Conference Notes 10-10-2018

Paquette/Friend Oral Boards

Case 1. 45 yo female with left knee injury while doing yoga.

 Lateral tibial plateau fracture

Lateral tibial plateau fracture

Tibial plateau fractures can be difficult to diagnose. Soft tissue injuries associated with tibial plateau fractures may influence outcomes. Anterior cruciate ligament and medial collateral ligament injuries are associated with lateral plateau fractures, whereas posterior cruciate and lateral collateral ligament injuries occur with medial plateau fractures. A Segond's fracture (see below) is pathognomonic for an anterior cruciate ligament injury, and it is important recognize and treat the ligament injury, rather than just the plateau fracture.12 Potential complications of tibial plateau fractures include popliteal artery injury with high-energy displaced fractures, the development of deep venous thrombosis, and osteoarthritis. (Tintinalli 8th ed)

 Segond Fracture

Segond Fracture



Case 2. Pregnant female patient presents with abdominal pain and syncope.

 Fast exam shows free fluid in Morrison’s pouch.  In the setting of early pregnancy with abdominal pain this finding is highly suggestive of ruptured ectopic pregnancy.

Fast exam shows free fluid in Morrison’s pouch. In the setting of early pregnancy with abdominal pain this finding is highly suggestive of ruptured ectopic pregnancy.

Patient was diagnosed with ruptured ectopic pregnancy and was taken to the OR.

Case 3. 40yo male presents with altered mental status and hypotension. EKG is shown below.

 3rd degree heart block

3rd degree heart block

Patient ingested a toxic dose of digoxin.

Digoxin poisoning can induce nearly every form of dysrhythmia or conduction disturbance. Classic ECG findings include supraventricular tachydysrhythmias (atrial flutter or fibrillation) combined with variable AV nodal blockade resulting in slow ventricular rates (Figure 59-1). Bidirectional ventricular tachycardia is nearly pathognomonic for serious digoxin toxicity. Additional ECG findings include sinus bradycardia, ventricular bigeminy, and ventricular fibrillation. (Tintinalli 8th ed)

 Bidirectional ventricular tachycardia which is highly specific for digoxin toxicity

Bidirectional ventricular tachycardia which is highly specific for digoxin toxicity

Chinwala M&M

To protect the anonymity of the case, I will only give some take home points.

Be sure to re-eval sign-out patients who are altered or intoxicated.

If you initiate a treatment, be sure you re-evaluate the patient in a timely fashion to assess how the treatment is working and how the patient is doing.

Lorenz/Shroff Toxicology Escape Room

Anion Gap calculation= “ABC” NA-(Bicarb +Chloride)

Osmolar Gap calculation streamlined= 2NA + BUN/3 +Glucose/20 + ETOH/5 (ETOH is actually 4.6 and the way to remember this is 4 6packs in a case of beer.)

ASA, Lithium, Toxic Alcohols (ALT)= things you can dialyze.

 TCA Overdose EKG. Wide terminal R wave in AVR and wide QRS complex in all leads. Treat with IV bicarb.

TCA Overdose EKG. Wide terminal R wave in AVR and wide QRS complex in all leads. Treat with IV bicarb.

 Ricin is a protein that inhibits ribosomes. It is used as a bioterrorism agent. It is dervied from the castor plant.

Ricin is a protein that inhibits ribosomes. It is used as a bioterrorism agent. It is dervied from the castor plant.

 Foxglove is a botanical cardiac glycoside. Basically it can cause digoxin toxicity. Treat with FAB fragments.

Foxglove is a botanical cardiac glycoside. Basically it can cause digoxin toxicity. Treat with FAB fragments.

 Amanita phylloides is the most toxic mushroom. Dr. Carlson noted the “death cup” at the base of the mushroom.

Amanita phylloides is the most toxic mushroom. Dr. Carlson noted the “death cup” at the base of the mushroom.

Dr. Carlson recommended using IV NAC for all patients with acetaminophen toxicity for practical reasons. Pregnant patients need IV NAC to get better fetal treatment.

Dr. Lovell comment: Critical Factoid for figuring out how many grams are in a given volume of solution. %=grams/deciliter. So 0.9% NS has 0.9 grams of saline in a deciliter and by extrapolation, 9 grams of saline in a liter of fluid.