A 14yo male presents to your ED after he dove into A 14yo male presents to your ED after he dove into a pool and felt shock going down his neck and back, a pool and felt shock going down his neck and back, but he was not knocked out. His friends helped him but he was not knocked out. His friends helped him out of the pool and brought him to the ED. He states out of the pool and brought him to the ED. He states all his symptoms are gone now. On exam you note all his symptoms are gone now. On exam you note some neck tenderness. His X-ray and CT neck are some neck tenderness. His X-ray and CT neck are negative. Your next best step is… negative. Your next best step is…

a. Home in soft collar FU with PCP a. Home in soft collar FU with PCP b. Hard C-collar transfer to institution with MRI b. Hard C-collar transfer to institution with MRI c. Admit to neurosurgery with C collar in place c. Admit to neurosurgery with C collar in place d. Admit to trauma surgery with C collar in place d. Admit to trauma surgery with C collar in place e. Discharge home, no need for follow up e. Discharge home, no need for follow up

SCIWORA SCIWORA • ______% of children with SCIWORA have • ______50 % of children with SCIWORA have delayed onset of paralysis, sometimes up to 4 delayed onset of paralysis, sometimes up to 4 days days • Many of these children have paresthesias, • Many of these children have paresthesias, numbness, or weakness at the time or shortly numbness, or weakness at the time or shortly after the injury after the injury • The most important factor in prognosis is • The most important factor in prognosis is ______initial neurologic status

1 SCIWORA Which of the following is NOT an expected • In the NEXUS study which included 34,000 finding on MRI of patients with SCIWORA ? patients of which 3,000 were children, all SCIWORA (27 total) occurred in adults a. Central disc herniation • Although still more common in kids b. Cord hemorrhage • THE POINT: c. Spinal stenosis • Anyone with initial neuro complaints regardless of a normal X-ray and a normal CT is a d. Cord edema SCIWORA until proven otherwise by an MRI e. Cord contusion (or seen by a neurosurgeon if no MRI)

Which of the following is NOT an expected finding on MRI of patients with SCIWORA ? SCIWORA in the Age of MRI

• Hemorrhagic changes within the spinal cord caused by MVC were accompanied by permanent a. Central disc herniation complete neuro deficits b. Cord hemorrhage • Trauma patients with initial transient neurological c. Spinal stenosis deficits whose MRI show no cord abnormality have full recovery d. Cord edema • In NEXUS the most common findings on MRI of e. Cord contusion patients with SCIWORA were: central disc herniation, spinal stenosis, cord edema, cord contusion

2 You are taking care of a multiple trauma You are taking care of a multiple trauma patient. After taking care of airway, breathing patient. After taking care of airway, breathing and IV access with volume resuscitation your and IV access with volume resuscitation your next best step is… next best step is… a. To undress the patient a. To undress the patient b. To assess for C-spine trauma b. To assess for C-spine trauma c. To assess Glascow coma score c. To assess Glascow coma score d. To assess pelvic injury d. To assess pelvic injury e. To assess the need for splints e. To assess the need for splints

+ F (Fast exam) if abdominal trauma

Primary Survey: ABCs

1. Airway and C-spine control 2. Breathing – Ventilation (rate and character) 3. Circulation (with hemorrhage control) • pulse, blood pressure, peripheral perfusion, pulse oximeter • MedicAlert® bracelets or necklaces 4. Disability – brief neurologic exam – Glasgow Coma Scale 5. Exposure/ Environment – completely undress the patient but prevent hypothermia

3 A 24yo male involved in rollover MVA where he was thrown out of his vehicle. He has no medical problems. VS: BP 100/70, P 110 , R 18, T37. His pelvis X-ray is shown. Negative FAST exam . Two large bore IV’s have been started. Which of the following is the next best step? a. Transfer to the OR with trauma surgeon b. Pelvic internal fixation c. Advanced airway management d. To radiology for angiography e. To the ICU for pelvic external fixation

A 24yo male involved in rollover MVA where he Things that differ, but seem the same was thrown out of his vehicle. He has no medical problems. VS: BP 100/70, P 110 , R 18, T37. His • A 28yo male in an MVA thrown from the vehicle pelvis X-ray is shown. Negative FAST exam . Two with hypotension and tachycardia with neg CXR large bore IV’s have been started. Which of the but obvious pelvic fractures and a +ve FAST following is the next best step? exam (gross blood +ve DPL) goes to the OR a. Transfer to the OR with trauma surgeon b. Pelvic internal fixation • A 28 yo in an MVA thrown from the vehicle with hypotension and tachycardia with neg CXR but c. Advanced airway management obvious pelvic fractures and a neg –ve FAST exam d. To radiology for angiography for embolization or lavage (or < 100,000 rbc/cc on DPL) , pelvic e. To the ICU for pelvic external fixation angiography is the next best step because that combination is due to hemorrhage from pelvic # that may be amenable to embolization

