Lithuania

-training in Lithuania is 6 years and they graduate with a masters degree with ability to practice in EMS, ED and palliative care

-EMS services only carried out by EMS personnel, not fire or police

-Ambulance types: BLS, ALS, ALS intensive care

-BLS-minor traumas, cardiac arrest if nearest, transport, psychiatric emergencies, minor medical- Can start IV and apply supraglottic airway, no meds

-ALS- Nurse and driver-paramedic- can administer medications, can interpret EKG, supraglottic devices, intubation, procedural sedation, etc.

-ALS ICU- Doctor, nurse, driver-paramedic- US, terminating CPR, invasive and non-invasive ventilation- most critically sick patients

Riot Dispersal Agents and GSW Management

-Tear gas fall under chemical weapons- designed to be an irritant that leaves no lasting damage (not always the case)

-14 cases of death from these agents, but all have been from people getting struck with the cannister (in the US)

-In Israel have had cases of people dying from chemical itself when deployed in poorly ventilated areas

-No long term studies- there are concerns for long term toxicity

-Decontamination- removing from exposure

-Copious water irrigation

-Velocity of the GSW is what determines damage- high velocity causes worse disruption

-Two types of wounds: 1. Penetrating- enters but does not leave body 2. Perforating- enters and leaves body

-ABI for concern vascular injury- <.9 needs angiography, >.9 but less than 1.0 needs obs

-71% of those with arterial injury have concomitant nerve injury

EDH

-Introduction to Dr. Syed Shah

AAEM

-Est. 1993 to advocate for EM as a specialty

-Key Issues: Advocacy, Board Certification, Corporate practice of medicine, EMTALA, Due process

-AAEM has multiple resources and benefits to include scientific conferences, podcasts, help in establishing/finding democratic groups, etc

-When thinking about your finances, replace your “buts” with “ands”- for instance “I’m about to make 300k a year AND I don’t know what to do with it”, rather than saying “…but I don’t know what to do with it”

-Think about other streams of revenue. Examples: selling a product, content creation, renting room/property

-Take inventory of your life. What does your millionaire life look like? What kind of car do you want? House? What do you want to do with your time?

-Estimate the monthly costs of these. It is likely easier for you to “live your millionaire life” than you might think, and setting these goals and visualizing them can help you in determining your pathway to them.

Ortho tips and tricks for closed reductions

-Purpose- to restore length, alignment, rotation

-Helps with patient comfort, protecting cartilage, keep neurovascular structures away from stress, prevent skin/wound complications

-Also trial of non-operative management

-Needs pre-reduction XR

-Recreate the deformity to “unhinge”

-Consider your deforming forces- what structures at risk, what muscles/forces pulling fracture, what will open joint space, etc.

-Tourniquets can get in the way, so try and take down if possible

-Molding- holds your reduction in place, 3 point mold (never mold over bony prominence)

-Purpose of CT is to evaluate joint

-Rare to obtain CT prior to reduction unless there is a block of some kind

-Every time a joint gets dislocated it will need to stressed to assess for stability- this will determine need for operative management

-Unstable hip dislocations need traction pins

-Elbow test flex/extension + varus and valgus stress

-Unstable dislocations get ex-fix EVEN IF NO FRACTURE

-Joint dislocation is emergent in the ortho world

-Shoulder reduction

              -Do not try alone if there is an associated fracture, TSA or rTSA in place

              -Milch maneuver

              -Stability exam

              -Scapular Y XR and axillary views

-Elbow Reduction- typically associated with ligamentous damage

              -Simple- no fracture, complex- fracture

              -Terrible triad injury- LUCL, radial head, coronoid

              -Inline traction, supination, flexion

              -Stress the joint

              -Neurovascular exam

              -Monteggia- Proximal 1/3 ulna + radiocapitellar jt- make sure that radial head is reduced!!

                            -Blocks to reduction- annular ligament, biceps tendon

                           -Stress- especially pronation and supination- need to splint in whichever is more stable

-Hip- posterior wall fracture

              -often associated with acetabular fracture- if it isn’t try not to cause one

              -Captain Morgan reduction, East Baltimore Lift

              -Flexion, adduction, internal rotation (for posterior dislocation)- Stress exam

              -Make sure to get pre-reduction XR

              -When to ask for help- traction pin, peri-prosthetic

-Knee dislocation- often associated with neurovascular injury

              -First steps- physical exam, doppler, ABI’s?, CTA’s? (not super sensitive for intimal flaps)- typically keep these for obs for 24 hours

              -Vascular consult?

