End of Life Discussion

1. Introduce yourself and your role. I would like to discuss the next steps in taking care of X.
2. Setting up the scene. Determine what the pt / family already knows.* Determine pt’s functional status prior to illness.
3. Deliver bad news. I would like to provide you with an update on X’s medical condition
  • don’t focus on the medical, but rather on what is pt-centered: function, quality, and time of remaining life
  • summarize condition with a bottom-line: ‘getting worse,’ ‘not going to improve,’ ‘dying and time is likely very short.’
4. Listen. Whether or not you use the word dying, when you have presented bad news (such as information about disease progression), the next step is for you to allow silence, and let the family/patient respond.
5. Respond to the questions as well as the emotions. Name and validate.
If the emergency physician recognizes that the patient is likely to die during this hospitalization, regardless of critical interventions, it would be reasonable to express to the surrogate “worry” about how dire the situation appears. It is also reasonable in such a situation to ask the surrogate about whether the patient had expressed, or if the surrogate has an understanding of, the patient’s goals, values, and perspective on medical priorities near the end of life. Had the patient talked about whether “dying on machines” was acceptable or unacceptable? Does “being comfortable in a peaceful situation if I am dying” sound more consistent? – from ACEPnow
  • Determine the legal decision maker if available and review any completed advance directives.
  • Complete a rapid goals of care discussion (see Fast Facts #223-227).
  • Make recommendations. For example, ‘According to what you want for [the patient], I would/would not recommend….
If comfort is the priority, then hospice involvement or a palliative care consultation might be the most important intervention.
* if you do not know the patient or family well, take a moment to build relationship. Ask a non-medical question such as I am just getting to know you. I had a chance to look at your chart and learn about your medical condition but it does not say much about your life before you got sick. Can you tell us about the things you liked to do before you got sick? Similarly, if the patient is not able to participate in the meeting, ask family to describe the patient prior to his becoming ill: As we get started, can you describe what Mr. Jones was like before he became ill?
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-Could you please share with me what is important to you (to him/her) regarding what quality of life you would want for the rest of your life? I want to make sure I understand so I can what I can to help you get there.
-Thank you for sharing this. Knowing that [] would want X, …
-It’s really hard not knowing whether or not you’re going to survive.  Can I offer to contact a patient rep if you would like help contacting your loved ones during this difficult time?
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This “resuscitation menu,” or asking “should we do everything if your heart stops?” is an ineffective way to have goals of care conversations. From the patient perspective, our medical expertise and knowledge mean that when we offer a treatment or a menu of options, they are reasonable and realistic options – when in reality, they may not be appropriate or in keeping with the patient’s values around the quality of life. Studies show that patients often have a poor understanding of CPR, intubation, and unrealistically optimistic expectations.
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-for renal pts: hydromorphone (dilaudid) is the longer lasting choice compared to fentanyl

O2 Therapy in Severe Viral Pneumonias

A Protocol for O2 Escalation (goal sat low 90s, unless end stage lung disease):
1. up to 6L nc (40% FiO2). Treat pleuritic pain to prevent splinting.
2. 12-15L facemask (50-60% FiO2)
3. HFNC if available. Use ROX index to determine failure.

Who to definitely intubate? End organ injury/hypoperfusion (ex elevated lactate), AMS, hypotension, respiratory acidosis/hypercapnea (w/o hx of CHF or COPD)

CPAP failure: PEEP >8? and 100% FiO2, not cooperative

Use ROX Index to determine failure of HFNC:
ROX = (SpO2/FiO2) / RR
ROX < 4.88 – intubate
failure with trial of HFNC @2h: ROX < 2.85,     @6h: ROX < 3.47,      @12h: ROX < 3.85

Note that PF ratio is meant for intubated pts (FiO2 is most accurate on vented pt).


From literature:

Noninvasive ventilation:
-NIV may be useful in preventing ETI if concomitant COPD or CHF – NIV shown to work for hypercapnea

-the vast majority of pts with hypoxemic respiratory failure with previously normal lungs (ie PNA, ARDS) fail NIV and need mechanical ventilation. The risk of a trial of NIV is delaying needed intubation, worsening end-organ damage (mechanical ventilation reduces energy expenditure on respiration), and possibly worsening volume-induced lung trauma for ARDS pts.
-some studies suggest mortality benefit to NIV and reduced need for intubation for early hypoxemic respiratory failure as compared to Venturi or NRB mask in carefully selected pts: no shock or end-organ dysfunction (including arrhythmia), can clear secretions, and are cooperative.
–however, evidence from different RCTs on both mortality and need for intubation is conflicting!
–if pursue, use CPAP only as tachypneic pts can pull excessive tidal volumes on BIPAP and further damage ARDS lungs
–if no clinical improvement after 1 hour, consider it a failure of NIV
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In ARDS patients, it has been shown that the use of noninvasive inspiratory pressure support can decrease the inspiratory effort compared with no inspiratory assistance only if sufficient pressure support is added [69]. Of concern, the tidal volume can also be significantly higher during NIV, especially when substantial inspiratory pressure is delivered, and further exacerbated by the high inspiratory demand seen in patients with acute hypoxic respiratory failure [70]. Therefore, the total pressure dissipated to inflate the lungs can be excessive during NIV. Such large transpulmonary pressures and the resulting large tidal volumes may exacerbate lung injury if prolonged over time. It is possible, although not proven, that NIV is especially useful in patients who do not substantially increase their tidal volume, but further work is needed in this area
Invasive ventilation for hypoxaemic respiratory failure clearly reduces work of breathing and permits paralysis if total control of breathing is desired, effects that can redistribute blood flow from the respiratory muscles to other organs in patients with shock and hence help to treat shock itself [72]. The ability of NIV to achieve optimal pressures to reduce the work of breathing reliably in acute hypoxaemic respiratory failure is challenging because the high pressures often required increase air leaks, gastric insufflation and patient intolerance [69]. Thus, the ability to use lung protective ventilator strategies (such as maintaining a low tidal volume of 6 mL·kg−1 of predicted body weight) may be more difficult with NIV than with invasive ventilation [7374]. Some evidence even supports the idea that spontaneous ventilation can induce harm similar to ventilator-induced lung injury in situations of severe lung injury [7577], which raises a note of caution when using NIV that combines spontaneous effort with ventilator support.