4 5-STEP METHOD OF QUICK AND SIMPLE Trauma in elderly KEYCEPTS PELVIC X-RAY INTERPRETATION • Nothing good about the ‘golden age’ – everything 1. Look quickly to get a feel for symmetry. goes to crap: heart, brain, lungs, kidneys etc… 2. Look at the “circles," the big circle being the • The leading cause of injuries ______pelvic inlet, the little circles being the obturator • VS may be deceptive foramina. • Increased morbidity w BP < ____ or pulse > ____ 3. Look at the sacroiliac jts. • C-spine have arthritis and spinal stenosis so 4. Look at the pubis potential for further injury during intubation is symphysis. increased 5. Look at the acetabula . • ______cord injury is increased – this is Hemorrhage is a major cause of death, ______injury 2 to 6 liters of blood may accumulate in the retroperitoneal space • Delayed presentation of SDH – more space in the brain for crap

Trauma in elderly KEYCEPTS Trauma in elderly KEYCEPTS

• Nothing good about the ‘golden age’ – everything • With multiple rib fractures – ADMIT them goes to crap: heart, brain, lungs, kidneys etc… • The leading cause of injuries ______falls • Pre-existing lung dz more common • VS may be deceptive • Require pain control • Increased morbidity w BP < ____110 or pulse > ____90 • C-spine have arthritis and spinal stenosis so • Alertness may be an issue potential for further injury during intubation is • May get pneumonia increased • ______Central cord injury is increased – this is • Think about incentive spirometer extension______injury • Delayed presentation of SDH – more space in the brain for crap

5 Trauma in Pregnancy KEYCEPTS Trauma in Pregnancy KEYCEPTS

• Leading cause of non-obstetric related death • Most common cause of fetal death ______• Most common cause is MVC >50% (abruption is common cause of maternal death) • Then violence • Other causes of fetal death: maternal shock/death • Then falls • Uterus out of pelvis at______• Penetrating trauma in pregnancy • Indications of perimortem C-section • Maternal mortality is LOW • ______+ ______• Fetal mortality is HIGH • Fetal viability: ______wks, ____ grams • Placental abruption most commonly • Hypotension on gurney, next best concealed step______

Trauma in Pregnancy KEYCEPTS Trauma in Pregnancy KEYCEPTS

• Fetal monitoring • Most common cause of fetal death ______abruptio >50% (abruption is common cause of maternal death) • Frequent uterine activity is more predictive of abruption than US • Other causes of fetal death: maternal • Indicated for all blunt trauma > 20 wks shock/death gestation • Uterus out of pelvis at______12 wks • > 8 contractions/hr x 4 hrs – risk of • Indications of perimortem C-section abruption • ______Uterus above umbilicus + ______FHT present • 3 – 7 contractions/hr x 4hrs – extend • Fetal viability: ______24 – 26 wks, ____500 grams monitor for 24 hrs • Hypotension on gurney, next best • < 3 contractions/hr x 4hrs – discharge step______L lat decub home

6 Kleihaur-BetkeTest – result next day

• Detects the presence and quantifies the volume of Cushing Reflex – Increased ICP fetal RBC in the maternal circulation • It is an INSENSITIVE test requiring a minimum • Bradycardia of 5cc of fetal hemorrhage for detection • Hypertension • (Since as little as 0.01 – 0.03cc of fetal blood may result in maternal Rh sensitization the KBT is not useful in most • Respiratory irregularity pregnant patients) • All Rh-ve pregnant patients should be given Rh- immune globulin after significant abdominal Seen in ___30 % of patients with rapid ICP rise trauma Late sign of increased ICP Caveat • 50 mmgm in first 12 wks – 300 mmgm > 12wks Sign of impending brain herniation

Preventing secondary insult in moderate TBI Preventing secondary insult in moderate TBI

• Intubate at GCS of ___ • Intubate at GCS of ___ • Ventilate to maintain ______• Ventilate to maintain ______• Prevent hypotension/anemia • Prevent hypotension/anemia • Elevate head of bed 30% (if you can???) • Elevate head of bed 30% (if you can???) • Seizure prophylaxis - phenytoin • Seizure prophylaxis - phenytoin • Reverse anticoagulants • Reverse anticoagulants • Mannitol/brief hyperventilation for • Mannitol/brief hyperventilation for herniation herniation • NS consult early • NS consult early

7 Trauma KEYCEPTS Trauma KEYCEPTS • MCC death ______• MCC death ______head injuries • 2nd MC ______• 2nd MC ______chest injuries – 25% of trauma deaths • 3rd MC ______• 3rd MC ______abdominal trauma – 15-20 % of trauma deaths • Aortic injury occurs at the greatest point of • Aortic injury occurs at the greatest point of fixation which is ______fixation which is ______ligamentum arteriosum • ____ % of patients lack external evidence of chest • ____50 % of patients lack external evidence of chest trauma (the MC valve injured in chest trauma is ______) trauma (the MC valve injured in chest trauma is ______aortic valve _) • Think about this injury with change of voice, pulse • Think about this injury with change of voice, pulse deficits, UE hypertension, harsh systolic murmur, deficits, UE hypertension, harsh systolic murmur, tearing chest pain radiation through to back tearing chest pain radiation through to back • CXR: wide mediastinum (>8cm), apical cap, indistinct • CXR: wide mediastinum (>8cm), apical cap, indistinct aortic knob, NG tube/tracheal deviation to right aortic knob, NG tube/tracheal deviation to right

