Trauma Conference – Amanda Corzine

• Domestic violence underreported in Louisville and nationally
• SANE and CWF are important resources to use here
• Have increased concern for women that present intoxicated on alcohol with no prior history of intoxications – be informed about domestic violence; Dr. Coleman has done research looking at the coincidence of domestic violence in this patient population

MICU Case Review – Royalty

• Patient with AMS, seizure-like activity. PMH of COPD on home O2, HFpEF, HTN, T2DM, Afib on AC, intubated prior to ICU
  • Subsequently COVID+ on floor transfer; sent back to MICU
  • Intubated again. Started on Remdesivir, Dexamethasone. Code during intubation.
  • Ultimately complicated course of Afib management and thrombocytopenia
  • +trop in trending labs q48h in COVID patient; cards consulted.

DED/72H Returns – Staben

• Remember to get labs in hypothermic patients who have arrested – it can lead to more appropriate prognostication and cessation of futile codes. K>12 means further resuscitative efforts are futile.
• Reviewed Brain Trauma Foundation guidelines regarding surgical management of acute SDH
• Remember to do indicated procedures like bilateral chest tubes or finger thoracostomy in blunt traumatic arrest even in seemingly futile cardiac arrest as these patients can have occult injury.

2-10-2020 Conference Notes

GME disability discussion – Calvin Rasey

• Endorsed by UofL
• COVID long term effects “long haulers.”

Pediatric Fractures – Elizabeth Lehto

• Torus fracture
• Plastic deformation, kids < 4
  • Generally associated fractures
  • >20 degrees of angulation require reduction
• Greenstick, kids < 10
  • Convex surface fracture
• Complete fractures
• Salter-Harris Fracture – SALTER vs know your MEME
  • I – Straight through the growth plate, may be radiographically absent
  • II – Above, through the growth plate and above into the metaphysis
  • III – Lower, fracture through growth plate and epiphysis
  • IV – Through both epiphysis, growth plate, and metaphysis
  • V – Rammed, growth plate crush injury
• Name that fracture game
• Elbow fractures
  • Capitellum – age 1
  • Radial head – age 3
  • Internal  epicondyle – age 5
  • Trochlea – age 7
  • Olecranon – age 9
  • External epicondyle – age 11
  • Need true 90 degree flexion X-rays – don’t get lazy with them.
    • Anterior fat pad – normal
      • Big sail sign = lipohemearthrosis
    • Posterior fat pad – pathological
    • Radiocapitellar Line
    • Anterior humeral line
  • Supracondylar fractures
    • Volkman’s Contracture if neurovascular injury
    • Anterior interosseous syndrome – normal if a good “okay sign”
  • Nursemaid’s elbow
• Non-accidental trauma
  • Torso, ears, neck, 4 years or younger
  • Watch out for kids that aren’t pulling up or walking – they should not have any bruises.
  • High specificity fractures
    • Metaphyseal fractures
      • Corner fractures – oblique avulsions of the metaphysis
      • Bucket handle fractures – horizontal avulsions of metaphysis
    • Rib fractures
      • Posterior more specific; CPR causes anterior rib fractures
    • Skull fractures
      • Non-parietal, cross suture lines, depressed
    • Scapular fractures
    • Sternal fractures
    • Spinous process fractures
• Leg fractures
  • Tibial fractures
    • High risk for compartment syndrome
      • Tibial shaft fractures requiring reduction tend to be admitted
    • Toddler’s fracture – distal shaft spiral/oblique fracture between 9-3 years
  • Juvenile Tillaux fracture – SH III
    • May require CT to evaluate closed vs open reduction, <2mm can be reduced
  • Triplane fracture, distal SH IV  – requires CT
• Hand fractures
  • Carpal fractures
    • Scaphoid fracture, think FOOSH, snuffbox tenderness
  • Distal phalanx fractures
    • Tuft fractures, splinted in DIP extension
    • Nailbed associated fractures – give abx
    • Seymour fracture – displaced SH II fracture, generally open, and requires reduction.
• Hip fractures
  • SCFE
    • Fat teens presenting with knee pain
    • Surgical pinning and NWB
  • Avascular necrosis – Legg-Calve-Perthes Disease
    • Preteen, insidious onset, antalgic gait