-Subtalar Dislocation

              -Difficult reduction- try and call ortho for this

              -Different than the tibiotalar dislocation (standard ankle dislocation

              -Dislocation of the talus and calcaneus

              -need to relax gastrocnemius muscle- flex the knee

              -Plantar flex the ankle

              -Is the talonavicular joint in place after reduction? Can see on post reduction lateral films

-Remember 3- point mold, and do not mold over bony prominence

-When does it not matter

              -certain fractures- humerus, femur shaft/ distal femur, both bone forearm, tibia +/- fibula

              -Just need to get to length

Lightning Lectures

Dr. Kushner- Kids with a limp

-fractures, muscle/tendon/ligament injury, insect bite, hemarthrosis, transient synovitis, cellulitis/abscess, plantar wart

-SCFE- type I Salter harris fracture

              -most common hip pathology in adolescents

              -Usually happens during periods of rapid growth

              -Risk factors: obesity, family history, endocrine/metabolic disorder, down syndrome

              -Stable- able to bear weight with crutches

              -Unstable- not able to bear any weight

              -Work-up: XR (AP and frog leg), MRI, possible workup for kidney disease or endocrine disorder

              -Non-weight bearing, consult to ortho

              -Unstable needs to be admitted

              -Complications: osteonecrosis, chondrolysis, femoroacetabular impingement

-Legg Calves Perthe- Osteonecrosis of femoral head- idiopathic

              -10-15% will be bilateral

              -Ages 2-12 with peak 4-9

              -Pain in hip, groin, thigh, knee

              -may wax and wane over weeks to months

              -Goals: pain relief, protect femoral head shape, restore hip mvmnt

              -Non-weight bearing, NSAIDS and consult to ortho

-Septic Arthritis- most commonly hematogenous spread

              -most common in hip, knee, ankle

              -Staph aureus, respiratory pathogens, kingella, e coli, salmonella

              -Need to rule out adjacent joint involvement

              -FABER position- Flexion, Abduction, External rotation

              -Workup: CBC, CRP/ESR, blood cultures- possible swabs if suspect gonorrhea

              -XR AP and frog leg

              ->50k WBC and >75% polymorphonuclear cells in synovial fluid suggestive of SA

              -Kochers criteria- fever, non-weight bearing, ESR >40, WBC >12k

              -Consider LP if septic joint caused by H. flu- high incidence of meningitis

              -Try and hold on abx until aspirate and cultures can be obtained

-Transient Synovitis

              -Etiology unclear but typically proceeded by URI, trauma, bacterial infection

              -Treatment NSAIDS, heating pads

              -Should resolve in 1 to 2 weeks- close follow up for resolution

Dr. Aiello- Conus medullaris and Cauda Equina Syndromes

-Conus medullaris syndrome- CM injury typically at L1-L2

              -Findings: Urinary incontinence, fecal incontinence, decreased rectal tone, erectile dysfunction, saddle anesthesia

              -What sets apart from cauda equina- muscle weakness typically bilateral, + upper motor neuron signs, loss of patellar reflexes

-Cauda equina syndrome

              -Begins at L2 and extends to sacral nerve roots

              -Can be asymmetric

              -Usually more painful than conus medullaris

-Management-

              -if neoplasm suspected- dexamethasone 10 mg IV?, MRI w/ contrast

              -Spine consult, likely surgery

R2 Clinical Pathway- Traumatic Injuries of the Spine- Drs. Bishop and Alia

-Up to 25% of SCI occurs after initial insult- extraction, transport, handling, early mobilization

-Spinal tracts:

              -Descending Motor tracts: Lateral corticospinal, ventral corticospinal

              -Ascending sensory tracts: Dorsal columns (fine touch, proprioception, vibration), Lateral spinothalamic (pain, temp), Anterior spinothalamic (course touch, pressure)

-High dose steroids not recommended in spinal cord injury

-Brown-Sequard Syndrome- transverse hemi-section or unilateral compression

              -ipsilateral spastic paresis, loss of proprioception/vibration

              -contralateral pain and temperature loss

-Central Cord syndrome- squeezing of the cord affecting inner portions

              -Quadriparesis worse in upper extremities

              -Cape like distribution

              -Sacral sparing

              -MRI, NES/Spine

-Anterior Cord Syndrome

              -Direct compression or ischemia of anterior 2/3 of spinal cord

                           -disc protrusion, AAA, hyperflexion, emboli

              -Symptoms:

                           -paraplegia below lesion

                           -loss of pain and temp

                           -Bowel/bladder dysfunction

                            -Dysautonomia

-Spinal Shock- injury resulting in transient global loss of function w/ temp flaccid paralysis, bowel/bladder dysfunction, anesthesia, loss of reflexes