NIV has also been studied as an alternative to intubation, with occasional reports showing benefit [84]. Positive studies on hypoxaemic, nonhypercapnic respiratory failure, mainly caused by community- or hospital-acquired pneumonia, have enrolled carefully selected patients who are cooperative with no associated major organ dysfunction, cardiac ischaemia or arrhythmias, and with no limitations in clearing secretions [29608587], which may explain the benefits seen.

Until recently, almost all studies on NIV for de novo ARF compared it with oxygen delivered with standard air entrainment (Venturi masks) or reservoir masks. Recently, high-flow nasal cannula therapy has been shown to offer several advantages compared with NIV, including better tolerance and dead space reduction [88]. One recent RCT reported a survival benefit of high-flow nasal cannula over standard oxygen therapy and bilevel NIV, although the primary end-point of intubation was not significantly different [67].

The main risk of NIV for the indication of de novo ARF is to delay a needed intubation [86]. Early predictors of NIV failure include higher severity score, older age, ARDS or pneumonia as the aetiology for respiratory failure, or a failure to improve after 1 h of treatment [89]. Although the reasons for a poorer outcome are not completely understood, patients with NIV failure have higher tidal volumes before intubation [71] and develop more complications after intubation [90]. Studies have shown that NIV failure is an independent risk factor for mortality specifically in this population, although careful patient selection seems to reduce this risk [9192].

References (reviews):

In summary: evidence of NIV on mortality and need for intubation is conflicting.
—Definite no’s: pts with shock, end-organ damage (including arrhythmias), poor cooperation, or poor secretion clearance
—Maybe: pts with concomitant hypercapneic failure from CHF or COPD, very early hypoxemic failure without other organ dysfunction, and pts not pulling large tidal volumes
Success rates in critically ill COVID-19-patients are limited, delayed intubation is associated with poor outcome and the treatment as well as a possibly necessary emergency intubation in cases of treatment failure increase the risk for transmission to staff []; however, in situations with an imbalanced resources-needs ratio, this approach could help bridge the time until decision-making and intubation, or it could also be a therapeutic option in cases of lacking ventilatory capacities.

Cognitive Forcing Strategies

Headache

  • Killers (11): SAH, ICH, meningitis, ENT/facial infection, CO poisoning, temporal arteritis, venous sinus thrombosis, cervical artery dissection, glaucoma, IIH, preeclampsia
  • Tx sequence: ivf, metoclopramide + benadryl, toradol, decadron. Sphenopalatine block.

Chest Pain

  • Killers (6): ACS, PE, ao dissection, tamponade, PTX, PNA
  • STEMI equivalents: aVR elevation, deep inverted/biphasic Ts (Wellens), ant precordial STD (posterior MI), hyperacute ST slope (deWinter), modified Sgarbossa in LBBB, *isolated TWI or STD in aVL*
  • Tx tips: ASA immed, NTG ointment, morphine worsens outcomes
  • Tips: pain above & below diaphragm = dissection w/u,

Syncope Plus

  • Structural/electrical heart disease or FH: arrhythmia
  • Exertion: HOCM
  • Young woman with abdominal pain: ectopic pregnancy
  • Older male with abdominal/flank pain: AAA
  • Sudden severe HA: SAH
  • Malignancy, SOB: PE

Dyspnea

Killers:

Agitated patient

  • Sequence: Must be undressed. Needs met? Verbal de-escalation, show of force, offer “something for the nerves” po, chemical + physical restraints (need to document & remove asap)
  • give home meds if possible, haldol 2-5mg IM +/- ativan 1-2mg IM, quetiapine/seroquel, olanzapine/zyprexa (safest for QTc)
  • Tips: avoid bzd in elderly and autistic, avoid antipsychotics if suspect tox, avoid benadryl in elderly

 

Procedural sedation
midazolam 0.05mg/kg IV, or haloperidol 5mg IV pretreatment to prevent recovery agitation after ketamine

Sick patient

  • eval: iv x 2 (io), O2, monitor, A-B-C-Dextrose
  • shock: empty tank (hypovolemia/hemorrhage), leaky tank (anaphylaxis, sepsis), pump failure (cardiogenic, dissection), obstructive (PE, tamponade)
  • Hs (5) & Ts (6): H’s, hypo/hyperK, hypoxia, hypovol, hypothermia; TPTX, tamponade, thrombosis ACS, thrombosis PE, tox, trauma
  • post ROSC (3): BP, EKG, gas, pressor
  • calling codes: unwitnessed arrest, nonshockable rhythm, no ROSC, age >60, pH<7, unknown downtime, pocus echo. K>12 futile.

