CONFERENCE NOTES 3-20-2012

LAST WEEK WAS ORAL BOARDS

CARLSON   ORAL BOARD DEBRIEF

Ductal Dependent Lesions can present with cyanosis or shock.   Mottled skin is prominent in these infants.   You have to consider sepsis and do full septic work up/give abx.  Lack of fever does not exclude sepsis in infants.  Prostaglandins are indicated.  Prostaglandins can mimic sepsis.    Prostaglandins relax smooth muscle of ductus arteriosis.

Treat HUS by reducing BP, treating hyperkalemia, and transfuse for severe anemia.   Transfuse in HUS with HGB<6.   Restrict or cautious  IV fluids and consult Nephrology for dialysis.  HUS is most common cause of renal failure in kids.  Most common trigger is Ecoli toxin.   Ask for missing vital signs on the oral boards. 

Treat INH overdose with benzos, phenobarb, and pyridoxine.   Talk to family members or EMS on the oral boards.  They have key info.  INH interferes with pyridoxine which is needed to synthesize GABA.  Gyrometra muschroom (False Morel) overdose acts the same way as an INH overdose.  

If giving TPA for stroke, no heparin/asa/plavix.  If a patient is on heparin, lovenox, asa, plavix then you can’t give TPA.

AKA can develop hypoglycemia.  AKA is a starvation ketoacidosis due to emesis/gastritis.  Treat AKA with IV hydration with glucose containing fluids and give thiamine.  In aspiration setting, lateral decubitus films are classically described.  The dependent hemithorax(down side) should compress.  If it remains expanded then you need to suspect bronchial obstruction.

The lateral cspine view may be helpful in the trauma patient in shock to get quick eval for spinal fx and neurogenic shock.

Electrical Alternans is a sign of Pericardial Effusion/Tamponade. 

Abhi  Khatiyar  ORTHO STUDY GUIDE

Patellar dislocation mostly occurs in lateral direction.  Reduce patella and use knee immobiizer. 

Knee dislocation, beware popliteal vascular injury.  Examine for hard and soft signs of vascular injury. ABI<0.9 is abnormal.  All knee dislocations need angiogram. 

Tibial Plateau fx is most common fx of knee.   Lateral plateau is most common.   Beware in the older patient who has subtle or negative xray and can’t bear weight.

If you see fat globules in synovial fluid it strongly suggests fx.

Gout crystals are negatively birefringent.  Pseudogout (calcium pyrophosphate deposition disease) crystals are positively birefringent.

Thompson’s test evaluates for Achilles’ tendon rupture.   Positive test means the forefoot doesn’t move with calf compression in prone/flexed knee position. Fluoroqiunalones can increase risk of rupture.

Adhesive capsulitis (frozen shoulder).  Common complication after shoulder fx.  Can occur after stroke as well.

Carpal Tunnel Syndome: most specific sign is splitting of sensation of the 4^th finger.

Lover’s fx (Don Juan Fx)is a calcaneal fx from fall from height.  Associated injury is burst fx of lumbar spine.

Jones fx of 5^th mt is a  diaphyseal fx, slow to heal and has high incidence of non union.   Pseudo Jones Fx is an  avulsion fx’s off of the proximal 5^th mt.

ROBBIE McDERMOTT   RADIATION MEDICINE PART 2

 Tx for local radiation injury: infection control, wound care, surgical consult, nsaid’s, hyperbaric oxygen, trental, vitamin E, topical steroids.

Acute Radiation Syndrome can occur from external exposures >1Gy.  DNA damage to cells within microseconds.  Intestinal cells, lymphocytes and stem cells are most prone to injury.

Stages of ARS: prodromal/nausea and vomit, fever, conjunctivitis; latent period; illness onset; recovery or death.

Hematopoietic syndrome(2Gy)   Lymphocytes and marrow cells are most sensitive to radation.

Gastrointestinal Syndrome (6Gy)  Earlier emesis=higher exposure.  If pt vomiting in 10 minutes or less than 60 minutes=bad outcome.

