01/29/2014

1

Basic Training

Diagnoses

Killer Foils

AssociationsBook of Commons

Lyte Notes

Complications

Causes

Paul de Saint Victor M.D., F.A.C.E.P., M.H.A., C.P.E., F.I.M.

Associate Director, Emergency Medicine Residency Program

St Vincent Mercy Medical Center

Assistant Clinical Professor

Department of Surgery

University of Toledo, College of Medicine

Toledo, OhioFriday, February 7

2

Muscarinic ToxidromeExcess acetylcholine (ACh) at muscarinic

parasympathetic end organ receptors

• Diarrhea

• Urination

• Miosis

• Bradycardia,

• Bronchorrhea, Bronchospasm

• Emesis

• Lacrimation

• Salivation, sweating, Secretion

D

U

M

B

B

E

L

S

Nicotinic ToxidromeExcess ACh at central autonomic receptors

Can be mixed sympathetic and parasympathetic presentation

• Mydriasis

• Tachycardia

• Weakness

• Hypertension, Hyperglycemia

• Fasciculation

• Seizures

MTWHFS (days of the week)

More severe toxicity:

- seizures

- respiratory depression

- hyperthermia

No specific antidote

Supportive care

Benzos

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www.ohacep.org/emrlectures

Trauma in Pregnancy and Fetal Death

• The most common cause of fetal death in

trauma is maternal shock and death.

• When the mother survives, abruption is the

next leading cause of fetal mortality

followed by uterine rupture

Match the following red eyes with the diagnosis

With preauricular adenopathy

With discharge and a cough

Painful with mild mucoserous

discharge for 5 d then spread

With cobblestone papillae under

upper lid

With hypopeon in contact wearer

After eye surgery

With diffuse punctate keratopathy

With cup:disc ratio > 1:2

Dendridic pattern (dumbells)

Cells in the vitreous cavity

Ciliary flush, flare in anterior chamber,

consensual photophobia

•EKC (epidemic keratoconjunctivitis)

•Uveitis

•Herpes simplex infection

•UV keratitis

•Pseudomonas

•Glaucoma

•Iritis

•Endophthalmitis

•Viral conjunctivitis

•Allergic conjuncitivitis

•Chlamydia

•GC

Herpes Zoster Ophthalmicus

Hutchinson sign

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ToxidromesAMS, Resp Alk,

Met Acid, tinnitus,

hyperpnea, diaphoresis

Salicylate

toxidrome

Agitation, mydriasis,

diphoresis, tachy, HTN,

hyperthermia, normal BS

Sympathomimetic

toxidrome

CNS depression,

miosis, resp depression

Opioid toxidrome

AMS, incr muscle tone,

hypereflexia, hypertherm

Serotonin

toxidrome

Sal, Lacr, urination, N/V,

diaphoresis, diarrhea,

muscle fasciculation,

bronchorhea, weakness

Cholinergic

toxidrome

AMS, mydriasis, dry mm

& skin, urinary retention,

BS, hyperthermia

Anticholinergic

toxidrome

WET/BS+

DRY/noBS

Sudden Loss of Vision

• Central retinal artery occlusion

• Central retinal vein occlusion

• Retinal detachment

• Temporal arteritis

• Multiple sclerosis

• Vitreous hemorrhage

• Amaurosis Fugax

Pale retina, cherry

red spot

squashed tomatoes

Blood and thunder

Sand dunes, flashes of light, floaters,

lowering curtain, visual field defect

Polymyalgia rheumatica, 50, CRP, prednisone, blindness, jaw claudication

Optic neuritis, Bilateral internuclear ophthalmoplegia, red desaturation test

Associations

Ocular TIA

Diabetic with visual floaters, loss of red reflex, with/without retinal detachment

3Fs

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Because the optic nerve is sensitive to red, when it is damaged,

the affected eye sees red colors as washed out pink-orange color.

Posterior Vitreous Detachment

• Very common problem in the elderly (75% of

patients > 65 yo)

• Floaters, Flashes of light, cobwebs

• May be difficult to differentiate from retinal

detachment

• Occasionally associated with vitreous hemorrhage

(significant visual impairment) which usually

resolves spontaneously

• Rarely PVD is associated with retinal tears with

subsequent retinal detachment

A well appearing 38 yo male presents with a 5 day

history of diarrhea. PMHx: HTN, smoker. Which of

the following is the management of choice?

a. IV fluids, laboratory tests, empiric antibiotics

b. Oral rehydration, laboratory tests, empiric

antibiotics

c. IV fluids, imaging, empiric antibiotics

d. Oral rehydration and symptomatic outpatient

therapy

e. Oral rehydration, ultrasound evaluation, stool

cultures

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Seizing pt w diarrhea

Diarrhea w anxiety and heat intoleranceDiarrhea w paresthesiasand reverse temperature sensation Elderly pt with bloody diarrhea and abd POOP

Diarrhea , crampy abd pain, fever, antecedent Hx of Abiotic use

Diarrhea c Pneumonia

Cholera like diarrhea

Shigellosis, Theo Tox

Thyrotoxicosis

Pseudomembranous colitis

Mesenteric ischemia

Legionella Pneumonia

Ciguatera

Arsenic Poisoning

Toxin producing C diffFever, toxic, profuse diarrheaStop Abx, No antidiarrhealVanco, Metronidazole

Diarrhea, pet turtle or eggs,

Sickle cell pts get septic

Salmonella

All of the following are intrinsic (Contact

Activation Pathway) factors of the

clotting cascade EXCEPT:• Factor 8

• Factor 9

• Factor 10

• Factor 11

• Factor 12

The Clotting Cascade

9-118- -12VII

INtrinsicExtrinsic

1, 2, 5, 10, 13Common pathway

Heparin, PTTProtamine zinc

Warfarin, INR (PT)Vit K

Vit K dependent factors: II, VII, IX, X

On 9/11 we

were Contacted

by outsiders

How it works (in a minute)

Contact Activation

Pathway

Tissue Activation

Pathway

3, 4, 6 are out

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Hematology: Match the Following

1. CAP Factors (intrinsic)

2. Common pathway

factors

3. TAP factors (extrinsic)

4. Vitamin K

dependent factors

a. Factors I, II, V,

X, XII

b. II, VII, IX, X

c. Factors 9-11 and

8 and 12

d. Factors VII

Sore Throat2 – 7yo appears ill, dysphagia

drooling , distress, muffled

voice, PE findings except for

high fever normal, pain hyoid

Epiglottitis

6 mo – 3 yo, URI that worsens, worse at night, mildly ill, barky cough, stridor, dyspnea, subglotticinflammation, viral

Croup

Severe croup pt not

responding to racemic epi,

pus from ET tube

Bacterial

Tracheitis

6mo – 3yo (<4yo) severe airway obstruction, retropharyngeal lymph nodes, dysphagia, ill appearing tripod, muffled voice

Retropharyngeal

abscess

> 8 yo, dysphagia, trouble swallowing, trismus, deviated uvula

Peritonsilar

abscess

Peds: systemic

OR for direct exam

Adult: localized

Diarrheal disease: Match’em

• RLQ pain, little diarrhea

• Camper, gay, flatulence

• Shellfish, alcoholic incr

morbidity mortality

• Liver cysts

• Tuna, (looks like allergic Rx),

peppery taste, facial flushing,

palp, abd cramps

Vibrio

Vulnificus

Yersinia

Scombroid

Amebiasis

Giardia

Looks like appendicitis

Invasive dz of terminal ileum

and cecum –MC in children

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Peritonsillar Abscess

• Polymicrobial infections are the rule

• Fusopbacterium

• GABH strep

• Streptococcus

• Staphylococcus

• Numerous anaerobes

• Rx

• Needle aspiration + antibiotics

Withdrawal Syndrome

• Clinical Presentation

• Mydriasis

• Tachycardia looks sympathomimetic

• Hypertension

• Diarrhea

• Hallucinations

• Piloerection

• Lacrimation

• Crampy abdominal pain

• Yawning

• Seizures – only EtOH, BZ, barb, propoxyphene

Alcoholics drink cheap

D-CHEaPLY

these indicate withdrawal

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Since the radius and ulna have adjacent joints at

both ends, a fracture of the shaft of one with

significant angulation implies fracture or

dislocation of the other. This X-ray depicts

which type of fracture?

a. Fitch's

b. Galeazzi

c. Smith's

d. Monteggia's

e. Colle's

Galeazzi - Montaggia

• Galeazzi:

• Monteggia

- radius fracture

-distal radio-ulnar joint

disruption

-distal deformity

-ulnar nerve ? injury

- ulnar fracture

-proximal radial head

dislocation

-elbow deformity

-radial nerve ? injury

GROUND

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Monteggia fracture

• Apex of ulnar fracture points in direction of

radial head dislocation (often missed on x-

ray interp)

• ORIF required

• Galiazzi (reverse Montegia): fracture distal

third of radius (G-closer to the Ground)

associated with a distal radioulnar joint

dislocation

Galeazzi - GRound

Ulnar dislocation easily missed

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A 28yo male playing soccer suffers this injury

during the game. Your next best step is…

a. Order an X-ray of the other ankle

b. Order an MRI of the same side knee

c. Consult orthopedics

d. Discharge the patient home in weight bearing

posterior splint and crutches

A 28yo male playing soccer suffers this injury

during the game. Your next best step is…

a. Order an X-ray of the other ankle

b. Order an MRI of the same side knee

c. Consult orthopedics

d. Discharge the patient home in weight bearing

posterior splint and crutches

Stress X-rays of the ankle is an important step because Maisonneuve fracture puts the ankle mortise joint at extreme risk of instability

X-ray

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Maisonneuve Fracture

Associations• Proximal fibular fracture

• Deltoid ligament disruption

• and ankle joint instability

• (stress views of the ankle)

• Peroneal nerve injury• Motor: foot dorsiflexion

• Sensory: dorsum of foot

• With deep peroneal n injury

• only: sensory dorsum between

• big toe and second toes

• May get Maisonneuve with bad ankle sprain only so must look for fibular fracture

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A 47yo male involved in MVA. He presents to your

ED, severely hypotensive, tachycardic. His GCS is 13.