 

Intubation

  • airway H&P (each with high LR+ for difficult airway): hx difficult tube, snoring, LEMON (Look externally [beard, retrognathia, obesity], Eval 3-3-2, Mallampati, Obstruction, Neck mobility), inability to exaggerate underbite (new!)
  • prep: SOAPME, position is ramped up, +/- push-dose pressor at hand (+bicarb if also severely acidotic), post-tube sedation +/- pressors hung, voice plan and backup to team

SCD patient

  • no O2 if not hypoxic!
  • no fluids if euvolemic (esp in AChS)! Only give D51/2NS, hypotonic fluids prevent further sickling. Bolus only for septic unstable patients.

Before discharge

  • have vitals normalized?
  • PO challenge? Road test?
  • review labs, imaging, & documentation – Does everything make sense? Any incidental findings?

 

Shoulder Reductions

elbow technique (new!)
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self-reduction
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scapular rotation: scapular tip pushed medially, acromion inferiorly (open-book)
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vertical pull (Spaso): lift arm vertically, fully externally rotate, and pull toward ceiling
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external rotation (Kocher): slowly rotate externally with humerus parallel to torso, then maintain externally rotate until cross midline
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lateral extension (Milch): while externally rotated and providing traction on the humerus, slowly extend laterally until above 90′
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traction-countertraction: tie sheets so that traction is pulled on humerus while body in place
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passive traction (Stimson): apply weight to extremity while pt prone (for young healthy pts only)
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oscillating method (Fares): while keeping traction, oscillate up and down while slowly extending laterally. Best if kept extremity in external rotation.
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up-close-and-personal (Cunningham): pt’s hand on your ipsil shoulder, put downward pressure on their elbow. With free hand, massage biceps and rotator cuff muscles.
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POSTERIOR dislocation traction-countertraction:
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INFERIOR dislocation traction-countertraction:
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Trauma

Burn transfer criteria:
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3 mL of lactated Ringer’s solution x weight in kilograms x % of body surface area burned (partial- and full-thickness burns)

Trauma in pregnant pts
–have a low threshold for giving Rhogam

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-types II & III may disrupt cribriform plate – look for CSF rhinorrhea

Traumatic iritis = inflam of ciliary body
-cycloplegic (homatropine. Relieve photophobia) +/- topical steroids (ONLY optho can Rx)

Globe rupture – elevate bed >30′ to reduce ocular pressure and prevent further extravasation (avoid sux if intubating – incr IOP)
-give abx prophyl

Infraorbital anesthesia is associated with this fracture due to injury to the infraorbital nerve. Other findings on physical exam include enophthalmos due to herniation of globe contents before the onset of edema. Diplopia on upward gaze occurs with entrapment of the inferior rectus muscle leading to binocular diplopia 

7 areas of ICH on CT Head: spinal cord, midbrain, 4th ventricle, lateral ventricles, gyri and sulci, gray-white matter differentiation

Spinal shock = cord concussion

3 types of pelvic fractures:
– lateral compression (T-bone MVC/pedestrian hit from side)
—look for vertical fracture of sacrum
—no benefit from pelvic binders
—mostly “elderly” (age >55) pts at risk of bleeding – calcified vessels break easily
—if suspect bleeding or binder already placed, benefits generally outweigh potential harm of overreduction so do not remove
– AP fracture (head on MVC)
– vertical shear (fall)

 

Hyponatremia & Hypernatremia

-Send serum osmolality!
-determine fluid status: hypo-, eu-, or hypervolemic
-Use formulas!

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Hyponatremia
-if asymptomatic, fluid restriction. Don’t give fluids!
-if altered/seizing,
-max rate of correction = 8 mEq/h
-Goal: <10-12 mEq total increase in 24h

Hypovolemic hyponatremia mechanism = decreased  arterial perfusion of kidneys -> ADH secretion -> reabsorption of free water
–fix the underlying problem: volume replete

Hypervolemic hyponatremia (CHF, cirrhosis) mechanism = depleted intravascular volume despite excess extravascular volume = decreased effective arterial perfusion of kidneys -> ADH secretion -> reabsorption of free water

Euvolemic hyponatremia
-SIADH – inappropriate excess ADH secretion
-psychogenic (excess free water intake), beer potomonia + “tea and toast syndrome” (inadequate solute intake)

Hypernatremia
-bolus NS if shock/hypoperfusion
-replace total body water (TBW) deficit

 

1. Treat Neurologic Emergencies Related to Hyponatremia

In the event of a seizurecoma or suspected cerebral herniation as a result of hyponatremia, IV 3% hypertonic saline should be administered as soon as possible according to the following guide:

  1. Administer 3% hypertonic saline 100-150cc IV over 5-10min
  2. If the patient does not improve clinically after the first bolus, repeat a second bolus of hypertonic saline.
  3. Stop all fluids after the second bolus of hypertonic saline to avoid raising the serum sodium any further

What if hypertonic saline is not readily available? –> Administer one ampule of Sodium Bicarbonate IV over 5min.

