Conference Notes 8-21-2012
Schwab/Barounis Oral Boards
Case 1. Toxic Alcohol-Methanol ingestion. Recognize anion gap acidosis. Calculate osmolal gap. Give Fomepizole. Arrange for hemodialysis. Pt required intubation to protect airway. Bicarb drip may be used for acidosis but it is not a critical action.
Case 2. Anterior Shoulder Dislocation. Perform neuro-vascualar exam of injured extremity. Give procedural sedation or intra-articular anesthetic. Use any described reduction technique.
Case 3. Retropharyngeal Abscess. Identify pre-spinal soft tissue swelling. >7mm at C2 or >14 at C6 is abnormal. The pre-vertebral soft tissue width should not exceed the width of the vertebral bodies. CT of neck will give more detail of soft tissues than plain radiograph. Give appropriate IV antibiotics. Intubation is rarely required unless patient looks very sick and is planned to be transferred. Surgical airway may rarely be required.
E Kulstad Work up for PE
The prevailing thought is that we try to identify PE’s to save someone’s life. This idea is based on older data that found PE’s to have a reasonably high mortality. Current data from Jeff Kline 2008 shows that in 13 ED’s in the US and NZ the overall PE mortality is 0.2% (13/8138).
Is PE mortality lower today because of better treatment? There is only 1 controlled trial of anticoagulation for venous thromboembolism. This one study showed no treatment difference between heparin and ibuprofen. The thought is that mortality is better today due to emergency physicians casting such a wide net that we are identifying small clinically insignificant PE’s. That broader group has a much lower overall mortality.
Small peripheral PE’s pose an unknown threat. Small clots may be transient and normal. If we scanned everyone in the audience, we would find a few small PE’s. One study showed a 20% rate of PE in autopsies for persons killed instantly by a traumatic accident.
When using a low specificity test in a population with a low prevalence of disease (ie. CT for PE in low risk patients) false positives exceed true positives. The PERC study showed a 7% prevalence of PE based on imaging. Probably many (most?) of these positive scans were false positives. To make matters worse inter-rater reliability between radiologists reviewing scans to identify PE is not very good. The more likely prevalence based on calculations Erik walked us through is 2.3%.
Assume there is an 80% reduction in mortality of PE due to heparinization. This is likely a gross overestimation of treatment effect. Erik then walked us through calculations of harm and benefit of identifying and treating PE. Risks of harm include renal injury, cancer risks, risks of hemorrhage. The final calculations show that work up and treatment for PE causes more harm than benefit for patients. These calculatons use conservative estimates of harm and generous estimates of benefit. The conclusion is that current practice of working up PE’s has 6X greater chance of harm than benefit.
In the US standard of care probably forces us to persist in working up patients for PE.
Lovell comment: Can we use normal vitals to not pursue a work up? Can we use a higher d-dimer cut off for low risk patients? Erik responded yes to both. You can use a double of the standard d-dimer cut off for low risk patients.
Barounis comment: He got a response from the author Dave Neuman that pt’s with a Well’s score less than 2 need no further work up .
Gourineni Peds Ortho
If pt has limb ischemia due to a fx or dlx you should immediately attempt reduction. Then consult both Ortho and Vascular Surgery. Don’t allow the child to eat or drink in the ER if there is any chance of patient going to OR.
Compartment syndrome: Gourineni feels compartment pressure measurements are not accurate. He prefers the symptom of muscle pain and sign of tense compartment. He also likes the delta pressure which is the difference between diastolic blood pressure and compartment pressure. Pain with passive movement is also a sign he favors. If you suspect compartment syndrome call both the Ortho resident and Ortho Attending. Keep limb at heart level, remove any bandages, reduce any deformity. These patients require surgery in 3-4 hours.
Open fractures: Early antibiotics with ancef is more important than timing of surgical debridement. Open fractures of hand do not require surgery. Irrigation and antibiotics in the ER is adequate for hand or distal extremity open fracutes.
Dislocations: All dislocations need to be reduced in ER. Delay in reduction in elbow/knee/ankle/foot will result in ischemic injury. 40% risk of posterior tibial artery injury in knee dislocations. Make sure joint has good range of motion after reduction. If it doesn’t, Dr. Gourineni wants to know about it.
Fractures: Boney deformity tends to straighten out. Deformity does not improve around elbow. So, all displaced elbow fractures require ORIF. Splints should be long for supracondylar fx’s to proximal humerus. Femur fractures need a splint extending up to chest wall.
Clavicle: most clavicle fx’s are treated non operatively. Surgery is required for skin tenting or posterior sterno-clavicular dislocation.
Proximal humerus fx: 100% displacement and 1cm of shortening will spontaneously remodal. This is due to majority of bone growth at proximal humerus.
Supracondylar Fx: Look at anterior humeral line. If it bisects the condyle there is minimal displacement. These patients can be splinted and discharged with close ortho follow up. If the condyle is posterior to anterior humeral line there is significant displacement and pt should be admitted for surgery. If there is vascular compromise, pt will go to OR in a few hours. Splints should not be at 90 degree flexion. 30-45 degrees is better. Check interosseus nerve and radial nerve function with thumb IP flex/extension or OK sign.
Monteggia Fx-Dlx: Think of this any time you see a proximal ulnar fx. It is the combination of proximal unlar fx and radial head dislocation. If the radial head doesn’t line up with the capitellum it is dislocation.
Elbow dislocation: For all elbow dislocations do the Roberts maneuver. Extend and supinate wrist to remove any boney particles in elbow joint.
Displaced distal forearm fractures will frequently heal and remodel in 2-3 months. You don’t need to reduce most of these. If parents want it reduced and you feel you can reduce it, it is ok to attempt reduction.
Any hip pain should initiate an Ortho consult.
MCP dislocations that are angulated not parallel to bone should be reduced by not pulling the digit but rather pushing the digit closer to the metacarpal bone and sliding the digit back into place.
Lis Franc: If patient has tenderness with torsion of forefoot. Get an xray looking for fx of prox 2nd metatarsal or non-allignment of middle cuneiform and 2nd metatarsal. Either way if xray is nl or abnormal splint patient and keep them non-weight bearing with follow up in Ortho clinic.
Joint Aspiration and Reduction Clinic