              -Resolves in days to weeks

-Neurogenic Shock- injury to spinal column resulting in hypotension, bradycardia, and hypothermia

              -occurs in <20% of SCI patients

              -injury level:

                           -Above T1- full sympathetic denervation

                           -T1-L3: partial denervation

              -Management:

                           -Exclude other causes of vital sign abnormalities

                            -MAP goals- first line pressor (MAP goal 85-90)

                           -Levo first line, can add phenylephrine as second line pressor

                           -Atropine, temp probe, bair hugger

-Unstable fractures:

              -Jefferson Bit Off A Hangman’s Thumb

                           -Jeffersons Burst Fracture- C1 fracture of anterior/posterior arches

                           -Bilateral cervical facet dislocation

                           -Odontoid Fracture, type II (full odontoid fracture) or III (vertebral body involvement)

                           -Atlanto-occipital dissociation

                           -Hangmans fracture- bilateral C2 pedicle fractures- displaces C2 anteriorly onto C3

                           -(Flexion) Tear drop fracture- associated with anterior cervical cord syndrome

-Remember Canadian C-spine, NEXUS criteria for clearing C-spine

-R2 Pathway on room9er

Dr. Jacobs- Life after Residency

-Show up 15 minutes (at least) early for your shifts

-Get to know the people you work with and be friendly

-Avoid arguments

-Flow is important- order everything you think you might need (within reason) right out of the gate- will speed things up ultimately

-Ask for help if you need to- case management, colleagues, PT/OT, nurse manager, etc.

-Don’t vent your anger in public- beware of being recorded

-Temper patient expectations- don’t over-promise, do what you can do

-Don’t get locked into a diagnosis and refuse to budge- avoid confirmation bias

-Listen to your nurses, involve them in care- will help with building relationships

-Recognize your feelings- if you need a minute to decompress or vent, do so before your feelings boil over

-Get a lawyer/accountant/financial advisor onboard early in your career so you can maximize your pre-tax deductions, retirement accounts, etc.

Ortho ppx

-Open fracture classification Gustilo- Anderson

-Size lac, degree soft tissue injury, contamination, vasc comp

-I: lac < 1cm, clean

-II: lac >1cm w/o extensive soft tissue

-III: lac >10 cm w extensive soft tissue injury or amp

-III A, B C

-Open fractures w/ increased incidence of infx/ osteo, vasc injury, nerve injury, compartment syndrome, VTE

-Orthopedic Trauma Association Open Fracture Classification- emerging classification system due to poor interobserver classification- Skin, muscle, contamination, bone loss- score greater than 5 add gram neg

-Goal for abx ASAP, 1-3 hours post injury by EAST guidelines

-Type I and II, Gram + only- Cefazolin 2 g Q8H

-Pts > 120kg get 3 g

-Alt clindamycin 900 mg IV Q8H

-Duration 24 hrs after closure

-Type III Gram + and –

-Cefazolin + Gentamicin or tobramycin 5mg/kg 1 time dose

-Adverse effects of aminoglycosides- Nephrotoxic- make sure adequately hydrated- Ototoxic(irreversible)

-Soil/feces contamination- Clostridium species- 4-6 million units penicillin IV q 4-6h- alt metronidazole 500 mg q 8H

-Fresh water contamination- Aeromonas- Zosyn or cefepime

-If unable can use cipro or levofloxacin

-Salt water Vibrio- Zosyn/cefepime + doxycycline (alt is cipro/levo + doxycycline)

-GSW open fx- EAST guidelines recommend to consider type 3

-Reality- low velocity (handguns) similar management to closed

-High velocity- Rifles/shotguns- similar to type III

-Recs- treat like type I or II unless contamination present. If extensive tissue damage treat like type III

Peds: Ortho/ NAT

-Le fort fractures never occur in children less than 2 due to lack of pneumatization of the sinuses

-Children less than 8- susceptible to ligamentous and growth plate C spine fx that are higher up

-Older children lower C spine fractures more common

-Posterior displaced medial clavicle fx needs CT to ensure no compression of mediastinal vessels or trachea

-Salter Harris classification

-Gartland Classification supracondylar fx- type II and III likely to require surgery

-Galeazzi

-Monteggia-

-Toddler’s Fractures- 12-94 months, low energy trauma w/ rotational force

-Subtalar joints have poor blood supply making it prone to osteonecrosis

-Chopart- separates midfoot from hindfoot- important for pronation and supination

-NAT- TEN 4 FACES P

-torso including genitals, ears, neck, frenulum, angle of the mandible, cheek, eyelid, subconjunctival hemorrhage, patterned bruising