Ringer’s lactate has a sodium concentration of 128mmol/L which will be more isotonic to the hyponatremic patient. Although never shown in clinical studies, administering Ringer’s lactate will likely result is a slower rise in serum serum sodium than Normal Saline, and therefore have a lower risk of potentiating osmotic demyelination syndrome. Ringer’s lactate is therefore recommended by our experts as the fluid of choice for resuscitation of the hypovolemic/hyponatremic patient.

Practical Approach to the Differential Diagnosis of Hyponatremia

  1. Look at chief complaint: look for conditions which can increase output or decrease intake such as vomiting and diarrhea, pain or altered level of awareness
  2. Review Medication List: look for those that cause SIADH, especially thiazide diuretics and SSRIs; patients who have been on chronic steroids may have adrenal insufficiency
  3. Evaluate PMHx: Look for history of end organ failure (CHF, liver failure and renal failure) or cancers (a cause of SIADH)
  4. Lab work: glucose (hyperglycemia), potassium (hyperkalemia may suggest adrenal insufficiency), TSH (hypothyroidism)

Note: if by history the hyponatremia is acute, it is safe to correct it quickly. The patients who are at risk of central pontine demyelinolysis are those whose hyponatremia is chronic.

 

Other lytes concepts:
-replete low ionized Ca after PRBC transfusions (contains citrate)
-alkylosis (ex: primary hyperventilation) causes more Ca from its ionized state to be bound to albumin (may develop signs of hypoCa)
-severe hypocalcemia -> cardiovascular collapse (loss of contractility/inotropy)
-hypocalcemia -> QTc prolongation -> torsades
-CaCl2 = 3x more ions than Ca-gluconate

-beware of further increasing serum bicarb for a pt that is hypoventilating (ex CHF exacerbation) – will worsen compensatory respiratory acidosis (hypercarbia). This is why MICU gives acetazolamide to CHF pts on BIPAP
-Dialysis dysequilibrium syndrome (dizziness during dialysis) – due to the rather rapid removal of BUN, which has an osmotic effect
—–serum osmolality = 2x(Na) + glucose/18 + BUN/2.8

0.9% NS = 154 mEq Na
0.45% NS = 77 mEq
plasmalyte = 140 mEq
LR = 128 mEq
D5W = 0 mEq
3% hypertonic saline = 513 mEq (3 / 0.9 = 3.33 x 154mEq)

References:
https://emergencymedicinecases.com/episode-60-emergency-management-hyponatremia/
https://coreem.net/core/hypocalcemia/

Cervical Spine Fractures

Assess alignment of the vertebrae as assessed by intact anterior spinal, posterior spinal, and spinolaminar lines (it should be possible to draw a smooth curved line touching all 7 cervical vertebrae at each of these locations without interruption).

Any soft-tissue swelling or disruption of normal lines, in the setting of trauma, suggests occult fracture or ligamentous injury.

In children under 8, ligamentous laxity of the upper C-spine can cause anterior displacement of C2 on C3, a normal variant called pseudosubluxation, which can be confused with an acute ligamentous injury. Up to 4 mm is normal in children <8yo.
Check Swishuk’s line (the line drawn in the additional image between the anterior aspects of the spinous processes of C1 and C3—in pediatric pseudosubluxation, it will be within 2 mm of the anterior aspect of the C2 spinous process).
((((pic in case 7 additional images))))

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In general: If both spinal columns are disrupted, the spine will move as 2 separate pieces, and there is high likelihood of that movement’s causing or worsening spinal cord injury. If only 1 column is disrupted, the other column resists further movement, and the likelihood of a spinal cord injury occurring is less and depends on the strength of the intact ligaments.

Unstable fracturesJefferson Bit Off a Hangman’s Thumb: Jefferson burst fracture (C1), Bilateral facet dislocation, Odontoid fractures (C2), Hangman fracture (C2), Teardrop fracture

  • Jefferson burst fracture: C1, axial load
  • Odontoid fracture: high cervical pain radiating to the occiput
  • Hangman fracture: C2, extreme hyperextension

The Hangman’s fracture, or spondylolysis of C2, occurs when the cervicocranium (skull, atlas, and axis) is thrown into extreme hyperextension as a result of abrupt decelerationBilateral fractures of the pedicles of the axis (C2) occur with or without dislocation. Although a hangman’s fracture is unstablecord damage is often minimal because the AP diameter of the neural canal is greatest at the C2 level, and the bilateral pedicular fractures permit the spinal canal to decompress itself.
-Deficits on neurologic exam are more likely due to associated head injury or vertebral artery injury than to damage to the spinal cord directly
-concomitant C spine injuries (esp C1-C3) are common – look for them
-immobilize and consult spine specialist ASAP

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  • A flexion teardrop fracture results when severe flexion forces cause anterior displacement of a wedge-shaped fragment (resembling a teardrop) of the anteroinferior portion of the involved vertebral body. This fracture involves complete disruption of the ligamentous structures at the level of the injury. This leads to a highly unstable fracture.

