Basics
The Literature is Consistent
Imaging?
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Anatomy - Internal carotid, sympathetic chain, IJ, cranial nerves - all pretty close in this small area Risks for PTA - smoking, bad teeth, chronic tonsillitis Complications - airway blockage, necrosis into carotid sheath, deep space infection, Lemierre's Syndrome Imaging Indications CT Scans should not be done routinely for PTA. PTA is primarily a clinical diagnosis. Consider Contrasted CT in: - toxic folks - immuncompromised - concern for deep space spread - Bilateral PTA (high extension rate) - uncertain diagnosis Ultrasound all PTA - Helps to improve diagnostic accuracy. - Helps to guide needle during aspiration. When to Consult - airway compromise - gas producing organism or air fluid levels - deep space infection - failure to respond in 48-72 hrs of IV anbx; - if meet indications for quinsy tonsillectomy (removal of tonsils while PTA is present) - Uncooperative patient - Pediatric patient - Recurrent tonsillitis or PTA - Severe trismus How to Drain 1. Apply anesthetic - 2 seconds of spray - hurricaine or cetacaine; atomize 4% lidocaine 2. Identify tonsil - use blood flow to help distinguish tonsil from abscess; Identify carotid 3. Supplies - need good lighting - bottom 1/2 of speculum or DL blade; - needle - 18 gauge only need 1 cm unsheathed; consider spinal needle 4. Aspiration - Parallel to floor of the mouth; start at superior pole of tonsil - if you don' t get pus - then move to middle, then third pole - this is the only way needle aspiration is comparable to I&D; - aspiration = less painful than I&D - speed of relief may be higher with I&D; ED literature rec's aspiration Medical Management 1. Antibiotics - group A strep and anaerobe coverage - Unasyn, Clindamycin, or Vancomycin (if life threatening or fail to respond) (everyone should get a dose of IV anbx) - Oral 10-14 day course Pen VK QID plus flagyl 500 QID; clindamycin 300-450mg q 6 hrs; augmentin 45 mg/kg q12 - in young folks test for mono 2. Steroids - jury is still out; initially decreases pain but in 48-72 hrs no difference; use IV solumedrol Disposition 1. 4-6 hrs observation, then DC if can tolerate PO; f/up in 24-48 hrs; gargle with H2O2 at least after each meal; soft diet and good oral hydration; antibiotics 2. Admit (23 hr obs on IV anbx) - peds; toxic; immuncompromised; can't tolerate PO The Ankle - 3 Bones - 3 Primary Joints - Medial mal with medial talus - Tibial plafond with talar dome - Lateral mal with lat talus Ankle Xrays - Medial clear space --- if over 4mm, its concerning for syndesmotic injury or possible deltoid ligament incompetence - Tib-fib clear space --- greater than 5mm is abnormal - Bi-mal and Tri-mal fxs often need surgery - Pilon fractures ---- high injury mechanism!! - Be sure to get additional films to look at tibia, knee and also LUMBAR SPINE - Pediatric patients are different - Ligaments stronger - More likely to fracture bone than sprain ligament The Foot - Foot has 28 bones - Divided into hindfoot, midfoot and forefoot - Hindfoot controls inversion and eversion - Midfoot controls foot abduction and adduction - Forefoot controls plantarflexion and dorsiflexion - Calcaneal fracture --- 10% associated lumbar fractures!! - Talar neck fractures - very bad injury, minimal blood flow there; often times need OR for reduction - LisFranc fracture dislocation - axial load and foot planted. - Can be severe or subtle. - If concerned for subtle, then get full weight bearing films. - Jones fx - 5th metatarsal head fracture - Put in post-op shoe or splint, follow up; Majority non-op Retroperitoneal Organs
Physical Exam Findings
Symptoms 1. Most common presenting complaint = abdominal pain; then leg/hip pain; back pain 2. Can have femoral neuropathy, iliopsoas spasm Traumatic RPH
Spontaneous RPH
Management - controversial Zone I - concern for vascular injury - likely OR Zone II & III - ?pulsatile, ?expanding - determines intervention Packing vs arterial embolization - majority of traumatic RPH are venous in nature CORE CONCEPTS: - RPH is a rare diagnosis with significant mortality - see keep on your differential! - Undress your adult patients too - look for Fox's sign, etc - Most common presenting symptom: abdominal pain, then leg or back pain - Seen more commonly in elderly and those on anticoagulation, but 1/3 of pts who presented with spontaneous RPH were not on anticoagulation Myocardial Infarction in TTP
Penetrating Scrotal Trauma:
Diagnotic Error in Medical Decision Making
