontozygomatic
    • • Zygomaticotemporal
    • • Zygomaticomaxillary
    • • Greater wing of the sphenoid
  26. ZMC MUSCLE ATTACHMENTS
    • • Masseter origin
    • • Levator labia superioris
    • • Zygomaticus major
    • • Temporalis fascia attached to superior aspect of arch
    • Whitnall's Tubercle: "marginal zygomatic tubercle"
    • • located approximately 5mm behind the lateral orbital rim
    • • all form lateral retinaculum
  27. Knight & North (1961) classified by direction of displacement in Waters' view radiograph
    • • Group 1: nondisplaced fractures
    • • Group II: Arch fxs only with classic 3 fracture lines producing V-shaped deformity
    • • Group III: Unrotated body fx. Direct blow to zygomatic prominence.
    • --The zygoma is driven posterior and medially.
    • --The infraorbital rim is displaced inferior and medially at the buttress
    • • Group IV: Medially rotated body fractures
    • • Group V: Laterally rotated body fractures
    • --Superior displacement of inf orbital rim w/ lat displacement at Z-F suture
    • • Group VI: Complex/comminuted fractures
  28. ZMC COMMON FINDINGS
    • • Periorbital ecchymosis/edema
    • • Subconjunctival heme/ecchymosis
    • • Malar depression
    • • Step defect at:
    • --infraorbital rim
    • --frontozygomatic suture
    • --zygomatic buttress of maxilla intraorally
    • • Ecchymosis at maxillary buttress region
    • • V2/infraorbital nerve para-/anesthesia
    • • Enopthalmos or Proptosis
    • • Diplopia (monocular vs. binocular)
    • • ↓ mobility of EOM -- upward gaze
    • LESS COMMON FINDINGS
    • • Injury to globe itself
    • • Limited mand ROM 2/2 zygomatic arch impingement on coronoid
    • • Epistaxis
    • • Crepitation from air emphysema
    • • Unequal pupilary level

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