GRIPPO-FELDER ORAL BOARDS
Case 1: Borhaave’s Esophogus. Consider PE, consult surgery, start broad spectrum antibiotics. Pregnancy and ETOH are risk factors for esophageal rupture. Don’t do a barium swallow because arium is not good for the mediastinum. Gastrograffen is preferred to evaluate with a swallow study or chest CT.
Harwood comment: If you see mediastinal air or air in soft tissue either on CXR or CT with this symptom complex, just consult surgery and start antibiotics. The ER doc doesn’t need to order an esophogram.
Case 2: Lyme Disease. Recognize erythema chronicum migrans, treat with doxy for kids over 8 and non-pregnant. 21 day course of doxy, amoxicillin, cefuroxime, or macrolide. Tick has to be on the patient for 36 hours to transmit disease.
Harwood comment: For oral exam with non-critical/toxic patient you don’t have to put an IV in. You may get scored down for system based practice. Think out loud so the examiner knows what you know.
Case 3: Polytrauma. Cspine immobilization, secure airway, chest tube, re-assess vital signs. Always remember to get complete set of vitals including accucheck glucose and UCG. Ask for family/paramedics. Treat pain. Be systematic in your exam for injuries.
BOLTON FUTILITY
Decisions: Respect the patient’s autonomy. The decision should be impartial and follow the Golden Rule (treat others as you would want to be treated) or Platinum Rule (treat other as they would want to be treated). Universable=categorical imperative=moral act that is always right in the same situation. Interpersonal justification=would you be comfortable with your decision if it is written in the newspaper?
Futility= action that has no useful purpose. AMA CEJA: there is no accepted definition of medical futility.
80% of persons die in a medical environment. People prioritize quality of life, touch of family at the time of death. They don’t prioritize prolongation of life at any cost.
Futility problem: patients and families have unreasonable expectations of the capacity of medical care to return the patient to prior state of health. This is based on peoples exposure to TV and movies where CPR and ICU care provide miracle saves. Physicians have a lot of difficulty prognosticating to patients and family with the goal of lower expectations. We frequently abandon patients/families to their own autonomy. (Do what you think is best).
We should help families/patients understand their goals prior to making end of life decisions.
You don’t have to be a DNR patient to be in hospice. It is however somewhat contradictory philosophically. The criteria for hospice is only an expected life span of less than 6 months.
Pt’s don’t have the right to demand treatment. Beneficence: CPR has 0% chance of survival with metastatic neoplasm admitted to the hospital. Justice: Fair resource allocation.
Harwood comment: After every successful resuscitation, look for the underlying cancer.
Girzadas comment: The EP can also factor in the pain or lawsuit that may impact the treating physician from the family.
Barounis comment: Recent case in ER having to decide whether to give post-resuscitation hypothermia in a young patient with metatstatic cancer who had ROSC following CPR. Some ICU personnel complained that the ER staff should not have cooled the patient. Everyone agreed that the case was extraordinarily difficult. Most agreed that if pt was not DNR and resuscitation was done and had ROSC then you have to give hypothermia therapy.
Willison comment: The LET form is very imperfect. Most people at the lecture agreed that the multiple check box format brings up ethical inconsistencies.
WILLISON/SALZMAN TRAUMA RESUSCITATION
Be sure to use personal protection like masks/eye shields/gloves/gowns/shoe covers.
Try to organize your team as much as possible.
Abnormal vitals, pregnant patients, elderly, another fatality, fall over 20 feet, auto vs. ped are all prearrival markers for badness.
To intubate, loesen c-collar but have a second person hold in line stabilization until tube is secured. Then re-apply the collar.
New info: 28 or 32 FR tube was no better or worse than 38 or 40FR tube.
Don’t “rock the pelvis” just give one firm push on the ASIS bilat. If it moves it is fractured.
Fix scalp lacs. Patients can bleed severely and even rarely bleed to death. Tourniquets (BP cuff at 300mm hg) can sometime be life saving but use these rarely and cautiously.
When transfusing large volume of prbc’s, match units of prbc’s, ffp and possibly platelets.
Positive FAST scan, Systolic <90, HR>120, penetrating injuries: 3-4 of these are high risk for needing massive transfusion. 1 probably not.
Penetrating wounds to abdomen/flank/low back/pelvis require rectal exam. Other injuries you can be more selective with rectal exams.
Keep patients warm in ER.
New Thoughts from Scott Weingart for Traumatic Arrest: No closed chest CPR, no acls meds, first airway is LMA, bilat finger thoracostomy, cardiac ultrasound looking for tamponade.
Salzman comments: ED thoracotomy only good for penetrating chest wounds (optimally stab wound to heart) that cause tamponade. Heart is very delicate and it can be easily damaged by a scalpel or by fingers during internal CPR. ED thoracotomy for blunt trauma is futile.
Can consider ED thoracotomy to cross clamp aorta for a patient who has exsanguinated from a limb amputation. Give patient rapid prbc transfusion and do cardiac massage.
Harwood comment: It’s a thought.
Barounis comment/Salzman response: Massive transfusion protocol for untable, hypotensive pelvic fractures should be started in ED. Pt’s with other types of injury, the protocol has to be used more judiciously. If the protocol is initiated you can always back off if bleeding lessens. Patients that need to go to IR are more likely to need the protocol than patients going directly to OR. Level 1 transfuser is a critical tool during resuscitation.
FORT 5 SLIDE F/U
Poly drug overdose including TCA. PT was agitated. Intubated, sedated with propofol. Toxsicon recommended charcoal, serial ekg’s and bicarb for QRS >100ms. Initial ekg was ok/not wide/no terminal prolongation of QRS (big R wave) in AVR. Remained stable over 16 hours in ER. Was extubated and transferred to psychiatry.
TCA: sodium channel block, antihistamine, anti-muscarinic, K efflux blockade, alpha blocker, and gaba blockade effects. “Dirty Drug” has multiple effects.
Treatment: Seizures give Benzos. Hypotension give fluids and pressors. QRS prolongation give sodium bicarb. Dialysis is worthless due to high volume of distribution.
Harwood comment: Bicarb is the main treatment for EKG abnormalities. Brian said if bicarb not helping consider magnesium.
HERRMANN 5 SLIDE F/U
Child with GSW to right thigh. Pt had right femoral arterial injury. Hard signs with loss of distal pulses and pulsatile bleeding. Pt also had abnormal ABI’s. CTA showed injury to femoral artery. Prbc’s transfused. Pt went OR. Surgeons used saphenous vein from contralateral leg in reverse orientation (to negate the venous valves) to fix artery.
ABI has 98% diagnostic accuracy. Measure BP in all 4 extremities. Divide ankle systolic BP by higher of two upper extremity systolic bp’s. ABI<0.9 is abnormal and pt should get CTA or go to surgery.
Hard signs: abnormal pulse, arterial bleeding, pulsatile hematoma, bruit, thrill, distal ischemia.
Barounis comment: Vascular injury signs can wax and wane. These patients are tricky. Need re-exams if the initial decision is to observe so not to miss developing hard signs.
Chastain comment: Compartment syndrome has been known to develop on trauma patients after the initial injury. Stay alert even if you are tired.