His C-spine, CXR and pelvis X-rays are all negative.

His monitor strip is shown. The most likely cause of

his hypotension is…

a. Cord injury

b. Cardiac tamponade

c. Pelvic vessel rupture

d. Long bone fracture bleeding

e. Acute myocardial infarction

A 47yo male involved in MVA. He presents to your

ED, severely hypotensive, tachycardic. His GCS is 13.

His C-spine, CXR and pelvis X-rays are all negative.

His monitor strip is shown. The most likely cause of

his hypotension is…a. Cord injury

b. Cardiac tamponade

c. Pelvic vessel rupture

d. Long bone fracture bleeding

e. Acute myocardial infarction

Persistent hypotension in a multiple trauma patient

with normal pelvis and chest X-rays is most likely due

to intraperitoneal hemorrhage or cardiac tamponade.

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A 47yo male involved in MVA presents

hypotensive to the ED. As you are doing the

FAST exam, he looses consciousness. The

ultrasound you immediately obtain is shown.

Your next best step is…

a. Intubate the patient

b. Insert US guided internal jugular

catheter

c. Start CPR

d. Perform immediate thoracotomy

e. Perform pericardiocentesis

Pericardial Window:

Pericardial Tamponade

Same scenario

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A 47yo male involved in MVA presents

hypotensive to the ED. As you are doing the

FAST exam, he loses consciousness. The

ultrasound you immediately obtain is shown.

Your next best step is…

a. Intubate the patient

b. Insert US guided internal jugular

catheter

c. Start CPR

d. Perform immediate thoracotomy

e. Perform pericardiocentesis US guided

Beck’s triad…

• Hypotension

• Muffled heart sounds

• JVD

Removal of ______ cc may result in

immediate improvement

20 - 30

Pericardial Window:

Pericardial Tamponade

Rt Ventricular collapse consistent with tamponade

Pericardial fluid

L ventricle

Same scenario

Identify what arrows point to

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Tricuspid v

Mitral v

Liver

All of the following are potential causes

of the following ECG EXCEPT…

a. Congestive heart failure

b. Cardiomyopathy

c. End-stage COPD

d. Morbid obesity

e. Pericardial effusion

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All of the following are potential causes

of the following ECG EXCEPT…

a. Congestive heart failure

b. Cardiomyopathy

c. End-stage COPD

d. Morbid obesity

e. Pericardial effusion

Pericardial effusion

Morbid obesityEnd stage COPD

MyocarditisCardiomyopathies

Severe hypothyroidism

Low voltage ECG

< 5 mV < 10 mV

AMI Associations

Inferior AMI

Anterior AMI

R V AMI

Posterior

AMI

Lower grade Blocks

Better prognosis

Assoc w Inferior MI

Ruptures

Fluid Load

Associated w RV and inferior AMI

Bad bradycardias

Missed

Hypotension

CHF/Shock

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A 32 yo male involved in a roll-over MVA

presents with neck pain. Based on X-ray you

suspect…

a. A ligamentous disruption

b. An unstable fracture

c. A subluxation

d. A unilateral facet dislocation

e. A stable fracture

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A 32 yo male involved in a roll-over MVA

presents with neck pain. Based on X-ray you

suspect…

a. A ligamentous disruption

b. An unstable fracture

c. A subluxation

d. A unilateral facet dislocation

e. A stable fracture

Axis Rings

Harris

Rings

Normal

Overlap

structures

Low Odontoid FX

Type III. ? II

Unstable

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AXIS RING (HARRIS RING)

• In the intubated patient,

loss of the continuous ring

may be the only indication

of fracture, because of

difficulty in assessing soft

tissue contours.

This “ring” should be continuous. Disruption indicates a

fracture at the base of the odontoid or upper C2 vertebral body.

(Unstable fracture)

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Most Common

Most unstable

Unstable Cervical Spine Fractures –

Jefferson bit off a hangman’s thumb

• Jefferson

• Bilateral facet dislocation

• Odontoid II and III

• Any fracture dislocation

• Hangman’s

• Tear drop fracture

Stable Fractures

- spinous fracture

- transverse process #

- wedge fracture

- unilateral facet dislocation

- vertebral burst fracture

(except Jefferson)

A 5 yo male presents to the ED after falling into a hay stack from 5 feet up. He complains of neck pain. His X-ray is shown. You suspect…

a. Unilateral facet dislocation

b. Bilateral facet dislocation

c. Pseudosubluxation

d. Fracture/dislocation of C2

e. Axis fracture

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A 5 yo male presents to the ED after falling into a hay stack from 5 feet up. He complains of neck pain. His X-ray is shown. You suspect…

a. Unilateral facet dislocation

b. Bilateral facet dislocation

c. Pseudosubluxation

d. Fracture/dislocation of C2

e. Axis fracture

Pediatric Pseudosubluxation

•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

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Alignment and Spaces

Spinous

process

Line

Spino

laminar

Line

Posterior

Longitudinal

ligament

Line

Anterior

Longitudinal

ligament

Line

6 at 2

22 at 6

Predental

� 3 mm in adults

is pathologic

� 5 mm in kids is

pathologic

A 27 yo male is involved in an MVA. He has no obvious fractures, head, neck, chest or pelvic injuries, but is hypotensive and tachycardic. His FAST scan is shown. The most likely cause for his hypotension is injury to the…

a. Liver

b. Kidneys

c. Bladder

d. Spleen

e. Diaphragm

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A 27 yo male is involved in an MVA. He has no obvious fractures, head, neck, chest or pelvic injuries, but is hypotensive and tachycardic. His FAST scan is shown. The most likely cause for his hypotension is injury to the…

a. Liver

b. Kidneys

c. Bladder

d. Spleen

e. Diaphragm

Spleen is MC organ injured, followed by:- liver- kidney- small bowel- bladder- colon- diaphragm- pancreas- retroperitoneal duodenum

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LIVER

KIDNEY

DIAPHRAGM

HEAD

SPINE

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Disseminated GC

Rocky Mountain Spotted Fever

Kawasaki

Muliforme (erythema)

Meningococcal Meningitis

Secondary syphilis

Scabies

Norwegian scabies

diSSeminated GC

hand Foot and mouth

Rash palms and soles – RKMSF

• Rocky Mountain Spotted Fever

• Kawasaki (sloughing)

• Multiforme (erythema), Meningococcal

Meningitis (petichiae)

• Scabies, Syphilis, diSSeminated GC

• Foot: hand foot and mouth disease

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Associate the bugs with the wound

• Cat bite…………………...

• PW through tennis shoe.…

• Osteo from above ………

• Dog bite………………….

• Human bite……………….

• Bat bite……………………

• Rat urine……………………

Pasteurella multocida

Staph, Strep MC

Bacteroides MC anaerobe

Eikenella corrodens (chronic/abscess)

Staph, Strep

Pseudomonas Aeruginosa

Alpha hemolytic strep, eik

corr pasteurella multocida

Rabies25%

50%

usually early infection after cat bite

Staph, Strep MCAlso consider: Hep B &C, Syph, TB, HIV

Leptospirosis

Associate the bugs with the wound

• Salt water abrasion infection…..

• Fish tank granuloma.…

• Rose thorn injury ………

• Reptile bites and exposures.

• Fish monger’s hand…….

