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--- resident:common_consults [2019/06/20 19:04] – [Sacral Decub] ryan
+++ resident:common_consults [2025/08/09 16:22] (current) – [Distal radius fracture] victoria
@@ Line 1: / Line 1: @@
+==== Lower Extremity Soft Tissue Coverage ====
+  * Mechanism of wound
+  * Size of wound
+  * Prior surgeries
+  * Existing hardware?
+  * Current dressing/vac, etc
+  * Weight bearing status
+  * Infection? Osteo versus soft tissue only.
+  * Antibiotics? Follow ALL cultures; know if they are soft tissue versus bone
+  * Has CTA runoff been obtained?
+  * Needs to be on SQH 5000U TID and hold the AM dose if going to OR
+  * Follow up CBCs especially after OR with ortho. If Hct is <28, will transfuse day BEFORE surgery.
+  * If planning for poss free flap, need to T&C 2u RBC.
+  * If going to surgery, need to make NPO, IVF, pre-op abx.
+No nicotine patch
+Example:\\
+Soandso brokemyleg (MRN, Rm #, Ortho primary)\\
+F with open bimalleolar left ankle fx. 1/15: I&D, ex-fix. Now s/p I&D, ex-fix removal, ORIF 1/29.\\
+Ortho plan for WV change today in OR. Will get pictures.\\
+Plan for Left medial ankle coverage with free flap, possible wound vac, possible skin graft, possible vein graft.\\ Scheduled 2/5/20 12:00.\\
+[ ] Mark and consent\\
+[X] CTA runoff: L AT open to hardware, DP open. L PT open. L peroneal occluded in zone of injury.\\
+[ ] Lovenox ppx: Change to SQH TID 5000U after Ortho OR\\
+[ ] F/u CBC- pending this AM (need pre-op trx?)\\
+[ ] T&C 2u RBC for OR 2/5.\\
+[ ] Need to hold SQH 2/5.\\
+- OR cx 1/29: NGTD.\\
+- Abx: none.\\
+==== Hand Pus ====
+Dr. Gordon is particularly  particular about these. You "wick" the wound, not pack it. He likes a 1/4 inch penrose drain, but he understands more practically, that a sliver of a glove is the easier option. Suture it to itself so it can't possibly fall out. ALWAYS get a culture if you would like to stay in this program. If the patient is compliant and able to care for themselves, he wants the patient to soak the hand once an hour for 10-20 minutes. If you are deciding between the OR, it's best to have inflammatory markers (WBC, ESR, CRP) and trend them.
 ==== Chest Wall Recon after sternal dehisence of sternectomy ====
@@ Line 23: / Line 61: @@
 Plan for postoperative disposition:  pressure relieving surface obtained prior to debridement, medical management and rehabilitation plan.
-The patient is to follow up with Dr.  *** in outpatient clinic.
+The patient is to follow up with Dr. *** in outpatient clinic.
 OR
-Surgical closure of pressure sores has a high rate of failure. To maximizing the patient's chance for success, the following criteria must be met prior to consideration of soft tissue closure or reconstruction for chronic pressure ulcers:
+.PLASTICSPRESSURESORECONSULT
-- Wound:
-The patient must have source control. Staged reconstruction can be considered for a clean wound after adequate debridement and antibiotic therapy optimization.
-Debridements should be performed by the patient's primary surgical service or by the general surgery service.
-If evaluation for osteomyelitis or bone biopsy is desired, the orthopedic service should be consulted. Often an MRI is necessary.
-The infectious disease service should be involved for antibiotic recommendations.
-The clean wound should be managed with a wound vac whenever possible until ready for soft tissue closure. There should be evidence of the ability to form healthy granulation tissue in the wound. If wound care recommendations are needed in the interim, please consult the wound care team.
-- Nutrition:
-Albumin > 3.0 gm/dl
-Prealbumin >16 mg/dl.
-In general, patients with osteomyelitis and inflammatory processes do not have a normal prealbumin (negative acute phase reactant). However, if they can show consistent elevation in prealbumin over 3 weeks, they can be considered candidates for reconstruction. A nutrition consult should be ordered if these goals are not being met.
-- Medical comorbidities:
+====Distal radius fracture====
-Medical comorbidities, such as diabetes, must be well controlled.
+Is it intraarticular or extra articular?
-Control of any spasms or release of fixed contractures that may impair flap mobilization should be obtained prior to soft tissue closure.
-A bowel regimen must be well established and urinary control must be obtained. If necessary, stool diversion must be arranged prior to soft tissue closure.
-- Postoperative disposition:
+Is the patient neurovascularly Intact? (Check ulnar and radial pulses, sensation in radial, medial, and ulnar distributions)
-Pressure relieving surfaces should be used during hospitalization and should be obtained for outpatient use prior to closure (e.g. mattress, wheelchair).
+Motor exam as much as pain limits
-Outpatient wound care, if needed, should be arranged.
-Medical management follow up and rehabilitation plan should be set up.
+The ED should have hand, wrist AND forearm X-rays ordered
-Physical therapy, occupation therapy, and social work should be involved with the disposition process.
+Ask the ED to have a mini C-arm ready, Ask them for Finger traps.
-Once these parameters have been met, the patient can follow up with Dr. *** in outpatient plastic surgery clinic for evaluation.
+Be sure there is Lidocaine 1% without epi, and 18 G needle to draw, 27 or 30 G needle to inject, two 10 mL syringe, alcohol wipe.
+Gather plaster roll (normally will fold into two sets 13-15 sheets each for a dorsal-volar splint, webril, a basin for warm water, bias wrap and an ACE to splint the patient after the reduction
+Call XR 88657
+Place order XR fluoro diagnostic set up less than one hour