KESSEN RSI DRUGS
Pre-treatment: moderates reflexic sympathetic response to laryngoscopy. Phayrnx and larynx are highly innervated with sympathetic and parasympathetic nerves. LOAD: Lido (no study shows neuro outcome improvement/Opioids (fentanyl can be considered for pain) /Atropine (for kids <5yo getting succ)/
Nelson comment: Contrarian view is that all these pretreatment drugs increase complexity and delay intubation.
Etomidate is most hemodynamically neutral sedation drug. Consider Ketamine as an alternative in the septic shock patient to avoid adrenal suppression.
Ketamine provides anesthesia and analgesia. Increases cerebral blood flow. May increase BP. It is a bronchodilator. May elevate ICP. Watch out for emergence phenomenon.
Propofol causes anesthesia and amnesia. May cause hypotension. No analgesic properties.
Versed provides anesthesia/amnesia but not analgesia. Can cause hypotension.
Barbiturates can provide anesthesia/amnesia and analgesia. Hypotension. Suppresses WBC function/recruitment.
Succinylcholine contraindicated in patients who have had severe trauma, burns, neuro injury all more than 72 hours prior to ED visit. These are not a problem if insult occurred the day of ED presentation.
Mistry comment: Many absolute contraindications to succinylcholine are actually relative contraindications and succ is pretty safe.
Rocuronium has less than 1 minute onset. Intubation conditions are similar to succinylcholine.
Sugammadex is a reversal agent for rocuronium that is being tested in Europe. Cuts the spontaneous ventillarion time from 400s to about 200s.
Harwood comment: Kid with severe astha, “Your risk of killing this patient is going up and up” Use etomidate, atropine to decrease secretions, and succinylcholine if airway is not predicted to be overly difficult.
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BENJAMIN TICHO OPHTHO TRAUMA
20:20 vision means you see at 20 feet what a normal person is expected to see at 20 feet. 20:40 means you need to be at 20 feet to see what a normal person sees at 40 feet. Basically think of it as the first 20 is the patient in comparison to the second number which is the normal person.
CRAO have a generally poor outcome no matter what you do but you should still contact ophtho emergently.
The cornea has the most dense distribution of nerve endings in the entire body.
Dr. Ticho has seen severe injury to cornea requiring corneal transplant in patients who used topical anesthetic at home for corneal abrasion. He advised strongly against giving topical anesthetic to patients with corneal abrasion.
Patching the eye for large corneal abrasions can speed healing. Don’t patch more than 12 hours and the patch has to be tight enough to keep eyelid from opening.
Base injury to eye is worse than acid because base injury causes sapponification. For both acid and base injury immediately irrigate the injured eye. Get ph before and after irrigation. Irrigate until ph gets between 7.3 to 7.7.
Treat superglue exposures to the eye with topical antibiotic ointment.
KERWIN STUDY GUIDE IMAGING
Deep sulcus sign= pneumothorax
Delta sign=cerebral venous thrombosis. Finding on posterior aspect, sagital sinus on CT brain.
On Chest xray, left mediastinal width greater than 5mm is a marker for aortic injury. Left mediastinal width is measured from the spinous process to lateral border of aortic knob. PAL CXR should be less than 5mm, AP CXR the measurement should be less than 5.4mm
Bohler angle should be 20-40 degrees normally. Less than 20 degrees suggests a fracture. (memory hint: low score when bowling is bad.)
Hold patient’s metformin for 48 hours after they receive iv contrast to avoid metabolic acidosis.
Tram lines or train-track lines describe pneumatosis intestinalis and is indicative of NEC.
Thickened, non-compressible appendix of greater than 6mm in diameter is diagnostic for appendicitis. (memory hint: appendix is six)
Fluid in morrison’s pouch on ultrasound has pretty close to %100 positive predictive value for ruptured ectopic pregnancy.
Scapho-lunate dissociation has a gap between the scaphoid and lunate called the Terry Thomas sign.
Duodenal atresia, volvulus, annular pancreas are the differential diagnoses for the “double bubble sign”.
Cardiac standstill on echo during resuscitation has 100% PPV for death.
Can’t give gadolinium to pregnant patients because it crosses the placenta. It is contraindicated, but there have not been reported fetal defects however.
Snowman sign of CXR in kids is a sign of Total Anamolous Pulmonary Return. (memory hint: Frosty said he would “be back again some day” that would definitely be an anamolous return)
CT scan for PE in a pregnant patient has lower radiation dose to child than a VQ scan. If you have to do VQ scan in a pregnant patient, you can reduce radiation exposure to child by putting foley catheter in mom to remove radioactive urine.
MENON M AND M
Obese=BMI of 30, Morbidly obese=BMI of 40, Super Obese=BMI 50
Obesity Hypoventilation Syndrome=Pickwickian syndrome. BMI>30 PCo2>45 while awake, no other source of hypoventilation.
When Intubating obese patients use RAMP positioning. Have the patient’s head elevated and face and jaw parallel to the ceiling. The patient’s external auditory meatus should also line up with their sternal notch.
Pre-oxygenation increases the patient’s oxygen reservoir and denitrogenates the residual capacity of lungs. 3 minutes on 15 L NRB or 8 tidal volume breaths on 15L NRB will accomplish this.
With the difficult to ventilate patients you can use a PEEP Valve on the ambu bag. Respiratory therapists have access to the PEEP valves. If you also put a nasal cannula on the patient (15 liters thru the cannula =passive apneic oxygenation) You in affect are giving CPAP.
BVM ventilate with low pressure(<25mm hg), low volume(6 ml/kg) and low rate (6-8/min). It is also important to use a two handed thumbs down technique to hold mask on face.
Our ED has an awake look intubation kit in the omnicell. It includes 4% lidocaine to nebulize and spray with mucosal atomizer, viscuous lidocaine also is included to put in back of throat.
NAP 4 Data: Higher mortality in ED and ICU, ETCO2 is the standard of care, awake intubation was not use when indicated, Failure to plan for failure, obesity was independent risk factor in a large %age of airway deaths.
Joan Coghlan made a great point that LMA is a great bridge device and a great device to help ventilate the difficult airway patient.
References for this talk:
WALCHUCK RECTAL FB/PRIAPISM
You gotta get these out. Never leave in place and wait for spontaneous passage
Look for signs of perforation on imaging studies.
Sedation may be helpful to remove. Viscous lido can be used to help lubricate. Have patient in Sims or lithotomy position. Sim’s position is with pt on their side with superior leg flexed at hip and knee.
Can attempt to place one or more foley balloons proximal to fb to remove fb. . Many patients will require GI to scope them to remove FB. Sharp or broken objects require surgery
Observe patient for 4-6 hours after removal to see if any signs of perforation develop.
Priapism: corpora cavernosa become engorged with blood, painful, can be due to sickle cell disease/thalassemia/leukemias, many other pharmacologic causes, erect penis with flaccid glans, tx with terbutaline in deltoid muscle, ice to perineum/penis/scrotum, narcotic analgesia, penile block at 11 and 1’oclock positions, aspirate the corpora at 10 and 2 o’clock, instill phenylepherine/saline, cardiac monitoring, for sickle cell patients exchange transfusion is indicated.
Penile fracture: rupture of the tunica albuginia, u/s is helpful for diagnosis, treatment is surgical, pt should not be sent home to follow up as an outpt.