Criteria for thoracotomy in trauma Beck’s Triad– Cardiac Tamponade • Penetrating chest trauma with loss of VS pre-hospital or ED + cardiac activity in ED. • Hypotension • RV or RA most commonly injured in • Distended neck veins penetrating chest trauma • Muffled heart tones • Blunt chest trauma with loss of VS in ED. ??

Removal of ______15 – 20 cc may result in • Abdominal trauma + cardiac activity immediate improvement requiring aortic cross clamping

8 Abdominal trauma KEYCEPTS Abdominal trauma KEYCEPTS

• Most common injuries: ______, ______• Most common injuries: ______,spleen ______liver • Anything in abdomen • Anything in abdomen • Handle bar injury at ABEM General consider • Handle bar injury at ABEM General consider • ______• Pancreatic______injury • ______• Duodenum______injury Symptoms delayed Insidious onset Delayed peritonitis Duodenal rupture often contained in retroperitoneum

Abdominal Trauma KEYCEPTS

• Most commonly injured organ in penetrating abdominal trauma GSW:_____ small intestine / Stab: liver • Most commonly injured organ in blunt abdominal trauma _____spleen - 50% have normal physical exam • Amylase elevation in abdominal trauma • 75___ % in blunt trauma • 27___ % in penetrating trauma

9 42yo male involved in MVA with C4 fracture, he 42yo male involved in MVA with C4 fracture, he has flaccid paralysis all four extremities and loss of has flaccid paralysis all four extremities and loss of DTRs. VS: BP 90/60, P 82, R 22, T 37 SaO2 92%. DTRs. VS: BP 90/60, P 82, R 22, T 37 SaO2 92%. His skin is warm flushed and dry. What is the most His skin is warm flushed and dry. What is the most likely diagnosis? likely diagnosis?

a. Spinal shock a. Spinal shock - Usually C spine fracture - Flaccid paralysis below b. Cardiogenic shock b. Cardiogenic shock level of lesion c. Hemorrhagic shock c. Hemorrhagic shock - Loss of autonomic tone d. Neurogenic shock d. Neurogenic shock - Warm flushed dry skin - Loss of DTRs Treat with fluids - Hypotension/bradycardia

Neurogenic shock is characterized by: Neurogenic shock is characterized by:

a. Loss of spinal cord reflex activity below a. Loss of spinal cord reflex activity below a cord injury a cord injury b. Transient flaccid paralysis following cord b. Transient flaccid paralysis following cord trauma trauma c. Hypertension and tachycardia c. Hypertension and tachycardia d. Hypotension and bradycardia d. Hypotension and bradycardia e. Increased ICP and loss of vagal tone e. Increased ICP and loss of vagal tone

10 Neurogenic shock: VS do not respond normally Suspect Child abuse • Hypotension and bradycardia • After acute spinal cord injury (above T-4) • Any child < 1yo with • Buttock • Disrupts sympathetic outflow, unopposed a fracture vagal tone • Genetalia • Unique features: warm, dry, pink skin with • Bilateral/multiple adequate urine output fractures at various • Neck Spinal Shock: VS respond normally stages of healing • Face • Temporary loss of spinal reflex activity below • Skull, spine, sternal • Low back a total or near total spinal cord injury fractures • Initial hypertension then hypotension • Abdomen • “bucket handle” • Flaccid paralysis, bowel/bladder, priapism metaphyseal fractures • Bulbocavernosis reflex lost (returns when spinal shock resolves) • Rib fractures

Corner Fracture Corner Fracture

11 Corner Fracture progressed to bucket handle fracture

12 Spiral fractures = abuse

13 Transverse fractures appear as a straight Transverse fractures appear as a straight across break, typically at the center of any across break, typically at the center of any given bone. Though they can happen from given bone. Though they can happen from an abusive event, transverse fractures are an abusive event, transverse fractures are more common in accidental situations. more common in accidental situations.

14 Fracture characteristics found considerably more often in abused children were: multiple or complex configuration; depressed , wide, and growing fracture ; involvement of more than a single 15 month old male cranial bone ; non-parietal fracture; and associated intracranial injury including subdural haematoma will not bear weight on R leg x 1 day. No history of injury.

