Conference Notes 10-8-2013

Another Conference chock full of high quality presentations!

Urumov     Study Guide   Orthopedics

Maisonneuve Fracture: Fracture of  proximal fibula with a tear in the tibiofibular syndesmosis. There is frequently a boney injury of the distal tibia or rupture of the deltoid ligament as well.


Bohler’s angle:  Normal is 20-40 degrees.  If less, suspect fracture.


Pittsburgh knee rules :  Get xrays in a patient that fell or had blunt injury to knee AND  pt is over 50 or under 12 or pt cannot take 4 steps in ED.


Lateral Tibial plateau fractures are associated with ACL and MCL ligamentous injuries.  Medial tibial plateau fractures are associated with PCL and LCL ligament injuries.  

Lateral knee xrays are most sensitive for fracture.  Lipohemarthrosis (blood/fat interface seen on lateral film, or fat globules in blood seen on arthrocentesis) is another sign of knee fracture.

Knee exam: collateral ligaments should be tested with the knee in 30 degrees flexion.  >1cm of laxity is significant.  If you test the knee in full extension and there is laxity that suggests that the ACL is also injured.   Harwood comment: compare the pt’s injured knee exam  to the un-injured knee and look for assymetrical laxity.  That is probably a better marker than the classic 1cm rule.

Osteo chondritis dessicans: Specifically, OCD is a localized lesion in which a segment of subchondral bone and articular cartilage separates from the underlying bone, leaving either a stable or unstable fragment (up to date)  Stages range from a small compressed/non-displaced fragment to a completely detached and displaced boney foreign body



 Chopart Joint (yellow squigly line) and Lis Franc Joint (red squigly line)


Delta Pressure in patient with concern for compartment syndrome: Diastolic pressure  minus   compartment pressure should be greater than 30mm hg.  In one study noted in Tintinalli no patients had serious outcomes from compartment syndrome with a delta pressure greater than 30.

Risk factors for Achilles tendon rupture:  Age over 40, quinolone use, prior steroid injection.   Also more common in weekend warriors.  Diagnose with thompson’s test.

Pylon Fracture: Severe axial load fracture to ankle mortis.


Lis Franc Fracture:  Complications include compartment syndrome of foot, chronic arthritis, nonunion.  Tips to diagnose the injury is plantar ecchymoses, fx of proximal 2nd metatarsal, and wide space between proximal first and second metatarsal.  2 examples below:


Jones and Pseudo Jones fracture:  Jones fracture involves the metaphysic of the 5th mt.  Pseudojones is an avulsion fracture of the tuberosity of the 5th mt.   Jones fractures require post mold and non-weight bearing.   Psuedojones can be treated with an ace wrap/cast shoe and weight bearing as tolerated.


Jones Fracture


Pseudojones Fx


  EKG changes with elevated ICP are giant T-wave inversions.

Sodium Channel Blockers like TCA’s will cause prolonged QRS, right axis deviation and prominent r wave in AVR.  Herrmann comment: If you have a TCA overdose with a wide complex rhythm and tall R wave in AVR, give repeated bolus doses of sodium bicarb until the QRS narrows down.   Elise comment:  Bicarb drip will not work initially, you have to give bolus dose bicarb.




Hyperkalemic changes of ekg include: Tall, narrow, peaked T waves,  p wave will flatten and eventually be lost,  qrs can progressively widen, bradycardia, sine wave.    Putman coment: Many of the critically ill hyperkalemic patients  I have seen had a wide, bradycardic rhythm.  So when you see bradycardia especially with a wide complex think hyperkalemia.

Hyperkalemia ECG



Gore       Tachyarrythmias

Consideration 1: Is the patient stable or unstable.   Place zoll pads on patient either way

Consideration 2: Are there P waves?

Consideration 3: Regular or Irregular

Consideration 4: QRS wide or narrow.


Narrow/Reg: If there are p waves, sinus tach.  If no p waves: 1. SVT  TX=adenosine. 2. Aflutter with consistent block Tx=diltiazem.  3. Orthodromic WPW  Tx=adenosine or procainamide.   Elise comment: Give 0.5 mg of propofol prior to giving adenosine to prevent the very uncomfortable chest pressure/impending doom  feeling related to adenosine.    Elise comment:  In a patient with Orthodromic SVT from WPW  treat with adenosine.   It will look initially like the run-of-the-mill SVT.  There is no danger in treating orthodromic, narrow complex SVT from WPW with adenosine.  On initial presentation, you won’t know that it is WPW.

Narrow/Irreg:  If P waves present think aflutter or MAT.  If no P waves think afib.   You can use diltiazem for all of these.  Magnesium is another option, as is Amiodarone.   If the patient is unstable with a narrow/irregular tachycardia consider cardioversion.   Afib usually takes higher doses of electricity to convert.   Harwood and Elise comment: Ibutalide, procainamide, and propafenone are also options for conversin of afib.   Elise comment: Check for hypomagnesiemia. Harwood  comment: I give magnesium prior to giving ibutilide. It may decrease the risk of torsades with ibutilide.   Tekwani comment: Digoxin is a nice option for the borderline hypotensive patient with rapid afib.