WATTS CENTRAL LINE PLACEMENT
TIP: Stretching the guidewire wil straighten the curved tip.
Avoid air embolism by flushing all lumens of CVC with saline prior to puncturing skin. Also keep thumb over hub of needle when it is in the vein.
Avoid wire embolism but not using force to pull wire out. If you meet resistance, remove needle and wire together as a unit.
WASH YOU HANDS PRIOR TO PROCEDURE! USE STERILE TECHNIQUE INCLUDING GOWN/GLOVE/MASK/DRAPE.
Trandelenburg is important to distend the IJ. For IJ central lines, turn the patient’s head to the left but over rotation can increase the risk of arterial puncture.
NEJM video was shown demonstrating proper placement of IJ central line.
Femoral lines are the highest risk lines so try to avoid them. CVP measurement is not reliable with femoral lines.
Supraclavicular approach for subclavian vein: Puncture skin one finger breath lateral to SCM and superior to clavicle. Aim toward contralateral nipple.
Harwood Comments: Look with U/S prior to draping patient and getting sterile. The RIJ may have an old clot precluding that site. Getting in the central vein requires a confident jab or poke through the vessel wall. You don’t need to place the wire all the way into the vein to just pull it back to thread thru the catheter. You can put the wire in part way and have the external wire to thread thru the catheter.
Coghlan: comments: Line up needle bevel with numbers on syringe so you know what direction your bevel is oriented when it is in the patient. With the subclavian approach if you turn your bevel downward after getting in the vessel will direct the wire into the chest.
Place catheter about 15 cm(14-20cm) into the chest. You should make an estimate prior to placing catheter. Extremes of body habitus will affect this distance.
Never let go of the guidewire!
ERIKSON GU EMERGENCIES
Balanoposthitis: evaluate for diabetes, treat with retraction of foreskin and cleansing with soap and water, topical antifungals or oral fluconazole. Some cases may require anti-staph antibiotics.
Phimosis: foreskin cannot be retracted. Treat with hygiene and topical steroids. If pt cannont void then emergent surgical procedure is indicated.
Paraphimosis: inability to reduce retracted foreskin. Tx with manual reduction, multiple small needle punctures of glans to release edema fluid. Can also try compression/ice cooling to decrease swelling.
Testicular torsion: cremasteric reflex is unlikely to be normal with torsion but this sign is not 100%. Gotta get a testicular u/s when considering torsion in the diagnosis. Treatment is surgery. Manual detorsion may be indicated. “open the book” is the way to think about how to reduce torsion. This is most commonly successful motion. If pain worsens then stop and try to detorse in opposite direction.
Torsed appendix tesis: blue dot sign. Treamtment with NSAIDS
Epididymitis: gradual onset, fever, dysuria, urethral symptoms. Pyuria in 50% of cases,get cultures of urine and urethra, r/o torsion. Tx with antibiotics. If sexually active treat with rocephin and doxy. If likely coliform source, give bactrim.
Fournier’s Gangrene: Polymicrobrial infection, imunocompromised patients, pt’s will have pain and look sick, check for crepitence in genital area, treat with big gun antibiotics Imipenem and Vanco. SURGERY is required.
Zipper entrapment injury: Cut bar of zipper
Harwood comment: Is Nair an option for hair tourniquet? Many people felt this would be irritating to skin. Also discussed was using sugar to decrease edema of a paraphimosis.
]]>Patel/Collins Oral Boards
Case #1: Hemophiliac with an intracranial hemorrhage. Give factor 8 to get level to 100%=50U/kg. Give factor 8 prior to CT imaging. If compartment syndrome suspected don’t check pressure until after giving factor 8.
Case #2: Splenic injury with intraperitoneal bleeding. Diagnose with FAST exam. Treat with fluid and PRBC resuscitation. Spleen is the most common organ injured due to blunt abdominal trauma in both adults and kids.
Case #3: Firefighter exposed to heat and smoke. He has airway injury, burns, and CO exposure. Have to know the Parkland Formula for burns.(4ml/kg/%BSA burned; half given in first 8 hours post injury, 2nd half given over the next 16 hours) Treat CO exposure with 100% FIO2 and get hyperbaric therapy arranged. Treat with pain meds/update tetanus status. CO is the most common tox cause of death. Smokers can have a baseling CO level up to 10%. Give hyperbaric therapy for syncope, confusion, seizure, neuro deficit, cardiac ischemia or level more than 25% in a normal adult or more than 15% in a pregnant patient.
GROMIS M AND M
Flash Pulmonary Edema:
STuPID HPI: Surgeries/Trauma/Pain or paresthesias/Infection or fever/Drugs or toxins. Ask this in a format to get yes or no answers.
Communication is vital during a resuscitation. You have to take leadership of a code situation and designate team members to certain tasks. Consider what the ramifications of your action will be prior to taking an action.
Dan discussed the multiple utilities of using ultrasound in the crashing patient. Do RUQ view, suprapubic view, sub-xiphoid and parasternal long views.
There are cardiac and non cardiac causes of Flash pulmonary edema. Non-cardiac causes include ASA or opiate overdose and HAPE.
Sgarbossa Criteria for AMI in LBBB: 5mm of discordant ST elevation anteriorly, or 1mm of concordant st elevation or depression in any lead.
Comments from Joan Coghlan:
WORKSHOP: CRITICAL CARE NURSING PROCEDURES
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RYAN MUSCULO-SKELETAL STUDY GUIDE
Medial meniscus injuries present with clicking, locking or pain with extension of knee.
Osteoarthritis: Gradual onset, pain is moderate. Joint not clearly “hot”.
>50,000 WBC’s on joint aspiration points to septic joint. This is a boards type cut off. Real life is less clear cut but it is a guideline. If you have a high suspicion of septic joint and the WBC count is less than 50,000 you should still culture the aspirate and consult ortho for close follow up or possible admission.
Sciatica can linger for 8 weeks duration.
Cauda Equina causes acute urinary retention and overflow incontinence. Also look for saddle anesthesia and lower extremity weakness.
Spinal stenosis: Pain with walking due to neurogenic claudication. Patient walks with anterior flexion of waist to reduce traction on spinal cord.
Empty can test specifically evaluates the supraspinatus muscle of the rotator cuff. The rotator cuff activates abduction and int/ext rotation of shoulder.
Foot puncture wound thru a gym shoe, prophylax for pseudomonas. If puncture wound thru sock or bare foot prophylax for staph/strep. Get xray for foot puncture wounds. Have high index of suspicion for fb especially if pt has fb sensation.
Treat a felon with a longitudinal incision at area with most fluctuance.
Carpal tunnel syndrome: Risks include obsesity, pregnancy, dm. Phalen’s and Tinnel’s tests. Tx with splint and analgesics. Refer to ortho.
Amputated digit: wrap in saline gauze, put in plastic bag, place bag on ice.
Finklestein test evaluates for De Quervan’s tenosynovitis.
CHASTAIN/BAROUNIS STEMI CONFERENCE
Think circumflex lesion with minimal inferior ST elevation, tall R waves anteriorly and lateral st depression and mostly anterior st depression. Circumflex lesion=posterior infarction.