Toddler’s Fracture

NOT child abuse

15 Toddler’s Fracture • 9 mo – 2 yo when they are always off balance • Spiral fracture of tibia , usually distal 1/3 • Usually from 1 to 2 foot jump off chair landing with external rotation and flexed knee • Swelling and tender to palpation • Initial radiographs may be negative – most sensitive is oblique view • Long leg splint if you feel clinically it is and see nothing on X-ray – repeat X-ray in 10 days (callus) • If fractured – long leg cast •

A 35yo female comes to the ED complaining of blurry vision in her right eye. He denies trauma, fever, numbness/weakness or any other vision problems. On exam she has normal mental status but her R eye is looking down and out with ptosis present and while the left pupil is 2mm and reactive the right pupil is 5mm and non-reactive. Which of the following is the most likely cause?

a. Ischemia b. Lyme disease c. Aneurysm d. Diabetes mellitus e. Uncal herniation

16 A 35yo female comes to the ED complaining of blurry For which of the following injuries is vision in her right eye. He denies trauma, fever, numbness/weakness or any other vision problems. On exam the CT LEAST sensitive? she has normal mental status but her R eye is looking down and out with ptosis present and while the left pupil is 2mm a. Retroperitoneal and reactive the right pupil is 5mm and non-reactive. Which b. Solid organ injury of the following is the most likely cause? c. Duodenum rd a. Ischemia 3 nerve palsy - Eye ‘down and out’ d. Bony structures b. Lyme disease - Ptosis - Cause c. Aneurysm - Ischemia pupil is spared d. Diabetes mellitus - Pressure (e.g. aneurysm, tumor) pupil midposn to e. Uncal herniation dilated non reactive

For which of the following injuries is Abdominal Trauma the CT LEAST sensitive?

a. Retroperitoneal b. Solid organ injury • Hollow organ injury • Solid organ injury c. Duodenum • Duodenum injury • Retroperitoneal d. Bony structures • Pancreas injury injury

• Diaphragm rupture • Bony structures

17 Diaphragmatic Injuries Seat belt Signs

• L > R • L > R • Seat belt sign on abdomen + pain – • Anterior aspect • Posterior (SW is to L • Large rent (6 -10cm) flank) intraabdominal esp hollow viscus injury • Delayed diagnosis • Small rent (3 -6cm) (up to 48hrs) • Delayed diagnosis • Seat belt sign on chest – no big deal • L hemothorax (years) • Translocation rare • Translocation occurs • Seat belt sign on neck + neuro Sx – in 50% • CXR normal • CXR abnormal but • Late herniation and - vascular studies required ( think not diagnostic strangulation • Knife L>R GSW equal carotid dissection ) CXR, CT, US, DPL – not great for Dx

Abdominal trauma More Signs • Grey-Turner’s • Stomach, duodenum and bowel injuries are • Flank discoloration more common in penetrating injuries (except in children) • Late sign for retroperitoneal hematoma • Seen in hemorrhagic pancreatitis • Most duodenal injuries are accompanied with liver injuries • Cullen’s • Periumbilical ecchymosis • If the colon is injured it is usually the • Hemorrhagic pancreatitis transverse colon • Ruptured ectopic pregnancy

18 More Signs Stab wounds to abdomen • Kehr’s

• Referred L shoulder pain due to • 1/3 – no penetration of peritoneum diaphragmatic irritation • Splenic rupture • 1/3 – penetration but no injury

• Fitz-Hugh Curtis • 1/3 – require surgery • Rovsing • RLQ pain with LLQ palpation

A 45-year-old man presents after outpatient MRI A 45-year-old man presents after outpatient MRI reveals cauda equina syndrome. Which of the reveals cauda equina syndrome. Which of the following additional findings is most likely present? following additional findings is most likely present? a. Hyperreflexia a. Hyperreflexia b. Distal motor weakness greater than b. Distal motor weakness greater than proximal motor weakness proximal motor weakness c. Saddle anesthesia c. Saddle anesthesia d. Urinary retention d. Urinary retention

Most consistent finding is urinary retention may manifest as overflow incontinence (sensitivity 90%).

19 UMN LMN Cauda Equina Syndrome • Clinically: CNS and spinal cord Peripheral nerves • low back pain and Lesion above the anterior horn Lesion from anterior horn cells of • bilateral motor or sensory findings, cells of spinal cord or proximal to the spinal cord to the muscles • nuclei of the cranial nerves including cauda equina classic finding is saddle anesthesia involving the buttocks, the backs of the Hyperreflexia Decreased DTRs thighs, and the perineum (pt may not be Clonus/Spasticity(increas Fasciculations aware of this, at risk for decub) ed tone and reflexes) • Hyporeflexia (it is a LMN lesion) Normal muscle mass Atrophy Weakness • signs and symptoms consistent with lumbosacral radiculopathies Babinski sign • sensory changes are dermatomal and correspond to the affected nerve roots