Wide/Reg: Vtach.   Unstable Cardiovert.   Stable: amiodarone, procainamide.   If you can prove by previous ekg that it is SVT with bundle branch block then adenosine is ok.  Any doubt, treat as V-tach. 

Wide/Irreg: Afib with Abberancy (WPW)  Tx with procainomide.  

Case discussed of pt with WPW and presented with antidromic  SVT.

Chastain                      OB Ultrasound

To document that a pregnancy is in the uterus the image must include bladder, vaginal stripe and uterus.   Gestational sac/yolk salk/fetus must be within the uterus.

Ovaries lay medial and anterior to iliac vessels.   Ovaries look like chocolate chip cookies because of the follicles.

Ovary on ultrasound

You should see a gestational sac with TVOB at a B-hcg level of 1000.

Fetal heart rate should be 150-170 at 7-9 weeks.  The heart rate  will be a little lower before and after this period.

In second trimester, measure the biparietal diameter (inner skull to outer skull) to get accurate gestational age.  In third trimester you can estimate gestational age with femur length.

Free fluid in pouch of douglas or morrison’s pouch in the setting of pregnancy with abdominal pain and no definite intrauterine pregnancy indicates very high risk of ruptured ectopic pregnancy.  

Michelle presented multiple OB ultrasounds for the residents to interpret.

Postive fetal heart tones does not mean that the baby is in the uterus.   Mike Lambert knows a person who was a full term ectopic pregnancy in the peritoneal cavity.    Lam Socratic Question:  Can you have an IUP with an empty uterus on U/S and a quant-hcg over 2000?  Yes it is possible.  These patients need close follow up and repeat beta-hcg and U/S in 48 hours.   Also should return for pain, lightheadedness, vaginal bleeding.    Girzadas comment: You should obviously be consulting with OB in this situation.  This clinical situation is very high risk.

Permar    Safety Lecture      Sharps Safety

800,000 needlestick injuries per year in US.  Most are un-reported.

Sharps injury risk exposure to HIV, HBV, HCV.

40% occur during procedure.   40% occur during clean up.  20% occur during recapping, passing needles, improper disposal.    25% are inflicted by a co-worker.

Trale presented the data on all our EM resident sharps injuries.   Girzadas comment: I have been notified by Hospital Safety that we have a high number of  sharps injuries in our department.

Harwood comment:  Straight needles seem to be a common cause of needle punctures during central lines.    We should consider getting the straight needles out of the central line kit.   Trale comment: In the ICU, they don’t allow you to suture in the lines.    Harwood comment: We need to  change our central line kit to have curved needles and a needle driver.  Harwood comment: Consider dermabond to attach line to skin.   Walchuck comment: We should invest in thimbles for all the residents.  J

No recapping of needles.   Elise comment: Just don’t recap the needle! Just don’t do it!

Include sharp safety during time out.   Vocalize when you are moving sharps on the field or tray.

Double gloving has multiple advantages.   It reduces perforations to inner glove, makes visualization of out glove perforations easier and reduces the amount of blood that is transmitted into the injured caregiver by 95%!  The first glove “wipes” the blood off the needle before it gets through the second glove.

If you get stuck: wash hand thoroughly and  immediately.  Go to the ER to get medical attention and to report the injury.

28 day anti-retroviral therapy for HIV has a lot of side effects.  

Girzadas comment:  We will have thicker ,first layer gloves (green indicator gloves) available in central line kits and in the charting rooms.  Use a sterile glove over these thicker green gloves.  Please double glove for invasive procedures.  Discuss sharps safety during timeouts.  Be careful out there!

Den Ouden      An ER Hobit’s Tale

Case 1. Pt felt Imminent delivery of child.    Multiple checks and U/S showed a second trimester baby who was not engaged in the pelvis.   Pt had a large BM and felt much better.  Lesson: Trust your exam.

Case2. 21yo male with headache for 2 weeks prior to ED visit.  CT head shows 5cm mass of right thalamus.  Pt became anxious and his BP went up in the ED after hearing this news.    Pt then began posturing and blew right pupil.  Pt was treated with intubation/hyperventilation, mannitol, IV lido, and surgery.   Pt survived but had neuro deficits.   Lesson: Be prepared for rare emergent  events like herniation,  crics, peds resuscitations. 

Case3. 49yo male with Down’s.   Severe constipation for 2 weeks.  Christian disimpacted the patient.   5 minutes later patient became unresponsive.   Pt was bradycardic and hypotensive.  IV fluids started.  Pt went to the unit on pressors.   Pt was dc’d home with diagnosis of presumed prolonged vaso-vagal response.    Lesson: Be aware of possible vagal response to disimpaction and even rectal exam.  Christian discussed an abstract that described using rectal exam to convert SVT.    Probably don’t do rectal exam in patients with bradycardia.

Case4. 29yo female, 20weeks pregnant with worse headache of life.  Pt had central venous thrombosis.  Lesson: Beware pregnant and post-partum complaints.

