![]() Dens fracture > Type I: Extends through the tip of the dens > Type II: Extends through the base of the dens - unstable > Type III: Extends through vertebral body of axis - can be unstable Geriatric Trauma - Falls - leading cause of injury - Frequently fail to mount a tachycardic response TB meningitis
> If lymphocytic meningitis, likely not viral if low glucose - LOW GLUCOSE IS NOT NORMAL FOR VIRAL MENINGITIS > Absence of fever doesn't exclude TB > Cranial nerve 6 = most common nerve palsy in meningitis Chronic Acetaminophen Toxicity - Can't use nomagram with chronic ingestions - NAC - replenished and maintains glutathione stores - also thought to have a role in free radical scavenging; IV or PO acceptable - If unknown ingestion time and LFTs or APAP elevated
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![]() Intussusception:
-Paucity of gas due to loss of gas in ascending colon
-Age rage 5 mo - 3 yr but typically <1 yr
-Ideal U/S patient: sens 98-100%, spec 88-100% -Must prep patient well for US with good pain control and anxiolysis Bowel obstruction:
Appy: 2007 JAMA RCE - Does my patient have appendicitis
Chronic Abd Pain:
![]() Impact - Head injury is the #1 killer the trauma patient To scan or not to scan? Cost Issues - Head CT = $2700 Occult Injury Issues
If GCS = 14, 10-20% + head CT If GCS 13 = 20-30% + head CT So, if GCS is not 15... risk increases substantially. 2 classes of head trauma patients:
New Orleans Head CT rule - goal was to identify all patients with abnormal scan.
Canadian Head CT rule - looking for clinically significant findings - more specific
Use with caution in drunk folks! Anticoagulation is the Enemy! IMAGE ALL ANTICOAGULATED HEAD TRAUMA -- Much higher mortality in anticoagulated patients when compared to age matched controls Plavix vs Coumadin? -- Observational study of adult ED patients with blunt head trauma on coumadin vs plavix -- higher risk of immediate bleed in plavix -- important - 60% of people with bleeds had GCS 15 and 70% had no LOC Delayed Bleeds? -- Risk of delayed bleed relatively small; -- People with negative head CT who are THERAPEUTICALLY anticoagulated can be DC'ed home -- People who are supra-therapeutic likely need observation. Blood in the Brain is Bad. Airway management - want to minimize increased ICP RSI > Lidocaine - theoretically is supposed to attenuate cough reflex but hasn't been proven to change outcomes > Sucyincholine - can use without concern of worsening ICP from fasiculations > Ketamine - is ok to use in ICP - good literature that ketamine can help with ICP and avoids risk of hypotension that can occur with etomidate (don't use if has history of obstructive hydrocephalus) - use 1-2mg/kg Ventilator settings - RR of 12 Mannitol: 1g/kg (0.5g/kg - 1.5g/kg) - some evidence higher doses are more effective. The Primary damage has been done... your job is to Prevent Secondary Injury
IMPENDING HERNIATION (and briefly in conjunction with other measures); endpoint 30 mm Hg d. Steroids, narcan, hypothermia - none has been proven to work * No fantastic evidence in people on ASA with head trauma* ![]() Pericarditis vs. MI Your goal is not to diagnose pericarditis... it is to not miss MI. Pericarditis = fever, position dependent pain, diffuse elevation, no reciprocal changes, no Q wave MI = focal ST changes, reciprocal changes, Q waves, +/- pulmonary edema {From Dr. Mattu's ECG Lessons} Factors strongly favoring Acute MI: -- ST Depression in any lead other than V1 or aVR -- ST elevation that is Convex upwards (tombstone) or Slant-like/Horizontal. -- ST elevation in III > II If you have none of those, then consider the Factors that favor pericarditis: -- Pronounced PR depression in multiple leads (often only seen early in viral pericarditis) -- Friction rub Spodick's Sign: downsloping of QRS-TP segment in 80% of acute pericarditis When in doubt, check SERIAL ECGs!! What to order? - Consider troponin, CRP, WBC, ESR, CXR - CRP can be used for diagnosis and disease monitoring Treatment: - NSAIDS = mainstay - Colchicine + conventional therapy => decrease in recurrence rate in patients with a first eposide of acute pericarditis - dose is 0.5mg daily (<70kg) or 0.5mg BID (>70kg) x 3months (none of our cardiologists treat for that long) Recurrent pericarditis = symptom-free for 6 weeks and then symptoms recur Caution with Colchicine - elderly, hepatic/renal failure, pregnant patients In refractory cases, consider steroids, chemotherapeutic agents ![]() Acute Mitral Regurgitation - acute vs chronic Most common cause of acute: 1. Rupture chordae tendinae due to myxomatous disease, infectious endocarditis, rhemuatic heart disease 2. Rupture papillary muscle due to MI (2-7 days prior) Can get pulmonary edema, cardiogenic shock, mimics ARDS, PNA, difficult exam findings Echo enables you to quantify degree of MR; use color flow doppler echo to evalute for acute MR Persistent Tachycardia
Buergers disease
![]() Basics
Type
Patho
Presentation
Risk factors
Diagnosis
Therapy
![]() Elderly Demented Pt s/p "Fall"
- family hx is the greatest risk factor - increases risk 10 fold - smoking is the most important modifiable risk factor - Triad of pain, hypotension, pulsatile mass = 10% - 60% of patients with ruptured AAA - normal vitals signs - bedside US - sensitivity/ specificity 98% Sore Throat After Intubation
- foreign body - vocal cord laceration - tracheal or esophageal perforation Is that a Pneumothorax > Pneumothorax ex vacu - forms adjacent to atelectatic lobe, results from bronchial obstructions - do not treat with chest tube - relieve but fixing obstruction ![]() Mechanism of GI injury Damage is due to multiple factors: - tissue contact time - pH and concentration - ability of caustic to penetrate tissues - presence of absence of food in stomach - titratable acid/allkaline reserve (TAR) - amount of neutralizer needed to titrate pH of caustic to physiologic pH of tissues - higher TARs produce more damaged tissue Alkalis - injury is due to LIQUEFACTION NECROSIS - bad because injury keeps penetrating until neutralized or penetration of organ occurs - can get esophageal and gastric injuries > Sodium hydroxide > Sodium hypochlorite (household bleach) - worry about ingestion of larger amounts or higher concentrations > Ammonium hydroxide (toilet bowel cleaner) > Household detergents - usually dont cause GI injury but massive ingestions can be bad Acids - + ion causes COAGULATION NECROSIS - ulceration and perforation can occur; can get gap or nonanion gao acidosis; both esophageal and gastric injuries as well as pylorospasm Classification of caustic injury of esophagus Grade I - hyperemia - diet as tolerated, early D/C (likely need to be brought in initially for obs) Grade II - ulcerations and exudates Grade III - necrosis and deep ulcerations * Be aware - these people can have an initially benign presentation * Don’t use presence or absence of oral pharyngeal lesions to determine damage distally Management - Hydration - Steroids for airway edema (not research base) - CBC, lytes, VBG, coags - Not unusual to have GI bleed early on, but check type and cross - Airway - manage early (WEAR MASK), get good visualization - No NG tube for alkali ingestions, but with acid ingestions use w/in 30-60 min, don't do charcoal unless bad ingestion (ex, Zinc Chloride) - Endoscopy for all intentional ingestions - perform in first 12-48 hrs, up to 96 hrs is safe - unless they ingest very concentrated products or large amounts - then scope immediately - If you do not scope - observe for 6-12 hrs with serial exams and small sips of water - Contraindications to endoscopy - perforation, supraglottic or epiglottic burns (concern for perforation if you scope) - if can’t do endoscopy - perform esophagram and upper GI series 24 hrs after ingestion - use water soluble contrast initially Sequelae - scarring - motility issues - gastric outlet obstruction - tracheoesphogeal fistulas - strictures which SIGNIFICANTLY increases risk for Cancer - need lifelong monitoring ![]() 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 ![]() Case - 7 month old male - hx of complex congenital heart disease
- Be on the same team as the parent - you both want the kid to live - Be aware of the limitations of the members of your team and if things aren’t going well, rearrange things - Be empathetic - If you can’t make it, fake it!
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