Give 2b3a inhibitors in patients with chest pain and not STEMI but has ST depression or dynamic EKG changes.
Cardiac patients who are unstable get kicked out of STEMI bundle. Resuscitate them first.
Consider strongly balloon pump in the patient with cardiogenic shock. Before placing a balloon pump, you have to exclude aortic dissection.
Neuro events can cause an adrenergic output that can make the cardiac apex ischemic. You can see ST segment elevation with no reciprocal changes.
STRASBURGER-VILLANO ORAL BOARDS
Case 1: Optic Neuritis due to MS. Usually a monocular condition. Painful with eye movement. Treat with IV steroids (has to be IV not po steroids). Be sure to get visual acuity on all eye related cases both for the boards and in real life.
Case2: PEA cardiac arrest due to variceal bleeding and pneumonia.
.Case3: Dislocated patella. Treat with passive extension of knee with firm pressure on patella redirecting it to the normal position. There was debate about the need for moderate sedation. Some felt pain control with no or light sedation was adequate.
CARLSON TOXICOLOGY MEDICATIONS FOR DIABETES (Sorry I missed the beginning portion of the lecture)
IV d5 or d10 drips give miniscule amounts of glucose. To replace glucose more robustly, feed pt if at all possible. If you need IV dextrose you will need to give 1 or more amps.
Octretide can be used for sulfonylurea and meglitinide toxicity
Admit: Any long acting insulin OD, intentional insulin OD, recurrent hypoglycemia, sulfonylurea/meglitinide, hypoglycemia related to significant change in renal function or liver function.
Glucophage can cause MALA (metformin associated lactic acidosis). It interferes with normal cellular aerobic metabolism. Mechanistically looks like a mild/non-fatal cyanide overdose. Can occur in mono-overdose. Treat with hemodialysis. Fatal cases prognostic factors are low ph 6.9 or lower, lactate over 25 or metformin level over 50. Should dialyze if ph around 7 or heading downward.
Avandia/Actos: increase insulin sensitivity and decreases glucose production in liver. Doesn’t cause hypoglycemia in OD.
Januvia: Stimulate insulin release with an elevated glucose. Has not been shown to cause hypoglycemia in OD.
Byetta: Glucagon-like peptides. Stimulate glucose dependent insulin release in gut. Does not cause hypoglycemia in OD.
Victoza: similar mechanism to Byetta. Can cause pancreatitis.
Symlin: Amylin agonists. Slows gastric emptying, decreases gluconeogenesis, increases satiety. No reports yet of hypoglycemia.
Insulin/Sulfonylureas/Meglitinides/Biguanides: These all can cause hypoglycemia in overdose.
MISTRY ROOM COVERAGE PROPOSAL
PUTMAN THERMAL BURNS IN THE ED
Stop the burning process by removing any object such as clothing or rings/watches that can retain heat and further burn or produce a tourniquet effect.
IV fluid resuscitation with Lactated Ringers
Treat with appropriate pain medications.
Get further history: chemicals/closed space/explosion/CO/cyanide/electrical injury.
Burn-specific secondary survey: eval for inhalational injury. Intubate for early signs of airway injury.
Estimate body surface area involved in burn with rule of 9’s, palm, Lund-Browder chart.
Burn depth: first=erythema of epidermis only, 2nd=blistering, 3rd=thru epidermis and dermis involving nerve endings and should have no pain in area of 3rd degree burn. 4th= involve deeper structures such as tendon and bone.
Intact blisters can be left alone.
Transfer criteria: probably need a check list to remember all of them.
Escharotomy for circumferential burns that are causing ischemia.
Skin is burned by temperatures over 113F.
Cellular Na pump is disrupted by burns. Depression of cardiac contractility can be caused by burns. Lactic acidosis can occur from burns.
Fluid resuscitation: Parkland formula is 4ml XKG X %BSA burned= volume. 50% given in first 8 hours after injury (no ED arrival). Remaining 50% given over the following 16 hours. This is a guideline that can be altered based on urine output/cvp/pulmonary status. Peds patients also need weight-based maintenance fluids.
Half of all fire related deaths are due to smoke inhalation.
Think cyanide for fires in which wool, silk, polyurethane have burned.
IV antibiotics not indicated for prophylaxis of burns. Only use if infection is evident.
Tegaderm or duoderm can be used as burn dressings for smaller burns.
Pregnant burn patients should have fetal monitoring for viable age gestations.
If the Burn Center asks for a photo of a potential transfer patient, do not identify the patient with any facial views. Document in the chart that patient consented to the photo.
]]>SCHROEDER/CHANDRA ORAL BOARDS
Case 1 Eczema herpeticum. Treat with anti-virals and anti-staph antibiotics. Acyclovir takes mortality down from @10% to 0%. Can complicate eczema. Staph is a frequent co-infection. Eczema herpeticum is more likely to be painful lesions in contrast with impetigo. Diagnosis more likely in patients taking immunomodulators for eczema. DO NOT GIVE STEROIDS!
Case 2 Fish hook embedded in thumb. EP should remove fishhook, examine for nerve or tendon injury. Irrigate wound if possible. Consider prophylactic antibiotics. Check tetanus status.
Case 3 Cervical Epidural Abscess. MRI is superior to CT for diagnosis. Consider in pt’s with: iv drugs, dm, steroids, invasive procedures, trauma, immucompromised. Consult neurosurgery. IV antibiotics.
SMALL GROUP SESSIONS PEDIATRIC MEGACODES
LAM PEDIATRIC U/S APPLICATIONS
Use a high frequency 5-10MHz probe
Graded Compression: slow gently increased compression on abdomen.
Appendicitis: Appendix is medial to psoas and anterior to iliac vein. Target sign on transverse view. Non compressible, Fluid collection, Target sign, Diameter>6mm (mnemonic is NFTD nothing further to do)
Intussusception: Use graded compression. Follow the expected contour of the colon. Again look for a target sign.
Pyloric Stenosis: find stomach first and go to pyloris. Anterior and lateral to aorta. Abnormal pyloris is too thick or too long.
BAROUNIS ABG BASICS
The 4 step approach to acid base disorders
Step 1: Get the labs (VBG=ABG), you need Na, Cl, HCO3, pH and PCO2
Step 2: Calculate the anion gap (Na - (HCO3+ Cl) Normal is < 15, abnormal > 15
Step 3: RULE of 15, the PCO2 and the last two digits of the pH should be the bicarb + 15.
ie- if bicarb is 15, PCO2 should be 30 and the pH should be 7.30
3 Possibilities of PCO2:
1. it is what it should be (simple wide gap metabolic acidosis with respiratory compensation)
2. The PCO2 is lower than it should be (patient is breathing faster) primary respiratory alkalosis
3. The PCO2 is higher than it should be (patient is breathing slower) primary respiratory acidosis
Step 4: 1:1; Normal bicarb - 24, normal gap = 15
The CHANGE or increase in anion gap from baseline should = the change or decrease in the bicarbonate
ie if the anion gap is 30, the change or delta gap is 15 (30-15=15) therefore the bicarb should decrease by 15 (24-15= 9)
3 possibilities of bicarb:
1. It is what is should be (simple wide anion gap acidosis)
2. The bicarb is LOWER than it should be (in the above case if the bicarb was 5 instead of 9) additional primary non-gap metabolic acidosis
3. The bicarb is HIGHER than it should be (in the above case if the bicarb was 15 instead of 9) additional primary metabolic alkalosis
Remember at SEVERLY low bicarbs the pH and the pCO2 will be less reliable. the PCO2 is not +15 when bicarb <5, it is 15.