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Flexion injuries can cause unstable injuries such as atlantoaxial dislocation, bilateral facet dislocations, and teardrop fractures, as well as stable injuries, such as spinous process avulsions (e.g. clay shoveler’s fracture) or simple wedge fractures.

Facet dislocation:
Unilateral facet dislocations typically present with ipsilateral radiculopathy (the affected superior facet displaces into the neural foramen) and less than 50% anterior vertebral body displacement on lateral radiographs
—considered stable, but a significant percentage have associated cord injury
—Head often held deviated away from the side of the injury, unable to straighten
—may be palpable malalignment of spinous processes
Bilateral facet dislocations often have frank neurologic deficit with greater than 50% vertebral body displacement on x rays
—unstable, majority have cord injury
—may have bony stepoff
-mgmt: immobilize in hard collar, but if spine locked, do not force it. Use sandbags, towel rolls, and tape instead
-call spine specialist (NSG) for closed reduction in ED prior to going to OR
-perform serial neurologic exams – neurologic deficit may worsen after closed reduction (from disc protrusion)
(((pic case 2))))

C2 (axis) fracture
-body:
-odontoid/dens fractures: Types I (tip), II (base), & III (body of C2)
—type III is unstable (involves C2 ring)
—consult ortho/NSG for mgmt for all of these
-The lateral masses of C1 should align perfectly with the lateral masses of C2 (blue lines). The medial aspect of the C1 lateral masses should be equidistant to the odontoid (letter A – in this case asymmetrically widened on the right). A distance of >7mm from a C1 lateral mass to the dens indicates transverse ligament rupture or C1 burst (Jefferson) fracture
-immobilize, MRI
(((pic case 3, diagnosis))))

Transverse spinous process fracture:
-there is a significant association between transverse process fractures and intraabdominal injury (given high energy mechanism), so these fractures should be regarded as possible markers for abdominal organ injuries, even though the spine is stable
-obtain CT abd/pelv with recon of T/L spine to look for intraabd injuries and other associated spine fractures
-if isolated, pain control and early mobilization

Lower spine fractures:

-it is important to distinguish a burst fracture from a simple compression fracture. In a simple compression fracture, the compression should only involve the anterior aspect of the vertebral body. In a burst, the posterior vertebral body is also compressed (and thus more likely to injure spinal cord).
–unstable if neuro deficit, >50% loss of vertebral body height, >20 degrees angulation at the thoracolumbar junction, canal compromise
—–dispo determined by ability to control pain. These pts can go home with TLSO brace or to rehab
If there is loss of height of the posterior portion of the vertebral body or retropulsed bone, the diagnosis is burst fracture. Burst fractures are unstable!

Upper Extremity Fractures

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Bones susceptible to avascular necrosis: scaphoid, lunate, capitate, talus, navicular, 5th metatarsal, femoral neck.

Ring structures, such as the pelvis, mandible, and C1 vertebrae, tend to disrupt in more than one location.

HAND

*Ring removal is the first priority for any injury with potential for digit swelling

Boxer’s Fracture:
-look for fight bite
-degree of rotation should be assessed by having the patient make a fist – all of the fingers should point to the scaphoid without overlap or “scissoring” of fingers.
-reduce if degree of angulation >45′
—hand is held in a clenched fist, while simultaneous dorsal force is applied on the flexed PIP joint and volar force applied to the proximal metacarpal shaft
hematoma block, a needle is inserted into the fracture and blood aspirated to confirm appropriate placement, then 5cc of lidocaine (without epinephrine) or bupivacaine is injected
ulnar nerve block, 5cc of anesthetic is injected proximal to the ulnar styloid between the ulnar artery (medial) and the tendon of the flexor carpi ulnaris (lateral).

Distal tuft fracture:
-Irrigation, debridement, and IV antibiotics are indicated for open tuft fractures
-prompt referral to a hand surgeon

  1. If the nail plate is intact, leave it in place. Drain the subungual hematoma (via trephination of the nail) to relieve pain and prevent pressure necrosis
  2. Damage or loss of the nail plate requires nail removal, nail bed repair with 6-0 chromic suture, and protection.

-Surgery if the dorsal surface of the phalanx that supports the nail matrix has significant step-off – requires reduction of the nail bed to a flat surface and surgical repair

Mallet Finger: = PIP extensor tendon injury
= either an avulsion of the extensor tendon (without fracture) or an avulsion fracture at the tendon’s attachment at base of the distal phalanx
-clinically: unable to extend the DIP joint actively (passive extension intact)
-pts may present late as pain often is minimal and deformity may be subtle
-splint in slight hyperextension with rapid follow-up with the hand specialist
-splint can be placed on the dorsal or volar surface of the DIP joint with the other joints left mobile
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Bennett’s Fracture:
= fracture at the base of first metacarpal with subluxation of the first metacarpal from the carpo-metacarpal joint
-usu due to axial load injury (ex punching)
-pain and swelling at the thumb base
-exam: limited ROM, CMC instability is frequently noted with gentle stress of the first metacarpal
-this injury may severely affect function bc the carpometacarpal (CMC) joint is critical for pinch and opposition
-can attempt to reduce (thumb traction combined + metacarpal extension) and immobilize in thumb spica however usu strength of APL subluxes the metacarpal again. Often require ORIF – prompt follow-up with a hand specialist
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Rolando’s fracture is a communicated Bennett’s fracture
–need true lateral of the 1st CMC joint xray – for accurate evaluation, determine whether surgery is needed
-thumb spica splint – from just distal to 1st IP joint to mid-forearm with 25 degrees extension at the CMC joint and 0 degrees at the MCP and IP joints.
-early hand follow up

