Conference Notes 1-16-2019

Katiyar Billing and Coding Lecture

Unfortunately I missed this outstanding lecture.

Katiyar Study Guide Orthopedics

Remember that infection and cancer/leukemia are possible in all these age groups.

Remember that infection and cancer/leukemia are possible in all these age groups.

Pediatric Hip pain differential

Any visible posterior fat pad sign on the lateral elbow film is abnormal. A large anterior fat pad sign is also abnormal. If you see a posterior fat pad sign in a child think supracondylar fracture. A visible posterior fat pad sign in an adult is associated with radial head fracture.

Any visible posterior fat pad sign on the lateral elbow film is abnormal. A large anterior fat pad sign is also abnormal. If you see a posterior fat pad sign in a child think supracondylar fracture. A visible posterior fat pad sign in an adult is associated with radial head fracture.

The S sign if normal is smooth with no step-off or sharp turns. An abnormal S sign has either a step off or an abrupt turn or buckle.   Klein's line and S-sign  A heterogeneous group of 20 orthopedic surgeons, radiologists, and pediatricians viewed 35 radiographs of SCFE using Klein's line on the AP view and the S-sign on frog-leg lateral view to make the diagnosis. They found the overall diagnostic accuracy was better with the S-sign than Klein's line, 92% vs 79%. Sensitivity of the S-sign was 89%, specificity 95%. Sensitivity of Klein's line was 68%, specificity 89%. Combined S-sign + Klein's line sensitivity was 96%, specificity 85%. Take a look and review Klein's line for the AP view and the new S-sign for the frog-leg lateral.

The S sign if normal is smooth with no step-off or sharp turns. An abnormal S sign has either a step off or an abrupt turn or buckle.

Klein's line and S-sign
A heterogeneous group of 20 orthopedic surgeons, radiologists, and pediatricians viewed 35 radiographs of SCFE using Klein's line on the AP view and the S-sign on frog-leg lateral view to make the diagnosis. They found the overall diagnostic accuracy was better with the S-sign than Klein's line, 92% vs 79%. Sensitivity of the S-sign was 89%, specificity 95%. Sensitivity of Klein's line was 68%, specificity 89%. Combined S-sign + Klein's line sensitivity was 96%, specificity 85%. Take a look and review Klein's line for the AP view and the new S-sign for the frog-leg lateral.


Kennedy/Jurkovic Oral Boards

Case 1. 47 yo male presents with abdominal pain and hematemesis. Patient has history of ETOHism. On exam, patient was hypotensive and vomiting large volumes of blood. Diagnosis was life-threatening variceal bleeding. Management included crystalloid and blood product resuscitation. Intubation. octreotide, PPI, reverse coagulopathy, antibiotics, and blakemore tube. GI consult and emergent endoscopy were all also indicated. Consider vasopressin. If endoscopy is not successful, consider IR for TIPS procedure.

A restrictive transfusion threshold using hemoglobin concentrations of <7 grams/dL in most patients and <9 grams/dL in older patients with comorbidities who are not tolerating the acute anemia is recommended. 5 , 31   Patients with cirrhosis have an impaired immune system and have an increased risk of gut bacterial translocation during an acute bleeding episode. Prophylactic antibiotics (e.g.,  ciprofloxacin  400 milligrams IV or ceftriaxone 1 gram IV) reduce infectious complications, rebleeding, days of hospitalization, mortality from bacterial infections, and all-cause mortality, 42  and should be started as soon as possible. (Tintinalli 8th ed)

A restrictive transfusion threshold using hemoglobin concentrations of <7 grams/dL in most patients and <9 grams/dL in older patients with comorbidities who are not tolerating the acute anemia is recommended.5,31

Patients with cirrhosis have an impaired immune system and have an increased risk of gut bacterial translocation during an acute bleeding episode. Prophylactic antibiotics (e.g., ciprofloxacin 400 milligrams IV or ceftriaxone 1 gram IV) reduce infectious complications, rebleeding, days of hospitalization, mortality from bacterial infections, and all-cause mortality,42 and should be started as soon as possible. (Tintinalli 8th ed)

Case 2. 62yo male patient with altered mental status. BP=85/62. Heart rate 46. Patient had history of thyroidectomy and clinical picture of hypothyroidism. Diagnosis was myxedema coma with hypoglycemia, hypothermia, and bradycardia. . Patient was intubated and paced. Patient was given IV dextrose, IV Synthroid, and IV hydrocortisone. Beware of massive tongue in patients with myxedema coma. It may make intubation more difficult.

myxedema tx.PNG

Case 3. 27 yo female involved in a motorcycle crash. BP=165/105 P=105. Patient injured her wrist. X-ray shows perilunate dislocation. You can attempt reduction in the ED using finger traps. Most of these patients need surgery.

