Conference Notes 3-27-2012




Pt presented with antero-lat STEMI and stroke symptoms.   DDX:dissection/endocarditis/prior mi with clot and embolism.

CTA was neg for dissection.  CT head showed some sign of stroke.

TPA was given

1% of MI patients will have stroke in 24 days.   Anterior MI is a risk factor for stroke.

0.1% of STEMI’s are caused by dissection.


14mo child with fever to 39.7 dx’d with viral illness and dc’d.  Came back 5 hours later with purpuric rash and LP showed meningitis.

<3mo: ecoli, GBS, listeria.  Tx: Cefotaxime and  ampicllin

>3mo: strep pneumo, neisseria, staph aureus.  Tx: ceftriaxone and vanco

Relationship with parents and good instructions are key to making sure parents brought child back to ER.   Parents impression of child’s condition is more sensitive than your clinical eval sometimes.


Signaling for help: highest ground is best,  SOS three short/three long/three short, three fires in triangle shape, mirror signaling.

SAM splint is a versatile and mobile splint material.

When splinting in wilderness, try to gently realign fracture fragments.

Be sure to pad your splints because using ski poles or sticks is not comfortable for patient.



96% of shoulder dislocations are anterior

Hill Sachs Deformity: impaction type fx on humeral head

If pt has an associated humeral neck fx with dislocation there is increased risk of avascular necrosis.

Intra-articular injection of 20ml of lidocaine can provide adequate anesthesia to perform reduction.

Posterior shoulder dislocation associated with seizure and lightning strike.  Much less common. Subtle signs of dislocation. Light bulb sign is when humeral head has the contour of a light bulb.

Luxatio Erecta: Inferior shoulder dislocation. Humerus is directed upward. Reduction is traction/counter traction

90% of hip dislocations are posterior.   Look for other injuries because these are high energy dislocations.   Patients can have sciatic nerve injury with posterior dislocations.

Femoral nerve injury can occur with Anterior dislocations

Shenton’s line: continuous curve from femoral neck to superior pubic ramus.  If not continuous suggests dislocation.

Hip dislocations do better with very prompt reduction.  It is an emergency.

Knee dislocation is a true ortho emergency as well.  Got to look for popliteal artery injury and check ABI’s.  ABI’s should be >0.9.  If ABI less than 0.9 then get angio or CT angio.   Tibial nerve or common peroneal nerves can also be injured.


When kids have chronic dull knee pain look for malignant lesions with xray


Pt coded.  After resuscitation EKG shows IRBBB.  PE considered and pt sent to CT.  Pt had recent SAH.

Chest CT showed bilat pe.  Ct head shows improved SAH.  Heparin started, pt was 13days after SAH. 

Pt  later had IR thrombectomy.  She did well.

EKG findings of PE: S1Q3T3,  Anterior T wave inversions,  IRBBB and tachycardia.    EKG has relatively poor  sensitivity/specificity for PE.

TPA contraindications mnemonic: TPA IS BAD

Trauma, pericarditis, active bleeding, intracranial pathology, bp >180, allergy, dissection


Lactate is a good marker of resuscitation status.  Base deficit can be used similarly with increasing negativity correlating with worsening outcomes.

Perimortem c-section should be done within 5 minutes of cardiac arrest.  Use large midline incision.  Make small uterine incison and extend with scissors

Pregnant woman with pneumothorax put tube in a higher rib space than normal because diaphragm is higher.

 Chest tube output: 15ml/kg  immediate   or 4ml/kg/hr  indicate need for surgery in kids.   In adults it is 1500ml immediate and 200ml/hr/4hours.

1:1:1 units prbc’s/ffp/cry is indicated for massive transfusion.

Antibiotics are indicated for open depressed, sinus related skull fractures and pneumocephalus. Tx with rocepin and vanco.

Head injury in pt on Coumadin.  Should always check INR. If INR is supratherapuetic, consider observation.

Impending herniation: Tx with mild hyperventilation with pco2=30-35, mannitol 0.25-1g/kg

Retrobulbar hematoma:  Retina can only tolerate ischemia for 90 minutes.  Do lateral canthotomy.

Zygomaticomaxillary fx: check facial sensation in multiple places, good eye exam, check jaw movement, extra ocular movement.

Fx of superior roof requires admission because it risks brain injury.   Fx’s of inferior and medial orbital walls can be repaired up to 2 weeks after injury.

Open jaw fx’s should get IV antibiotics and Oral Surgery consult, and admission.

Anogenital reflexes:anal wink, cremasteric reflex, bulbocavernosis reflex.

Neurogenic shock is hypotension due to cord injury,   Spinal Shock is physiologic loss of reflexes below spinal cord injury

Central cord syndrome: upper extremity more weak than lower extremity,

Brown Sequard: ipsilateral paralysis  and loss of proprioception,  contralateral pain and temperature loss

Flexion tear drop fx is unstable and requires surgery

NEXUS Criteria:  Midline posterior tenderness, intoxication, nl mental status, focal neuro deficits, intoxication

Canadian Rules: Severe mechanism of injury, age>65, extremity paresthesias,  able to rotate head 45 degrees.

Strangulation injuries should probably be admitted to observe for noncardiogenic pulmonary edema and delayed blunt laryngeal  (pt will have hoarseness and significant anterior neck pain) injury.

Carotid injuries can cause Horner’s syndrome.  


32 teeth in the adult mouth.   Start counting at upper right posterior molar.   Finish at lower right posterior molar.  

Primary teeth 6 months to 6 years.

Pericoronitis: inflammation of gingival overlying erupting tooth.

ABX for mouth organisms use PCN, Augmentin, Clindamycin.

Dental Caries and Pulpitis: Tx with abx and pain meds

Temrex in our dental box can be used to cover dental carie.  

Apical Periodontitis: fluid or abscess around root of tooth.  ABx treatment

Ludwig’s Angina: infection around teeth can extend into soft tissue planes in neck.

Periodontal abscess: starts from gingival margin.   ABx, drainage, pain meds

ANUG: due to anaerobes.  Patients with lowered immune response are more prone to this.   Also stress, poor sleep and other things can predispose.   Pain/ulcerated interdental papillae/bleeding gingiva.  Cholorhexidine rinses and abx.

Postextraction Pain:  less than 48 hours post op is self limited. Treat pain.  Greater than 48 hours think dry socket.   Topical anesthesia, irrigate socket,  oil of cloves/eugenol in paste or ribbon gauze gives immediate relief.

Post extraction bleeding: Tx with gelfoam, surgical, hemecon.   Local injection of lido with epi.

Ellis classification of dental trauma not used by dentists.  But ER boards do so, Class 1 enamil, Class2 dentin, Class 3 pulp.

Cover ellis 2 and 3 fx’s with calcium hydroxide paste.

Splint luxated teeth or root fx’s with Coe-Pak (zinc oxide)

Intrusive luxations should be left alone.  Don’t pull the tooth out further.  The dentist will wait to see if tooth moves down over several days.

Reimplant avulsed teeth as soon as possible.   Fluids to preserve tooth: hanks>saliva>milk>sterile saline.

Avulsed primary teeth, leave them out.