Gamekeeper’s thumb
= injury of the ulnar collateral ligament of the first digit with or without concomitant avulsion fracture of first proximal phalanx
-UCL helps stabilize the thumb MCP joint. It inserts on the ulnar side of the proximal phalanx (next to the webspace). UCL disruption causes significant instability and morbidity
-mechanism: abduction and hyperextension of thumb
-exam: ttp over ulnar aspect of base of proximal phalanx of thumb. Stress the UCL by applying valgus pressure, compare with unaffected side. May need local anesthesia prior
-if suspected, immobilize in thumb spica and f/u with hand 
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Proximal phalanx fracture:
-usu angulated due to forces exerted by the extensors and interosseous muscles
check for rotational deformities, which may be more easily diagnosed by physical exam than radiographically. Have the patient flex all the digits simultaneously. Each finger should point toward the scaphoid. If the injured finger points in a different direction than the others when flexed, a rotational deformity is present. Also assess for nerve and tendon injuries.
-stable, nondisplaced, and nonrotated fractures can be buddy taped
-Reduction (difficult) and immobilization in a gutter splint if unstable: rotational deformity, displaced >5mm, angulated >15mm, or intraarticular
-Surgical fixation if reduction fails, comminution, or in athletes
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PIP dislocation (uncommon in DIP joint which is very stable)
-clinically: unable to extend finger at PIP joint
-reduce (mild exaggeration in the direction of the dislocation to disengage from the articular plate. Then the clinician applies longitudinal traction and firm pressure on the proximal aspect of the middle phalanx to reduce the fracture) and immobilize
-obtain post-reduction films to assess for bony fragments not visualized on prior films
-the articular cartilage may be entrapped, and a hand specialist should be immediately consulted
-If there is evidence of complete ligamentous disruption in all directions on postreduction ROM testing, refer to a hand surgeon for possible operative repair
Screen Shot 2018-01-26 at 1.59.46 PM<– dorsal displacement/dislocations is more common
-Volar dislocations (pic below) are more difficult and often result in hand consultation
Screen Shot 2018-01-26 at 1.58.32 PM

Digit amputations
-obtain information to determine if pt is candidate for reimplantation: time of injury, mechanism of injury, hand dominance, tetanus status, past medical history, and occupation
-exam: note amount of soft tissue soiling and damage. Look for any devitalized tissue which may require debridement and inspect closely for exposed bone (this may be easier after obtaining hemostasis). Observe the amount of remaining nail matrix – remove if <5mm (unlikely to grow)
-amputated digits should immediately be covered in saline-soaked gauze and placed in watertight bag. This bag should then be immersed in a 50/50 mix of ice and water
-use pressure dressings, elevation, and tourniquets to control bleeding (no clamps!)
-treat as open fx and give abx

Proximal PIP avulsion fracture
-injury to volar plate (fibrocartilaginous) which stabilizes PIP joint
-hyperextension injury. Seen on lateral xray
-isolated avulsion fractures –> dorsal finger splint
-if concomitant dislocation (middle phalanx subluxes dorsally) –> reduce in the ED (disengage the middle phalanx, apply traction, and then flex the PIP joint). Place in dorsal extension block splint with the PIP joint in 30° of flexion
Screen Shot 2018-01-29 at 3.39.00 PMScreen Shot 2018-01-29 at 3.38.21 PM

FOREARM

Colles’ fracture:
= distal radius fx with dorsal displacement
-eval for median nerve injury

Smith’s (or reverse Colles’) fracture:
= distal radius fx with volar displacement
-also eval for median nerve injury

Galeazzi Fracture:  RG 
= Fracture of the shaft of Radius + dislocation of distal radioulnar joint (widened DRUJ space)
-Mechanism: direct wrist trauma, FOOSH with forearm in pronation
-tx – OR acutely
-complications:
—Compartment syndrome: increased risk with high energy crush injuries
—anterior interosseous nerve palsy: pure motor deficit – inability to pinch between the thumb and index finger
Screen Shot 2018-01-29 at 3.59.08 PM

Monteggia Fracture: UM 
= Fracture of the proximal portion of the Ulna combined with dislocation of the radial head.
-FOOSH with the forearm in excessive pronation (hyper-pronation injury)
-Complications: radial nerve injury (common) or posterior interosseus nerve injury (pure motor deficit of finger extension)
-consult ortho for OR in adults (Reduction of the radial head and splinting in 90 degrees of flexion with the hand supinated may be done in the ED prior to surgery) or casting in children
-make sure that line drawn through middle of radius intersects capitellum in all views
Screen Shot 2018-01-29 at 4.02.05 PM

