first aid—what not to miss · what not to miss-ankle injuries ottowa ankle rules •x-rays may be...
TRANSCRIPT
First Aid—
What not to missLora S. Regan, MD, MPH, FACOEM
Penn Medicine Lancaster General Health
September 6, 2019
Is first-aid just a stop-gap measure,
or can it be the main type of care?
https://www.redcross.org/
https://www.heart.org/en/cpr
Non-OSHA Recordable First aid
• OTC medication at nonprescription strength, tetanus immunizations
• Cleaning skin wounds, and coverings: Band-Aids™, butterfly bandages or Steri-Strips™
• Using hot or cold therapy, massages
• non-rigid elastic bandages, wraps, finger “guards”
• Drilling of a fingernail or toenail
• Removing eye foreign body with irrigation or cotton swab
• Removing non-eye foreign body by irrigation, tweezers, cotton swab
OSHA Recordable Medical Treatment
• Using medication in prescription strength
• Hepatitis B vaccine or rabies vaccine (if post-exposure)
• sutures, staples, surgical glue
• Splint or cast to immobilize parts of the body, except for transport
• physical therapy or chiropractic treatment
Value of first aid—local client
manufacturing/warehouse compared to
benchmarkFirst-Aid case
rate
OSHA recordable
case rate
Lost time case
rate
Modified work
case rate
Other
recordables
(Unknown) 5.0 1.7 2.1 1.3
10 1.8 0.5 0.7 0.9
Benchmark
https://www.bls.gov/iif/oshsum.htm
Case rate=
Cases/100 FTEs
Analyzing cases by injury type
Type of injury First-Aid only OSHA Recordable
Upper extremity-sprain/strain 53 33
Lower extremity-sprain/strain 61 11
Neck/Back strain/sprain 26 7
Contusion/crush injury 21 4
Wound 36 4
Head contusion/closed head injury 19 1
Chemical exposures 9 2
Abrasions, burns, eye injury, electrical injury 49 0
First Aid—what is “OK to miss”
(you can find out later)
• Shoulder rotator cuff tears
• Knee meniscus tear or anterior cruciate ligament tear
• Joints sprains without fracture
• Spinal disc herniation in absence of neurologic symptoms
First Aid ONLY providers
• MD/PA/CRNP’s are NOT the
best providers of first aid only
medical care
• Other licenses health care
providers: RNs, LPNs
• On site first responders
Psychological First Aid
• Convey to the injured worker
• I care about you
• I listened to your concerns
• You are in capable hands
• Many acute injuries are self-limited, and improve without “medical”
interventions
First-Aid Pain Management
Combining acetaminophen with nonsteroidal anti-inflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg. 2010; 110(4):1170-9 Ong CK; Seymour RA; Lirk P; Merry AF
Review of randomized controlled trials: 21 human studies of 1909 patients. The NSAIDs used were ibuprofen (n = 6), diclofenac (n = 8), ketoprofen (n = 3), ketorolac (n = 1), aspirin (n = 1), tenoxicam (n = 1), and rofecoxib (n = 1).
The combination of acetaminophen and NSAID was more effective than acetaminophen or NSAID alone in 85% and 64% of relevant studies, respectively.
What not to miss--chemical exposures
• Employee spilled concentrated cleaning solution on his foot.
• He removed shoe, briefly rinsed off foot
• Noticed discoloration on foot
• He threw away sock, put foot in plastic bag and put foot back in shoe
2 weeks after splash to the foot
• Safety Data Sheet reviewed:
• Alkaline Cleaner
• Corrosive to eyes, skin, mouth throat and stomach. Spray mists are extremely irritating to mucous membranes and upper respiratory tract.
• Potassium Hydroxide 10 – 30% CAS # 1310-58-3 pH 12
First Aid Measures for alkaline exposures
• Skin Contact: Flush skin immediately with plenty of running water for
45 minutes, more effective than soaking.
• Do not reuse clothing or shoes unless thoroughly decontaminated.
• Ingestion: Do not induce vomiting. Get medical attention.
• Alkaline exposures are worse than acid exposures that coagulate proteins and create a barrier for further chemical penetration.
First Aid Wound Management
Steri-Strips are good for:
• Wounds less than 1/4″ deep.
• Wounds less than 3/4″ long.
• No exposed fat in the wound.
• No exposed muscle in the wound.
When not to use Steri-Strips
• gaping open with irregular edges
• located over a joint
• lips, eyelids, or in the genital area.
• if bleeding not controlled with 10
minutes of direct pressure
• caused by an animal or human bite
What not to miss-flexor tendon injury
What not to miss-shoulder injury
• remove shirt, use gown if needed
• Inspection of landmarks of the
shoulder
• Range of motion
Anterior shoulder dislocation
Shoulder Dislocation Management
• Transfer to Emergency Department
• Neurovascular compromise is minimized with rapid treatment
• Shoulder immobilizer or arm sling if available
• May require sedation to reposition
• Follow up: surgery usually not needed
• Limit use of arm until pain resolves
• Out of work: 0 days to 4 weeks
Wrist/hand injury
FOOSH-Fall on outstretched hand
What not to miss- wrist/scaphoid fracture
Dorsal hand anatomy
Physical exam findings
in Scaphoid Fracture
Fall on hand-initial management
• If no swelling-try first aid
• If swelling and tenderness, obtain x-ray
• If fracture, can use temporary fiberglass splint pending ortho referral
• over the counter Velcro splint NOT best
• CAST is required 6 weeks
What not to miss-knee injuries
Ottowa Knee Rules
• X-Rays may be safely deferred if:
• Age is <55
• NO tenderness at head of fibula
• NO tenderness of the patella
• Able to bend knee joint >90 degrees
• Able to take 4 steps immediately at scene and >1 hour later
Knee surface anatomy
What not to miss-ankle injuries
Ottowa Ankle Rules
• X-rays may be safely deferred if:
• No tenderness of the posterior/distal 6 cm of the medial or lateral malleoli
• NO tenderness of the navicular region or base of 5th metatarsal
• Able to bear weight and walk 4 steps immediately and one hour later
What not to miss-calf injuries
Acute compartment syndrome
• Most common location is anterior compartment of the calf
• Contains extensor muscles of the toes, anterior tibial artery, and deep
peroneal nerve (supplies motor control for great toe dorsiflexors and
sensation to the webspace between the great toe and second toe)
• Syndrome develops due to fracture or muscle injury causing bleeding and
compression of the compartment
Symptoms of compartment syndrome
• Pain of ischemia is deep and poorly localized
• Not improved with conservative measures
• Pain increases with range of motion of the ankle
• Paresthesias of the affected nerve (numbness and tingling below the site of
injury in the foot)
Guidelines for implementing a trial of
“first-aid only” program
• Standing orders for x-rays using established criteria such as Ottawa Rules
• Implement first aid for 48-72 hours and schedule follow up (not “as
needed”)
• Aggressive use of OTC meds, ice, and topical modalities around the clock
• If injured worker not improved after 48-72 hours, refer for “advanced
medical care” using most appropriate site of care
Thank you for your time!
717-544-3155
Website:
http://lancastergeneralhealth.org/LGH/Our-Services/Outpatient-
Services/Occupational-Medicine.aspx