Conference Notes 5-22-2012

BENJAMIN TICHO  OPHTHO TRAUMA

 20:20 vision means you see at 20 feet what a normal person is expected to see at 20 feet.  20:40 means you need to be at 20 feet to see what a normal person sees at 40 feet.   Basically think of it as the first 20 is the patient in comparison to the second number which is the normal person. 

CRAO have a generally poor outcome no matter what you do but you should still contact ophtho emergently.

The cornea has the most dense distribution of nerve endings in the entire body.

Dr. Ticho has seen severe injury to cornea requiring corneal transplant in patients who used topical anesthetic at home for corneal abrasion.   He advised strongly against giving topical anesthetic to patients with corneal abrasion.

Patching the eye for large corneal abrasions can speed healing.  Don’t patch more than 12 hours and the patch has to be tight enough to keep eyelid from opening.

Base injury to eye is worse than acid because base injury causes sapponification.   For both acid and base injury immediately irrigate the injured eye.   Get ph before and after irrigation.  Irrigate until ph gets between 7.3 to 7.7.

Treat superglue exposures to the eye with topical antibiotic ointment. 

KERWIN    STUDY GUIDE   IMAGING

Deep sulcus sign= pneumothorax

Delta sign=cerebral venous thrombosis.  Finding on posterior aspect, sagital sinus on CT brain.

On Chest xray, left mediastinal width greater than 5mm is a marker for aortic injury.  Left mediastinal width is measured from the spinous process to lateral border of aortic knob.   PAL CXR should be less than 5mm,   AP CXR the measurement should be less than 5.4mm

Bohler angle should be 20-40 degrees normally.   Less than 20 degrees suggests a fracture.   (memory hint: low score when bowling is bad.)

Hold patient’s metformin for 48 hours after they receive iv contrast to avoid metabolic acidosis.

Tram lines or train-track lines describe pneumatosis intestinalis and is indicative of NEC.

Thickened, non-compressible appendix of greater than 6mm in diameter is diagnostic for appendicitis. (memory hint: appendix is six)

Fluid in morrison’s pouch on ultrasound has pretty close to %100 positive predictive value for ruptured ectopic pregnancy.  

Scapho-lunate dissociation has a gap between the scaphoid and lunate called the Terry Thomas sign.

 Duodenal atresia, volvulus, annular pancreas are the differential diagnoses for the “double bubble sign”.

Cardiac standstill on echo during resuscitation has 100% PPV for death.

Can’t give gadolinium to pregnant patients because it crosses the placenta.  It is contraindicated, but there have not been reported fetal defects however.

Snowman sign of CXR in kids is a sign of Total Anamolous Pulmonary Return.  (memory hint: Frosty said he would “be back again some day”  that would definitely be an anamolous return)

 CT scan for PE in a pregnant patient has lower radiation dose to child than a VQ scan.  If you have to do VQ scan in a pregnant patient,  you can reduce radiation exposure to child by putting foley catheter in mom to remove radioactive urine.

MENON  M AND M

Obese=BMI of 30, Morbidly obese=BMI of 40, Super Obese=BMI 50

Obesity Hypoventilation Syndrome=Pickwickian syndrome.  BMI>30 PCo2>45 while awake, no other source of hypoventilation.  

When Intubating obese patients use  RAMP positioning.   Have the patient’s head elevated and face and jaw  parallel to the ceiling.  The patient’s external auditory meatus should also line up with their sternal notch.        

Pre-oxygenation increases the patient’s oxygen reservoir and denitrogenates the residual capacity of lungs.   3 minutes on 15 L NRB or 8 tidal volume breaths on 15L NRB will accomplish this.

With the difficult to ventilate patients you can use a PEEP Valve on the ambu bag. Respiratory therapists have access to the PEEP valves.  If you also put a nasal cannula on the patient (15 liters thru the cannula =passive apneic oxygenation) You in affect are giving CPAP.

BVM ventilate with low pressure(<25mm hg), low volume(6 ml/kg) and low rate (6-8/min).  It is also important to use a two handed thumbs down technique to hold mask on face.

Our ED has an awake look intubation kit in the omnicell.   It includes 4% lidocaine to nebulize and spray with mucosal atomizer, viscuous lidocaine also is included to put in back of throat.

NAP 4 Data: Higher mortality in ED and ICU, ETCO2 is the standard of care, awake intubation was not use when indicated, Failure to plan for failure, obesity was independent risk factor in a large %age of airway deaths.

Joan Coghlan made a great point that LMA is a great bridge device and a great device to help ventilate the difficult airway patient.