Perilunate dislocation. Note overlapping bones on AP view. On lateral view the capitate is posterior to the lunate and the lunate is in line with the radius.

Perilunate dislocation. Note overlapping bones on AP view. On lateral view the capitate is posterior to the lunate and the lunate is in line with the radius.

Perilunate dislocation highlighted on lateral view of wrist.. Note the capitate is posterior to the lunate and the lunate is still in line with the distal radius.     Perilunate or lunate dislocations require emergency orthopedic/hand consultation . 22  Treatment is determined by the extent of the injury. Closed reduction and long arm splint immobilization is appropriate for reducible dislocations. 23  Open, unstable, and irreducible dislocations require open reduction and internal fixation, with repair of the ligaments and fractures. Some orthopedists operate on all perilunate and lunate dislocations. 15   The complications include development of carpal instability patterns that lead to early degenerative arthritis, delayed union, malunion, nonunion, avascular necrosis, and, occasionally, median nerve compression from the volar dislocation of the lunate into the carpal tunnel . 21

Perilunate dislocation highlighted on lateral view of wrist.. Note the capitate is posterior to the lunate and the lunate is still in line with the distal radius.

Perilunate or lunate dislocations require emergency orthopedic/hand consultation.22 Treatment is determined by the extent of the injury. Closed reduction and long arm splint immobilization is appropriate for reducible dislocations.23 Open, unstable, and irreducible dislocations require open reduction and internal fixation, with repair of the ligaments and fractures. Some orthopedists operate on all perilunate and lunate dislocations.15 The complications include development of carpal instability patterns that lead to early degenerative arthritis, delayed union, malunion, nonunion, avascular necrosis, and, occasionally, median nerve compression from the volar dislocation of the lunate into the carpal tunnel.21

Goodmanson The Legend of the Ventilator

 Thanks to Dr. Lovell for writing the notes for this lecture!

Initial Settings: 

Lung Injury:

Mode:  AC

TV:  6-8 cc/kg IBW (protective)

Rate:  16  higher side....mid/high teens

FiO2:  start high, titrate down ASAP!

PEEP:  5 to start, may go up

 

-versus-

Obstructive Disease:

Mode:  VC

TV:  8 cc/kg IBW

Rate: 8-10 (lower, think permissive hypercapnea)

FiO2: start high, titrate down ASAP!

PEEP:  5 to start, may go down

Goals:  Higher flow rate, higher I:E ratio which is most impacted with slow RR

 

Increase oxygenation:  increase FiO2 or increase PEEP

Increase ventilation:  increase RR or TV, but really it’s all about the RR-shouldn’t exceed 8 cc/kg IBW

 

Airway Pressures:

Peak Pressure = Vt + Insp flow rate + airway resistance + lung compliance (focus on resistance and compliance)

Plateau Pressure = Vt + lung compliance (focus on lung compliance)

 

Hi peak + nml plateau = Hi resistance

Hi peak + Hi plateau = decreased compliance

 

Peak pressure continuously reported, but Plateau pressure obtained through inspiratory hold

 

The Crashing Ventilated Patient:  DOPES mnemonic

 

Think:

Dislodgement

Obstruction (of tube or of patient)

Pneumothorax or Patient (eg big PE)

Equipment failure

Stacked breaths (auto PEEP)

 

Do:

Disconnect from the ventilator (P, E, S)

Begin BVM ventilation

Feel, look, listen (D, O, P, S)

Pass a suction catheter or bougie through the ETT (O)

Consider needle/finger thoracostomy (P)

Consider manual expiration maneuver (S)

 

Auto-PEEP (aka breath stacking):

Look at Flow display on ventilator for incomplete emptying-expiratory flow is still occurring at the beginning of the next breath

Prevent by decreasing respiratory rate

Correct by disconnecting ventilator, manual expiration maneuver (lean on chest)

Remember, tension pneumothorax and breath stacking represent same end-pathophysiology (obstructive).  Use US if you have time, otherwise needle the chest bilaterally if patient coding.

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