Cauda Equina • The spinal cord ends at T12 – L1, then comes the conus • Conus Medullaris Syndrome medularis (still part of the spinal cord), then comes the • An upper motor neuron lesion or a mix of upper cauda equine which is peripheral nerves within the spinal and lower column • Involvement of the distal spinal cord, • Compression here can be caused by: • S&S consistent with spinal cord compression • Disk herniation, tumor, abscess, hemorrhage • • Clinically (a LMN lesion): weak legs, Nondermatomal sensory loss consistent with sphincter tone, urinary retention with overflow spinal cord compression and dysfunction incontinence • These symptoms and other forms of spinal • Rx: immediate neurosurgery cord compression are referred to collectively • Cauda equina syndrome is not a true cord syndrome. It is as the epidural compression syndromes, with a syndrome that affects the cluster of lumbar and sacral nerve roots that continues distal to the cord known as the the symptoms differing only by the level of cauda equina, or "horse's tail." compression.

20 Axis Rings Harris Rings

Normal

Overlap structures

21 Low Odontoid FX

Type III . ? II

Unstable

This “ring ” should be continuous. Disruption indicates a fracture at the base of the odontoid or upper C2 vertebral body. (Unstable fracture)

Hyperflexion Bilateral Facet

NOT perched One facet in front of the other

22 Bilateral Pediatric Pseudosubluxation Facet Dislocation •Usually C2 on C3

•Sometimes C3 on C4

•Check the spinolaminar line •(Swischuk line)

•The spinolaminar line connecting the anterior portions of the spinous processes of C1 and C3 is within 2 mm of the C2 spinous process

Which of the following is likely to be to be a finding on a climber that would require immediate descent from a high altitude?

a. Recurrent headache b. Retinal hemorrhage c. Ataxia d. Nausea, vomiting e. Lassitude

23 Which of the following is likely to be to be a Question about what requires immediate finding on a climber that would require descent in a mountain climber at high altitude immediate descent from a high altitude? • If ATAXIA is one of the answers, use it • It is an early sign of HACE, and HACE is lethal a. Recurrent headache (HAPE is more common, HACE is more lethal) b. Retinal hemorrhage • Others such as lassitude, headache (even severe, because this is very variable) occur to people at high c. Ataxia altitude d. Nausea, vomiting • Retinal hemorrhages would not be something that in e. Lassitude the wild we would check, so you can exclude that answer • Rales would be difficult to evaluate in the wild because many climbers get bronchitis etc…

A patient presents with severe pain along his right A patient presents with severe pain along his right middle finger after a minor penetrating injury to that middle finger after a minor penetrating injury to that finger approximately one week ago. On examination finger approximately one week ago. On examination you note he is holding the finger in slight flexion, he you note he is holding the finger in slight flexion, he is tender along the flexor sheath and he complains of is tender along the flexor sheath and he complains of pain on passive extension. Another finding you pain on passive extension. Another finding you would expect on examination is… would expect on examination is…

a. Erythema along the entire finger a. Erythema along the entire finger b. Purulent material under the finger nail b. Purulent material under the finger nail c. Adnexal tenderness in the antecubital fossa c. Adnexal tenderness in the antecubital fossa d. Fusiform swelling of the finger d. Fusiform swelling of the finger e. Swelling and erythema of the proximal palm e. Swelling and erythema of the proximal palm

24 Kanavel ’s signs Kanavel ’’’s Signs of Purulent Tenosynovitis • diffuse fusiform swelling of finger

• pain on passive extension 1. Slightly flexed finger • tenderness along 2. Tenderness over the tendon flexor tendon sheath 3. Pain with passive • held in slight flexion extension 4. Symmetrical swelling -Usually from of the involved digit penetrating wound -Usually Staph -At risk for compartment syndrome -Hand surgeon: I&D and Abx

A 66 y.o. previously healthy female presents to the ED with A 66 y.o. previously healthy female presents to the ED with sudden onset of severe vertigo , and vomiting. Her Sx sudden onset of severe vertigo , and vomiting. Her Sx dramatically worsen when she opens her eyes and so the dramatically worsen when she opens her eyes and so the physical exam is limited. The neuro exam was grossly normal physical exam is limited. The neuro exam was grossly normal except for truncal ataxia , the patient follows commands and except for truncal ataxia , the patient follows commands and has no focal weaknesses. She was given lorazepam IV and has no focal weaknesses. She was given lorazepam IV and now has a headache . You should… now has a headache . You should…

a. Add diazepam and acetaminophen to your Rx a. Add diazepam and acetaminophen to your Rx b. Perform an Epley maneuver on the patient b. Perform an Epley maneuver on the patient c. Add meclazine (Antivert)to your Rx c. Add meclazine (Antivert)to your Rx d. Give IV corticosteroids d. Give IV corticosteroids e. Order a CT scan e. Order a CT scan