References for this talk:

 

WALCHUCK   RECTAL FB/PRIAPISM

You gotta get these out.  Never leave in place and wait for spontaneous passage

Look for signs of perforation on imaging studies.

Sedation may be helpful to remove.  Viscous lido can be used to help lubricate. Have patient in Sims or lithotomy position.  Sim’s position is with pt on their side with superior leg flexed at hip and knee.

Can attempt to place one or more foley balloons proximal to fb to remove fb.   .  Many patients will require GI to scope them to remove FB.  Sharp or  broken objects require surgery

Observe patient for 4-6 hours after removal to see if any signs of perforation develop.

 Priapism: corpora cavernosa become engorged with blood,  painful, can be due to sickle cell disease/thalassemia/leukemias, many other pharmacologic causes, erect penis with flaccid glans, tx with terbutaline in deltoid muscle, ice to perineum/penis/scrotum, narcotic analgesia, penile block at 11 and 1’oclock positions, aspirate the corpora at 10 and 2 o’clock, instill phenylepherine/saline, cardiac monitoring, for sickle cell patients exchange transfusion is indicated.

Penile fracture: rupture of the tunica albuginia, u/s is helpful for diagnosis, treatment is surgical, pt should not be sent home to follow up as an outpt.

WATTS      CENTRAL LINE PLACEMENT

TIP: Stretching the guidewire wil straighten the curved tip.

Avoid air embolism by flushing all lumens of CVC with saline prior to puncturing skin.  Also keep thumb over hub of needle when it is in the vein.

Avoid wire embolism but not using force to pull wire out.  If you meet resistance, remove needle and wire together as a unit.

WASH YOU HANDS PRIOR TO PROCEDURE!   USE STERILE TECHNIQUE INCLUDING GOWN/GLOVE/MASK/DRAPE.

Trandelenburg is important to distend the IJ.  For IJ central lines, turn the patient’s head to the left but over rotation can increase the risk of arterial puncture.  

NEJM video was shown demonstrating proper placement of IJ central line.

Femoral lines are the highest risk lines so try to avoid them.  CVP measurement is not reliable with femoral lines.  

Supraclavicular approach for subclavian vein: Puncture skin one finger breath lateral to SCM and superior to clavicle. Aim toward contralateral nipple.  

Harwood Comments: Look with U/S prior to draping patient and getting sterile.  The RIJ may have an old clot precluding that site.   Getting in the central vein requires a confident jab or poke through the vessel wall.     You don’t need to place the wire all the way into the vein to just pull it back to thread thru the catheter.  You can put the wire in part way and have the external wire to thread thru the catheter.

Coghlan: comments: Line up needle bevel  with  numbers on syringe so you know what direction your bevel is oriented when it is in the patient.  With the subclavian approach if you turn your bevel downward after getting in the vessel will direct the wire into the chest.

Place catheter about 15 cm(14-20cm) into the chest.   You should make an estimate prior to placing catheter.  Extremes of body habitus will affect this distance.

Never let go of the guidewire!

ERIKSON   GU EMERGENCIES

 Balanoposthitis: evaluate for diabetes, treat with retraction of foreskin and cleansing with soap and water, topical antifungals or oral fluconazole. Some cases may require anti-staph antibiotics.

Phimosis: foreskin cannot be retracted. Treat with hygiene and topical steroids.  If pt cannont void then emergent surgical procedure is indicated.

Paraphimosis: inability to reduce retracted foreskin.  Tx with manual reduction, multiple small needle punctures of glans to release edema fluid.  Can also try compression/ice cooling to decrease swelling.

Testicular torsion: cremasteric reflex is unlikely to be normal with torsion but this sign is not 100%.  Gotta get a testicular u/s when considering torsion in the diagnosis.  Treatment is surgery.  Manual detorsion may be indicated.  “open the book” is the way to think about how to reduce torsion.  This is most commonly successful motion. If pain worsens then stop and try to detorse in opposite direction.

Torsed appendix tesis: blue dot sign. Treamtment with NSAIDS

Epididymitis: gradual onset, fever, dysuria, urethral symptoms.   Pyuria in 50% of cases,get cultures of urine and urethra,  r/o torsion.   Tx with antibiotics.  If sexually active treat with rocephin and doxy.  If likely coliform source, give bactrim.

Fournier’s  Gangrene: Polymicrobrial infection, imunocompromised patients,  pt’s will have pain and look sick, check for crepitence in genital area, treat with big gun antibiotics Imipenem and Vanco. SURGERY is required.

Zipper entrapment injury: Cut bar of zipper

Harwood comment: Is Nair an option for hair tourniquet?  Many people felt this would be irritating to skin.  Also discussed was using sugar to decrease edema of a paraphimosis.