Conference Notes 10-9-2012
McDermott/C. Kulstad Oral Boards
Sorry I missed this Oral Boards Triple Cases but the highlights per Dr. Kulstad were:
Case 1: spinal shock fro cspine injury: treat with iv fluids, pressors if needed. Board Question Alert! Pt’s may be paradoxically bradycardic with hypotension. Neurogenic shock refers to hypotension, usually with bradycardia, attributed to interruption of autonomic pathways in the spinal cord causing decreased vascular resistance. Patients with TSCI may also suffer from hemodynamic shock related to blood loss and other complications. An adequate blood pressure is believed to be critical in maintaining adequate perfusion to the injured spinal cord and thereby limiting secondary ischemic injury. Albeit with little empiric supporting data, guidelines currently recommend maintaining mean arterial pressures of at least 85 to 90 mmHg, using intravenous fluids, transfusion, and pharmacologic vasopressors as needed
Case 2: Heat stroke: Rapid cooling. Altered mental status separates heat stroke from heat exhaustion.
Case 3: Stingray injury: Hot water treatment and don’t close wound. Xray to make sure no fb
Kessen Hand Trauma (Sorry missed a lot of this lecture)
Jersey finger is due to rupture of the flexor tendon. Pt can’t flex finger. Called Jersey finger because football players would get this when tackling someone by grabbing their jersey.
For amputations: get all the pieces and x-ray all the pieces. Digit survival is 12 hours when warm, 24 hours if cooled. Major replant survival is 6 hours warm, 12 hours cold. Keep amputated digit cool by wrapping in saline soaked gauze, place in a plastic bag and put the plastic bag on ice. We have a cool to keep on patients cart.
Harwood comment: MRI can be used to identify FB and many specialists have access to MRI in their offices. Using a tourniquet to get a bloodless field will be less painful for a patient if you keep the cuff pressure only 20 mm hg above the patient’s systolic BP. Current standard of care is that EP’s don’t do tendon repairs in most areas of the US. Hand specialists and ortho specialists will take almost all tendon injuries.
Discussion of Regional anesthesia for the hand. See Diagrams Below
Flexor tendon approach
Web space approach
Levato UTI treatment (I missed a lot of this lecture also)
Uncomlicated UTI’s use macrobid for 5 days or keflex for 7 days. Bactrim has too much resistance to be considered reliable. Cipro should be used only if other options not possible because cipro use has complications of c-diff/neuro effects/tendonopathy/interactions with Coumadin. Use cipro for only 3 days for cystitis.
Collander Unstable C-spine Injuries
Intubate for Cspine fractes C5 or higher.
Rectal tone presence identifies incomplete cspine injuries.
Nexus criteria are 99.6 % sensitive for clinically significant Cspine injuries.
The NLC decision instrument stipulates that radiography is not necessary if patients satisfy ALL five of the following low-risk criteria:
- § Absence of posterior midline cervical tenderness
- § Normal level of alertness
- § No evidence of intoxication
- § No abnormal neurologic findings
- § No painful distracting injuries
Insignificant injuries were defined as those that would not lead to any consequences if left undiagnosed. The NEXUS investigators evaluated 34,069 blunt trauma patients who underwent radiography of the cervical spine comprised of either a 3-view cervical spine x-ray or a cervical spine computed tomography (CT) scan. Of these patients, 818 (2.4 percent) had sustained a cervical spinal column injury. Sensitivity, specificity, and negative predictive value (NPV) of the NLC were found to be 99.6 percent (95% CI 98.6-100), 12.9 percent (95% CI 12.8-13.0), and 99.9 percent (95% CI 99.8-100), respectively
Canadian Cspine rule is 100% sensitive for clinically significant spinal injury.
The CCR involves the following steps:
- § Condition One: Perform radiography in patients with any of the following:
- · Age 65 years or older
- · Dangerous mechanism of injury: fall from 1 m (3 ft) or five stairs; axial load to the head, such as diving accident; motor vehicle crash at high speed (>100 km/hour [>62 mph]); motorized recreational vehicle accident; ejection from a vehicle; bicycle collision with an immovable object, such as tree or parked car
- · Paresthesias in the extremities
- · Simple rear end motor vehicle accident; excludes: pushed into oncoming traffic; hit by bus or large truck; rollover; hit by high speed (>100 km/hour [>62 mph]) vehicle
- · Sitting position in emergency department
- · Ambulatory at any time
- · Delayed onset of neck pain
- · Absence of midline cervical spine tenderness
Patients who do not exhibit any of the low-risk factors listed here are NOT suitable for range of motion testing and must be assessed with radiographs.