Case5. 25 yo female 13 weeks pregnant with 2 days of left eye pain with eye movement.   Diagnosis with mri showed optic neuritis and MS.  Lesson: See Lesson 4.

Case 6. 35yo male with chest wall pain. Tender lump on exam.   CRP was 17.  Osteo/abscess at sterno-clavicular joint.    Lesson: Bad shit can happen with minimal exam findings.

Case 7. 40 yo male with Pharyngitis on amox.   Pt had thrush.   Do wet mount to check for candida.   Rapid HIV was positive.   Treated with nystatin and anti-retrovirals.   Lesson: Adult with oral candidiasis, think HIV.

Case 8. Pt had Infer-Posterior STEMI on EKg.  On exam, pt has acute left side paralysis.  History of acute chest pain.   Pt got CT on way to Cath Lab.   Wife later arrived and said stroke findings were chronic.   CT’s showed old stroke and no aortic dissection.  Lesson: Be alert for possible aortic dissection with chest pain and neuro findings/complaints.

Case9. 45 yo female with septic cholangitis.  Lactate=13, hypotensive.   Know how to give your own pressors without the pharmacist’s help to get through a tight spot when the pharmacist is not available.  1mg of any pressor in 1 liter of NS= 1mcg/ml.   Epi give 1mcg/min.  Norepi (levo) 10mcg/min.  Phenylepherine (Neo) 100mcg/min.   (1:10:100 rule)

Case10. 31yo male altered mental status,  in restraints.  Na was 106. Pt on multiple psych meds.  Pt received bolus NS by nursing staff.  Pt developed massive dieresis and rapidly corrected NA.  Chrisitian consulted nephrology and started D5 and DDAVP.  Hypertonic saline dosage if you are going to give it is 50-100ml. (maybe only for seizures) Harwood comment:  Psychogenic polydispia patients frequently don’t need any treatment.  If they have normal kidneys they will correct themselves with water restriction.   Lessson: Altered mental status in psychiatric patients can have serious organic causes.

Case 11. 1am, patient wants to leave. 33 male with hx of HTN.  Pt has chest pain. EKG, 2 trops,  and PERC all negative.   Pt came back to ED with severe leg pain.   Pt had ischemic right leg on second visit.  Chrisitian started esmolol/ntg.   5 min later pt becomes unresponsive.   Pt intubated.  Pt’s ekg shows ST elevation.   Pt gets tachy then bradycardic and arrests.   Labs come back with trop#3 negative.  Dimer was elevated to 3. Suspected diagnosis was aortic dissection.   Lesson: Diagnosing aortic dissection is a bitch.   The standard of care is to miss the diagnosis.

Case12. 35yo morbidly obese male.  Ruq and periumbilical pain. Couldn’t  scan him due to size.  Surgery wouldn’t OBS him without scan.   Brookfield Zoo CT is an urban legend, they don’t have CT’s for large animals.  Other hospital  had a CT that could handle a patient up to 550lbs. Pt was transferred for CT only and then back to same hospital for admission. Lesson: It is good to be aware of both your hospital and nearby institutions’ resources.

Case13. 55 you female with severe agitation.  Ativan, etomidate, succinylcholine all not working!!   IV access was the problem.   The first IV was not working.  Second IV placed and pt went down quickly with IV meds.   Lesson: If drugs aren’t working, check your patient’s IV.

Iannitelli       Acute Pancreatitis

Case1. Psych patient with ETOH abuse.  Pt had markedly elevated lipase.

Case2.  Severe epigastric pain.  Pt had ruq tenderness.  RUQ U/S showed acute cholecystitis.   Pt had gallstone pancreatitis.

Case3. 42 yo male with abdominal pain for one month.  Etoh abuse due to PTSD.   Lipase was normal but CT showed edema of pancreas.

20% of pancreatitis cases progress to SIRS and multi-organ failure.

Difficult diagnosis because presentation is protean and there is no diagnostic gold standard.

Etiology:  Gallstones, ETOH (heavy etoh abuse for more than 5 years), medications, infections, hypertriglyceridemia (increasing incidence, level should be >1000 to cause pancreatitis).

  Serum lipase is more specific and remains elevated longer than amylase.  Only downside to Lipase is that it can be elevated in other GI diseases.  To make the diagnosis of pancreatitis the lipase should be   3X normal.   All patients that you diagnose pancreatitis should get RUQ U/S to look for stones.   You don’t need to get a CT on every patient.   Get CT for uncertainty of diagnosis or concern for complications.

Most severe pancreatitis cases present initially as mild run-of-the-mill pancreatitis.  Probably safest to assume all initial cases have the potential to become severe in 48 hours.  

Cornerstone of treatment is early aggressive IV hydration in the first 24 hours.   250-500ml/hour in the first 12-24 hours.  LR is preferred due to lower rate of SIRS development.      

Give antibiotics if infection is suspected. Don’t give antibiotics for straightforward pancreatitis.

Consult GI and General Surgery as needed.

Hypoxemia, tachycardia, or confusion are subtle signs of early organ failure.   1 or 2 Ranson criteria should suggest a sicker patient.


Have a great week everybody!