R4 Simulation with Dr. Betham, Kircher, Scupp, and Thomas
Simulation: patient is a young female G1P0 @ 39wks who had her membranes rupture at home who got in an MVC on the way to the hospital. Presents tachycardic, normotensive with abdominal pain. +FAST with imminent delivery complicated by a shoulder dystocia. Baby with APGAR of 4, breathing but limp and bradycardic upon delivery.
Trauma in Pregnancy: Stick to your trauma evaluation, resuscitating mom is resuscitating baby initially.
- Have mom stop pushing and call for help
- McRobert's maneuver (legs hyperflexed)
- Suprapubic pressure (not fundal) to disimpact the anterior shoulder
- Manually deliver the posterior arm
Oral Boards: Post-partum pre-eclampsia and HELLP syndrome: Consider pre-eclampsia in women who are 6 weeks or less from delivery who present with RUQ pain or headache, even if they did not have preeclampsia during pregnancy (<1%).
- Diagnosis of preeclampsia requires two BP >140/80 + proteinuria (though proteinuria can be absent if other signs of severe preeclampsia are present - https://www.acog.org/~/media/Task%20Force%20and%20Work%20Group%20Reports/public/HypertensioninPregnancy.pdf)
- Severe preeclampsia requires evidence of end organ dysfunction as manifested by headache, RUQ pain, visual changes, hyperreflexia, and signs of HELLP syndrome (low platelets, elevated AST/ALT).
- Treatment of postpartum preeclampsia consists of BP control (labetalol and hydralazine first line) and magnesium infusions (4g over 20min initially), and then admission to an ICU or L&D floor.
- HELLP should be treated similarly, add on DIC labs
CPC with Dr. Continenza and Dr. Paulsen
Case: Elderly man with slurred speech, left sided weakness worked up for TIA at an OSH, transferred for further work-up. Has dysarthria, left sided facial droop, tongue deviation to the right. Normal MRI at the OSH, normal lab work up.
Neurologic complaint approach sorted by emergency and localization:
- Is the patient experiencing respiratory failure?
- Level of AMS?
- Global v Focal Deficit?
- Non-neurologic (Infection, toxic, iatrogenic, metabolic, ACS, adrenal insufficiency, hypothyroidism, anemia)
- Neurologic (post-ictal, myasthenia gravis, Guillain-barre syndrome, botulism toxicity, tick paralysis)
- Unilateral or Bilateral?
- Sensory, Motor, or Both?
- Motor (multiple CNS lesions, polyneuropathy)
- Proximal v Distal
- Proximal>Distal (neuromuscular disorders ie myasthenia gravis, lambert-eaton, botulism)
- Bulbar signs?
- Sudden onset?
- Sudden (vascular, toxic metabolic, infectious, autoimmune)
- Gradual (autoimmune, mass, neurodegenerative)
- Localize the lesion
Our patient's constellation of syndrome fits the neuromuscular junction and peripheral nerves. Test ordered: Ice Pack Test for Myasthenia Gravis.
Myasthenia Gravis: antibodies to acetylcholine receptor causing muscle weakness and fatiguability.
Epidemiology: 0.9-2.1 per 100,000
- Ocular symptoms (~50%)
- Generalized symptoms
- slurred speech
- Serum antibodies to acetylcholine receptor
- Ice pack test: sensitivity 96% specificity 88% (apply ice pack to 1 eye for 2 mins which improves the ptosis)
- May work by decreasing the action of the acetylcholine esterase to leave more ACh in the synapse
- Tensilon test
Causes of Crisis:
- Beta Blockers
Treatment of crisis: corticosteroids, immunomodulators initially. Consider thymectomy if applicable.
- Respiratory Acidosis
- Unable to handle secretions
- FVC <20ml/kg
- NIF (aka MIP) < 30 cm H20
- Depolarizing: resistant
- Non-depolarizing: sensitive
- Avoid if PCO2 >45, secretions
R4 Clinical Soapbox with Dr. DeVries
First US was in the 1960s, was a huge machine that cost $300,000.
Fraction of overall ED US from 0.2->3%. From 1992-2012 increased by >4000%.
Potential Pitfalls for US:
- Physician competency
- ACEP defined goals
- Consultant interaction
- Ignoring clinical context
POCUS in patients admitted with respiratory studies: Increased diagnostic accuracy of POCUS v CXR at 4 hours with absolute increase in 24%. NNT about 4. Pts with CXR had:
- Increased downstream testing
- Trends towards harm
- No change in hospital LOS
Future of POCUS
- Critical time for the incorporation of POCUS
R1 Diagnostics with Dr. Golden: Foot and ankle x-rays
Take a look through Dr. Golden's introductory post for the basics
Lisfranc Injury: ligamentous injury +/- fracture dislocation
- Rest, Ice, Compression, Elevation
- Pain control
- If <2mm displacement: 6-8 weeks NWB short leg splint
- If >2mm displacement, fracture dislocations: surgical repair may be indicated
- Urgent consultation: Neurovascular compromise or compartment syndrome
Fifth Metatarsal Injuries:
- Zone 1: Tuberosity Avulsion (Pseudo-Jones)
- No studies comparing operative v non-operative
- Protected weight bearing (walking boots) does better than non-weight bearing
- Outpatient follow-up within 2 weeks
- Zone 2: Jones Fractures (peroneus longus tendon rupture)
- NWB short leg splint
- Operative repair: nonunion (20% of conservatively managed patients), re-fracture, athletes
- Outpatient follow-up within 2 weeks
- Zone 3: Diaphyseal stress fractures
Bohlers Angle (should be between 20-40 degrees): if angle lies outside of this, suspect a calcaneal injury
- Surgical: compartment syndrome, neurovascular compromise, open, dislocation
- Intra-articular fracture: urgent need for surgical consultation
- Extra-articular fracture: okay for outpatient consultation