Grand Rounds Recap 6.21.17

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Ultrasound Guided Regional Anesthesia with Dr. Carleton

Maximizing Safety

  • Pre-procedural assessment of nerve function
  • Bullet proof knowledge of relevant anatomy
  • Optimize imagine and know nerve appearance
  • Know where you are injecting
  • Use the least amount of local anesthetic as possible
  • Know and identify LAST

Identifying Nerves

  • Distal peripheral nerves have echogenic sheaths containing echolucent fascicles (honeycomb appearance)
  • They are markedly anisotropic
  • They look similar to tendons
  • They often are accompanied by vascular structures

Median Nerve

  • Descends in forearm adherent to the fascia on the deep surface of the Flexor Digitorum Superficialis (FDS)
  • Gives off the anterior interosseous nerve while in the cubital fossa
  • Gives off the palmar cutaneous nerve just proximal to the flexor retinaculum of the wrist
  • Enters the wrist just radial to the palmaris longus tendon

Ulnar Nerve

  • Enters the forearm between the olecranon and medial humeral epicondyle
  • Lies between the more superficial flexor carpi ulnaris and deeper flexor digitalis profundus muscles
  • Runs with the ulnar artery in distal half of forearm, with artery on radial side
  • Gives off palmer cutaneous branch in mid-forearm and dorsal cut. branch at distal ulna
  • Superficial at the wrist, covered only by the antebrachial fascia 
  • Divides at carpus into deep and superficial branches 

Radial Nerve

  • Gives off the posterior ante brachial cutaneous nerve in mid-arm
  • Enters the forearm laterally just deep to brachioradialis and extensor carpi radialis longus muscles
  • Divides into superficial and deep branches in distal arm/cubital fossa
  • Superficial branch is all cutaneous
  • Deep branch ends as post. interosseous nerve deep to extensor pollicus longus muscle

R3 Small Groups with Drs. Dang, O'Brien, Lagasse, and Thompson

US Guided Posterior Tibial Nerve Block

  • For superficial lacerations to the plantar surface of the foot
  • Isolated calcaneal fracture
  • Blind success rate as low as 22%

R1 Pediatric EKGs with Dr. Nagle

Please see Dr. Nagle's original post that covers the basic of the Pediatric EKG

Syncope

  • 15% of adolescents will experience syncope
  • 70-80% will be neurocardiogenic and orthostatic 
  • <5% due to cardiac cause

History

  • Precipitating Factors: Activity, Position, Stress, Arousal
  • Description of Event: Palpitations, Posturing, Prodrome
  • PMHx: Congenital disease, recent illness, medications
  • Family History: sudden death

Normal findings in children compared to adults:

  • HR >100
  • RAD with QRS >90 degrees
  • T wave inversions in V1-V3
  • Dominant R wave in V1
  • RsR' pattern in V1
  • Marked sinus arrhythmia
  • Short PR interval and QRS duration
  • Slightly peaked P waves
  • Prolonged QTc
  • Q waves in inferior and left precordial leads

Conduction abnormality causing syncope

  • Long QT Syndrome
    • Channelopathy causing prolonged action potential
    • Acquired: Hypo-K/Mg/Ca, eating disorder, hypothyroid, drug induced, head trauma
    • Congenital: 12 genetic defects
      • Two phenotypes: Romano-Ward and Jervell & Larnge Nielsen
    • Most common presentation is after syncopal episode
    • Prolonged QTc
    • T wave alternans
    • Notched T waves
    • Prominent U-waves
  • Pre-excitation syndrome (WPW)
    • Arrhythmias with typical EKG findings while in sinus rhythm

Structural Heart Disease causing Syncope-- Hypertrophic cardiomyopathy

Blausen_0166_Cardiomyopathy_Hypertrophic.png
  • 1 in 5000 people
  • #1 cause of cardiac death in young athletes
  • Autosomal dominant with variable penetrance
  • Anterior interventricular septum growth
  • LVH
  • Dagger like Q-Waves in lateral and inferior leads
  • P mitrale

ALCAPA (anomalous left coronary artery arising from pulmonary artery)

  • LV insufficiency secondary to coronary steal
  • High mortality, ~90% if untreated
  • Asymptomatic at birth
  • <2yo ~75%
    • Present with signs of CHF or dilated cardiomyopathy
  • >2yo ~25%
    • Mitral valve issues secondary to ischemia