Conference 7-26-11 Topics

Iv Antibiotics are critical for open fractures.  Reduce fracture so bone is not exposed.  Don't use betadine dressings
After reducing a disolcation, put joint thru easy range of motion to assess the patients range of motion.  This is helpful info for the orthopedist.
Very few pediatric fractures have to be reduced in the ED.   If fracture is in plane of joint it will remodel very well even if there is diplacement and shortening
Supracondylar Fractures:  Admit all Gartland 3's (displaced fractures)
Pulselss but pink hand does not need emergent surgery.  Ischemic hand requires emergent surgery.
If there is varus angulation of elbow they need operative reduction within a week or they will have dformity for life.
When splinting elbow fractures don't splint with elbow flexed more than 90 degrees.   It decreases venous return.
If you are treating a pediatric elbow dislocation and on the f/u xray do not see the medial epicondyle, it may be stuck in the joint.
Femoral shaft fracture in kids under age 5 can go home in a splint from the rib cage to the lower leg.  Don't include the ankle in the splint.  Gotta rule out child abuse before they go home.  
Velcro splint is acceptable for a buckle fracture.
Reducing paraphimosis: thumbs on glans and index middle fingers on parphimotic ring
Use absorbable sutures when repairing the genitalia
Any young adult with painful scrotum needs an u/s.  Testicular cancer can present in a myriad of ways.
Blue dot sign on scrotum signifies torsed appendix testes.  Appendix testes is the remnant of the mullerian duct.   The wolfian duct forms the vas deferens, epidymus and ejaculatory duct.
Strangulated hernia will obscure the spermatic cord.
Varicocoele is usually on the left side.   Varicocoele is more prominent when standing and can go away when laying down.  If it stays prominent when laying down you have to consider retroperitoneal neoplastic process.
Priapism stems from the god Priapis who is the protector of the male genitalia.  (Not sure if that is greek or roman god)  Many drugs can cause priapism. Treat priapism  with phenylepherine injection.   First aspirate the corpora cavernosum on one side 50ml of blood (the copora communicate) then inject phenylepherine 1ml Q3min for one hour.  If that fails, GU will have to do a shunting procedure.
Ureteral stones more common with increase BMI, sunny climate, males, caucasions.  Stones more likely to pass if <6mm and distal ureter.  If  a patient has a stone <10mm and symptoms controlled, pt can be discharged.   If stone >10mm they will need a procedure.   Stone and sepsis needs iv abx and urgent drainage (stent or nephrostomy)
Traumatic placental abruption
AFib RVR and WPW
Supracondylar Fracture
ST segment elevation mi's
Look for R wave amplitude to decrease as mi evolves
Criteria for st elevation= 2mm in men, 1.5mm in women in precrodial leads, 1mm  for men and women in other leads
Inferior mi with st segment elevation of lead3>lead2  suggests right sided mi
Beware posterior mi with st depression and tall r wave in V1-V3 (carosel pony)
Code STEMI  requires attending to attending discussion
Vancomycin ominously has MIC creep with decreasing ability to treat MRSA. 42% has MIC of 1.
VRE already has 14% resistance to Linezolid
Gram neg can produce amp-C beta-lactamase which gives resistance to ceftriaxone and zosyn.
There is a new hyper toxin producing strain of c-diff (NAP-1 =60% of isolates at ACMC). Gotta use vanco.
Uncomplicated uti recommendations: 3 days bactrim, 7days of nitrofurantoin, or single dose 3g of phosphomycin (50bucks), or 3 days of a second generation cephalosporin.
Recommendation for community aquired cellulitis=ancef or nafcillin.  Early cellulitis in diabetic=unasyn.   severe diabetic foot infection=vanco/zosyn.
Verapamil Sensitive V-Tach
Differentiating vtach from svt with abberrancy: concordance, fusion or capture beats, morpholgy that is not c/w classic lbbb or rbbb, pt with hx of heart disease, av dissociation, rbbb with left ear>right ear, v5,6 predominantly negative all point to vtach.
Idiopathic Vtach occur in young patients with no heart disease. Excellent prognosis. QRS duration is around 120ms, left axis deviation, rbbb.  Responds to iv verapamil 2.5mg.