Cardio/CNS syndrome (20Gy)  Not usually survivable.

2Gy and less exposure has almost 100% survival.

Cytogenic Biodosimetry=# of dicentric chromosomes gives best estimate of radiation dose.

Absolute lymphocyte count is best test in first 24 hours for estimating radiation exposure.

Irradiated patients generally do not pose a threat to care providers.  Treat medical/surgical patients first.

Time to emesis if less than 2 hours likely exposure of 3Gy and greater.   Be aware that psychogenic emesis is common with radiation event.

Triage score=N/L+E.    E=0 for no emesis,   E=2 for emesis.   N/L is neutrophill/lymphocyte ratio.  Nl =2.21  If T>3.7 radiation dose is high.

 Colony stimulating factors for exposures >3Gy.   Implement  IDSA guidelines for neutropenia.

Amylase is another marker (baseling and 24 hours) for radiatin exposure.  Amylase will increase with significant exposure.

Contaminated patients in ER need to be kept in strict isolation.  Remove patient clothing.  Wash off patient and save all fluid runoff in a closed system.  Don’t let wash fluid run down drain.

Exposed patients with no symptoms for 6-8 hours can be discharged.

ER caregivers  for contaminated patients  should wear a  whole body coverall, surgical mask, double glove.

DAVE BAROUNIS   FEIBA FOR REVERSAL OF Coumadin COAGULOPATHY

Life threatening bleeding and INR>5 use 1000U of FEIBA over 15 min plus 10mg of IV vitamin K over 30 minutes

Life threatening bleeding and INR<5 use 500U of FEIBA over 15 min plus 10mg of IV vitamin K over 30 minutes

INR should be repeated in 30 minutes.   If INR<5 then you are done.   If INR still>5 give another 500U.

JOELLEN CHANNON   M and M   Massive PE

 Massive PE: sbp <90 for 15 minutes.   Submassive PE: RV dilation on echo.  Low risk PE has neither.

Mortality is highest with massive pe and lowest with low risk pe.

McConnell’s sign: apical contraction with wall motion abnormalities away from apex.

On CT if RV diameter/LV diameter >0.9 is sign of RV dysfunction.

Elevated troponin in PEis indicative of increased short term mortality.

T wave inversion inferiorly and anteriorly is a sign of RV strain.

TPA for submassive PE may result in better RV pressures at 6 months.   No one has been able to shows mortality benefit so far in this group.

Ways to identify the sicker patient with pe: echo, shock index>1, any hypotension at all, any respiratory distress.  These patients should be strongly considered for TPA.

If high probability of PE give heparin during workup; Recommended by AHA

 No TPA for undifferentiated arrest.

Effect of respiratory depression with benzos is pronounced in patients who have some aspect of co2 retention.

LOUIS HERRMANN  PEDIATRIC HIP PAIN

Legg-Calve-Perthes (idiopathic osteonecrosis/avascular necrosis)more common in short statured male  kids.  Insidious in onset.  Lesion on xray is more common on lateral aspect of femoral head.  Conservative management usually works well

If patient has thigh or knee or groin pain gotta evaluate the hip.

SCFE  more common in 11-14 years of age.  More common in Obese kids.  Related to thyroid disease.  Kids prefer his in abduction with external rotation.   Internal rotation is painful and limited due to the altered mechanics of hip.   Klein’s line runs along lateral femoral neck and should hit the epiphysis.  Also on xray lesser trochanter will be more prominent on xray due to external rotation.   SCFE requires surgery.

Transient synovitis: most common cause of hip pain in children.  Post viral process is thought to be the cause.   Non-toxic appearing patient. May have some fever. 

Septic Arthritis: More prominent effusion compared with transient synovitis.  Can be a tense effusion.  ROM of hip is commonly exquisitely tender.  U/S can identify the effusion.   Synovial fluid with wbc count>50000 is diagnostic for septic joint.   Surgical treatment with arthrotomy and joint wash out with 2 weeks of iv antibiotics is the treatment.   4 factors are more predictive:fever, non weight bearing, elevated esr >40, wbc>12,000.