• Cat-scratch fever………………

Vibrio Vulnificus

Erysipelothrix rhusiopathae

Mycobacterium marinum

Sporothrix schenckii

Salmonella (non typhi)

Bortonella henselaeBuboes in arm pit with

large lymph nodes

(Fungus)(skin lesions going up arm)

Which of the following vasopressors have

been shown to improve mortality in the setting

of shock (excluding anaphylaxis)?

a. Dobutamine

b. Vasopressin

c. Norepinephrine

d. Epinephrine

e. None of the above

Dose of norepinephrine: 1 – 20 mcg/min

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What is the most common mode of

completed suicide?

a. Medication overdose

b. Hanging

c. Firearms

d. Wrist slashing

e. Carbon monoxide

Completed Suicide• Most common method is firearms and presence of

firearms in the home is a independent risk factor

for completed suicide and patients should be asked

about presence of firearms in their home

• Medication is most MC of suicide attempt

• Hanging is 2nd MC method of completed suicide in

men

• Women attempt more, men succeed more

• Wrist slash and CO uncommon

Suicide

• Nearly half a million visits per year

• 9th leading cause of death

• 3rd leading cause of death in 10 - 24 yo

• Attempt to complete ratio 40:1

• Majority of attempts: drug OD

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S

A

D

P

E

R

S

O

N

S

Sex: male > female

Age < 19 or > 45

Depression S&S

Previous attempt or psych

ETOH or drug Excess

Rational thought loss

Separated/divorces/widow/single

Organized attempt

No social support

Stated future intent

� > 8 High

�6 – 8 Intermediate

� < 6 Low

In

S

A

D

C

A

G

E

S

Interest

Sleep

Appetite

Depression

Concentration

Affect

Guilt

Energy

Suicide

Plan

Means

Family Hx

completed

Diarrhea - Chinese

restaurant or fried rice

Bacillus Cereus

Secretory diarrhea in kids

6mo – 2yo in winter

Rotavirus

Froathy foul smelling

Giardia

Travellers’ diarrhea

ETEC

Diarrhea: then HUS

E-coli 0157:H7

Most common cause of bacterial diarrhea

Campylobacter

Most common cause of

chronic diarrhea in AIDS

Cryptosporidium

Rice water stool

Vibrio cholera

Diarrhea assoc with Guillain-Barre Syndalso Reiter’s, HUS

No antibiotics

MCC of HUS which is

MCC of ARF in kids

E-coli is MC

2nd MC is shigella

3rd viral/protozoa

A 32 y.o. obese female patient presents with abdominal pain. Her US is depicted. What is your next step?

a. Office visit to her OB-GYN

b. Start an IV, call her OB-GYN

c. Start IV antibiotics

d. Admit for D&C in the morning

e. Discharge home with radiotherapy

appointment for tomorrow

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A 32 y.o. obese female patient presents with abdominal pain. Her US is depicted. What is your next step?

a. Office visit to her OB-GYN

b. Start an IV, call her OB-GYN

c. Start IV antibiotics

d. Admit for D&C in the morning

e. Discharge home with radiotherapy

appointment for tomorrow

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Ectopic Pregnancy – Keycepts

• Second leading cause of death of maternal death

• 50% missed diagnosis first office visit

• 36% missed diagnosis first ED visit

• Risk Factors: previous ectopic (7x), PID (6x),

IUD, recent elective abortion, older age, infertility

treatment, smoker

• Unilateral adnexal tenderness +/-

Ectopic Pregnancy - Keycepts

• Syncope = rupture (also BP, tachycardia)

• No blood on culdocentesis is non diagnostic

• B-hCG should double every 1 – 3 days (first 6 wks)

• B-hCG discriminatory zone for US (1500 TV,

6500 TA)

• Methotrexate treatment for stable patient with

unruptured ectopic < 4cm; can present one week

later with pelvic pain – but could be ectopic

progression

• Laparoscopy for definitive diagnosis

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The CDC states that all major criteria and one

minor criteria be present if the diagnosis of

PID is to be established. All of the following

are major criteria for the diagnosis of PID

EXCEPT…

a. Abdominal pain

b. Vaginal discharge

c. Adnexal tenderness

d. Cervical motion tenderness

Diagnosis of PID based on major and minor

criteria. All major criteria must be present and

at least on minor criteria• Minimal Criteria

• Abdominal (pelvic) pain

• Uterine/adnexal tenderness

• Cervical motion tenderness

• Additional Criteria

• Temp > 100 F

• Abnormal cervical/vaginal discharge

• Elevated ESR/CRP

• Positive cervical cultures for N gon or C. trachomatis,

anearobes

The most common

clear cut risk for

ectopic pregnancy

>25% of patients

admitted for PID

will develop TOA

Risk Factors for PID

• Young women (15 – 25)

• Multiple sex partners

• Smoking

• Bacterial vaginosis

Peak time is within 1st week of menses

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Who gets admitted

• Adnexal mass

• Pregnant

• IUD

• Peritonitis

• Immunocompromised

• OP Failure

• Unable to tolerate PO

• Concerns about future fertility

Treatment of PID

• Inpatient: • Cefoxitin 2 gm QID or Cefotetan 2 gm IV

BID + Doxy 100 mg BID or

• Clindamycin 900 mg IV Q8H + Gentamycin

• Augmentin 3 gms IV Q6H + Doxy

• Outpatient: • Ceftriaxone 250 mg IM x 1

• + Doxy 100 BID for 14 days

• +/- Flagyl 500 mg BID x 14 d

• NO quinolones – too much resistance

PID Morbidity

• Ectopic pregnancy is 6 times more likely in

women who have had PID

• Infertility 8 % with first episode

• Chronic pelvic pain in up to 18% of women

after PID had resolved

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What about IUDs in patients with PID

• The risk of PID assoc with IUD is confined

to the first 3 weeks after insertion and

uncommon thereafter. No evidence suggests

that IUD should be removed in women

diagnosed with acute PID, but close follow

up is mandatory

Fitz-Hugh-Curtis

MCC is…..………........

Occurs in 4% - 14% of patients with PID,

more common in adolescents with PID

Patient with PID

RUQ pain worse with deep breathing or cough

Radiation to Right Shoulder

Perihepatitis (LFT: N or minimally elevated)

“Violin string” adhesions on laparoscope

Chlamydia >>> GC

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A patient presents with this injury after a fall

down some stairs. You should suspect…

a. Occult malignancy

b. Radial nerve injury

c. Associated wrist injury

d. Associated elbow injury

e. Seizure

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A patient presents with this injury after a fall

down some stairs. You should suspect…

a. Occult malignancy

b. Radial nerve injury

c. Associated wrist injury

d. Associated elbow injury

e. Seizure

Axillary

> 6 mm

Glenoid fossa faces anteriorly and laterally

Post dislocated head of humerus rests against

posterior rim giving appearance of increased

space between humeral head and anterior rim

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The lightbulb sign

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Posterior Dislocation - Clinically

• Occurs with violent force: seizure,

electrocution…

• Cannot abduct or externally rotate humerus

• Less likely to have neurovascular injury than

anterior dislocation due to anterior position

of neurovascular bundle

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Causes of Eosinophilia

• N Neoplasm

• A Allergy

• A Addison’s

• C Chlamydia

• P Parasites

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

a. Add diazepam and acetaminophen to your Rx

b. Perform an Epley maneuver on the patient

c. Add meclazine (Antivert)to your Rx

d. Give IV corticosteroids

e. Order a CT scan

Vertigo

Peripheral Central

Acute onset

Intense illusion of motion

Worse with movement

Nystagmus fatigues

Nystagmus latency period

Nystagmus inhibited by

fixation

Gradual onset (going on for a while)

Milder illusion of motion

Mildly worse with movement

Nystagmus does not fatigue

Nystagmus has no latency

Nystagmus not inhibited by

fixation

Nystagmus vertical

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Illusion of motion

Vestibular System

Peripheral System Central System

BPPV

Labyrinthitis

Vestibular neuronitis

Meuniere’s

85% 15%

Cerebellar (infarct, infection, hem)

CNS infection

Brainstem (infarct, hem, tumor)

Multiple sclerosis

Vertebrobasilar dz

ETOHic cerebellar

degeneration

Cerebellar hemorrhage

• Neurosurgical emergency

• Headache

• Acute vertigo

• Vomiting

• Marked truncal ataxia

• Inability to walk

• Gaze palsies (6th Cr.N.),

• Increasing stupor. Romberg +ve.

Consider CT/MRI in any:

- Unable to ambulate

- Associated H/A

- Physical findings

suggestive of

central cause

- abn VS

- Cr N findings

- Truncal ataxia

V

II, III ,IV

VIVIIVIII

IX, X,XI, XII

Brainstem Fx:

RAS

Vital signs

Cranial nerve

01/29/2014

40

Cerebellar hemorrhage

• Neurosurgical emergency

• Headache

• Acute vertigo

• Vomiting

• Marked truncal ataxia

• Inability to walk

• Gaze palsies (6th Cr.N.),

• Increasing stupor. Romberg +ve.

