Brought to you by: Priya Ghelani and Maninder Singh
Radiation Exposure (Dr. Nguyen):
- Radiological issues are rarely medical emergencies for the patient. The priority when it comes to a caring for a patient involved in a blast + radiation exposure, is to care for the blast injuries.
- Universal precaution (the kind you would use when putting in a central venous catheter), is enough to protect you from radiation exposure from a contaminated patient.
- Removal of clothing and shower with water + soap will rid 95% of radiological contamination.
Butt Pain (Dr. Sas):
- External hemorrhoids shouldn’t cause pain unless they are thrombosed
- Internal hemorrhoids shouldn’t cause pain unless they are prolapsed and irreducible
- Simple peri-anal abscesses do not require imaging
- Incise and drain perianal abscesses yourself- “You’re not going to make someone incontinent unless you are reckless”
C-collars (Dr. Sun):
- Alert, awake, stable, and reliable patient with no midline tenderness and an unremarkable neurological and motor exam + negative CT = Clear C-Collar
- Alert, awake, stable, and reliable patient with midline tenderness and/or an remarkable neurological and motor exam + negative CT = MRI
- Obtunded patient with unreliable neuro exam + negative CT = Consider MRI based on clinical findings prior to removing C-Collar
- For hyperextension neck injuries, think about Central Cord Syndrome findings
Necrotizing Fasciitis (Dr. Barajas):
- Consider it early especially if there is pain out of proportion to physical examination- When you do suspect it get your surgeon down ASAP!
- Healthy people can have necrotizing fasciitis too.
- Consider concomitant toxic shock syndrome, which may complicate 50% of type II necrotizing fasciitis
- Cirrhotic patients and people exposed to sea/brackish water can get vibrio necrotizing fasciitis.
Ankle Fractures (Dr. Ghelani)
- Goal: determine which ankle fractures are stable and which are unstable
- Stability based on the deltoid ligament:
- If the integrity of the syndesmosis is affected, this is unstable
- Use an algorithmic approach to evaluate ankle x-rays:
- Evaluate the mortoise
- Red flags suggestive of instability:
- Decreased tibiofibular overlap,
- Increased medial clear space,
- Increased tibiofibular clear space
- Normal tibiofibular overlap:
- >6 mm on AP
- >1 mm on the mortoise view
- Normal medial clear space is </= 4 mm
- Normal tibiofibular clear space is < 5-6 mm on both the ankle and mortoise views
- Red flags suggestive of instability:
- Evaluate the fibula (determine the Weber classification)
- Weber A – infrasyndesmotic (conservatively managed)
- Weber B – transsyndesmotic (stress views required to determine management if no red flags already met to r/o bimal equivalent)
- Weber C – suprasyndesmotic (surgically managed)
- Bimal = fracture of the medial and lateral malleolus
- Trimal = bimal + fracture of malleolus tertius
- Evaluate the stress view (Weber B) to determine if there is a bimal equivalent
- Bimal equivalence* –> require fixation
- Evaluate the mortoise
- All ankle fractures require cast immobilization +/- surgical reduction
- Exception: Avulsion fractures
- Treated like stable ankle sprains (if they are minimally displaced, smaller than 3 mm, and if there is no indication of a medial ligamentous injury)
- Exception: Avulsion fractures
- Think of Maisonnevre fracture as a high Weber C
- Keep a high index of suspicion if you see an isolated fracture of the medial malleolus or malleolus tertius or a medial hematoma/swelling without a clear fracture
Traumatic Hemothorax (Dr. Balbin):
- When to call surgery for traumatic hemothorax (needs OR):
- Massive hemothorax- 1500cc output of initial drainage after chest tube insertion
- 300cc output over first hour
- 200cc output per hour over three hours
- hemodynamic instability