ELBOW

Olecranon fracture:
-direct blow to elbow
-olecranon is essential for triceps strength and normal extension of the elbow
-exam: palpable bony fragment, inability to extend elbow against force
-eval for ulnar nerve injury: motor weakness of the interossei muscles of the hand and loss of sensation on the palmar surface of the fifth digit and hypothenar eminence
-displacement >2 mm –> surgery. A fracture line that displaces with flexion of the elbow is considered a displaced fracture
-nondisplaced fractures can be treated by immobilization in 45 to 90 degrees
-fractures that are displaced, involve articular surface, or with nerve injury  –> consult ortho in ED

Occult radial head fracture
-FOOSH mechanism (radial head driven against capitellum)
-look for posterior fat pad, displaced anterior fat pad (“sail sign”)
-exam: ttp of the lateral elbow, may have limited elbow ROM depending on the size of the effusion. Pain on passive forearm pronation, which rotates the radial head
-eval for AIN injury: have pt show OK sign
-sling for comfort with ortho follow up; if comminuted or displaced, immobilize with posterior mold

Supracondylar fracture
-FOOSH with elbow extension, adults and peds
-high risk of vascular injury: brachial artery injury or compartment syndrome – if missed, Volkmann’s ischemic contracture
-also assess ulnar, radial, and median nerve function
-obtain true lateral film: line along the anterior border of the humerus should bisect the capitellum. If not –> posteriorly displaced
-consult ortho for all of these to determine management; pt will likely need admission at the minimum to monitor for compartment syndrome, if not surgery

Elbow dislocation
-can occur in any direction; often assoc with fracture
-for posterior dislocations (most common), brachial artery and median nerve should be assessed before and after reduction attempts
-anterior dislocations are rare and severe. Eval for neurovascular injury
-Reduce by stabilizing the humerus while an assistant applies steady longitudinal traction is applied at the wrist. A “clunk” should be appreciated as the elbow reduces; the elbow then should be flexed to 90° and a posterior mold applied to the elbow in 90 degrees of flexion with the hand in neutral position, and the patient given a sling.
—also the Parvin method: Place the patient prone with the forearm hanging down off the bed with 5-10 lbs of weight hanging off the wrist. Reduction should occur within 15-20 minutes
-consult ortho for open dislocations or those associated with fractures

HUMERUS

Humeral neck fractures:
-occur at surgical neck, anatomic neck, greater &/or lesser tuberosity
-use Neer classification system to guide management:

  • 1-part fractures: nondisplaced, nonangulated –> sling, ortho f/u as outpt
  • 2, 3, 4-part fracture: require ortho consult in ED for surgical planning & management

-obtain axillary or scapular (Y) views (give pain meds prior) to classify accurately and r/u glenohumeral dislocation
-Fractures of the anatomic neck are at risk for avascular necrosis due to the distal-to-proximal vascular supply of the proximal humerus –> close orthopedic f/u regardless of the Neer classification
-isolated greater tuberosity fractures with >5mm of displacement need prompt orthopedic follow-up
Screen Shot 2018-01-27 at 1.44.46 PM.png

Humeral shaft fracture:
-in peds, think of child abuse esp if spiral (rotational force)
-eval for radial nerve injury and associated shoulder and elbow injuries
-consult ortho if: a neurovascular deficit, an open fracture, or a distal spiral shaft fracture
Transverse fractures: can be managed with a sugar-tong splint and a sling
Spiral or oblique fractures: reduction with traction, immobilized in a coaptation splint or a hanging arm splint. Do NOT use a sling in these cases because it worsens displacement
Screen Shot 2018-01-27 at 2.04.04 PM

SHOULDER

Screen Shot 2018-02-03 at 1.16.53 PM.png
Anterior dislocation:
-severe pain, held in slight abduction and external rotation and often supported by the opposite extremity, “squared off” appearance (prominence of acromion)
-Assess for neurovascular injury, particularly axillary and radial nerves. Axillary nerve function can be assessed by testing for sensation over the lateral aspect of the shoulder and with motor function of shoulder abduction. The radial nerve can be assessed by asking the patient to extend the wrist and elbow and abducting the thumb
-if neurovascularly intact, obtain films before reduction (and after)
-postreduction films can detect bony defects caused by dislocation that are associated with an increased risk of recurrent shoulder dislocation:

  • Hill-Sach’s deformity -cortical depression (compression fracture) in the head of the humerus (blue arrow)
  • Bankart lesion – avulsion of the anteroinferior glenoid labrum (red arrow)Screen Shot 2018-01-26 at 6.40.08 PM

-complications from most to least frequent: axillary nerve injury (anesthesia of deltoid), humeral head fracture (Hill-Sach’s), and glenoid rim disruption (Bankart)
-can use intra-articular anesthesia or conscious sedation (to decrease muscle tone) for reduction
-reduction techniques:

  • The Stimson technique of hanging weights from the forearm of the prone patient.
  • The two person technique of traction-countertraction with bedsheets.
  • External rotation of Leidelmeyer performed on the supine patient.
  • Elevation maneuver of Cooper and Milch.
  • Scapular manipulation.

