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AFP Journal ReviewAFP Journal ReviewJanuary 1, 2009January 1, 2009
Cindi Hurley, MD MBAFebruary 12, 2009
TopicsTopics
1. Principles of Casting & Splinting
2. Mgmt of Blood Sugar in Type 2 Diabetes
Casting & Splinting Casting & Splinting ReviewReview
Assess Need for Assess Need for ImmobilizationImmobilizationCasts & Splints serve to promote
healing, maintain bone alignment, decrease pain, protect the injury and compensate for weakness
Conditions that benefit from immobilization:
Fracture Inflammatory conditions
Sprains Deep lac repairs across joints
Tendon laceration Severe soft tissue injury
Reduced joint dislocations
What’s the Difference? What’s the Difference? Both start with application of a
stockinette & paddingSplinting involves non–
circumferential application of a plaster or fiberglass support held in place by an elastic bandage
Casting involves circumferential application of plaster or
fiberglass
Splint or Cast?Splint or Cast?
Must assess the stage & severity of the injury, potential for instability, risk of complications, and patient’s functional requirements
Splints used more often for simple or stable fractures, sprains, tendon injuries & other soft tissue injuries
Casting used for definitive and/or complex fractures
Advantages of SplintingAdvantages of SplintingFaster & Easier to ApplyMay be static & prevent motion
or dynamic & allow controlled motion
Allows for natural swellingEasily removed to allow for
regular inspection
Disadvantages of Disadvantages of SplintingSplintingAllow excessive motion at injury
siteInappropriate for definitive
treatment of unstable or potentially unstable fractures such as those requiring reduction, spiral fractures and dislocation fractures
Advantages of CastingAdvantages of CastingMore effective immobilization
Disadvantages of CastingDisadvantages of CastingTakes more time & skill to applyHigher risk of complications
Complications of Splinting & Complications of Splinting & CastingCastingCompartment Syndrome
◦ Most serious complication◦ Increased pressure within a closed space,
compromises blood flow & tissue perfusion◦ If pt experiences severe swelling, worsening
pain, numbness or tingling , or dusky appearance ER
Heat InjuryPressure Sores and Skin Breakdown
◦ often caused by pressure from a wrinkled, unpadded or underpadded area over a bony prominence
Complications, continuedComplications, continuedInfection
◦ Common with open wound◦ Moist, warm environment is ideal for
infectionIschemiaDermatitisJoint StiffnessNeurological Injury
GuidelinesGuidelinesInspect the involved extremity and
document skin lesions, soft-tissue injuries, and neurovascular status beforehand
Protect the patient’s clothingProperly position the extremity
before, during & after application of materials
Properly pad bony prominences and high-pressure areas
Guidelines, continuedGuidelines, continuedAvoid tension and wrinkles on
materialsUse the right temperature of water
– the hotter the water the faster the material sets and the greater the risk for heat injuries – use tepid water for plaster and room temp water for fiberglass
Do not dump water used on plaster down the sink – it will clog!
VideosVideoshttp://intermed.med.uottawa.ca/
procedures/cast/
Follow-Up Follow-Up Elevate the injured extremity to
decrease pain & swellingRefrain from getting the material wet Educate pt re: compartment
syndromeAvoid strong opioids so pain is not
masked that should prompt a doctor’s visit
Most require initial follow-up within 1 -2 weeks
Management of Blood Management of Blood Glucose in Type 2 Glucose in Type 2 Diabetes MellitusDiabetes Mellitus
Statistics on Type 2 Statistics on Type 2 DiabetesDiabetes6th cause of death in USLeading cause of kidney failureLeading cause of new blindness
in adultsMore than 20 million Americans
have T2DM, however 30% are undiagnosed
We Need to Focus OnWe Need to Focus OnLifestyle ChangesManagement of Cardiovascular
Risk FactorsManagement of Blood Glucose
Levels
Lifestyle ModificationsLifestyle ModificationsWeight loss goal of 7%
◦Reduces incidence of T2DM by 58% !!!
