Grand Rounds Recap 03.13.24
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sports medicine gr: all about xrays WITH drs. gawron and betz
Shoulder xray: Think ABO
Alignment: gleno-humeral alignment and AC joint alignment
Bones: correlated with point tenderness from exam and then look at the individual bones
Other: views of the ribs, lungs and other visualized
Scapular Y: the long portion of the y is the humerus and the ears are the acromion process and the coracoid
Helpful view to evaluate for dislocation, can be missed or misclassified based on AP view
Anterior: towards the coracoid; Posterior: past the scapular spine
Also consider adding on an axillary view though note this is uncomfortable for patients
Lightbulb sign: subtle rotation of humeral head, which can be suggestive of a posterior shoulder dislocation
Concern for sternoclavicular joint injury: can utilize serendipty/rookwood view, bilateral xrays for symmetry comparison or CT scan
Wrist xrays: follow the 3 ARCS to ensure proper alignment and always utilize multiple views
Ankle xrays: Mortis view includes the ankle joint head on, there should be direct visualization with appropriate space between the joint
Stress views: internally rotate the leg, stabilize the tibia, dorsiflex the ankle and externally rotate it, which mimics weight bearing
Use to visualize whether the ankle joint “opens up”
Weber classification: level of fibular fracture relative to the syndesmosis; you can get injury to the medial ligaments without fracture that can be considered a bimalleolar equivalent
A: below; stable, treat similar to ankle sprain
B: at the level of; potentially unstable and may need ORIF
C: above; potentially unstable and may need ORIF
clinical pathologic conference with drs. arnold and lafollette
A case of a 70 yo male presenting with double vision for 2 weeks. Found to have a CN VI palsy on exam with negative CT head and CTA imaging. Ultimately, the test of choice was an ESR, which was found to be elevated and led the team towards a diagnosis of giant cell arteritis.
Giant cell arteritis: most common systemic vasculitis in adults with a lifetime incidence of 1%
Diagnosis in the Emergency Department relies on clinical gestalt from elements of the history and physical exam and can be aided by inflammatory markers
Treatment is necessary to prevent permanent vision loss and involves high-dose corticosteroids
r1 diagnostics and therapeutics: hernias with dr. gabor
Tips/tricks for a successful hernia reduction:
Position the patient in a supine Trendelenburg position to allow gravity to assist you
Apply ice packs to the hernia to help reduce swelling
Provide adequate analgesia and consider conscious sedation
Apply firm and steady pressure with one hand at the base of the hernia guiding it in, and one at the distal end.
Incarcerated hernias:
Not easily reducible, but there is still adequate blood flow to the herniated contents
Reduction should be done within 24 hours, either manually or surgically.
Strangulated hernias:
Blood flow has been compromised and hernia contents become ischemic.
Do not attempt reduction! This is a surgical emergency.
r4 case follow-up WITH dr. fabiano
Patients with ARDS and refractory hypoxemia despite maximum therapy require early referral to an ECMO capable center before they are too unstable for transport
These are some of the sickest patients we will ever fly on Air Care
Patients with these complaints require a full understanding of of physiology, ventilator mechanics, and pharmacology
Air Care is incredibly unique in its IFR capabilities and team-based care
IFR allows us to save patient's lives when they would otherwise die purely because of the weather
The excellent training of our flight teams ensures our patients receive the best care in the world
The care we deliver in the ED and ICU is only a fraction of the patient's recovery journey
Patients have years-long roads to recovery with many complications we never see and don't appreciate
Understanding the patient's full journey helps us become better, more holistic physicians
What we do matters
Although the care we give sometimes feels futile, occasionally the stars align, and we really do save lives
Give 100% every day because you never know which resuscitation or transport is going to change someone's life
r3 small groups with drs. shaw, grisoli and brower
Neonatal Resuscitation Program (NRP)
Respiratory support and positive pressure ventilation are the mainstays of NRP. Ensure SpO2 monitors are placed on the right upper extremity to measure pre-ductal values.
Position newborns in the “sniffing” position to open their airway by placing a shoulder roll in addition to a headrest to align the suprasternal notch with the external auditory meatus. Lift the tongue using a jaw thrust to minimize upper airway obstruction.
