Conference Notes 5-8-2012
RYAN MUSCULO-SKELETAL STUDY GUIDE
Medial meniscus injuries present with clicking, locking or pain with extension of knee.
Osteoarthritis: Gradual onset, pain is moderate. Joint not clearly “hot”.
>50,000 WBC’s on joint aspiration points to septic joint. This is a boards type cut off. Real life is less clear cut but it is a guideline. If you have a high suspicion of septic joint and the WBC count is less than 50,000 you should still culture the aspirate and consult ortho for close follow up or possible admission.
Sciatica can linger for 8 weeks duration.
Cauda Equina causes acute urinary retention and overflow incontinence. Also look for saddle anesthesia and lower extremity weakness.
Spinal stenosis: Pain with walking due to neurogenic claudication. Patient walks with anterior flexion of waist to reduce traction on spinal cord.
Empty can test specifically evaluates the supraspinatus muscle of the rotator cuff. The rotator cuff activates abduction and int/ext rotation of shoulder.
Foot puncture wound thru a gym shoe, prophylax for pseudomonas. If puncture wound thru sock or bare foot prophylax for staph/strep. Get xray for foot puncture wounds. Have high index of suspicion for fb especially if pt has fb sensation.
Treat a felon with a longitudinal incision at area with most fluctuance.
Carpal tunnel syndrome: Risks include obsesity, pregnancy, dm. Phalen’s and Tinnel’s tests. Tx with splint and analgesics. Refer to ortho.
Amputated digit: wrap in saline gauze, put in plastic bag, place bag on ice.
Finklestein test evaluates for De Quervan’s tenosynovitis.
CHASTAIN/BAROUNIS STEMI CONFERENCE
Think circumflex lesion with minimal inferior ST elevation, tall R waves anteriorly and lateral st depression and mostly anterior st depression. Circumflex lesion=posterior infarction.
Give 2b3a inhibitors in patients with chest pain and not STEMI but has ST depression or dynamic EKG changes.
Cardiac patients who are unstable get kicked out of STEMI bundle. Resuscitate them first.
Consider strongly balloon pump in the patient with cardiogenic shock. Before placing a balloon pump, you have to exclude aortic dissection.
Neuro events can cause an adrenergic output that can make the cardiac apex ischemic. You can see ST segment elevation with no reciprocal changes.
STRASBURGER-VILLANO ORAL BOARDS
Case 1: Optic Neuritis due to MS. Usually a monocular condition. Painful with eye movement. Treat with IV steroids (has to be IV not po steroids). Be sure to get visual acuity on all eye related cases both for the boards and in real life.
Case2: PEA cardiac arrest due to variceal bleeding and pneumonia.
.Case3: Dislocated patella. Treat with passive extension of knee with firm pressure on patella redirecting it to the normal position. There was debate about the need for moderate sedation. Some felt pain control with no or light sedation was adequate.
CARLSON TOXICOLOGY MEDICATIONS FOR DIABETES (Sorry I missed the beginning portion of the lecture)
IV d5 or d10 drips give miniscule amounts of glucose. To replace glucose more robustly, feed pt if at all possible. If you need IV dextrose you will need to give 1 or more amps.
Octretide can be used for sulfonylurea and meglitinide toxicity
Admit: Any long acting insulin OD, intentional insulin OD, recurrent hypoglycemia, sulfonylurea/meglitinide, hypoglycemia related to significant change in renal function or liver function.
Glucophage can cause MALA (metformin associated lactic acidosis). It interferes with normal cellular aerobic metabolism. Mechanistically looks like a mild/non-fatal cyanide overdose. Can occur in mono-overdose. Treat with hemodialysis. Fatal cases prognostic factors are low ph 6.9 or lower, lactate over 25 or metformin level over 50. Should dialyze if ph around 7 or heading downward.
Avandia/Actos: increase insulin sensitivity and decreases glucose production in liver. Doesn’t cause hypoglycemia in OD.
Januvia: Stimulate insulin release with an elevated glucose. Has not been shown to cause hypoglycemia in OD.
Byetta: Glucagon-like peptides. Stimulate glucose dependent insulin release in gut. Does not cause hypoglycemia in OD.
Victoza: similar mechanism to Byetta. Can cause pancreatitis.
Symlin: Amylin agonists. Slows gastric emptying, decreases gluconeogenesis, increases satiety. No reports yet of hypoglycemia.
Insulin/Sulfonylureas/Meglitinides/Biguanides: These all can cause hypoglycemia in overdose.
MISTRY ROOM COVERAGE PROPOSAL
PUTMAN THERMAL BURNS IN THE ED
Stop the burning process by removing any object such as clothing or rings/watches that can retain heat and further burn or produce a tourniquet effect.
IV fluid resuscitation with Lactated Ringers
Treat with appropriate pain medications.
Get further history: chemicals/closed space/explosion/CO/cyanide/electrical injury.
Burn-specific secondary survey: eval for inhalational injury. Intubate for early signs of airway injury.
Estimate body surface area involved in burn with rule of 9’s, palm, Lund-Browder chart.
Burn depth: first=erythema of epidermis only, 2nd=blistering, 3rd=thru epidermis and dermis involving nerve endings and should have no pain in area of 3rd degree burn. 4th= involve deeper structures such as tendon and bone.
Intact blisters can be left alone.
Transfer criteria: probably need a check list to remember all of them.
Escharotomy for circumferential burns that are causing ischemia.
Skin is burned by temperatures over 113F.
Cellular Na pump is disrupted by burns. Depression of cardiac contractility can be caused by burns. Lactic acidosis can occur from burns.
Fluid resuscitation: Parkland formula is 4ml XKG X %BSA burned= volume. 50% given in first 8 hours after injury (no ED arrival). Remaining 50% given over the following 16 hours. This is a guideline that can be altered based on urine output/cvp/pulmonary status. Peds patients also need weight-based maintenance fluids.
Half of all fire related deaths are due to smoke inhalation.
Think cyanide for fires in which wool, silk, polyurethane have burned.
IV antibiotics not indicated for prophylaxis of burns. Only use if infection is evident.
Tegaderm or duoderm can be used as burn dressings for smaller burns.
Pregnant burn patients should have fetal monitoring for viable age gestations.
If the Burn Center asks for a photo of a potential transfer patient, do not identify the patient with any facial views. Document in the chart that patient consented to the photo.