25 Vertigo Illusion of motion Peripheral Central Vestibular System 85% 15% Acute onset Gradual onset (going on for a while) Peripheral System Central System Intense illusion of motion Milder illusion of motion Worse with movement Mildly worse with movement BPPV Cerebellar (infarct, infection, hem) Nystagmus fatigues Nystagmus does not fatigue CNS infection Labyrinthitis Nystagmus latency period Nystagmus has no latency Brainstem (infarct, hem, tumor) Multiple sclerosis Nystagmus inhibited by Nystagmus not inhibited by Vestibular neuronitis Vertebrobasilar dz fixation fixation Meuniere ’s ETOHic cerebellar Nystagmus vertical degeneration

A 37yo G2P1 full term presents to the ED with onset of Cerebellar hemorrhage regular painful contractions, after a gush of fluid. The nurses bring you the following fetal monitor strip. What is the most appropriate therapy at this time? • Neurosurgical emergency Consider CT/MRI in any: • Headache - Unable to ambulate - Associated H/A a. These are normal early decelerations, continue to • Acute vertigo - Physical findings monitor suggestive of b. Start 2 large bore IVs and call OB and the OR for C- • Vomiting central cause section - abn VS • Marked truncal ataxia - Cr N findings c. Place patient on L lateral decubitus position, start IV NS • Inability to walk - Truncal ataxia and provide nasal oxygen d. Start Oxytocin IV • Gaze palsies (6 th Cr.N.), • Increasing stupor.

26 A 37yo G2P1 female full term presents to the ED with onset of regular painful contractions, after a gush of fluid. The nurses bring you the following fetal monitor strip. What is the most appropriate therapy at this time?

a. These are normal early decelerations, continue to monitor b. Start 2 large bore IVs and call OB and the OR for C- section c. Place patient on L lateral decubitus position, start IV NS and provide nasal oxygen d. Start Oxytocin IV

• The strip shows late deceleration. Early deceleration Late deceleration occurs after contraction • Late deceleration is a decrease in fetal heart rate with onset of deceleration to nadir in 30 seconds or more. • Onset of deceleration occurs after the contraction begins • the nadir of the heart rate occurs after the peak of contraction . • Late decelerations are associated with uteroplacental insufficiency . When it occurs, take the pressure off the IVC with L lateral decubitus position of the patient • If patient is receiving oxytocin, it should be discontinued. • Fetal heart monitoring must be continued to assure , deceleration does not become persistent which would be an indication of fetal distress and cesarean section .

27 Which of the following statements regarding necrotizing soft tissue infections is correct?

a. Antibiotic monotherapy is not appropriate b. Clostridial myonecrosis is most commonly caused by wound contamination c. Degree of muscle necrosis can be estimated based on associated skin change d. Early signs of gas in the tissue help make the diagnosis in the majority of patients

Which of the following statements regarding Gas Gangrene necrotizing soft tissue infections is correct? • Clostridium perfrengens • Anaerobic a. Antibiotic monotherapy is not appropriate • Pain out of proportion (POOP) b. Clostridial myonecrosis is most commonly • Brawny edema caused by wound contamination • “dish water” discharge c. Degree of muscle necrosis can be estimated • Subcutaneous emphysema based on associated skin change • Low grade fever d. Early signs of gas in the tissue help make the • Gram stain NOT helpful diagnosis in the majority of patients • Fluids, High dose PCN, OR stat • Hyperbarics (HBOT)

28 Clostridial myonecrosis

Severe pain • Clostridial myonecrosis most commonly ‘La belle indifference’ occurs from contaminated postsurgical Dirty dishwater smell or traumatic wounds • It does not affect healthy tissue, but Crepitus rather is a superinfection of already infected or traumatized tissue. • Clostridial myonecrosis is commonly referred to as gas gangrene and spreads unless taken to surgery for debridement and excision

Necrotizing Cellulitis – Fasciitis – Myonecrosis

Cellulitis Fasciitis Myonecrosis

Spectrum of necrotizing

29 Necrotizing fasciitis

Necrotizing Gas Fasciitis Gangrene High fever Low grade fever Bullae Dirty dish water discharge Very painful La belle indifference GpA strep, staph, clostridium, Clostridium Perfringes bacteroides, aeromonas hydrophila Skin and Sub Q tissue Muscle infection Rx: Surgical debridement and excision Rx: surgical debridement Piperacillin/Tazobactam Vancomycin and excision ? Amputation Clindamycin PCN Fluoroquinones

30 Fournier’s Gangrene • Diabetic Mortality? ______2% - 10% • Scrotal pain • out of proportion with clinical findings • Polymicrobial synergistic infection of the subcutaneous tissue • Originates from: urethra, rectum, skin • Rx: wide I&D, culture wound, Abiotics (anearobes, Gm –ve enterics), IV fluids Infection leads to end artery thrombosis in sub-Q tissue that promotes widespread necrosis

A patient presents with a big bite on his right A patient presents with a big bite on his right hand, he states this is what bit him. Which of hand, he states this is what bit him. Which of the following is correct: the following is correct: a. The patient is likely to complain of severe a. The patient is likely to complain of severe pain pain b. Local tissue necrosis is the most common b. Local tissue necrosis is the most common finding finding c. Abdominal pain is likely c. Abdominal pain is likely d. It is unlikely to involve the joints d. It is unlikely to involve the joints e. You must use antiserum e. You must use antiserum immediately immediately