Consider CT/MRI in any:

- Unable to ambulate

- Associated H/A

- Physical findings

suggestive of

central cause

- abn VS

- Cr N findings

- Truncal ataxia

It’s all about the 4th ventricle

• All patients with cerebellar hemorrhage may

deteriorate rapidly due to obstructive

hydrocephalus (4th ventricle becomes compressed)

or progressive brainstem compression – both

of which require emergent operative

intervention

It’s all about the 4th ventricle

• Cerebellar infarcts can also progress to

impingement on the 4th ventricle with

subsequent hydrocephalus requiring

operative intervention and should all be

admitted to the ICU.

• Patients with vertebrobasilar insufficiency

(TIA) should be admitted because of

potential 4th ventricle compromise

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Steroids and Cerebellar infarct

• Although corticosteroids help reduce

vasogenic edema associated with tumors

they do not help in the cytotoxic edema

associated with infarction

With hemorrhage or edema from infarction, fourth ventricle gets compressed causing

obstructive hydrocephalus which requires immediate neurosurgical interventionn

A 26 yo fell of his bicycle when he hit a lamp post.

You are about to clear his C-spine. All of the

following must be met prior to clearing the C-spine

(NEXUS) EXCEPT:

a. No drugs or alcohol

b. No neck tenderness

c. No neurologic findings

d. No distracting injury

e. Clear sensorium

No midline neck tenderness

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Clearance of C-Spine

• Clinical• No neck pain

• No neck tenderness(midline) - *

• No neurologic signs/ symptoms - *

• Reliable• Clear sensorium - *

• No drugs/ ETOH - *

• No distracting injury - *

• Age > 4 years

• Lack of mechanism

* = NEXUS

All of the following are true about heat

stroke EXCEPT:

1. Classic heat stroke is associated with

temperature > 40.5 C

2. Classic heat stroke is associated with sweating

3. The hallmark of heat stroke is altered mental

status

4. Classic heat stroke may be associated with

coagulopathy

5. Classic heat stroke may be associated with mild

lactic acidosis

Heat Stroke – requires CNS dysfunction

• Elderly, debilitated

• Sedentary

• Associated with heat waves

• Anhidrosis common

• Normal glucose

• Mild coagulopathy

• CK mildly increased

• Oliguria

• Mild lactic acidosis

Classic Heat Stroke Exertional Heat Stroke

• Young healthy

• Extreme exertion

• Occurrence sporadic

• Sweating preserved

• Hypoglycemia

• Severe coagulopathy /DIC

• Rhabdomyolysis

• Acute renal failure

• Severe lactic acidosis

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Spectrum of Illness

Heat

Edema

Heat

Syncope

Heat

Cramps

Heat

Exhaustion

Heat

Stroke

Heat edema

Prickly heat

Heat cramps

Heat tetany

Heat syncope

Heat exhaustion

Heat stroke

ankles, feet and hands swollen

Pruritic maculopapular rash due to inflammation blocked sweat ducts

painful, involuntary contractions calves, in people who previously sweat profusely

Paresthesias m cramps due to hyperventilation

Faint due to volume depletion, postural hypotension

severe volume depletion, weak malaise, fatigue, orthostatic drop in BP

hyperpyrexia (> 40C, CNS dysfunction, ataxia, later anhydrosis, and +ve LFTs

Heat related illness

• The most common ECG finding in patients

with heat related illness is ______________

which is also a common ECG finding in

hypothermia

• Although bradycardia is common in

hypothermia it is not in heat related illness

QT prolongation

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A 17 yo male presents to the ED after a temporary and brief

interruption of neurologic function after hitting the goal post

with his head while playing soccer. He is feeling fine in

your ED. All of the following are true regarding this

condition EXCEPT…

a. Patients may be amnesic for the event

b. Patients may have insomnia after the event

c. Patients may have difficulty concentrating after

the event

d. Patients may have transient ataxia after the event

e. Patients may have headaches after the event

Which of the following regarding concussion

is correct?

a. It does not necessarily require a loss of

consciousness

b. Retrograde amnesia is more common than and

longer in duration than antegrade amnesia

c. Otherwise well patients may not be able to recall

their name or date of birth

d. Skull fractures is a strong predictor of brain

hemorrhage

e. Postconcussion syndrome (headache, dizziness, memory problems,

neuropsych complaints) is common in young children

malingering

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Head Trauma: Post Concussive Syndrome

• Headache: For weeks to years

• Dizziness

• Insomnia

• Anxiety

• Decreased concentration

• Any change in mental function

No ataxia, no focal neurologic signs

2011 Concussion Guidelines

• 1. Rest until asymptomatic ( physical, mental)

• 2. Light aerobic exercise ( exercise bike)

• 3. Sport- specific exercise

• 4. Non-contact training drills ( wt lifting or sleds)

• 5. Full contact training (after medical clearance)

• 6. Return to competition( game play)

� Each stage can be 24 hrs or longer

� and return to stage one if symptoms re-occur

What we are trying to avoid

• Second impact syndrome: The sudden death

that may result with a second concussion

before complete recovery from the first one.

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Head injury in kids – Who avoids a CT brain

• < 2yrs old

• Normal neuro exam

• No scalp hematoma except frontal

• No LOC or LOC < 5 seconds

• Consider mechanism

• No palpable skull fracture

• Acting normally

• > 2yrs old

• Normal mental status

• Normal neuro exam

• No LOC

• No severe headache

• No vomiting

• No signs of basilar skull fracture

• Consider mechanism

Bottom line for concussion guidelines

in children and adolescents

• No comprehensive return-to-play guidelines have

been adapted for the young athlete, and the

majority of current and past studies were

performed with older athletes.

This patient front seat passenger involved in

MVA, suffered this injury which is most

likely…

a. Anterior hip dislocation

b. Femur neck fracture

c. Open book pelvis fracture

d. Posterior hip dislocation

e. Achilles tendon rupture

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This patient front seat passenger involved in

MVA, suffered this injury which is most

likely…

a. Anterior hip dislocation

b. Femur neck fracture

c. Open book pelvis fracture

d. Posterior hip dislocation

e. Achilles tendon rupture

Shortened

Internal rotation of hip

Adducted

Flexed

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Posterior Hip Dislocation

• Posterior hip dislocation is most common

90%: __________________ leg,

_______________ rotation of hip,

_______________ and slightly __________

• 27% get osteoarthritis

• 8% - 30% get avascular necrosis of femoral

head

• Must be reduced within 6 hours

internal/external

shortened/lengthened

abducted/adducted flexed/extended

Hip Injuries

Posterior Hip disl

Anterior Hip disl

Femoral neck #

Abd Add Int R Ext R

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Aortic Dissection

2 lumens in aorta. Suspect dissection, you might

see it by scanning abdominal aorta.

75 yo male with abdominal pain

Upper extremity pulse deficit is the most specific

physical exam finding but its sensitivity is < 15%

50% do not survive to make it to the ED – of those who do

mortality increases 1% per minute

Heart

Belly

Back

Feet

Celiac

Aorta

SMA

Acute Thoracic Aortic Dissection

• Widened mediastinum is the most common abnormal finding

• 12% of patients have normal CXR

• 21% of patients have a normal mediastinum and aortic contour

• Non specific findings may be very subtle and not typically picked up by the ED physician

• Abnormal aortic contour in 50%

• Abnormal cardiac contour in 25%

• Pleural effusion in 19%

• Displacement or abnormal calcification of aorta in 14%

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There has been a radiation accident at your local nuclear power plant. A patient present at the site at the time of the accident presents to your ED with complaints of nausea and vomiting. She is now, 48 hours after the event, worried about this exposure. Her absolute lymphocyte count is 1600/mcL. You should explain to her that…

a. That her exposure will require intensive and aggressive therapy for her to survive

b. That her lab value suggests that she has a 50:50 chance of survival

c. That she requires no treatment and is expected to recover from her exposure without significant complications

d. That it is to early to tell and that her ALC will have to be re-taken in 24 hours

e. That she has likely suffered a lethal dose of radiation

Absolute lymphocyte counts at 48 hours

after exposure as a prognostic factor

• > 1200/mcL means it is unlikely that the

patient has received a clinically significant

dose of radiation

• 500 – 1200/mcL serial counts especially

if symptomatic

• 100 - 500 /mcL possibility of exposure to

a lethal dose of radiation should be

suspected

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All of the following are true regarding

radiation exposure EXCEPT:

a. Alpha rays are the most penetrating

b. GI syndrome (N/V/D) occurs at 1 Gy (gray)

c. Survival is unlikely with a exposure of greater than 800 rads

d. The GI tract is one of the tissues most affected by radiation

e. The absolute lymphocyte count (ALC) at 48 hours of 1200 indicates a 50% mortality

Types of Radiation

Alpha

0000−1−1−1−1ββββ−−−−

44442222α α α α ++++++++

00γ

Beta

Gamma and X-rays

Neutron

Paper Plastic Lead Concrete

10n

Geiger counter

Skin burns

Primary cause of acute radiation syndrome

Stopped neutrons are captured and cause

previously stable atoms to become

radioactive – source of radioactive fallout

? need alpha counter

a. Ciguatoxin

b. Scombroid fish poisoning

c. Bacillus cereus

d. Cyclospora cayentnenensis

e. E-coli 0157:H7

A 28 y.o. male presents to the ED with throbbing headache, palpitations and abdominal pain after eating at the Golden Lobster, where he states they put too much pepper on their fish. You note marked facial and neck flushing, conjunctival injection and scattered urticaria on his trunk. His BP 150/100, P 110, R 24, T N. What is the most likely cause?