Sorry I went a little fast and I can send out the ppt later if you want to practice the cases.
VILLANO ABCD’S OF HYPOTENSION AND BRADYCARDIA IN TOXICOLOGY
Alpha Agonists, Beta Blockers, Calcium Channel Blockers, Digoxin
Alpha Agonists (clonidine): centrally acting antihypertensive. Onset 30-60 minutes after ingestion. Pt will get hypotensive. They wil have respiratory depression, lethargy and coma, miosis. Treatment is supportive. Try narcan, it may help. This overdose will look somewhat like an opioid overdose with more hypotension.
Beta blockers: Usually symptomatic by 2 hours. Look for hypotension, bradycardia, and early altered mental status. Seizures are possible. Pt’s can have normo to hypoglycemia and mild hyperkalemia. Tx with atropine, glucagon (activates g protein that increases cyclic amp by alternate no beta receptor pathway) 5 mg over 5 minutes. Glucagon may induce vomiting. Tx also can include calcium, pressors, hyperinsulinemia-euglycemia , intra-lipid can be tried in crashing pt. Pacing and balloon pump may be required. Can d/c to psych for immediate release form and asymptomatic after 6 hours. All other admit to tele or icu if abnormal vitals.
Calcium Channel Blockers: Dihydropyridines cause decrease in smooth muscle tone andlower bp. Monohydropyridines affect cardiac conduction and cause bradycardia. Look for hypotension, bradycardia, hyperglycemia, late mental status changes, acidosis. Treat with Calcium (1g chloride central, 3g gluconate peripherally) , iv fluids, iv atropine, insulin-glucose therapy (insulin is a pressor/response may take 60 minutes/bolus 1u/kg and infuse 0.5-1u/kg/hr/titrate to bp>90/give D50/hypoglycemia doesn’t happen as much as you would think), glucagon, intra-lipid. Have a low threshold to put pt in ICU.
Digoxin: Recently covered in a previous conference. Look for nausea/vomiting and arrhythmia.
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Research Presentations
Dr. Phillips: Absorbable sutures are a lower cost method compared to non-absorbable sutures to repair wounds. No difference in scar outcome, and similar complication rates. Also easier on the patient. No need for suture removal.
Dr. Cambride: Intubation during CPR (manual vs. automated). Success rate and time to intubation was no different when compressions were or weren’t being done. No difference between manual or automated compressions either. So don’t stop compressions to intubate.
Dr. Hartman: Patient follow up requirements are carried out in widely different manners across the country. Program Directors are generally dissatisfied with patient follow up learning methods.
Dr. Rifenburg: PE patients presenting with syncope are more likely to have a saddle embolus and less likely to have a small embolus than PE patients without syncope. PE patients with syncope were more likely to have EKG changes. PE patients with syncope were more likely to have RVH than non-syncope patients.
DR. CANTOR MISTAKES YOU DON’T WANT TO MAKE-PEDIATRICS
Investigation priorities in seizures: infection, mass, metabolic (electrolytes), toxins. Dilutional hyponatremia can occur from not mixing formula correctly. Genital ambiguity suggests congenital adrenal hyperplasia.
Progressive causes of altered mental status: mass, meningitis, opioids, hypoglycemia. All must be treated emergently. Don’t give full dose narcan to heroin addicts. Beware of hypoglycemia. It can mimic any neuro deficit. If you can’t talk to someone, check their blood glucose.
Anticholinergics vs. Sympathomimetics= Dry skin vs. diaphoresis
Pheochromocytoma can mimic sympathomimetic overdose.
Psoas abscess can cause limp. If work up of febrile limping patient with leukocytosis is not fruitful, consider ct abd/pelvis to look for abscess.
Encephalitic patients should be treated with acyclovir. Look for cold sores to suggest HSV encephalitis. Pt’s can have seizures with HSV that appear like unusual behavior or agitation.
Common cyanotic heart lestions: truncus, transposition, tricuspid atresia, tetrology of fallot, total anamolous return. Tetrology is the one that can present with a patient 1-2 years old. Failed hyperoxia test strongly favors cyanotic heart disease
Dr. Thompson Toxicology: What’s New in the Street
Sorry I missed this one, talking with old friends.
Dr. Allen To DNR or CPR
1960 was the first description of modern CPR (ventilation,chest compressions, defibrillation). 1974 were first ACLS Guidelines.
22% overall rate of survival from CPR in ED’s across the country. This is better than any other setting. In general, survival is around 17% in all settings.
EP’s have reservations about CPR: overhyped, can cause suffering, costly, benefit is mostly extra days alive but not quality of life.
Slow CODE is not acceptable. It is deception and could lead to survival with poor neurologic outcome.
APPLE Shared Decision Making with Patient/Family at End of Life: Awareness , Prognosticate (make an estimate of short term outcome), Plan (basically figure out the patient’s goal and it is ok to give recommendation), Lay the ground work, Empathize (sit down, be quiet and spend time listening, express regret, hopeful attitude)
NEXT Lectures
Dr. Kegg: Within 6 hours CT brain may have a high enough sensitivity to rule out SAH.
Dr. Mehan: Itralipid for local anesthetic toxicity acts as a lipid sink, metabolic substrate, or direct activation of CA channels. Can also be used for beta blocker and CCB, TCA, Atypical antipsychotics and buproprion Od’s. Downsides: ARDS, pancreatitis, has compatibility issues with other meds.
Dr. Oh: You can use IVC/Ao ratio to evaluate dehydration in pediatric patients with diarrhea. Serum bicarb over 15 is reasonable cut off for non-serious dehydration. ETCO2>34 ruled out HCO3<15. Check glucose because hypoglycemia is present about 10% of the time in pediatric patients with diarrhea. Can give up to 60ml/kg bolus of saline for more severe dehydration.
Dr. Pirotte: CDC and NIH say we should not due femoral lines (cat 1a recommendation) unless we have no other options. They are more likely to cause infection. Complications are worse, retroperitoneal hemorrhage, DVT, fistula, pseudoaneurysms. Consider IO line in place of doing femoral line.
Dr. Rushforth: Tranxemic Acid (TXA)will be more likely to be used in Trauma patients due to efficacy reports, no evidence of theoretical complications, inexpensive. Most studies on this drug were done in under-developed countries where the baseline mortality may be higher to start with and critical care resources are less than in the US.
Dr. Vogt: Scombroid most common around Florida and Hawaii. Supportive care is the indicated treatment for all common fish toxins. Ciguatera symptoms can persist for weeks to months. Mannitol is still controversial as a treatment for ciguatera. Alcohol can cause recurrence of ciguatera symptoms. Be aware that fish flown in from other areas can cause various fish toxidromes.
Dr. Williamson: Allergy to shellfish is due to shell proteins and not iodine . Patients with shellfish allergy can receive radiology contrast. Scombroid poisioning is due to bacterial overgrowth of improperly stored fish producing histidine. The histidine is converted to histamine. Pt’s will have flushing, rash, palpitations. Treat with antihistamines. Fugu is due to tetradotoxin that binds to sodium channels. Treat with supportive care and charcoal.
