Author Archives: Matthew Keller

Conference Notes 09/29/21

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US for Shoulder Dislocation and Reduction

  • Approach
    • Position the probe over posterior aspect of affected shoulder with indicator to patient’s left
    • Measure distance between glenoid and humeral head
  • Advantages: faster than XR, ~100% sensitivity
  • Disadvantages: less sensitive for fractures, operator dependent, not full agreement on measurements

Fascia iliaca compartment block (FICB)

  • This is different from the “femoral nerve block” and “3 in 1 block”
    • FICB anesthetizes femoral nerve and lateral femoral cutaneous nerve
  • Target: facial plane above the iliacus muscle. Infrainguinal.
  • Inject 30-40 mL medial to femoral nerve using a 21 or 20 gauge spinal needle and extension tubing
  • 0.2% or 0.5% Ropivacaine or Bupivacaine
    • Analgesia onset within 30 min and lasts ~12 hrs
    • If using 0.5% dilute 20 mL anesthesia with 20 mL NS
    • ALWAYS calculate your dose

PE Clinical Pathway

  • Categorization
    • Massive: hypotension
    • Submassive: RV dysfunction or myocardial necrosis w/o hypotension
    • Non-massive or Sub-segmental: no hypotension, RV dysfunction, myocardial necrosis
  • Utilize PERC and Wells criteria
  • See full pathway posted separately

Extremity Trauma by Dr. Caleb Davis

  • Clavicle fx – typically manage with sling
    • May need OR if there is skin tenting or blanching
  • Beware of scapulothoracic dissociation in AC joint injury. Requires OR
  • Luxatio erecta (inferior dislocation) – to reduce, push the humeral head anteriorly under traction and then reduce like an anterior dislocation
  • Scaphoid fracture – MRI is best imaging modality in the acute setting
  • Pelvic ring injuries a thorough rectal and vaginal exam is indicated to rule out hollow viscus injury from the bone.
  • Hip dislocation – need post-reduction pelvic CT to look for fracture fragments
  • Femoral shaft fractures
    • associated injuries common
    • Need to make sure patient is adequately resusicated prior to operation to avoid 2nd hit injury to lungs. Get lactic and ABG to measure resus. Place on 2L NC.
    • Don’t miss open fractures. Can be small “poke-hole”
  • Knee dislocations – get ABG and CTA
  • Tibial plateau fractures are often too swollen to fix initially.
  • Fractures 2/2 GSW from 9mm rounds or lower are not considered open fractures
  • Compartment syndromes
    • pain out of proportion (first symptom)
    • pain with passive stretch (most sensitive finding)
    • Clinical diagnosis

Airway Assessment and Interventions

  • Sedation/RSI
    • Depth of sedation: mild, moderate, deep, general anesthesia
    • Risk assessment with ASA class and LEMON
    • SOAP-ME
      • Suction
      • Oxygen- preoxygenation and apneic oxygenation
      • Airway equipment
      • Positioning – put the towel roll under the occiput (NOT the shoulder) to align the tragus and sternal notch. Consider ramping the patient.
      • Meds
      • Equipment/EtCo2

Conference Notes 9/22/21

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Complications of the Foot by Dr. Ford

  • Osteomyelitis
    • High risk groups: Substance abusers, Diabetics, open fractures
    • Bone biopsy is gold standard for diagnosis
    • Get a deep culture (with a piece of tissue or bone) before initiating abx
    • Bone mineral loss of 30% is required for changes to be visible on X-ray
  • Charcot neuroarthropathy
    • Progressive noninfectious condition
    • 2 etiologies: neurovascular and neurotraumatic (microfractures)
      • Neurovascular: massive amounts of blood flow “water log” the bones. Caused by autonomic dysfunction
    • Initial phases can look like cellulitis but erythema is DEPENDENT (resolves with 10min of elevation)
    • Consolidation (chronic) phase = rocker bottom foot. Mid foot bony deformity
    • DISCHARGE if no WBC or open wound. Normal to have elevated ESR, CRP, temperature.
    • ADMIT if open wound present to r/o infection with biopsy
    • Treatment is offloading with total-contact cast
  • Gout
    • Gouty arthritis can break down bone and mimic osteo. Differentiate with history.
    • Uric acid level will be elevated

Lightning Lectures

Gout

  • Monosodium urate crystal deposition
  • Elevated uric acid levels
  • Monoarthritis often involving first MTP or knee joint
  • US can demonstrate “double contour sign”
  • Treatment options: NSAIDs, Prednisone, Colchicine

Septic Arthritis

  • <35yo: N gonorrhea; >35yo: S. aureus
  • Pain with ROM
  • Arthrocentesis with synovial fluid analysis is diagnostic