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Scombroid• Multiple patients with ‘allergic reaction’ –

due to excessive histamine levels in the fish

due to inadequate refrigeration

• Tuna, mackerel, mahi-mahi

• Peppery taste

• Sx occur within minutes of eating the fish

• Facial flushing, throbbing H/A, abd cramps,

diarrhea, palpitations, burning sensation in

the mouth, pruritus

• Rx: antihistamines, H-2 blockers

Multiple patients

Facial flushing

allergic reaction

Tuna, mackerel, mahi-mahi

Peppery taste

38 y.o. female presents to ED with acute onset of N/V, watery diarrhea, diaphoresis and cramping abdominal pain that woke her up from sleep. Also c/o tingling tongue and around mouth. She refused a cold drink of water saying if felt like hot water. She had dinner at the “Fish House” 5 hours earlier. The most likely cause is:

a. Ciguatoxin

b. Scombroid fish poisoning

c. Bacillus cereus

d. Cyclospora cayentnenensis

e. E-coli 0157:H7

Ciguatera Fish Poisoning: neurotoxin

• Common cause of fish poisoning diarrhea

• Ciguatoxin produced by marine dinoflagellate –

Gambierdiscus toxicus; mostly in South Pacific

• Fish: grouper, barracuda, sea bass, red snapper

• Odorless and tasteless

• Incubation: 2 – 6 hrs; Duration: 12 – 30 hrs

• GI and neuro Sx

• Rx: symptomatic, ? Mannitol

• Common cause of fish poisoning diarrhea

• Ciguatoxin produced by marine dinoflagellate –

Gambierdiscus toxicus; mostly in South Pacific

• Fish: grouper, barracuda, sea bass, red snapper

• Odorless and tasteless

• Incubation: 2 – 6 hrs; Duration: 12 – 30 hrs

• GI and neuro Sx

• Rx: symptomatic, ? Mannitol

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Fish PoisoningCiguatera

- Produced by marine dinoflagylate

- Perioral paresthesia “loose teeth”

- Hot cold reversal

- Ataxia, weakness, vertigo

- Sx worse with ETOH

- Rx: Supportive, manitol (neuro

Sx)

- Antihistamines, H2-bl

- May be permanent

Scombroid

- Inadequate refrigeration

(excess histamine)

- Peppery taste

- Facial flushing

- Multiple patients –

allergic reaction

- Red meat fish

- Rx: Antihistamines, H-1,

H2-blockers, beta-2

agonists for bronchospasm

Parvovirus B-19• In pregnant patients

• Hydrops faetalis (due to severe fetal anemia) leading to miscarriage or stillbirth

• Risk of fetal loss is 10% if contracted before 20 wks gestation but minimal after that

• Patients with hemolytic anemias (incl SCDz)• Can cause aplastic crisis

• In AIDS patient• Can trigger an inflammatory reaction on patients

started on antiretroviral therapy

• Causes chronic anemia – frequently overlooked

• Adults• Seronegative arthritis, resolves by 1- 3 wks

• In kids• Erythema infectiosum – slapped cheek syndrome

Ciguatera Poisoning

• Perioral paresthesia, feels like loose painful teeth, burning hands/feet

• Hot cold reversal

• Ataxia, weakness, vertigo, visual hallucinations

• Abdominal pain, vomiting, profuse diarrhea (occur earlier)

• Fish eat dinoflagellates that contain toxins

• Sxtic treatment, lasts 1 – 2 wks (50% Sx at 8 wks)

• Sx may get worse with ETOH

• Sx may be permanent

• Perioral paresthesia, feels like loose painful teeth, burning hands/feet

• Hot cold reversal

• Ataxia, weakness, vertigo, visual hallucinations

• Abdominal pain, vomiting, profuse diarrhea (occur earlier)

• Fish eat dinoflagellates that contain toxins

• Sxtic treatment, lasts 1 – 2 wks (50% Sx at 8 wks)

• Sx may get worse with ETOH

• Sx may be permanent

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All of the following are true regarding

pancreatic injuries EXCEPT…a. They are more common in penetrating trauma

b. Although the pancreatic injury itself in blunt trauma may be subtle, pancreatic injuries usually occur in more severely injured patients

c. Classically the physical exam initially worsens and over the first 6 hours the patient looks and feels better

d. Serum amylase is elevated in only 27% of penetrating injuries to the pancreas

e. Release of pancreatic enzymes more commonly cause mild tenderness to palpation (rather than peritoneal signs)

Classically, physical exam improves initially and then worsens over the first six hours

All of the following are more consistent with

delirium than dementia EXCEPT…

a. Onset is acute (days to weeks)

b. It is usually reversible

c. Hallucinations

d. Consciousness is clear

e. Fluctuating course

Features Delirium Dementia

Onset

Course

Duration

Consciousness

Attention

Reversibility

Hallucinations

Delusions

Additional Info

Acute Insidious

Disorganized thoughtFlight of ideas Global disorder of cognition and attentionSleep/wake cycle disturbmeds, lytes, infection, liver fail

Mortality 20% - 30%

Fluctuating Progressive

Days to weeks Months to years

Clear – awake/alertAltered LOC

Poor attention Pays attention

Usually Rarely

Yes No

Fleeting delusions None until very late

50% of pts > 85Alzheimer’s accounts for 70% of dementia ptsImpaired memory and judgment ‘Sundowning’

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Treatable Causes of Dementia

Drugs

Electrolytes

Metabolic

Emotional

Nutritional/Normal pressure hydrocephalus

Trauma/Tumor

Inflammation (SLE,/infection)

Alcohol

Keycepts: Dementia

• Before diagnosing dementia R/O treatable Dz:

• Normal Pressure Hydrocephalus:

• dementia, ataxia, incontinence

• Wernicke-Korsakoff Syndrome:

• ataxia, ocular abn, confusion

• Pseudodimentia (depression):

• severely depressed patient

• Disturbed sleep pattern

• Sudden onset ppted by emotional event

• Mental status improves with encouragement

• Medical problem: drugs, lytes, metabolic dz

PSYCHO-BEHAVIORAL 165

Delirium

Frequency: 10-15% of admissions to

hospitals (but usually not primary diagnosis)

Mortality: 20-30%

Race: more common in Caucasians

Age: elderly, (20-40’s think toxic/withdrawal)

Sex: female > male

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166

Dementia

• Incidence: 50% over 85

• Alzheimer’s accounts for 70%

• Vascular dementia is 10-20%

• Earlier stages are subtle and may be concealed by the pt.

• Stuttering course points to multi-infarct

Transient Global Amnesia

• Patient working in garage all of a

sudden gets confused as to where he is,

and does not know how to get home

from where he is.

• Restricted memory loss

• Only 5% relapse

• What it is not:

• Not a stroke

• Not delirium

Terms

• Gray (Gy) is the international unit of

absorbed radiation dose of ionizing radiation

(IR) defined as absorption of one joule of IR

by 1Kg of matter

• Seivert is an international unit of equivalent

dose which for X-rays is numerically equal

to a Gy

• One Rad (old term) = 0.01Gy (1Gy = 100 rad)

• Roentgen equivalent man (REM) = 1 rad

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A patient presents to the ED with the

following injury. You tell him he has…

a. A fractured triquetrum

b. A perilunate dislocation

c. A Smith fracture

d. A Rolando fracture

e. A lunate dislocation

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A patient presents to the ED with the

following injury. You tell him he has…

a. A fractured triquetrum

b. A lunate dislocation

c. A Smith fracture

d. A Rolando fracture

e. A perilunate dislocation

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““““KEEP THE LUNATE IN LINE””””

Lunate Capitate

Ask yourself: Which bone is more out of line with the radius?