]]>PAQUETTE STUDY GUIDE SPECIAL PATIENTS
One year risk of death after a fall in the elderly is 50%.
Heroin users: Cotton fever is due to unknown pyrogen effect. Thought to be due to particulate matter from cotton or gram neg endotoxin. However, even patients who don’t use cotton to filter their heroin get cotton fever. So cause is unknown. Fever resolves spontaneously.
Patients over 65yo account for 30% of trauma deaths even though they only account for 20% of total trauma patients.
Patients over age 80 have chest pain as the presenting complaint for AMI less than 50% of the time. SOB is more common.
Myositis ossificans (heterotpic ossification) usually found in chronically immobilized patients. Can be painful. Usually around the hip/knee/femur/shoulder.
Post traumatic syringomyelia: ascending spinal cord lesion in a patients who’s neuro deficit had been previously stable.
STRASBURGER HIV EMERGENCIES
1.2 million people in US are living with HIV infection. 1/5 people are unaware of their HIV infection.
17,000 people died from AIDS in 2009.
HIV deaths peaked around 1995.
AIDS: CD4 count less than 200 or an AIDs defining illness.
CD4 count >500 is an immunocompetent patient. CD4 200-499 is indeterminate so look for AIDS defining illness and consider CD4 %.
CD4% is a more reliable measurement than the CD4 count because it varies less. Normal CD4% is 32-68%.
www.aidsmeds.com is a good reference website for side effects and drug interactions of ART (anti-retroviral therapy). UCSF post exposure prophylaxis hotline can help you make decisions for starting prophylactic therapy after body fluid exposure. Other good website hivinsite.ucsf.edu.
General approach to HIV/AIDS patient: Find out CD4 count, CD4 trend, viral load, opportunistic infections/medication side effects.
AIDs patients who need CT: CD4<200, fever and nuero findings or stiff neck. Follow CT with LP. If patient has a CD4 count >200 you can do LP without prior CT if no focal deficits or headache. Absolute lymphocyte count= WBC count X %lymphocytes=>2000 then CD4 count is most likely over 200. If less than 2000 CD4 count may be less than 200. Have low threshold for doing LP in pt’s with neuro complaints.
Toxoplasmosis may have ring enhancing lesions on head CT.
Cryptococcus Neoformans: usually CD4 count is <100 but not always. Have chronic meningitis picture or prolonged headache. CT is usually unremarkable. Serum cryptococcal antigen is 95% sensitive and may be useful in the patient refusing LP. CSF cryptococcal antigen is 100% sensitive and specific. India ink staining is only 60-80% sensitive. Treat with amphoB and flucytosine.
Respiratory infections: most common are bronchitis or uri. Keep guard up for bacterial pneumonia and PCP pneumonia. Bacterial pneumonia due to strep pneumo is most common. PCP is the most common opportunistic infection.
PCP pneumonia: chronic cough, hypoxia with exertion. Walk them on a pulse ox and see if their sats drop. ABG can help if paO2 is <70 or AA gradient is >35 signifies severe PCP. Serum LDH can help identify PCP pneumonia. 1/3 of patients will have a nl CXR. Can also have a focal infiltrate. CT that does not show ground glass appearance is unlikely to be PCP.
Diarrheal illness: Get stool sample for lab testing. CD4>200 and labs look ok, and they look well, they can go home on cipro/flagyl. If not then admit.
CMV retinitis: CD4 count usually less than 50. Blindness in 30%. Fundoscopy shows cotton wool like findings. ART does not reverse disease but just slows it down.
Retinal varicella zoster can also occur in patients with very low CD4 counts
HIV patients have accelerated progression of coronary heart disease. HIV should be considered a CAD risk factor.
Immune Reconstitution Inflammatory Syndrome (IRIS): Rapid CD4 cell count increase or rapid decrease in viral load. Can happen within several weeks of starting ART. Due to underlying infection that the immune system was previously not responding to. Treat infection like PCP prior to starting ART. Steroids also can diminish the symptoms of IRIS.
Health Department Clinics can provide free HIV testing for patients.
ANGELA ROMERO PERFECT SERVE
GARRETT-HAUSER ETHICS
Elder abuse: 4 felony convictions in and Kane and Cook counties in past 18 months for physical abuse and neglect.
NH Abuse: Psychiatric patients and and sexual felons in NH population. 2 elderly alzheimers got into fight and one died. The NH owner and staff are being prosecuted for murder/manslaughter. NH cannot give psychiatric meds (geodon) for dementia.
Case #1: Is withdrawing care the same as murder? The right of a competent individual to refuse any form of care is absolute. Power of attorney also has the right to refuse care for a patient. In some states, surrogates have similar power to refuse care. We have a withdrawl of care form to use in ED if you want to withdraw care. Need terminal condition, permanent unconsciousness, incurable or irreversible condition. So answer is no, withdrawing care is not the same as murder. Withdrawing care is not the cause of death but rather returning patient to condition of illness that will result in death. In a DNR situation, there is no difference in not initiating treatment and withdrawing treatment.
Case #2 13 yo girl with vaginal bleeding and dangling umbilical cord with no fetus. Pt will not say where baby is. Baby was in garbage dumpster. To whom do you have a duty as an ER doc? You have duty to patient and to baby both ethically and legally. Long discussion on this case but consensus felt probably smart move would be to place mom in psychiatric care rather than sending her directly to jail.
Case#3 How do we manage patients with chronic pain issues and drug seeking behavior? 10% of general population has substance abuse problems. Top 3 medical specialties with substance abuse are EM, anesthesia, and psychiatry. Oak Forest Hospital has a free urgent care 24/7. This clinic can give patients access to Cook County Clinics (pain clinic).
WILLIAMSON NEXT LECTURE FISH TOXINS
Anaphylactic Shellfish Reaction: Type 1 IGE immune mediated response. Can patients with shellfish allergy get IV contrast? Yes very safe. Shellfish allergy is to the shell not to iodine.
Shellfish poisoning: 4 syndromes diarrheal/ amnestic reaction/neurotoxic/paralytic (sodium channel blockade) multiple cases identified in Alaska. Pt’s have to be intubated sometimes.
Scromboid: Bacterial overgrowth in improperly stored fish producing histidine. Can be indistinguishable from allergic reaction. Tx with antihistamines.
Ciguatera: activation of sodium channels. Onset 3-6 hours after ingestion. Symptoms are paresthesias, dental pain and paradoxical temperature reversal. Iv mannitol can be tried.
Fugu: Tetradotoxin binds sodium channels resulting in ascending paralysis. Supportive care and charcoal decontamination of gut are treatments.
Stingray: Venom has no specific antidote. Get an xray for retained fb. Give prophylactic levoquin.
Mercury: Fish consumption is most common cause. Symptoms include fatigue, sensory impairment. Dimercaprol is treatment.
PATEL SAEM CPC CASE PRESENTATION
Neuromuscular causes of weakness: Brain, Cord, NM junction, Muscle disorders.
Periodic Paralysis causes acute weakness due to channelopathy.