Pharmacology in Open Fractures and Reductions

  • In antibiotic selection in open fractures consider Gustilo Classification and environmental exposures.
  • Grade I & II fractures: gram positive coverage w/ Cefazolin
  • Grade III fracture: gram positive and negative coverage w/ cefazoline and gentamicin

Conference Notes 9/8/21

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Rhabdomyolysis

Causes: traumatic, non-traumatic exertional, non-traumatic non-exertional

Workup:

  • Hyperkalemia
  • hyperphosphatemia
  • hypocalcemia
  • CK 3-5x upper limit of normal
  • UA: +blood (myoglobin), -RBC

Management: IVF 2.5 mL/kg/hr with UOP goal of 2-3 cc/kg/hr

Upper and Lower Extremity Nerve Palsies

Source: https://geekymedics.com/nerve-supply-to-the-upper-limb/
Source: Uptodate.com

Pediatric Ortho

  • Always consider non-accidental trauma in children
  • Occult fractures are more common in peds
  • If in doubt, splint and follow-up with ortho
  • Presence of fat pads can indicate underlying fracture
    • Posterior is always pathologic.
    • A thin anterior fat pad is normal, but a “sail sign” is pathologic
  • Management of common fractures
    • Monteggia fracture – urgent ortho consult for ORIF
    • Seymour fracture – physeal fracture of distal phalanx with associated nailbed injury. High risk for soft tissue entrapment. Requires Hand consult for likely ORIF
    • Tufts fracture w/ nailbed injury – antibiotics not required. Follow-up in 7-10 days with Hand
    • Common avulsion fractures (e.g. ASIS, lesser troch, iliac crest apophysis avulsion) should be NWB on affected extremity and f/u with ortho.
    • Torus fracture – splint with short arm cock-up splint
    • Greenstick fracture – unstable, requires splinting
    • Bowing deformity – treat it like a fracture and splint it
    • Mid and proximal humerus fracture – sling and swathe OR coaptation splint, sling, ortho f/u
Source: https://rebelem.com/rebel-review/rebel-review-23-salter-harris-fracture-classification/salter-harris-fracture-classification/

Drug Rashes

  • Common drug-induced rashes
    • Exanthematous drug eruption (EDE) – maculopapular
    • Urticaria w/o anaphylaxis
    • Vancomycin flushing syndrome (“Red man”)
  • Uncommon and severe drug-induced rashes
    • Fixed drug eruptions
    • angioedema
    • acute generalized exanthematous pustulosis
    • DRESS
    • SJS and TEN
  • DRESS can occur up to 8 weeks from drug exposure
  • EDE (T-cell related) vs Urticaria (histamine) – draw an image on patient’s skin. If it appears red and/or raised after 10 min, it is urticaria
  • Antihistamines: First gen (sedating): diphenhydramine, hydroxyzine; Second gen (less sedating): cetirizine, loratadine
  • Topical corticosteroids – medium to high potency preferred for short course

Conference Notes 9/1/21

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ABEM

  • ABEM exists to verify the abilities of physicians and to promote quality, trust, and responsibility.
  • They aim to make our board certification more valuable by advocating for our value in hospitals
  • See ABEM website for details about board certification and the exam
  • Study for your exam!

Small Group: Nail bed Infections

  • Flexor tenosynovitis
    • Hand emergency. Pt will often require OR washout with Hand surgery.
  • Paronychia
    • Manage with warm compress and/or I&D
  • Subungual hematoma
    • Ensure there is no underlying fracture
    • Trephination is generally reserved for symptomatic treatment within the first 24hrs

HIPAA: common scenarios and what is appropriate

  • Family member: provider may disclose “directory info” (patient location and general health status) if caller identifies the patient by name.
    • The provider must first provide the patient with opportunity to agree or object
  • Personal physician
    • Disclosures of PHI from one provider to another for treatment purposes are permissible without the patient’s authorization. Disclosing provider must use professional judgement to determine whether the requested PHI relates to the patient’s treatment by the requesting physician
  • Press
    • Location and general health status can be disclosed if requestor identifies the patient by name, unless the patient has objected to such disclosures
    • Can’t just ask about the status of a GSW
  • Test results
    • Provider must use their judgement to infer from the situation that a patient does or does not object
  • Law Enforcement
    • Limited situations – PHI about a patient who is suspected to be a crime victim and the patient cannot agree to disclosure; the provider may disclose the PHI if (1) she/he determines that disclosures is in the patient’s best interest and the law enforcement officials represent that the PHI needed to determine whether another person violated the law. (2) The PHI is not intended to be used against the patient. (3) An immediate law enforcement activity depends on disclosure.