AFP Journal Review January 1, 2009 Cindi Hurley, MD MBA February 12, 2009.

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.