Familial Hypokalemic Periodic Paralyssis: white race,
Thyrotoxic Periodic Paralysis: Acquired disorder, age 20-50, Asian males. Carbo load can precipitate an acute episode. Ekg may show U waves. Treat with beta blockers and possibly potassium. Hypokalemia and labs c/w hyperthyroidism confirms diagnosis.
]]>BRAD KUTKA CPC Case Presentation
BEAU WILLISON/DENNIS RYAN ORAL BOARDS
Case 1: Ascending Cholangitis : Patient had Charcot’s Triad of Fever/Pain/Jaundice. Reynold’s Pentad adds altered mental status and hypotension. Treated with antibiotics and ERCP.
Case 2:Fitz Hugh Curtis. Pt had PID Symptoms with RUQ pain. Treated with iv Rocephin and Iv Doxy/ Azithromycin.
Case 3: Disseminated Zoster in a lymphoma patient on chemotherapy. Treated with IV Acyclovir. Panculture for neutropenia. Cover with Cefipime as well.
ANDREA CARLSON TOXIC MELTDOWNS
The hypothalamus triggers sweating in response to heat. As you sweat, your serum osmolarity goes up. At a certain point, high osmolarity will trigger the hypothalamus to decrease sweat losses to conserve fluids in body.
TCA’s can cause seizures, sweat gland dysfunction both factors in hyperthermia
Cocaine associated deaths are more frequent on hot days.
Hypothermia when sustained and severe causes denaturation of proteins and enzymes.
Hypothermia is the most important negative prognostic indicator for a drug overdose.
Serotonin Syndrome: Serotonergic medication AND 4 major or 3 major and 2 minor criteria. Altered consciousness, mood change, coma, tremor, shivering, hyperreflexia, fever, rigidity, sweating, restlessness. 3 aspects of the syndrome: 1. Cognitive /behavioral 2. Autonomic changes 3. Neuromuscular findings. Most common findings for these three arms are: confusion, fever, myoclonus. Common drugs: SSRI’s, amphetamines, Cocaine, tramadol, DXM, lithium, MAOI’s, methylene blue (multiple case reports), linezolid, metoclopramide, prochlorperazine.
Cyproheptadine is an old antihistamine. Direct serotonin antagonist. Anecdotal evidence of improved survival in serotonin syndrome. PO forms only available.
Neuroleptic Malignant Syndrome: due to dopamine deficit. Slower in onset than Serotonin syndrome. Altered mental status and rigidity precede hyperthermia and autonomic instability. Bradykinesia and “lead pipe rigidity” are key neuro findings.
For both SS and NMS you gotta cool the patient. Control seizures, give benzos, give Dantrolene (dantrolene is a skeletal muscle relaxant and can make a pt weak but not paralyzed). Bromocriptine for NMS, Cyproheptadine for SS. Use other cooling measures like fans and misters. No reports yet of using cool guard to bring down pt’s temp.
TONY GRIPPO TRAUMATIC BRAIN DEATH
Uniform Death Act 1981 makes brain death equivalent to cardiovascular death.
Prerequisites: Know cause of coma, normothermia, no drug intoxication/poisoning. ETOH < 80. No treatable metabolic causes. BP>100systolic.
Exam: Coma; completely unresponsive to noxious stimuli. Absent Brain Reflexes; no papillary light reflex/no corneal reflex/no ocular movement to cold calorics or doll’s eyes/response to painful stimuli above the neck/no jaw jerk/no gag or cough with suctioning. Apnea;Vent disconnected, o2 given via tracheal canula. If after 10 minutes pCo2 of 60 or greater and no breath that is positive for brain death. Need two tests to be definitive. If apnea test is inconclusive you can do nuclear medicine testing or cerebral angiography. Nuclear medicine scan shows “empty light bulb” and “hot nose” findings when positive for brain death.
Lazarus reflex: There are some spinal reflexes even though the patient is brain dead. Neck flexion can cause upper extremity flexion even though brain death is present. Cremasteric reflex is preserved. There are other toe and finger reflexes that persist after brain death as well.
You have to wait 72 hours after therapeutic hypothermia (some say 6 days) before you can start considering for brain death.
Brain dead patients are the source of 50% of renal transplants and majority of extra renal organ transplants.
Supporting the brain dead patient to maintain organ perfusion should include volume infusion, pressor management, and hormone replacement therapy. Dopamine first and then vasopression if needed are the recommended pressors. Amiodarone is the recommended antiarrythmic. Hormonal resuscitation includes T3, Vasopressin, Methylprenisolone, and Insulin.
MARK HINTON M&M
Pt on Coumadin falls and hits head. Subtle mental status changes. Initial CT was neg. INR was prolonged to 5 range. Pt came back 1-2 days later for increased mental status changes and ataxia and renal insufficiency. Family notes on second visit that pt has been having multiple falls. Pt found to be digoxin toxic.
Digoxin toxicity:
Sources of error: minimizing problems by patient. Recall biases, Attending/Resident discrepencies. Anchor bias, premature closure.
William Withering discovered digoxin in 1785. Treated dropsy.
Foxglove, oleander, and lily of the valley are botanical sources of digoxin. You can also get digoxin toxic from licking the skin of toads (also hallucigenic).
Digoxin is mostly eliminated renally.
Ekg changes with therapeutic digoxin level, lateral/inferior st depression with downsloping st segment and inverted t wave.
First symptoms of overdose are somnolence, dizziness, and confusion.
Causes of toxicity: overdose, renal insufficiency, and drug interations (amiodarone, verapamil, vytorin, other statins, macrolides).
EKG changes in toxicity: pvc’s, any svt with av block, pat with block is pathognomonic, bidirectional V-tach, sinus bradycardia, slow afib, regularized afib,
Severity of hyperkalemia correlates with mortality.
Xanthopsia: yellow vision. Did Van Gogh suffer from digoxin toxicity? He painted his doctor sitting with a foxglove plant nearby.
Treat hyperkalemia with standard treatement insulin/dextrose, bicarb, kayexelate. Calcium now thought to be ok for hyperkalemia. Digibind treats the digoxin overdose and the hyperkalemia. Digibind works in about 30-60 minutes. Digibind is safe in kids down to 12 weeks old.
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RESIDENT TOWN HALL MEETING
JIM MALETICH 5 SLIDE FOLLOW UP
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.
ADAM WISE 5 SLIDE FOLLOW UP
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.
PAARUL CHANDRA WILDERNESS EM
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.
SPLINTING LAB WITH MAKE SHIFT MATERIALS
ANNA LOUGHLIN DISLOCATIONS
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.
JIM MCKEAN OSTEOFIBROMA
When kids have chronic dull knee pain look for malignant lesions with xray
BRIAN KESSEN
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
CHRISTINE KULSTAD JEOPARDY TRAUMA
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.
BRIAN FORT DENTAL EMERGENCIES
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.
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LAST WEEK WAS ORAL BOARDS
CARLSON ORAL BOARD DEBRIEF
Ductal Dependent Lesions can present with cyanosis or shock. Mottled skin is prominent in these infants. You have to consider sepsis and do full septic work up/give abx. Lack of fever does not exclude sepsis in infants. Prostaglandins are indicated. Prostaglandins can mimic sepsis. Prostaglandins relax smooth muscle of ductus arteriosis.