31 Day 2

Day 4 Day 14

32 Large brown recluse

Black Widow - Lactrodectus Brown Recluse - Loxoscelidae Outhouses, woodpiles Cellars, woodpiles Ventral hour glass Dorsal violin Aggressive Passive

Immediate pain – prick then quickly Delay in pain onset – 2 – 6 hours extending to entire extremity later itching/aching Bite – circular erythematous Bite – ischemic, clear avascular lesion – tiny fang marks center, later necrosis, volcano Potent Neurotoxin; release of Cytotoxin, hemolytic acetylcholine and norepinephrine Tremor, paresthesias, painful Tissue necrosis around wound muscle contractions, N/V, abd may expand within 10 days pain mimic acute abdomen enough to require plastic repair Benzodiazepine, Ca Gluconate HBO, surgery

Antivenom available – rarely useful No antivenom except in children w dysautonomia

33 A 34yo male with a history of IVDA presents to the A 34yo male with a history of IVDA presents to the ED with back pain. His ESR is 100 and CRP is 30. ED with back pain. His ESR is 100 and CRP is 30. His PMHx is otherwise negative. His CT spine is His PMHx is otherwise negative. His CT spine is shown. The most likely diagnosis is… shown. The most likely diagnosis is… a. Osteomyelitis a. Osteomyelitis 3 important spinal b. Spinal epidural abscess b. Spinal epidural abscess infections associated c. Disciitis c. Discitis with IVDA d. Spinal fracture d. Spinal fracture e. Syringomyelia e. Syringomyelia At ABEM General you will get help to differentiate these three infections

Spinal Epidural Abscess For osteomyelitis findings at ABEM Gen • Causes: the image would show • IVDA • Foley one level only • Dental work • LP involved • At risk: DM, immunocompromised (HIV, alcoholic) For spinal epidural • Staph, Strep, Bacteroides abscess at ABEM Gen • Clinically: back pain maybe fever, maybe the image would be an neuro deficit (late) MRI • CRP, Sed rate • MRI is the diagnostic test of choice

34 4 yo brought by parents because child is crying excessively. Normal pregnancy delivery, childbirth and has been well except for this recent excessive crying. What is your next best step? CXR, U/A, undress, monitor, etc…

• Strangulation: digit, penis also SVT • Open diaper pin monitor • Anal fissure • Battered

• Infection ( UTI, OM, meningitis) /Intussusception • Testicular torsion • Corneal abrasion • Hernia (incarcerated)

There has been a radiation accident at your local There has been a radiation accident at your local nuclear power plant. A patient present at the site at nuclear power plant. A patient present at the site at the time of the accident presents to your ED with the time of the accident presents to your ED with complaints of nausea and vomiting. She is now, 48 complaints of nausea and vomiting. She is now, 48 hours after the event, worried about this exposure. hours after the event, worried about this exposure. Her absolute lymphocyte count is 1600/mcL. You Her absolute lymphocyte count is 1600/mcL. You should explain to her that… should explain to her that… a. That her exposure will require intensive and aggressive a. That her exposure will require intensive and aggressive therapy for her to survive therapy for her to survive b. That her lab value suggests that she has a 50:50 chance b. That her lab value suggests that she has a 50:50 chance of survival of survival c. That she requires no treatment and is expected to recover c. That she requires no treatment and is expected to recover from her exposure without significant complications from her exposure without significant complications d. That it is to early to tell and that her ALC will have to be d. That it is to early to tell and that her ALC will have to be re-taken in 24 hours re-taken in 24 hours e. That she has likely suffered a lethal dose of radiation e. That she has likely suffered a lethal dose of radiation

35 Absolute lymphocyte counts at 48 hours Radiation Accidents after exposure as a prognostic factor • Exposures with poorer prognosis • Early GI Sx: N/V within a few hours • > 1200/mcL means it is unlikely that the patient has received a clinically significant • Bone marrow suppression (ALC < 500 at 24 hours) poor prognosis dose of radiation • Radiation are particles – they can be washed • 500 – 1200/mcL serial counts especially off if symptomatic – > 50% mortality • Remove the patient’s clothing • 100 - 500 /mcL possibility of exposure to • Wash the patient with water +++++ a lethal dose of radiation should be suspected • GI and bone marrow have high cell division so they are most at risk from radiation

Radiation Accidents Radiation Accidents • Phases of Rediation Exposure: 4 Phases • Phase 3: manifest illness • Phase 1: Prodromal • Sub-syndrome A: Hematopoietic syndrome • transient period of self-limiting autonomic • Begins with rapid decline in lymphocytes symptoms, which usually include anorexia, nausea , and vomiting • Absolute lymphocyte count ( ALC) at 48 hours • Phase 2: Latent phase post-exposure is best early indicator of prognosis for ARS • Symptom free (lasts weeks in low dose; few hours in high dose) • The decline in lymphocytes is followed by • Phase 3: Manifest illness further declines in granulocytes and platelets with resulting pancytopenia • 3 sub-syndromes based on whole body irradiation dose