Piece of

Pie

Triagular

appearance

of lunate

Spilled

tea cup

of

lunate

Lunate Dislocation

No big tilt

Although some gap

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Ortho

Renal Ca

A patient presents with this lesion. The

most likely cause of this lesion is…

a. Syphilis

b. Human papilloma virus

c. Venereal warts

d. Hemorrhoids (bad ones)

e. LGV (lymphogranuloma venereum)

The most common anorectal STD

May turn malignant in HIV patients

If indurated consider squamous cell CA

Condylomata Acuminata

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Condylomata acuminata

From secondary syphilis

Flat weeping warts on genitalia

Emits foul odor

Look also for diffuse maculo

papular rash all over body

including palm and soles

Loss of lateral 1/3 of eyebrow

Patchy alopecia

Benz pen 2.4 if greater than 1 yr

give weekly for 3 weeks

Human papilloma virusPedunculated papulesDevelop into cauliflower like massesDry, keratinized surfaceRx: Cryotherapy

A patient presents to the ED after he fell 20feet to the ground off a scaffolding landing on his feet. He comes in with the injury seen on this X-ray. His contrasted CT shows a non enhanced kidney on the left side. The most likely diagnosis is…

a. Acute traumatic hydronephrosis

b. Renal artery thrombosis

c. Acute renal contusion

d. Acute renal rupture

e. Patient only has one kidney

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A patient presents to the ED after he fell 15 feet to the ground off a scaffolding. He comes in with the injury seen on this X-ray. His contrasted CT shows a non enhanced kidney on the left side. The most likely diagnosis is…

a. Acute traumatic hydronephrosis

b. Renal artery thrombosis

c. Acute renal contusion

d. Acute renal rupture

e. Patient only has one kidney

3415

o

Apex of anterior

process

Apex of

posterior

facet

Posterior

calcaneal

tuberosity

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Boehler’s

angle

Bilateral

Dorsolumbar

compression

fractures

Tibial plateau

fracture

Ortho

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Boehler’s angle and calcaneus fracture associated injuries

• Falls from heights onto feet and MVCs are the most common mechanisms of injury for a calcaneus fracture

• Boehler’s angle: can be measured and should be 20 to 40 degrees

• Associated injuries include:

• Lumbosacral fracture (10%)

• Other calcaneus (10%)

• Tibial plateau fracture

• Other extremity injuries (26%)

• GU and renal injuries (left pedicle injuries more common than right cuz right is well locked in)

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AAA

� Definition > 3cm

� 90% begin below renal arteries

� 4 – 5 cm 50% are palpable

� 5cm are palpable, but pulsatileabdominal mass is felt in < 50%

� Grow at 4mm per year

� > 5cm requires vascular surgeon

� Audible bruit is rare

A 43yo male presents to the ED with altered mental

status. His wife says he just got over a “bad sore

throat” a few days ago. VS BP 90/60, P 110, RR 24,

T 39C. On exam you note a anisocoria (R >L), a

drooping L eyelid. You also note some tongue

deviation. Which of the following is the most likely

diagnosis?

a. Peritonsillar abscess

b. Epiglottitis

c. Ludwig’s angina

d. Parapharyngeal abscess

e. Tracheitis

Parapharyngeal Abscess leading to sepsis

• These patients typically present after resolution of

sore throat

• Can encroach of adjacent tissues:

• Cervical sympathetic chain (Horner’s)

• Carotid artery and jugular vein (causing sepsis)

• Patients with this complication will present in severe sepsis• Organ hypoperfusion (AMS in this case)

• Two of the following 4 (for dx of SIRS)• Fever > 38 or < 36

• Pulse rate > 90

• RR > 20 or PCO2 < 32

• WBC count > 12,000 or > 4,000 or > 10% bands

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Match the following regarding

lightning injuriesDirect strike

Side flash

Contact strike

Ground current

Upward streamer

Flashover

Current transferred through the ground

Current travels over surface of skin

May injure multiple victims at once

Current strikes object victim is holding

Causes most serious injuries

Not connected to the completed lightning channel

Lightning (in a minute)• Lightning is high voltage DC electrical discharge

• Pregnant patients have _______fetal mortality

• ________ of persons struck by lightning survive –

______ of survivors have permanent sequelae

• Tympanic membrane perforation occurs in ______

• Asystole is the MCC of death in lightning victims;

spont cardiac activity may resume spontaneously;

resp arrest may persist with resultant hypoxia

which sometimes causes V.fib (go to them first)

• Rhabdo and myoglobinuria in ___%

• Burns and myoglobinuric renal failure are uncommon in the setting of lightning strikes

50%

70% - 90%

> 50%

< 6

> 70%

Lightning

• Flashover: lightning traveling over the surface of the body (more likely with wet skin) this protects internal organs from injury – get fern like skin pattern but no burns

• Direct strike produce the most serious injuries

• Side flash: nearby object struck and current travels through the air (multiple victims at once)

• Triage priorities reversed in high voltage injuries, go to patients without signs of life first – do CPR until pt starts to breathe spontaneously

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Keraunoparalysis

• Caused by lightning strike

• Typically occurs in the lower extremities

• Characterized by:

• Transient paralysis

• Mottled, cool, blue, pulseless extremities

• Typically resolves on its own within minutes

to hours

AC/DC (in a minute)• AC > danger than DC

• AC causes tetany once “let go current” is

exceeded

• Impossible to predict degree of underlying damage

by looking at extent of cutaneous burn

• ……. % of patients who suffer low voltage injury

have cardiac dysrhythmia and most common is

………………………..

• High-voltage electrical injuries (>1000V) =

increased risk of spinal injuries (immobilize)

• ECG changes or LOC requires 24 hrs monitoring.

< 10

ventricular fibrillation

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A 24 yo male presents with this injury after

falling off his motor cycle. You know…

a. This is an extension injury

b. The patient is likely to have significant motor paralysis

c. The patient should receive methylprednisolone 1 gm IV now and 30 mg/kg/hr for the next 24 hours

d. May require open reduction

e. This is a pseudosubluxation in a patient with connective tissue disease

A 24 yo male presents with this injury after

falling off his motor cycle. You know…

a. This is an extension injury

b. The patient is likely to have significant motor paralysis

c. The patient should receive methylprednisolone 1 gm IV now and 30 mg/kg/hr for the next 24 hours

d. May require open reduction

e. This is a pseudosubluxation in a patient with connective tissue disease

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Unilateral Facet Dislocation

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Anterior Subluxation

Injury

Hyperflexion Sprain

Delayed instability

Forced flexion disrupts

posterior ligaments

Often missed

Flexion Injury

Bilateral Facet

Hyperflexion

NOT perched

One facet in front of the other

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Bilateral Facet Dislocation

• Severe Flexion with distraction and

disruption of posterior ligaments

• Both inferior facets jump over the

corresponding superior facets

• > 50% subluxation of vert. body width

• Cord injury very common

• HIGHLY UNSTABLE

bilateralperched

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Bilateral Facet

• “doubly locked = misnomer”• Implication of stability could not be further

from the truth

• Use of the word locked is pathologically inaccurate and clinically misleading and should be avoided

• The Radiology of Acute Cervical Spine Trauma third edition

Bilateral

Facet

Dislocation

Which of the following is most likely to help

prevent secondary brain injury in the trauma

patient?

a. Treat hypertension aggressively

b. Treat hypothermia aggressively

c. Treat hypoxia aggressively

d. Use blood transfusions and blood products

aggressively

e. Treat metabolic disturbances aggressively

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A 35 y.o. male presents after he miss-stepped off a curb. He complains of severe left knee pain. His X-ray is depicted. The most likely diagnosis is…

a. Tibial plateau fracture

b. Patellar extensor tendon disruption

c. Quadriceps tendon rupture

d. Maisonneuve fracture

e. Anterior cruciate tear

A 35 y.o. male presents after he miss-stepped off a curb. He complains of severe left knee pain. His X-ray is depicted. The most likely diagnosis is…

a. Tibial plateau fracture

b. Patellar extensor tendon disruption

c. Quadriceps tendon rupture

d. Maisonneuve fracture

e. Anterior cruciate tear

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Insall and Salvati Method

A

B

B/A =1

< 1 = patella alta

Greatest diagonal length measured

Lower pole of patella to tibial tubercle

A

B

A/B < 0.8

Blackburn

A

B

B/A =1

< 1 = patella alta

Insall and Salvati Method

Greatest diagonal length measured

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High riding patella – Patella Alta

• 80% of knee extensor disruptions in < 40

y.o. will be patellar extensor tendon that

will be affected

• 80% of knee extensor disruptions in > 40

y.o. will be the quadriceps tendon that will

be affected

• No trauma then chronic patella alta (not

expected at ABEM General)

A patient presents in coma after minor

traumatic event. You inject cold water into the

patient’s left ear and the eyes slowly move to

the left. This means

a. His cerebral cortex is intact

b. His brainstem is not functioning

c. His brainstem and cerebral cortex are not

functioning

d. His brainstem is functioning

e. His brainstem and cerebral cortex is intact

Cold calorics (Oculovestibular reflex)

• If you inject cold water into the left ear and the

eyes slowly move towards the left ear, this means

the brainstem is intact

• If then the eyes move with fast movement

(nystagmus) towards the opposite ear this means

the cerebral cortex is intact

• If both of the above occur, the patient is faking it

• If there is no movement then nothing is working

Corneal stimulation will cause eye to blink if Cr V and VII

are intact which is another way to check brainstem function

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Doll’s eyes (oculocephalic reflex)

• When you turn a doll’s head to one side, the eyes follow

slowly after the head is turned

• When you do this to a comatose patient (not a trauma pt)

and his eyes lag behind (as if the patient is maintaining

fixation on a single point in space). The eyes thus appear

to be moving relative to the head in the direction opposite

to the head movement (this means normal functioning

brainstem).