Finger Infections - Paronychia- disruption of nail fold/ plate, mixed flora + staph - erythema swelling tender, can extend into eponychium - tx- warm soaks, po abx, I&D - Felon- infection of hyponychium, progressing to pulp - tx- soaks, elevation, abx; surgical- incision options for i&d - may use transverse incision here, must disrupt all septae, - wick/drain that is changed at 24hrs, - abx- iv in ed - Flexor Tenosynovitis- infx of synovial sheath around flexor tendon, - mechanism is penetrating injury, may be direct spread from other area; - s. aureus; - kanaval signs - flexed posturing, pain with passive extension, fusiform swelling of digit; TTP over palmar aspect of digit - tx- early- admit, obs, abx but will usually go to OR Nail Bed Injuries - get an xray, 50%with tuft fracture - repair: removal of plate, elevate proximal nail fold if needed; wash out; closure 5-0 chromic, 4-0 nylon for surrounding skin - protection of repair- native nail is ideal, or silicone, aluminum; secure with suture; protect scaring of nail fold down Tip Amuptations - Preserve fxnal length, durable coverage - <1cm squared can be healed by 2ndary intention; 4-5 weeks to heal, pain control, abx, tetanus; - Find digital nerves, pull out, trim to avoid neuromas. - Exposed bone- need rongeurs, bone cutters, take joint surface off - If you close primarily, space out sutures - Dressings non-circumferntial, loose2x2, cast padding, bias Finger Dislocations - palmar dislocation - recreated deformity then volar force - no splint needed, buddy tape - volar dislocations - hyperflex, dorsally reduce, splint in extension * Propofol is used in >95% of residency training programs - well established to be safe & effective* > Propofol - Fast onset (2-5 min) fast recovery (5-10 min) - Great for short painful procedures - fracure DL, I&D, etc - Possible ADR - hypoventilation, partial obstruction, apnea, hypotension, bradycardia - No analgesia - however most patients do not recall or report pain; if you give additional opiods - taper propofol dose > Get equipped! {These are specific for CMC at current date} 1. Oral & nasal airways, O2, ambu bag with mask, direct or video laryngoscopes, ET tubes, suction, ECG monitoring with pulse ox, End tidal CO2 , code cart, narcan and flumazenil 2. For ASA class 1 & 2, Mallampati class <3 - consult anesthesia if outside these guidelines or pregnant 3. NPO for 2 hrs from clear liquids, 6 hrs nonclear liquds & food; deviation MUST be justified by attending physician 4. Need 2 physicians - attending needs to push meds 5. QA review - things that must be documented - apnea > 15 sec, ETT PPV, O2 dsat < 90% for > 90 sec, vomiting, unexpected change in vital signs, use of reversal agent, emergent anesthesia consultation, NPO guideline deviation 6. Nurses CANNOT push; only attending can push or a resident under direct supervision of attending not also doing the procedure (required 3 docs at bedside) 7. Doses - 0.25 - 1 mg/kg bolus (adults and peds) then q3-5 min can give 0.2-0.5 mg/kg; - Draw up 1 mg/kg & infuse slowly over 3-5 min 8. Consider lidocaine or fentanyl predosing to help ease pain at injection site (fentanyl 1mcg/kg IV in same line you're giving propofol) DDX
- septic hip or osteomyelitis, discitis, transient synovitis; trauma, congenital, neoplastic, SCFE, LCPD > Your goal should be to rule out potential catastrophic disease Physical Exam - undress!! - watch gait (antalgic gait - less time in stance phase on injured limb; trendelenberg, leaning over the side of the affected hip) - Evaluate for point of maximum tenderness - Hip pain > think spine - Knee pain > think hips - Range of motion - logroll thigh - gives good range of motion of hip Imaging - plain films are a good place to start - image everything if hard story or difficult to pinpoint pain Labs - ESR, CRP, CBC with diff, blood cultures Diagnosis - Transient Synovitis - get hip XRay - bony landmakrs are normal; may see widened joint space - may have joint effusion on US > Management = Rest and NSAIDs; f/up with ortho vs peds in 24-48 hrs; > Kids can limp on and off for a month > Can look like septic hip, usually follows URI; usually had normal labs > Kocher Criteria - 4 criteria: non-weight bearing on affected side; ESR > 40, Fever, WBC >12K - All 4 = 99%; 3 criteria 93%; 2 criteria = 40%; 1 criteria,3% chance of septic arthritis - Toddlers Fracture - Common in young kids; accidental - Stable; do above knee cast with knee flexed - The developing Bone - thicker periosteum, bone is more eleastic; avulsion before tendon rupture - Allows for unique fracture type: Torus and Bowing - SCFE - widened physis; Kleins line - should have bone on other line of femoral neck (get AP and frog leg views) > Stable - kid can walk (at all) - 90% - DC home; nonweight bearing; f/up with ortho; > Unstable - unable to walk (10%) - higher rate of avascular necrosis - non weight bearing; admit to ortho - Septic Arthritis - Common in large joints; severe pain; muscle spasms; fever - Staph and think Neiserria in sexually active teens > Be aware that little kids (< 3 months) have adjacent osteomyelitis (need MRI); 6mo-2 yrs - 50% will have associated infection > Aspirate and OR (antbx after debridement) - ortho urgency States of sedation
-- Aspiration risk - sedation depth and length don’t correlate with poor outcomes; - solids vs liquids - can impact aspiration risk; - GERD & age can increase risk; - no evidence based literature that has a definite time that patient needs to be NPO for -- Monitoring - pulse ox, response to commands, ventilation, CO2 monitoring, continuous cardiac monitoring - ETCO2 - goal 35-45 mmHg
Etomidate - complications of myoclonus Propofol - benefits - gives deep sedation, doesn’t give analgesia (need pain relief too); patients can have apnea and laryngospasm Combining sedatives - like ketofol? - may improve HD stability A phenomenal time was had by all who attended Dr. Bustin's Nerve Block Extravaganza!!
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