Pelvic Trauma
Dr. Ferko

• Signs of pelvic trauma: hematuria, inability to void, abnormally positioned prostate
• Diagnosis:
• Hematuria, but severity of hematuria on UA does not equal severity of injury
  • Plainfilms to evaluate for fx near kidney/bladder/urethra
  • Retrograde urethrogram
  • Retrograde cystogram
• Retrograde urethrogram-when?
  • Male with external signs of trauma
  • Perform ideally before foley placement
  • Females-urology consult needed
  • Defer if CTA pelvis needed as it will interfere with contrast
• Retrograde urethrogram-how?
  • Patient supine
  • Obtain baseline KUB
  • 60cc syringe with 10% contrast, in last 10cc repeat KUB
  • For stretch injury/partial disruption, usually conservative management with catheter
• Retrograde cystogram
  • Fully fill bladder; inject until full and then 50cc further (usually around 400cc)

(from Journal of Urology)

Le Fort Fractures
Dr. Lehnig

• Complete or partial separation of mid face from skull
• Pterygoid involved in all
• Usually caused by blunt trauma
• LeFort I most common
• Higher velocity more likely to cause II/III
• LeFort I: palate-facial separation (think dentures)-mobility of the maxilla
• LeFort II: (nose and mouth) Nasal bridge, maxilla, lacrimal bones, orbital floor, and rim
• LeFort III: across nasal bridge, orbital walls, zygomatic arch (“floating face”)
• Endotracheal intubation preferred over nasal, prep for difficult airway
• LeFort II/III: CTA indicated
• Complications: Vascular injury (internal carotid as high as 7%), nerve injury, eye injury
• Treatment: definitive tx is surgical, ophtho consult, NES if CSF leak
• No specific guidelines on abx, many get augmentin

Prehospital Airway Management
Dr. Price

• Methods available? ET tube (oral or nasal), BVM (with OPA/NPA), supraglottic, needle cric (methods vary by state per state regulations)
• Variables to consider: patient (age, condition), provider (level, experience, training), setting (environment, distance)
• Study with 4 Key questions addressed
  • BVM vs SGA
  • BVM vs ETI
  • SGA vs ETI
  • Benefits and harms comparison based on pt type, technique, and devices
  • Methods: 1990-2020, >9000 abstracts, 99 studies
  • Results…inconclusive benefits, but harms: no difference in reported aspiration, airway trauma, regurgitation with any devices; BUT number of attempts less with SGA than ETI
  • Conclusion: current evidence does not favor more invasive airway approaches based on survival, neurologic function, ROSC, or successful airway insertion
• More research needed, may be more useful to study ventilation management as it may reveal clinically relevant differences

Oral Boards Prep
Dr. Shaw

Learning Points:

• In every patient, unless something requires emergent intervention, perform physical exam head to toe
• Remember to request repeat vitals
• Use a systematic approach
• Primary survey in trauma:
  • MARCH
    • Massive hemorrhage
    • Airway
    • Respiration
    • Circulation
    • Hypothermia/Head injury
  • Massive hemorrhage:
    • Tourniquet: place proximal to bleed, write time of placement
    • Twist tourniquet until you lose pulses in the extremity
    • 2 inches, 2 hours
    • 2 inches proximal to wound
    • On for up to 2 hours (can be left up to 6 hours, but can have neurovascular damage)
  • Airway:
    • Oxygenate
    • Ventilate (apnea)
    • Protect airway (secretions, mental status)
    • Clinical course (too agitated for CT)
  • Respiratory:
    • Rate, breath sounds, stridor, tracheal deviation, JVD
    • Needle decompression can be done either anteriorly at mid-clavicular line or laterally at anterior axillary
    • If needle decompression or chest tube for penetrating trauma, remember to place occlusive dressing over the initial injuries/wounds
  • Circulation:
    • BP, HR
    • 14G (250ml/min) and 16G (150ml/min) peripheral IVs have higher flow rate than Cordis (130ml/min)
  • Head Injury/Hypothermia:
    • GCS, pupillary exam, neuro exam
• Primary survey for every trauma patient, every time

Tumor Lysis Syndrome – Dr. Aher

typically occurs within days after chemotherapy.

Findings of: Hyperkalemia, Hyperuricemia, Hyperphosphatemia, HYPOcalcemia (2/2 phosphate binding Calcium

Dialysis indications: Potassium >6, Cr. >10, Uric Acid >10, symptomatic hypocalcemia, Phos >10, Volume overload

Methemoglobinemia – Dr. Norby-Hill

Can happen with dapsone overdose

Dissociation between SPaO2 and PaO2

Acquired cases from medications and environment, commonly dapsone, local anesthetics, nitrites, h202

50% is fatal

Features: refractory to supplemental o2, color of blood, cyanosis, respiratory depression

Tx: methylene blue (Not in G6PD or those on SSRIs as MB is MAOI), ASCORBIC ACID, EXCHANGE TRANSFUSION

Pediatric Surgical Emergencies – Dr. Robin Lund

Early blood tinged emesis – cracked nipples

Pyloric stenosis: M>F 4:1, 3 to 5 weeks, veracious eaters, NBNB projectile every feed, dehydration, malnutrition

Appy’s usually missed the younger they are

Intuss – 6 mo to 3 yo; ddx Meckels and hsp. 

Features: colicky severe, 20 min, emesis, sausage mass

NEC: sudden feeding intolerance, distention, tenderness, bilious vomiting, diarrhea, rectal bleeding

Malrotation: <1* vomiting, sick, abd distension, peritonitis.

Heme emergencies – Dr. McGee

1 single unit of donor platelets raises plts by 30k

Transfusion indications: <10k (20k if febrile or septic), <50k active bleeding, <100k CNS bleeding or neuraxial surgery

-vwb dz tx for minor bleeding is ddavp

Post transfusion purpura: alloantigen on transfused plts: t penia, purport, clinically significant bleeding. Tx IVIG

Don’t forget about HIIT if recent inpatient stint

MAHAs – non immune HA.

TMAs: microvascular hemolysis; tap, has, drug, complement, pregnancy, htn emergency

High Sensitivity Troponin – Dr. Adam Ross

6 or above reported. Anything less than 20 nl in males; <15 normal in females

>88 MI

15 or greater (change in either direction) increase is clinically significant (2 hours)

TBD if there will be poc trop in R9

Single trop undetectable with >3 hours of symptoms

Hemophilia Lecture

A is Factor VIII deficiency

B is Factor IX

Both are 

VWD: VWf “chaperones” Factor VIII and facilitates its efficacy

Emicizumab: bispecific mab. Helps factor 9 and 10 work. Subcutaneous injection prophylactically.

Meds ending in -ate are for VIII deficiency.