Treat HUS by reducing BP, treating hyperkalemia, and transfuse for severe anemia. Transfuse in HUS with HGB<6. Restrict or cautious IV fluids and consult Nephrology for dialysis. HUS is most common cause of renal failure in kids. Most common trigger is Ecoli toxin. Ask for missing vital signs on the oral boards.
Treat INH overdose with benzos, phenobarb, and pyridoxine. Talk to family members or EMS on the oral boards. They have key info. INH interferes with pyridoxine which is needed to synthesize GABA. Gyrometra muschroom (False Morel) overdose acts the same way as an INH overdose.
If giving TPA for stroke, no heparin/asa/plavix. If a patient is on heparin, lovenox, asa, plavix then you can’t give TPA.
AKA can develop hypoglycemia. AKA is a starvation ketoacidosis due to emesis/gastritis. Treat AKA with IV hydration with glucose containing fluids and give thiamine. In aspiration setting, lateral decubitus films are classically described. The dependent hemithorax(down side) should compress. If it remains expanded then you need to suspect bronchial obstruction.
The lateral cspine view may be helpful in the trauma patient in shock to get quick eval for spinal fx and neurogenic shock.
Electrical Alternans is a sign of Pericardial Effusion/Tamponade.
Abhi Khatiyar ORTHO STUDY GUIDE
Patellar dislocation mostly occurs in lateral direction. Reduce patella and use knee immobiizer.
Knee dislocation, beware popliteal vascular injury. Examine for hard and soft signs of vascular injury. ABI<0.9 is abnormal. All knee dislocations need angiogram.
Tibial Plateau fx is most common fx of knee. Lateral plateau is most common. Beware in the older patient who has subtle or negative xray and can’t bear weight.
If you see fat globules in synovial fluid it strongly suggests fx.
Gout crystals are negatively birefringent. Pseudogout (calcium pyrophosphate deposition disease) crystals are positively birefringent.
Thompson’s test evaluates for Achilles’ tendon rupture. Positive test means the forefoot doesn’t move with calf compression in prone/flexed knee position. Fluoroqiunalones can increase risk of rupture.
Adhesive capsulitis (frozen shoulder). Common complication after shoulder fx. Can occur after stroke as well.
Carpal Tunnel Syndome: most specific sign is splitting of sensation of the 4th finger.
Lover’s fx (Don Juan Fx)is a calcaneal fx from fall from height. Associated injury is burst fx of lumbar spine.
Jones fx of 5th mt is a diaphyseal fx, slow to heal and has high incidence of non union. Pseudo Jones Fx is an avulsion fx’s off of the proximal 5th mt.
ROBBIE McDERMOTT RADIATION MEDICINE PART 2
Tx for local radiation injury: infection control, wound care, surgical consult, nsaid’s, hyperbaric oxygen, trental, vitamin E, topical steroids.
Acute Radiation Syndrome can occur from external exposures >1Gy. DNA damage to cells within microseconds. Intestinal cells, lymphocytes and stem cells are most prone to injury.
Stages of ARS: prodromal/nausea and vomit, fever, conjunctivitis; latent period; illness onset; recovery or death.
Hematopoietic syndrome(2Gy) Lymphocytes and marrow cells are most sensitive to radation.
Gastrointestinal Syndrome (6Gy) Earlier emesis=higher exposure. If pt vomiting in 10 minutes or less than 60 minutes=bad outcome.
Cardio/CNS syndrome (20Gy) Not usually survivable.
2Gy and less exposure has almost 100% survival.
Cytogenic Biodosimetry=# of dicentric chromosomes gives best estimate of radiation dose.
Absolute lymphocyte count is best test in first 24 hours for estimating radiation exposure.
Irradiated patients generally do not pose a threat to care providers. Treat medical/surgical patients first.
Time to emesis if less than 2 hours likely exposure of 3Gy and greater. Be aware that psychogenic emesis is common with radiation event.
Triage score=N/L+E. E=0 for no emesis, E=2 for emesis. N/L is neutrophill/lymphocyte ratio. Nl =2.21 If T>3.7 radiation dose is high.
Colony stimulating factors for exposures >3Gy. Implement IDSA guidelines for neutropenia.
Amylase is another marker (baseling and 24 hours) for radiatin exposure. Amylase will increase with significant exposure.
Contaminated patients in ER need to be kept in strict isolation. Remove patient clothing. Wash off patient and save all fluid runoff in a closed system. Don’t let wash fluid run down drain.
Exposed patients with no symptoms for 6-8 hours can be discharged.
ER caregivers for contaminated patients should wear a whole body coverall, surgical mask, double glove.
DAVE BAROUNIS FEIBA FOR REVERSAL OF Coumadin COAGULOPATHY
Life threatening bleeding and INR>5 use 1000U of FEIBA over 15 min plus 10mg of IV vitamin K over 30 minutes
Life threatening bleeding and INR<5 use 500U of FEIBA over 15 min plus 10mg of IV vitamin K over 30 minutes
INR should be repeated in 30 minutes. If INR<5 then you are done. If INR still>5 give another 500U.
JOELLEN CHANNON M and M Massive PE
Massive PE: sbp <90 for 15 minutes. Submassive PE: RV dilation on echo. Low risk PE has neither.
Mortality is highest with massive pe and lowest with low risk pe.
McConnell’s sign: apical contraction with wall motion abnormalities away from apex.
On CT if RV diameter/LV diameter >0.9 is sign of RV dysfunction.
Elevated troponin in PEis indicative of increased short term mortality.
T wave inversion inferiorly and anteriorly is a sign of RV strain.
TPA for submassive PE may result in better RV pressures at 6 months. No one has been able to shows mortality benefit so far in this group.
Ways to identify the sicker patient with pe: echo, shock index>1, any hypotension at all, any respiratory distress. These patients should be strongly considered for TPA.
If high probability of PE give heparin during workup; Recommended by AHA
No TPA for undifferentiated arrest.
Effect of respiratory depression with benzos is pronounced in patients who have some aspect of co2 retention.
LOUIS HERRMANN PEDIATRIC HIP PAIN
Legg-Calve-Perthes (idiopathic osteonecrosis/avascular necrosis)more common in short statured male kids. Insidious in onset. Lesion on xray is more common on lateral aspect of femoral head. Conservative management usually works well
If patient has thigh or knee or groin pain gotta evaluate the hip.
SCFE more common in 11-14 years of age. More common in Obese kids. Related to thyroid disease. Kids prefer his in abduction with external rotation. Internal rotation is painful and limited due to the altered mechanics of hip. Klein’s line runs along lateral femoral neck and should hit the epiphysis. Also on xray lesser trochanter will be more prominent on xray due to external rotation. SCFE requires surgery.
Transient synovitis: most common cause of hip pain in children. Post viral process is thought to be the cause. Non-toxic appearing patient. May have some fever.
Septic Arthritis: More prominent effusion compared with transient synovitis. Can be a tense effusion. ROM of hip is commonly exquisitely tender. U/S can identify the effusion. Synovial fluid with wbc count>50000 is diagnostic for septic joint. Surgical treatment with arthrotomy and joint wash out with 2 weeks of iv antibiotics is the treatment. 4 factors are more predictive:fever, non weight bearing, elevated esr >40, wbc>12,000.
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