• The absence of this reflex suggests brainstem dysfunction

in a comatose patient.

• This reflex is suppressed in the conscious patient but is

normal in the unconscious patient without brainstem

injury

A 74 yo male known diabetic and hypertensive presents to the ED with sudden onset of left eye pain. He also complains of blurred vision, headache, abdominal pain and nausea. His VA is 20/200 OS and 20/40 OD. Exam of the eye shows conjunctival injection and pupil is mid position and non reactive to light. Funduscopic exam is shown. Your next best step

a. Order a sedimentation rate

b. Give prednisone 60 mg

c. Perform tonometry

d. Order a CTA brain

e. Order an ultrasound of L eye

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A 74 yo male known diabetic and hypertensive presents to the ED with sudden onset of left eye pain. He also complains of blurred vision, headache, abdominal pain and nausea. His VA is 20/200 OS and 20/40 OD. Exam of the eye shows conjunctival injection and pupil is mid position and non reactive to light. Funduscopic exam is shown. Your next best step

a. Order a sedimentation rate

b. Give prednisone 60 mg

c. Perform tonometry

d. Order a CTA brain

e. Order an ultrasound of L eye

Glaucoma: Associations

• Red painful eye

• ‘Steamy cornea’

• Blurred vision

• Nausea/headache

• Abdominal pain

• Mid dilated pupil

poorly reactive

• Cup/disc > 1:2

• Risks:

• Hypertension

• Vascular disease

• Familial

• IOP

• Diabetes mellitus

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Glaucoma

• Glaucoma = increased IOP

Cup/disk should < 0.5

Glaucoma = > 0.5

Caution other DZ

High Myopes

cupDisc

Ratio = 0.8

Treatment and Why?

Patient supine….. Gravity pulls lens away

from iris

Timolol 0.5% (Timoptic)1 gtte Q-15-min……

suppress aqueous humor

production

Pilocarpine 1% 1 drop Q-

15-min X 1 hour, then

Q-30-min……

facilitates drainage of

aqueous humor

Topical steroids (pred-forte) Decreases aqueous

humor

Treatment and Why?

Acetazolamide 500 mg I.V…… Decreases AH production

Ophtho consult…. peripheral iridectomy

osmotically drains eye

reduce vitreous volumeMannitol 20 gms I.V…..

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Which of the following is true regarding

fetal exposure to radiationa. A single CXR in a women who is 6 weeks

pregnant could increase the risk of fetal

malformation by 20%

b. A CT of the abdomen of a 20 week pregnant

female gives more radiation to the fetus that is

considered a safe level of radiation exposure to

any fetus

c. During the nine months in utero the fetus is

exposed to an average of 50 – 100 mrads

d. The highest risk of radiation to the fetus occurs at

fetal age 8 to 16 weeks

Fetal exposure to radiation

• _______ is considered to be safe

• During the 9 months in utero the fetus is

exposed to ____________

• _______ increases the risk of childhood

cancer but does not increase the risk of:

• Fetal malformation

• Spontaneous abortion

• Growth retardation

< 5 rads

50 – 100 mrads

>10 rads

Fetal exposure to radiation

• Maternal plain films of the head, C-spine, T-

spine, extremities or CXR exposes the fetus

to _________

• X-rays of the LS spine, hips or pelvis expose

the fetus to ________

• CT of the abdomen exposes the fetus to

______

< 5 mrads (1000 times less than safe threshold)

> 5 mrads

2.5 rads

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Fetal exposure to radiation

• Maternal abdominal lead shielding decreases

radiation to the fetus by 50%

• The highest risk of radiation to the fetus is

__________ gestation 2 – 7 weeks organogenesis

53yo male presents to the ED with sudden

SOB. He is a smoker and has COPD and has

renal insufficiency. His dimer is +ve. A CXR

shows evidence of COPD but no PTX. What is

the most appropriate diagnostic test?

a. Alveolar dead space determination

b. PET Scan

c. VQ scan

d. Spiral CT scan

e. Pulmonary angiography

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A 66 yo diabetic hypertensive is brought in by

his daugther. His CT is shown. Which of the

following findings are you more likely to find

a. Tongue deviation to the left with R sided

hemiparesis

b. L sided oculomotor paralysis with R hemisensory

loss

c. L sided facial sensory loss R sided paralysis

d. R sided facial droop with L sided sensory loss

e. Rotatory nystagmus with L sided facial droop

A 66 yo diabetic hypertensive is brought in by

his daugther. His CT is shown. Which of the

following findings are you more likely to find

a. Tongue deviation to the left with R sided

hemiparesis

b. L sided oculomotor paralysis with R hemisensory

loss

c. L sided facial sensory loss R sided paralysis

d. R sided facial droop with L sided sensory loss

e. Rotatory nystagmus with L sided facial droop

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V

II, III ,IV

VIVIIVIII

IX, X,XI, XII

Brainstem Fx:

RAS

Vital signs

Cranial nerve

Pontomedullary

junction

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Match’ em

Vertigo, N/V, nystagmus, drop ataxia, (fatal gastroenteritis)

Cerebellar infarct

Circumoral paresthesia, ipsiCr N contra hemi-loss, HTN

Brainstem stroke

Vertigo, dysarthria, syncope, diplopia, ipsilateral CN deficits, contralat motor dfts

Vertibrobasilar stroke

Contralateral paralysis: Leg > Arm, distal weakness > prox weakness, perseverates, responds slowly, abulia

Contralateral paralysis: , Face/Arm > Leg, homonoms hemianopsia, conj gaze impair

Middle cerebral artery stroke

Anterior cerebral

stroke

Homonomous hemianopsia, visual agnosia, memory loss, cortical blindness, minimal motor involvment, ipsi CN 3

Posterior cerebral

stroke

Coma, miosis, apneustic breathing, only up eye mvt

Pontine stroke

Significant edema

KEYCEPT

• The hallmark of a brainstem stroke is

crossed findings

• Think about this diagnosis in patients

with perioral paresthesia

• Ipsilateral cranial nerve findings with

contralateral hemi – findings (paresis or

sensory loss

Associate K-stones

Calcium

Struvite

Uric Acid

Stones

Cystine

Stones

2/3rd of all Kstones

HyperparathyroidSarcoidosis

Laxative abuse, IBS

Ammonia-phosphate

Radioluscent

Inborn error of metabolism

1/5th of all Kstones

Least common

Gout

UTI: proteus, klebsiella, pseudomonas

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Associate K-stones

Calcium

Struvite

Uric Acid

Stones

Cystine

Stones

2/3rd of all Kstones

HyperparathyroidSarcoidosis

Laxative abuse, IBS

Ammonia-phosphate

Radioluscent

Inborn error of metabolism

1/5th of all Kstones

Least common

Gout

Asthma

UTI: proteus, klebsiella, pseudomonas

Associate S&S

Roseola Infantum

Rubeola

Measles

Rubella German Measles

Erythema

infectiosum

seizures

Rash after fever subsides

Sudden fever

Koplik spots

Post cervical lymphadenopathy

Slapped cheek

K

Generalized lymphadenopathy

Associate S&S

Roseola Infantum

Rubeola

Measles

Rubella German Measles

Erythema

infectiosum

seizures

Rash after fever subsides

Sudden fever

Koplik spots

Post cervical lymphadenopathy

Slapped cheek

K

Generalized lymphadenopathy

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Associate

HSV-2

Syphilis

Chancroid

LGV

1 in 5 sexually active adults

MCC of ulcerative vulvarand vaginal lesions

Primary infections more severe than recurrent infections

Painless chancre

Lymphadenopathy is unilateral and occurs in 50% of patients

Painless primary genital lesion – ignored

Bubos

Multiple genital ulcerations with tender inguinal lymphadenitis

Tender unilateral lymphadenopathy

Granuloma

Inguinale

Chronic painless genital ulcerations

Associate

HSV-2

Syphilis

Chancroid

LGV

1 in 5 sexually active adults

MCC of ulcerative vulvarand vaginal lesions

Primary infections more severe than recurrent infections

Painless chancre

Lymphadenopathy is unilateral and occurs in 50% of patients

Painless primary genital lesion – ignored

Bubos

Multiple genital ulcerations with tender inguinal lymphadenitis

Tender unilateral lymphadenopathy

Granuloma

Inguinale

Chronic painless genital ulcerations

STDs - Match em

Painless indurated genital ulcer with tender inguinal adenopathy

Treponema Palladium

Small painless shallow anal or perianal ulcers with significant tender inguinal adenopathy that evolves into painful inguinal buboes

Lymphogranuloma

venereum - LGVPainless genital ulcers often mistaken for syphilis

Granuloma

inguinale

Painful nonindurated irregular genial ulcers and solitary tender unilateral lymph node (could be bilateral inguinal adenopathy)

