Grand Rounds Recap 9.18.19

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EM-Neuro Combined Lecture WITH Dr. NeEl

  • Common Approach:

    • Is the problem neurologic?

    • If neurologic, what is the location?

      • Focal, Multi-focal, or Diffuse?

      • Atrophy and pain point more toward peripheral etiologies

    • What is the timing of the problem?

      • Acute: seconds to minutes

      • Subacute: hours to days

      • Chronic: >6 weeks

      • Progressive or non-progressive?

    • What are likely etiologies?

  • Case 1: A middle-age woman presents with acute numbness in the entire left arm with 8/10 headaches. Her symptoms were present for three hours but have now resolved.

    • Acute and focal

    • Etiologies include vascular (stroke and TIA), seizure, migraines

    • Seizure risk factors:

      • Past trauma to head with concussion or skull fracture

      • History of seizure as child

      • Family history of seizures

      • History of meningitis or encephalitis

  • Case 2: A 35 year old female presents with a breakthrough seizure. She is back to baseline. She is on lamotrigine 200mg BID and Keppra 1000 BID.

    • Think about pregnancy, infection, and medication noncompliance

    • Have a low threshold to call the patient’s epileptologist to help co-manage patients, especially in adjusting medications

  • Case 3: A 32 year old male presents with 1-2 weeks headaches and intermittent confusion over the past two days. He is unable to give a coherent history.

    • If concerned for meningoencephalitis: start vancomycin, ceftriaxone, acyclovir, and ampicillin

    • Differential diagnosis includes infectious, metabolic, autoimmune, iatrogenic, toxicologic

  • Case 4: A middle age male presents with 10/10 low back pain shooting down the legs while working at a construction site. He feels weaker than normal.

    • What are low back symptoms?

      • Pain: arthritic pain, claudication (can be neurogenic or vascular), radicular pain

      • Numbness

      • Muscle weakness

      • Bowel/bladder symptoms

    • About 50% of patients with Guillain Barre syndrome present with pain.

Blunt Pancreatic Injury WITH Dr. Jarrell

  • Approximately 0.2-12% of patients with abdominal trauma will have pancreatic injury

  • Diagnostic imaging modality of choice is CT scan

    • Imaging findings of pancreatic injury are often delayed, potentially up to 12 hours

  • EAST Guidelines on Pancreatic Injury Grade

    • Grade I/II: Hematoma or laceration to body of pancreas not involving the duct

      • Pursue MRCP

      • Likely non-operative management

    • Grade III: Duct injuries in the body and tail of the pancreas

      • Operative management

    • Grade IV: duct injury in the head of the pancreas

      • Operative management

    • Grade V: transection of the pancreas

      • Operative management

    • Octreotide is not recommended, as this has been shown to increase mortality

Non-Accidental Trauma

  • Characteristics to be cautious of:

    • Presenting to multiple different hospitals

    • Stories that don’t match up

  • Approximately 17% of patients with abdominal injury from non-accidental trauma will have a pancreatic or hollow viscus injury

  • Two-thirds of pancreatic injuries in pediatrics are from non-accidental trauma

Global Health Grand Rounds WITH Dr. Wyrick

  • In 4 days, was able to operate on 31 patients

    • 12 distal femur osteotomies

    • 12 high tibial osteotomies

    • 4 Achilles tendon lengthening

    • 3 hand burn contracture releases

    • Tibial malunion osteotomy

    • 2 amputations

  • Saw a total of 125 clinic patients

  • Lower limb deformities are common and likely related to nutritional disorders, as many of them are bilateral

R3 Small Groups: Ortho Injuries WITH Drs. Iparraguirre, Jensen, and Lane

Clavicle Fractures

  • Most fractures are mid-shaft

  • Indications for emergent referral:

    • Open fracture

    • Neurovascular compromise

    • Tenting of skin

  • Indications for urgent referral

    • Floating shoulder

    • Greater than 1 bone width of displacement

    • Cosmetic or functional recovery

  • Treat with sling and pain control

Foot and Ankle

  • Can use pencil as a fulcrum to attempt reduction of toe fracture-dislocation

  • Ankle nerve blocks

    • Perform a ring block around the most superior portions of the malleolus

    • This will provide most of your anesthesia by blocking the superficial peroneal, sural, and saphenous nerves

  • LisFranc fractures

    • No consistent injury patterns

    • Look for fleck sign and diastasis

    • Can obtain weight-bearing views or CT if high clinical suspicion

Distal Radius Fractures

  • Hematoma block with hanging has similar outcomes (potential even better reduction) than sedation with manual reduction