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Source: HQMedEd

Nexus works if > 9 years

Most common complaint is a sensory deficit

8 screening factors: (Leonard 2010, annals of emergency medicine) 98% Sn, 26% Sp if have 1

  • Altered mental status
  • Focal neuro findings/symptoms
  • Complaints of neck pain
  • Torticollis
  • Substantial injury to torso
  • Diving injury
  • High risk mva:head on, rollover, ejection, death, >55mph
  • Predisposing conditions (downs, Marfans, oi,ehlers danlos)
2011 trauma Canadian consensus- no need imaging if:

  • Low risk mechanism
  • No distracting injuries
  • Able to verbalize/cooperate with exam
  • No altered mental status
  • No neck pain, tenderness, limitation to movement
  • No neuro deficit (including paresthesia)
 

Pediatric Cervical Spine Injuries from HQMedEd on Vimeo.

 
Chronic ingestion

  • In 2004, Daly et al demonstrated that patients with delayed presentations (more than 24 hours after ingestion) or chronic ingestions who had an acetaminophen level of less than 10 mcg/mL and an AST below 50 IU/mL had a 0% risk of developing hepatotoxicity
  • detectable serum acetaminophen levels (>10 mcg/mL) or elevated liver enzymes should be presumed to have acetaminophen toxicity.
  • all patients with delayed presentations should be empirically treated with NAC prior to any laboratory evaluation.
  • If the acute ingestion occurred within the past 24 hours, the acetaminophen level should be plotted on the nomogram. If the patient's level is above the toxic level, NAC should be continued
Which patients should be transferred to a liver transplant center following acetaminophen overdose? (king criteria)
  • serum pH below 7.3 after adequate fluid resuscitation
  • INR above 6.5,
  • grade III or IV encephalopathy.
  • If any of the above criteria are met, serious consideration should be given to transferring the patient to a regional liver transplant center for definitive management
acute poisoning key numbers

  • Toxic dose: 150mg/kg
  • 4 hr toxic level: 150mcg/ml
  • Loading dose: 150mg/kg
Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Syncope. 2007

1. What history and physical examination data help to risk-stratify patients with syncope?


  • heart failure - higher risk of an adverse outcome.
  • Riskmfactors: older age, structural heart disease, or a history cad
  • Low risk: younger patients with syncope that is nonexertional, without history or signs of cardiovascular disease, a family history of sudden death, and without comorbidities
2. Who should be admitted after an episode of syncope of unclear cause?

  • evidence of heart failure or structural heart disease.
  • other factors that lead to stratification as high-risk for adverse outcome: Older age and associated comorbidities, Abnormal ECG, hct< 30 (if obtained), History or presence of heart failure, coronary artery disease, or structural heart disease
EKGs



-(short pr interval)- wpw: most common ventricular pre excitation syndrome. 1) short pr 2) prolonged qrs complex, 3) slurred upstroke of qrs complex- delta wave; can produce large r wave in v 1

-brugada syndrome: abnormalities in v1-v3: RBBB or incomplete RBBB and ST elevation; ST elevation convex upward (saddle) or "coved" (concave) morphology; need electrophysiology studies to diagnose; can develop polymorphic or monomorphic VT

-prolonged qt

-bradycardia: hr < 50 sick sinus syndrome

-prolonged pr interval: 2nd or 3rd degree av block

-Arryythmogenic Right Ventricular Dysplasia (ARVD): T Wave inversion in leads V1-V3, QRS Complex duration > 110 ms in leads V1-V3

-Abnormal QRS: Left Bundle Branch Block or Bifascicular Heart Block, QRS Duration > 120 ms, Q Waves

References:



http://www.fpnotebook.com/cv/ekg/EkgChngsInSyncpDTArhythm.htm

 
Dr. Smith's ECG Blog: Right Bundle Branch Block after Blunt Trauma: A Tragic Case.

RBBB never has ST elevation in any lead

ST abnormalities due to myocardial contusion have the highest risk of any ECG finding for adverse outcomes and a higher risk than positive cardiac biomarkers

Recs: for myocardial contusions

1) do a formal echocardiogram on anyone with new significant ECG abnormalities

2) consider an angiogram if there is ST elevation (as here) and a wall motion abnormality

3) measure troponins, as a very high peak troponin would confirm large territory of contusion

3) limit physical activity if there is concern for a large area of contusion.
Cocaine Chest Pain, “Answers” | EM Lyceum

Effect on heart: increases plasma levels of dopamine and norepinephrine through central adrenergic stimulation and inhibition of reuptake at the synapse--> sympathetic outflow---> tachycardia, hypertension, and increased myocardial oxygen demand

hypercoaguable state

Chest pain: one minute to four days after cocaine use; half-life of cocaine of thirty to ninety minutes; active metabolites of cocaine detectable for over forty-eight hours after use

greatest risk of MI is within the first few hours after cocaine use. In the first hour, it is estimated that cocaine users are at a full twenty-four-fold increase in risk

Medical management: ASA, ntg, bzd

Avoid b-blocker

Phentolamine could work, but not standard of care






Academic Life in Emergency Medicine: Trick of the Trade: Massaging a mandibular dislocation back in


How to reduce a mandibular dislocation from Rob from ercast on Vimeo.
  1. Massage the masseter muscles before and during the procedure
  2. Apply rotational force (rather than downward and posterior force) on Mandibular ramus
The rotational approach to reduction is similar to the wrist pivot method described in the Journal of Emergency Medicine; Lowery LE, Beeson MS, Lum KK. The wrist pivot method, a novel technique for temporomandibular joint reduction. J Emerg Med. 2004 Aug;27(2):167-70. Pubmed

 

 
Source: An unusual blood gas with severe acidemia


The aim of treatment is to evacuate anoxic blood, decompress the corpora cavernosa and achieve perfusion.

  • This is a simple procedure, and often delayed because of unnecessary discomfort (on behalf of the practitioner, not the patient).
  • Penile anaesthesia is achieved easily by circumferential superficial infiltration at the base of the penis, or local infiltration at the site of needle placement.
  • A 19 or 21G butterfly needle is then introduced next to the peno-scrotal junction at either the 3 or 9 o’clock positions to avoid hitting the neurovascular bundle. It is recommended to aspirate until fresh, red, oxygenated blood is aspirated, and detumescence (can be anywhere from 10ml to 100ml).
  • The current recommendation for injecting alpha agonist is phenylephrine 200 micrograms, injected into the corpora once aspiration is finished, repeated every 5-10 minutes. If phenylephrine is not available, then metaraminol (1mg in 5ml of saline), or adrenaline (varying ranges throughout the literature – anywhere from 0.01-0.1mg, diluted from 1-5ml).
    — Phenylephrine is preferred due to its much lower THEORETICAL risk of systemic cardiovascular effects.
    — If one was to use metaraminol, or adrenaline, there is no documented frequency or risk of systemic effects, however it would be prudent to monitor the patient clinically, and reconsider its use in the patient with less than optimal coronary artery flow.
  • Recently intracavernosal injection of methylene blue has been advocated (with the curious adverse effects being penile burning and discolouration).
https://sites.google.com/site/emprocedures/genitourinary-procedures/priapism-intercavernous-aspiration