-4- any bruising in a child less than 4 months of age

-95.6% sensitive, 87.1% specific for NAT

-Point tenderness over an unfused epiphysis concern for non-displaced salter harris- need splinting and follow up

-Nursemaids elbow- mechanism is being pulled

-Reduced by hyper-pronation or supination/flexion

-pain is usually at wrist

Tactical Medicine

-Swat developed after the Texas tower incident Aug 1, 1966

-1989 to 1990 interest began in involving medical professionals with SWAT

-Officers to learn methods of self rescue and to provide basic medical care

-TCCC- Tactical Combat Casualty Care

-Hot zone- immediate area with perpetrator- shooting back, moving casualty out of hot zone are priority

-Warm zone- potential for hostile threat, not under direct fire- Immediate care can be performed here- tourniquet, Chest seal/decompress, airway

-Cold zone- No significant threat of danger- more definitive care

-They use (S)MARCH- security, massive hemorrhage, airway, circulation, hypothermia

Nailbed Injuries and Arthrocentesis

-Indication for trephination- less than 1-2 days old, 50% or more of nail bed

-Be careful with flammable alcohols and check for acrylic nails as these are also flammable

-Nail bed laceration- digital nerve block, remove nail, repair w/ 5-0 or 6-0 absorbable sutures, replace nail into fold

-Arthrocentesis- suspicion of septic arthritis, crytal arthropathies, unexplained arthritis W/ effusion, eval of jt capsule integrity in trauma, therapeutic relief of pain/ effusion

-Contraindications: No absolute but relative include overlying cellulitis, prosthetics

– >50k WBC, >90% PMN cells indicative of septic joint

Venous thromboembolism

• 90 day overall PE mortality rates were 17% in 1999, 16% in 2018
• Inari FLASH registry 30 day mortality rates for High and intermediate risk PE patients were 0.8%
• Nearly half of submassive 30 day mortality occurs outside of hospital
• Lightning Lectures:

Pelvic Fractures

-3 month mortality 3x higher in trauma patients with pelvic fractures

-Increased concern for bladder/urethra injury

-Sacral fractures -zone 1, 2, 3- 3 is worst prognostically

-APC 1 <2.5 cm pubic symph

-APC 2 >2.5 + anterior ligament

-APC 3 >2.5 + ant+ post

-Vertical sheer

-Pelvic binders: unstable and pelvic injury suspected. Over trochanters.

-Inlet/outlet films, judet AP and lateral decubitus position once stable

-FAST can help determine if needs lap (+ blood) or embolization

Compartment Syndrome

-1-10% of tibial fractures, ant compartment most common

-Normal compartment pressure < 10 mmHg

-<20 mmHg unlikely to cause damage

-CK, UA for myoglobin (rhabdo in 40%)

-Stryker- compartment >30 mmHg in one compartment

– Delta pressure: diastolic – pressure (30 or less is indication for fasciotomy)

-Fasciotomy w/in 6 hrs 100% recovery

-12 hr 66%

Ortho Plain Films

-Most often missed finding is the 2^nd finding

-More views are better

-Axillary view very helpful in glenohumeral joint evaluation

-Posterior shoulder dislocations- hard to see, patient can’t externally rotate (lightbulb sign), lack of crescent sign

-4 views at the elbow

-Monteggia fracture- Proximal ulnar fracture with dislocation of radiocapetallar joint (radial head dislocation)

-Galeazzi fracture- Mid to distal third of ulna with dislocation of distal radioulnar joint

-Maisonneuve- total disruption of interosseous membrane

Strangulation injuries are a tough chief complaint. We have many considerations in evaluating and managing these patients. Top priority is ABCs, and then ruling out other serious injuries in the patient.

We may tend to have too low a threshold for CTA in these patients. But they often end up in court proceedings and one could argue for the more aggressive imaging strategy for this reason. Of note, strangulation in the setting of domestic violence represents a VERY high risk mechanism to predict subsequent fatal injury in intimate partner violence.

I am not offering a clear cut answer on when to CTA and when not to. This should be a decision you make with the patient and your attending, considering patient age, injury severity, etc. But the two resources below can at least provide some context on evidence for imaging.

1. Check out this algorithm, authored by Dr. Bill Smock who was UL EM faculty for years and worked with the LMPD as the police surgeon for years. He writes the forensic medicine chapters in a few textbooks as well.

Imaging Recommendations for the Medical/Radiographic Evaluation of Acute Adult, Non-Fatal Strangulation

2. Also check out the paper below, authored by UL Emergency Radiology physicians including Dr. Jonathan Joshi.

https://pubmed.ncbi.nlm.nih.gov/31055673/