Positive-pressure ventilation is most effective when using a T-piece resuscitator (JournalFeed instructional video here). Begin with inflation pressures (PIPs) of 20 cm H2O, but you may have to up-titrate to PIPs of 30-40 cm H2O to recruit the lungs initially. Titrate to chest rise and use the lowest possible PIPs to achieve chest rise to avoid barotrauma. Target a respiratory rate of 40-60 and use PEEP of 5 cm H2O.
Supraglottic devices (such as an i-Gel size 1) are appropriate for newborns born at ≥34 weeks gestation and have been shown to decrease the likelihood of intubation. When intubating term (≥38 weeks) neonates, use a Miller 1 with a 3.5 mm uncuffed or 3.0 mm cuffed ETT. For preterm (<38 weeks) neonates, use a Miller 0 with a 3.0 mm uncuffed or 2.5 mm cuffed ETT. You can estimated appropriate tube depth as follows: Depth (cm) = 6 + Weight in Kg.
Umbilical vein cannulation is the preferred means of intravenous access in newborns and can be performed in newborns up to 7-10 days old. Intraosseous access can also be performed though is less reliable given the narrow marrow space and thin cortex of neonatal bones. Review this procedure by watching this EM:RAP video here.
Trauma in Pregnancy
Trauma in pregnancy should be evaluated and treated similarly to non-pregnant patients but all periviable, even with minor blunt trauma should be observed on tocometry for 4 hours and be evaluated in conjunction with Ob specialists when available
Rh negative patients with any trauma apart from isolation orthopedic injury should receive 300 mcg IM RhoGAM and send KB stain
Resuscitative hysterotomy is indicated to increase likelihood of ROSC for any pregnant patient with cardiac arrest 20+ weeks as soon as possible. With newer data, this could be considered even with a later presentation (20-30 min)
Obstetric Complications
Shoulder dystocia is a common complication of delivery
Most common in babies who weight more than 4000 grams
McRoberts maneuver can help relieve shoulder dystocia; perform hyperflexion of the hips with concurrent suprapubic pressure
If this fails, can attempt delivery of the posterior shoulder
Postpartum hemorrhage is quantified as >1L of blood loss in the first 24 hours following birth
Most common cause in uterine atony
Bimanual massage should be first maneuver of choice
Should also give 10 units of oxytocin IM
Other adjuncts you can use are balloon tamponade like a Bakri balloon
Preeclampsia can occur up to 6 weeks postpartum
Mainstay of treatment is blood pressure management and magnesium administration
If a patient seizes they are eclamptic and definitive treatment is delivery of the baby
pediatric cardiac emergencies WITH Dr. Ladzekpo
SVT: most common arrhythmia in children
Infants: inconsolable, color change, sweating, poor feeding, lethargic, tachypneic
School kids/adolescents: heart “beeping” or pounding, chest pain, shortness of breath, exercise, intolerance, sweating
Tachycardic HR by age:
Neonates: >220-270
School aged: >180-240
Teenagers: >180-240
Vagal maneuvers, adenosine (0.1-0.2mg/kg) or cardioversion 2 J/kg
Congestive heart failure: can present in a variety of ways such as tachycardia, tachypnea, hepatosplenomegaly
Can also have failure to thrive, fatigue, headaches, non-specific GI symptoms
Usually does not present with JVD, LE edema, abdominal ascites or rales
Etiology: ranging from acute viral myocarditis, cardiomyopathy, congenital heart disease, inborn errors of metabolism, anemia, hypothyroidism, Kawasaki disease, SLE, Rheumatic heart disease etc.
Congenital heart disease: usually early in life
Appropriate range of O2 sats from 75-95% based on minute from delivery
Morbidity and mortality due to arrhythmias, thrombosis (PE, stroke), dehydration
Caution with O2: can decrease PVR causing pulmonary overload
Caution with PPV: low PEEP to help pulmonary blood flow
Bidirectional Glenn: intermediate stage at 4-6 months; wait for kids to grow before doing this surgery
O2 sat 75-90%
Fontan: typically 1.5-3 years old
Systolic ventricular function is preserved for first few decades; later in life, act like adult heart failure
O2 saturation 90-100%, 85-95% if fenestrated