GI Review Game – Dr. Shaw

• NEC – new babies, mostly premature, pre-E, cocaine use in pregnancy
  • Amp/Gent, bowel rest
• Giardia – treat with flagyl
• Boerhaave – L pleural effusion, CXR with pneumomediastinum
• Esophageal foreign bodies
  • Esophageal bodies align in coronal plane
  • Sharp objects, objects > 6cm in length require surgical removal, then 24h trial of passage
  • All EFB require GI f/u to rule-out structural abnormalities
• AAA
  • >5.5cm = OR, include the mural thrombus
• Hernias
  • Indirect vs direct vs femoral hernias
    • Indirect follows inguinal canal

Ventilator Management Lecture – Obrien

• Check out Scott Weingart’s post on EMcrit regarding mastering the vent.
• PRVC or VC is preferred
• Remember ARDSNet

Intern Lightning Lectures – Schutzman, French, Strohmaier

• Positively electrifying.
• Acid-Base Status
  • Bicarb vs respiration vs buffers control pH
  • Delta gap in context of AGMA  – (AG-12) – (24-Bicarb)
    • Normal -6 to +6
    • Can indicate AGMA +NAGMA superimposed or vice versa.
• Unstable C-spine fractures
  • Denis Column Concept
    • Anterior column – always stable
    • Middle column – sometimes stable
    • Posterior column – always unstable
  • Jefferson’s Fracture
    • Consider vertebral artery injury
  • Bilateral Facet Dislocation
    • Consider CTA C-spine, MRI may be warranted as SCI strongly associated
  • Odontoid Fracture
    • Types I, II, III
  • Atlanto-Occipital Dissociation
    • Calculate that Power’s ratio, folks.
  • Atlanto-Axial Dislocation
    • Remember increased likelihood in some populations; Trisomy 21, OI, Marfan, NF1, SLE, AS, psoriasis, RA
  • Hangman’s Fracture
    • C2 fx with anterior displacement
  • Flexion Teardrop
    • Can disrupt posterior longitudinal ligament, high association with anterior cord syndrome
• DRESS vs SJS vs TEN
  • DRESS – drug rash with eosinophilia – morbilliform rash
    • Remember herpes reactivation
  • SJS/TEN
    • Mucosal involvement

Can’t Miss EKG Review – Huecker

• Didn’t miss a beat.
• Read Amal Mattu. If you don’t, you won’t understand EKGs very well
• He’ll send out his presentation

Test Taking Strategies – Shreffler

• 225 multiple choice questions, 4.5 hours to complete
• Feel okay to change answers after you re-read questions; you will likely have more insight later on.
• He will send out his presentation

Headaches in Small Groups – Nichols

• HA1
  • Temporal Arteritis
    • Get ESR, can do US vs MRI, will require temporal artery biopsy
    • Ophtho involvement means a larger burst x3 days of methylprednisolone, likely requires admission
• HA2
  • CO poisoning
    • Need ABG with co-oximetry
    • Consider EKG and troponin
    • Remember fetal Hb binds CO much more preferentially than maternal Hb, so lower threshold to treat with hyperbarics.
• HA3
  • Epidural hematoma
    • Consider BP goals, mannitol/3%, elevate HOB, hyperventilate

Procedural Review – Baker

• Excellent multiple choice questions.
• SBP
  • Remember albumin, get abx early
  • Low thresholds for diagnosis with cell count greater than or equal to 100 in peritoneal dialysis
  • We need to do more paracentesis
• LP
  • Watch that bevel
  • Platelets > 20/25, INR >=1.5
• Pacemakers
  • RIJ
  • Transvenous: 80 BPM, 20mA, 20cm
• Thoracotomy
  • >1500 initial output, >200mL over first 3 hours
  • 5^th intercostal space
• Yolk sac + gestational sac required for confirming IUP earliest.