Haemophilus

ducreyi

Syphilis

Gm –ve bacillus

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Associate

GC

Salmonella

Staph

Aureus

MCC of septic arthritis in young sexually active adults

MCC of osteomyelitis in SCDz patients

Primay cause of osteomyelitis in healthy host

Predominant cause of septic arthritis in SCDz patients

AssociateOsteoarthritis

(OA)

Rheumatoid

Arthritis

(RA)DIP joints

PIP joints

MCP joints

First Carpometacarpal joint

Best Antibiotic to use

Trimethoprim-sulfamethoxazole

Macrolides

Ciprofloxacin

C.difficile

Campylobacter diarrhea

Most cases of invasive bacterial diarrhea

Yersinia diarrhea

Vibrio diarrhea

ETEC

Giardia

Metronidazole

Doxycycline

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Clinical Spectrum

Target lesions

Benign dz

from host

hypersensititivit

y

50% of cases

are idiopathic

HSV is MC

infectious agent

Mucosa

involved

limited to

oral cavity

Symmetical face/trunk rashSore throatMucosal involvementPainful eating, urinating, profuse diarrheaPhotophobia, decreased vision

Exfoliative mucocutaneous disorder – life threateningPurulent conjunctivitisTender diffuse erythematous lesionsBlistered inflammed mm

Infectious agentsDrug Exposure

Odors

Laetrile

Cyanide

Arsenic

Organosphosphates

Ethanol

Salicylates

Acetone

Garlic

Almonds

Peanuts

Pear like odor

Rotten eggs

Isopropyl alcohol

Ketosis

Vacor (RH-787)

Chroral hydrate

Paraldehyde

HS, mercaptan

Selenium

Zinc

Toluene

Fishy odor

Smell of Glue

Phosgene

Ricin

Newly mown hay

Castor bean processing

AssociatePAN –polyarteritis nodosa

Takayasu’s dz

Behcet’s dz

Wegener’s

Agranulomatosis

Churg-Strauss

Syndrome

Peripheral neuropathy

Mesenteric ischemia

Cutaneous findings

Coronary ischemia

Recurrent hypopeon

Sinusitis, otitis, nasal congestion

Pregnancy, DM, hyperthyroidism, RA

Glomerulonephritis

Recurrent oral and genital ulcerations

Carpal Tunnel

syndrome

Asthma

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Associate

Medical cause of

Psychosis

Psychiatric

cause of

Psychosis

Acute onset

Older patient

Visual hallucinations

Disorientation

Gradual onsetFlat affect

Aphasia, ataxia

Auditory hallucinations

Young adult

Impaired consciousness

Abnormal VS

You are working in Nome, Alaska. A 15 yo fell 7 feet and hit his head. He was initially unconscious then woke up for a while and now is unconscious again and while you are attending to him his R pupil dilates and he no longer moves his L side and then crashes.Your next best step is…

a. Hyperventilate, manitol, call neurosurgeon in

Fairbanks for transfer

b. Elevated head of bed, manitol, decadron

c. Burr hole on the R if unsuccessful, burr hole on L

d. Burr hole on the L if unsuccessful bur hole on R

e. Call the neurosurgeon in Fairbanks

Epidural

• Classic: Brief LOC, then lucid interval, then LOC

• Decrease LOC, ipsilateral pupillary dilatation (due to compression of CN III and its superficial parasympathetic fibers), contralateral hemiparesis (due to compression of ipsilateral cerebral peduncle – motor fibers cross below this level)

• Lenticular (football) shape lesion on CT

• Mortality rate 0% - 20%

• Middle meningeal artery injury

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Uncal portion of temporal lobe pushes through tentorium, causes 3rd nerve compression on edge of tentorium, causing injury to the superficial parasympathetic nerves causing unopposed sympathetic stimulation thus ipsilateral dilatedpupil. In addition corticospinal tract fibers in midbrain become compressed causing contralateral paralysis

3rd nerve

Parasympathetic fibers

arachnoid

dura

corticospinal tracts

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Transtentorial (Uncal) herniation syndrome

• In 20% of cases

hematoma

compresses opposite

side of midbrain

against tentorium

edge resulting in

contralat pupil

dilatation and ipsilateral paralysis

• This is why bilateral burr holes is necessary

in ipsilateral burr hole does not work

Collection of blood below inner table of dura but

external to the brain (between cortex and venous

sinuses – dissects the arachnoid away from the dura)

Occurs in 33% of patients with severe head injury

Subdural

• H/A

• Decreased LOC

• Bridging veins

• 25% are bilateral

• Crescent shape lesion on CT

• 30% - 60% mortality

• Acute, subacute (isodense, coumadin), chronic

6X more common than epidural

Below inner layer of dura

External to arachnoid

subacute

acute

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Types of brain herniation11)Uncal

2) Central

3) Cingulate

4) Transcalvarial

5) Upward

6) Tonsillar

An 87 yo male fell a week ago, hit head but not knocked out. On admission to the ED his LOC is depressed. His CT brain is shown. Of the following which is most likely

a. He is likely to have urinary incontinence

and some dementia

b. He has a history of atrial fibrillation

c. He has a family history of brain cancer

d. This is probably physical elderly abuse

e. Most patients with this injury have a cycle

of loss of consciousness, awake period and

return to loss of consciousness over hours

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An 87 yo male fell a week ago, hit head but not knocked out. On admission to the ED his LOC is depressed. His CT brain is shown. Of the following which is most likely

a. His LOC has been disturbed for at least 2

weeks

b. He has a history of atrial fibrillation

c. He has a family history of brain cancer

d. This is probably physical elderly abuse

e. Most patients with this injury have a cycle

of loss of consciousness, awake period and

return to loss of consciousness over hours

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An 87 yo male fell a week ago, hit head but not knocked out. On admission to the ED his LOC is depressed. His CT brain is shown. Of the following which is most likely

a. He is likely to have urinary incontinence

and some dementia

b. He has a history of atrial fibrillation

c. He has a family history of brain cancer

d. This is probably physical elderly abuse

e. Most patients with this injury have a cycle

of loss of consciousness, awake period and

return to loss of consciousness over hours

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An 87 yo male fell a week ago, hit head but not knocked out. On admission to the ED his LOC is depressed. His CT brain is shown. Of the following which is most likely

a. His LOC has been disturbed for at least 2

weeks

b. He has a history of atrial fibrillation

c. He has a family history of brain cancer

d. This is probably physical elderly abuse

e. Most patients with this injury have a cycle

of loss of consciousness, awake period and

return to loss of consciousness over hours

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Subdural

• H/A

• Decreased LOC

• Bridging veins

• 25% are bilateral

• Crescent shape lesion on CT

• 30% - 60% mortality

• Acute, subacute (isodense, coumadin), chronic

6X more common than epidural

Below inner layer of dura

External to arachnoid

subacute

acute

Collection of blood below inner table of dura but

external to the brain (between cortex and venous

sinuses – dissects the arachnoid away from the dura)

Occurs in 33% of patients with severe head injury

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Epidural

• Classic: Brief LOC, then lucid interval, then LOC

• Decrease LOC, ipsilateral pupillary dilatation (due to compression of CN III and its superficial parasympathetic fibers), contralateral hemiparesis (due to compression of ipsilateral cerebral peduncle – motor fibers cross below this level)

• Lenticular (football) shape lesion on CT

• Mortality rate 0% - 20%

• Middle meningeal artery injury

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You are working in Nome, Alaska. A 15 yo fell 7 feet and hit his head. He is unconscious and while you are attending to him his R pupil dilates and he no longer moves his L side and then crashes.Your next best step is…

a. Hyperventilate, manitol, call neurosurgeon in

Fairbanks for transfer

b. Elevated head of bed, manitol, decadron

c. Burr hole on the R if unsuccessful, burr hole on L

d. Burr hole on the L if unsuccessful bur hole on R

e. Call the neurosurgeon in Fairbanks

Transtentorial (Uncal) herniation syndrome

• In 20% of cases

hematoma

compresses opposite

side of midbrain

against tentorium

edge resulting in

contralat pupil

dilatation and ipsilateral paralysis

• This is why bilateral burr holes is necessary

in ipsilateral burr hole does not work

Match the following red eyes with the diagnosis

With preauricular adenopathy

With discharge and a cough

Painful with mild mucoserous

discharge for 5 d then spread

With cobblestone papillae under

upper lid

With hypopeon in contact wearer

After eye surgery

With diffuse punctate keratopathy

With cup:disc ratio > 1:2

Dendridic pattern (dumbells)

Cells in the vitreous cavity

Ciliary flush, flare in anterior chamber,

consensual photophobia

•EKC (epidemic keratoconjunctivitis)

•Uveitis

•Herpes simplex infection

•UV keratitis

•Pseudomonas

•Glaucoma

•Iritis

•Endophthalmitis

•Viral conjunctivitis

•Allergic conjuncitivitis

•Chlamydia

•GC