36 Radiation Accidents Radiation Accidents • Phase 3: manifest illness • Phase 3: manifest illness • Sub-syndrome B : Gastrointestinal syndrome • Sub-syndrome C: CVS and CNS syndrome • Occurs at radiation doses above those required • Occurs at radiation doses above those required for the hematopoietic syndrome for the GI syndrome • Characterized by severe vomiting, diarrhea , • Characterized by refractory hypotension , and abdominal pain leading to significant altered mental status , lethargy, ataxia, tremors, dehydration and electrolyte abnormalities and convulsions within hours of exposure. which can progresses to fulminant enterocolitis Death occurs within 24 to 72 hours as a result which is uniformly fatal of circulatory collapse

Radiation Accidents All of the following are true regarding • Phase 4: recovery or death radiation exposure EXCEPT: • This can be predicted based on the patient's ALC a. Alpha rays are the most penetrating measured at 24 and 48 hours. b. GI syndrome (N/V/D) occurs at 1 Gy (gray) • ALC > 1,200/mcL at 24 hrs – requires no clinical support and has a fair to good prognosis. An c. Survival is unlikely with a exposure of • ALC < 500/mcL at 24 hours is predictive of a poor greater than 800 rads prognosis and the need for intense levels of support d. The GI tract is one of the tissues most and treatment. An affected by radiation • ALC > 1,200/mcL at 48 hours indicates a good prognosis and minimal supportive therapy; an e. The absolute lymphocyte count (ALC) at 48 hours of 1200 indicates ~ 50% mortality • ALC < 300/mcL at 48 hours is uniformly predictive of death.

37 All of the following are true regarding Types of Radiation radiation exposure EXCEPT: Paper Plastic Lead Concrete 444 α ++++++ Alpha ? need alpha counter a. Alpha rays are the most penetrating 222

b. GI syndrome (N/V/D) occurs at 1 Gy (gray) 000 −−− −1−1−1 βββ Beta Skin burns c. Survival is unlikely with a exposure of Geiger counter 0 greater than 800 rads 0γ Gamma and X-rays d. The GI tract is one of the tissues most Primary cause of acute radiation syndrome 1 n affected by radiation 0 Neutron e. The absolute lymphocyte count (ALC) at 48 Stopped neutrons are captured and cause hours of 1200 indicates ~ 50% mortality previously stable atoms to become radioactive – source of radioactive fallout

All of the following are more consistent with All of the following are more consistent with delirium than dementia EXCEPT… delirium than dementia EXCEPT…

a. Onset is acute (days to weeks) a. Onset is acute (days to weeks)

b. It is usually reversible b. It is usually reversible

c. Hallucinations c. Hallucinations

d. Consciousness is clear d. Consciousness is clear

e. Fluctuating course e. Fluctuating course

38 Features Delirium Dementia Delirium vs. Dementia Onset Acute Insidious, chronic state Consciousness Clouded, altered LOC No clouding of consciousness DELIRIUM DEMENTIA Clear, awake, alert Course Fluctuating Progressive acute onset insidious onset Attention Poor attention Pays attention Hallucinations Yes (visual) None till late fluctuating course stable course Delusions Fleeting None inattention maintains attention Short term memory test: 3 Most senstitive early finding item to repeat later hallucinations (often visual) no hallucinations, Cognitive functioning Decreased cognitive functioning, judgement and fleeting delusions no delusions R/O: lytes imbalance, R/O superimposed medical altered LOC appears awake and alert hypoxia, hepatic failure, drug illness if acute worsening of use, CNS lesion dementia Consciousness OK Alzheimer’s : age > 65, no focal neuro findings, no trauma – CT 10% - 15% of patients admitted to 50% of patients > 85yo; Alzheimer’s brain shows cortical atrophy hospital have some level of delirium accounts for 70% Multi-infarct dementia : focal neuro findings, CT shows lacunar Both delirium and dementia can involve memory deficits infarcts

Keycepts: Dementia Treatable Causes of Dementia • Before diagnosing dementia R/O treatable Dz: Drugs • Normal Pressure Hydrocephalus: Electrolytes • dementia, ataxia , incontinence • Wernicke-Korsakoff Syndrome: Metabolic • ataxia, ocular abn, confusion Emotional • Pseudodimentia (depression): Nutritional/Normal pressure hydrocephalus • severely depressed patient • Disturbed sleep pattern Trauma/Tumor • Sudden onset ppted by emotional event Inflammation (SLE…)/Infection • Mental status improves with encouragement Alcohol • Medical problem: drugs, lytes , metabolic dz

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