If a patient does exhibit any of the low-risk factors, perform range of motion testing, as described in Condition Three below.
- § not
In the derivation study, the CCR demonstrated a sensitivity of 100 percent and a specificity of 42.5 percent for identifying clinically important cervical spine injuries
Flexion teardrop fracture: Anteroinferior portion of vertebral body is fractures off. Can have associatated anterior cord syndrome. May have widening of spinous process spaces.
Wedge Compression fracture: Posterior ligament disruption may be associated. Considered unstable if >25% compression of the anterior border of the vertebral body or widening of the spinous processes.
Extension teardrop fracture: Anteroinferior portion of vertebral body is avulsed. Fragment is usually taller than wide.
Hangman’s fracture: Fracture of both pedicles of C2. C2 displaces anteriorly. Usually see in car and diving accidents. Patients can be neurologically intact because there is a wide canal at that level.
C1 Jefferson Burst Fracture: Due to an axial load. C1 is laterally displaced on C2. If sum of total displacement of lateral masses from body of c2 is greater than 7mm that is the criteria.
Occipital-atlantal Dissociation: figure
The Powers ratio is commonly used to assess for atlanto-occipital dislocation (figure 9). It is defined by the ratio of BC:OA, where BC is the distance between the basion and the midpoint of the posterior laminar line of C1, and OA is the distance between the midpoint of the posterior margin of the foramen magnum (opisthion) and the midpoint of the posterior surface of the anterior arch of C1 . A ratio greater than one suggests anterior subluxation.
Another radiologic finding suggestive of an atlanto-occipital dislocation is disruption of the “basilar line of Wackenheim,” a line drawn from the posterior surface of the clivus to the odontoid tip [18,19]. Normally, the inferior extension of this line should just touch the posterior aspect of the tip of the odontoid. If the line runs anterior or posterior to the odontoid tip, this suggests an atlanto-occipital dislocation.
Carlson Salicylate Toxicity
1960’s there was concern for ASA causing Reyes syndrome and people were told not to have asa at home. Toxic ASA exposures decreased for a few decades because people didn’t keep ASA at home as much. Since the 1990’s ASA use has again resurged due to it’s value for cardiac disease.
Board Question Alert! Oil of wintergreen has a very high concentrate of methylsalicylate. 7grams of ASA in a teaspoon!
Enteric coating of ASA prolongs absorption to 4-6 hours and asorption is less predictable.
ASA inhibits cycloxygenase to block prostaglandin synthesis. Toxic levels stimulate respiratory center (respiratory alkalosis), stimulates vomiting center, increased capillary permeability (pulmonary edema) and uncouples oxidative phosphorylation (metabolic acidosis, fever). Pts will develop ketosis and hypokalemia in addition to metabolic acidosis and respiratory alkalosis. Toxic patients also will have tinnitus.
More severe toxicity will cause agitation, dehydration, acid/base disturbances, pulmonary edema.
A death from ASA is a CNS death. ASA is a brain poison.
ASA poisoning gets missed because it looks like sepsis or alteredmental status or chf.
Toxic dose is >150mg/kg. Serious toxicity can be approximated by 1 (325mg) tab per kg. therapeutic level of salicylate is 3-6mg/dl, toxic level is >30mg/dl. Levels correlate poorly with toxicity. Done nomogram is no longer used because it is inaccurate. Don’t use the Done nomogram.
Board Question Alert! If you need to intubate a patient with severe ASA toxicity or any patient who is markedly tachypneic, be sure to set your ventilation parameters to maintain the patient’s minute ventilation so they don’t become more acidotic.
Management: Activated charcoal, additional dose 2 hours later of activated charcoal, alkalinize blood and urine (target urine ph is 7.5-8), need to keep potassium in normal range or you will not be able to effectively alkalinize the urine. You will usually need to hang a lot of potassium. Hemodialysis is indicated for severe overdoses. (acute level>100, chronic level>60, pulmonary edema, renal failure, pulmonary edema, rapidly rising levels, altered mental status and academia.
Mistry FirstNET EMR
Tech support continues thru 10-17. Make sure you work some shifts/see some patients while tech support is her on site.
Chintan went through multiple optimizations of First Net.