Exercise goal of 150 minutes per week ◦(30 mins/day x 5 days/week)
TLC much more effective than Metformin in reducing blood glucose & HbA1C
Mgmt of Cardiovascular Mgmt of Cardiovascular Disease Risk FactorsDisease Risk FactorsInterventions to manage blood
pressure, cholesterol and microalbuminuria have been shown to decrease mortality
Use ASA if T2DM and ◦Have existing CAD◦Have RFs for CAD◦Are over 40 yo
Mgmt of Cardiovascular Mgmt of Cardiovascular RF’sRF’sUse Statins if T2DM and
- have existing CAD- they are older than 40 with at least one CAD RF
Use ACE or ARBs if T2DM and ◦Micro- or macroalbuminuria
Management of Blood Management of Blood GlucoseGlucoseOral AgentsOral AgentsBiguanidesSulfonylureasNon-SulfonylureasAlpha Glucosidase InhibitorsAmylin AnaloguesIncretin EnhancersIncretin MimeticsThiazolidinediones (TZDs)
BiguanidesBiguanidesExamples: Metformin (Glucophage) Mechanism: decreases hepatic
glucose production and intestinal glucose absorption; and to a lesser extent, increases insulin sensitivity of peripheral cells
SA’s: nausea, diarrhea, flatulenceCaution: RI (d/c if Cr > 1.4), using IV
dyeCost: $20-30/month if genericNote: 1) only hypoglycemic agent
shown to reduce mortality 2) approved for children > 10 yo
Insulin Secretatogues: Insulin Secretatogues: SulfonylureasSulfonylureasExamples: Glyburide, Glipizide,
Amaryl Mechanism: incease insulin
secretion from the pancreatic islet beta cell by closing K+ channels
SA’s: hypoglycemia, wt gainCost: $50/month
Insulin Secretatogues: Insulin Secretatogues: Non-sulfonylureasNon-sulfonylureasExamples: Starlix, Prandin Mechanism: stimulates
pancreatic islet beta cell insulin release
SA’s: hypoglycemia Cost: $175/month
Alpha Glucosidase InhibitorsAlpha Glucosidase Inhibitors
Examples: Acarbose (Precose), Miglitol (Glyset)
Mechanism: acts at the brush border in the small intestine to delay glucose absorption
SA’s: flatulence, abdominal pain, diarrhea
Cost: $80-$90/monthNote: Shown to decrease CV
events
Amylin AnaloguesAmylin AnaloguesExamples: Pramlintide (Symlin) Mechanism: exact mechanism of
action unknown; decreases postprandial plasma glucose rise, suppresses glucagon secretion, slows gastric emptying
SA’s: nausea, vomiting, anorexia, headache, diarrhea
Caution: Severe hypoglycemia can occur, especially with co-administration of insulin
Cost: $150-$250/month
Incretin EnhancersIncretin EnhancersExamples: Januvia, Onglyza Mechanism: slows incretin
metabolism, increasing insulin synthesis/release, decreasing glucagon levels
SA’s: nausea & vomitingCaution: adjust dosage in pts
with RICost: $180/month
Incretin MimeticsIncretin MimeticsExamples: Byetta Mechanism: enhances insulin secretion
in response to elevated plasma glucose levels
SA’s: nausea & vomiting, diarrhea, dizziness
Caution: not recommended in pts with Cr Cl < 30
Cost: $250/monthTidbit: derived from a compound found
in the saliva of the Gila monster, a large lizard native to the southwestern US
Thiazolidinediones (TZDs)Thiazolidinediones (TZDs)Examples: Actos & Avandia Mechanism: increases insulin
sensitivity in peripheral tissue, and to a lesser extent, decreases hepatic glucose production
SA’s: wt gain, fluid retentionCaution: liver dz, pregnancy, HF,
association between Avandia and CV events
Cost: $150/month
Goal for Blood GlucoseGoal for Blood GlucoseMaintain as close to normal as
possible without causing hypoglycemia
ADA recommends A1C < 7%In relatively well-controlled DM,
home monitoring has not been associated with significant improvement in A1C levels
Rapid Acting Insulin Rapid Acting Insulin
1. Lispro (Humalog), Aspart (Novolog) onset: 5-15 minutes peak: 1-2 hours duration: 4-5 hours
2. Regular (Humulin R) onset: 30-60 minutes peak : 2-4 hours duration: 8-10 hours note: inject 30 minutes before meal
Intermediate-Acting Intermediate-Acting InsulinInsulinNPH (Humulin N) onset: 1-2 hours peak: 4-8 hours duration: 10-20 hours
Long-Acting InsulinLong-Acting InsulinGlargine (Lantus) onset: 1-2 hours peak: relatively flat duration: 20-24 hours dosing: start at 10 units per
day, titrate at 2 units per day q 3 days
ReferencesBoyd A, Benjamin H, Chad A.
Principles of Casting and Splinting. American Family Physician. Jan 1, 2009.
Ripsin C, Randall U. Management of Blood Glucose in Type 2 Diabetes Mellitus. American Family Physician. Jan 1, 2009.