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A Minnesota tube (choice A) is a type of esophageal tube with a large balloon at thedistal end. Thetube, much less commonly used today, can be used to tamponade esophagealvariceal bleeds. It hasno benefit in management of gastric bleeds. If there is evidence that this patient is continuing to bleed, then urgent upperendoscopy (choice B) iswarranted. Otherwise, stabilization with red cells, placement of large boreintravenous access, andstable transport to the endoscopy suite is both safer and more appropriate.
For refractory cases of upper GI bleeding gastrectomy is often performed. Since thispatient has hadno therapeutic intervention as of yet, an urgent gastrectomy (choice D) is notindicated at this time. It is unclear how much this patient has bled since there is no hematocrit level.Therefore, to transfuse2 units packed red cells (choice E) at this time is not appropriate. Rather, ensuringthat the patienthas large-bore intravenous access and has type-specific blood available are bothappropriateinterventions.A 3-year-old boy is brought to the emergency department 3 hours after being bittenon the hand byanother boy at his daycare center. The child's mother is frantic and wants to "sue thecenter for allowingsuch behavior!" The child is up-to-date on his vaccinations. The other child is veryhealthy and hisvaccinations are current. On physical examination, there is puncture wound on theright hand. You gentlyclean the wound and consult with the hand surgeon who says that there does notappear to be anydamage to the nerves, muscles, tendons, or joints of the hand. The most appropriatenext step is to A. close the wound with a sutureB. obtain a wound cultureC. provide ampicillin-sulbactamD. send him home with a follow-up appointment within 48 hoursE. vigorously irrigate and debride the woundExplanation:The correct answer C. Human bites have a high rate of infection and should alwaysbe treatedpresumptively with an antibiotic. The most common organisms to infect the woundare streptococci, S.
aureus, Eikenella corrodens, and anaerobes. The preferred antibiotic is ampicillin-sulbactam oramoxicillin-clavulanate. An alternative for a penicillin-allergic patient istrimethoprim-sulfamethoxazoleplus clindamycin. The wound should be inspected within 48 hours for signs ofinfection.Since puncture-type hand wounds have such a high risk of infection, suturing thewound could enhancethe risk of infection. Therefore it is inappropriate to close the wound with a suture(choice A).A wound culture (choice B) should only be taken in wounds less than 8 hours oldwhen there are signsof infection (erythema, foul odor, and exudate) and in wounds greater than 8 hoursold (except if morethan 24 hours and without signs of infection).