-Shoulder immobilization for 3-6 weeks in younger patients, 1-2 weeks in patients over 40. Primary dislocations or cases with associated fracture, rotator cuff injury, axillary nerve injury require orthopedic follow-up
Screen Shot 2018-01-26 at 2.50.49 PMabnl          Screen Shot 2018-01-26 at 2.51.55 PMnl

Posterior dislocation:
-severe pain with the arm held across the trunk in adduction and internal rotation
-usu there is no obvious deformity. The patient will not be able to range the shoulder.
-Neurovascular injuries are uncommon; associated fractures are common
-the normal overlap of the humeral head and the glenoid may be absent in posterior shoulder dislocations
Screen Shot 2018-01-26 at 2.25.49 PM
-on scapular Y or axillary views, the humeral appears lateral to the Y (actually posterior to the glenoid) rather than in-line with the Y
Screen Shot 2018-01-26 at 2.27.13 PMScreen Shot 2018-01-26 at 2.33.28 PM.png
-blue line: the “trough line sign”, which represents an impaction fracture, or “reverse Hill-Sach’s” lesion (compression fracture of the anteromedial portion of the humeral head produced by the posterior cortical rim of the glenoid)
-reduce by applying axial traction. Anterior pressure from behind the humeral head may help coax the humeral head over the glenoid rim. Place in a sling or shoulder immobilizer and obtain postreduction films to better visualize fractures

Clavicular fracture:
-pts hold the arm adducted; shoulder ROM is limited due to pain. Point ttp, swelling and crepitance. Look for skin tenting and step-offs. Assess for neurovascular injury: brachial plexus and subclavian artery
-conservative mgmt with sling for nondisplaced fractures
-ortho referral for pts at risk of nonunion: distal clavicle fractures, displacement greater than one bone width, shortening >1.5cm, and elderly pts

AC separation:
-fall onto lateral shoulder while adducted. The AC ligaments rupture first, then the coracoclavicular (CC) ligaments
-exam: pain on the superior aspect of the shoulder, shoulder may sag and the clavicle appear prominent. +ttp over the AC joint. Shoulder ROM is often painful. +pain with cross arm adduction testing
-normal AC joint space is 3mm and the normal coracoclavicular distance is 13 mm
—an AC sprain (type 1) is ttp over AC joint without joint separation on films
Screen Shot 2018-01-27 at 2.14.36 PM.png
Screen Shot 2018-01-27 at 2.11.32 PM–> AC joint widened, CC intact
Screen Shot 2018-01-27 at 2.06.10 PM–> both AC & CC joints widened (clavicle elevates)
-type 1 & 2 (just AC joint affected) –> sling and early ROM
-types 3 & up –> ortho consult to arrange for outpt surgical repair

Ortho Peds & Other

Open intraarticular wound:

  • Use a 30 ml syringe with an 18 gauge needle.
  • Select a site for arthrocentesis away from the wound tract.
  • Sterilly aspirate the joint. Blood return signifies hemarthrosis likely from intraarticular extension of the wound.
  • If no blood is aspirated, inject normal saline with a few drops of sterile fluorescein or methylene blue until the joint is fully distended.
  • Observe for extravasation of the dye from the wound, which would confirm intraarticular involvement.

If confirmed, pt needs OR for joint washout, Tdap, and iv abx.

Wound FB

If a WFB is small, in a harmless location, deep, asymptomatic, and an inert material (i.e. glass, metal), than it may be more damaging to attempt removal than to leave it in place. A WFB that is causing symptoms, soiled, in a location likely to cause future problems (i.e. sole of foot), or a reactive material (i.e. wood) is more likely to require removal. WFBs such as wood, plastic, clothing and vegetative matter can be detected by ultrasound however. Not all WFBs can be removed by irrigation or exploration in the ED. In these cases, the area should be padded and the patient should be referred to the appropriate consultant for removal. Consider antibiotics for retained WFBs. Give good disx instructions as this is a huge source of litigation.

Fight bite:
-appropriate antibiotics include ampicillin/sulbactam, piperacillin/tazobactam, ceftriaxone with metronidazole, or ciprofloxacin with metronidazole or clindamycin. Clindamycin does not cover Eikenella so it should NOT be used as a sole agent. The joint should be splinted.
-if NO infection present and pt can f/u for re-exam in 24h, outpt abx ok
-if infection present OR tendon/bone/joint capsule involved, admit for iv abx

Flexor tenosynovitis
-injury may be minor or even remote. Course may be fulminant or indolent
-may lead to tendon rupture, loss of function, and sepsis
-need Staph and Strep coverage +/- MRSA, GNR, or anaerobic coverage depending on risk factors
-Cover for Pseudomonas if the patient is diabetic and for Pasteurella multocida if the patient was bitten by an animal
-Kanavel signs:
1. Exquisite tenderness over the flexor tendon
2. Finger held in flexion at rest
3. Exquisite pain upon passive extension of the finger
4. Fusiform swelling of the finger
-consult ortho & hand surgeon ASAP; this is a surgical emergency requiring I&D in the OR

Septic olecranon bursitis
-history of local trauma (laceration, puncture) or preceding infection should raise suspicion. However, the absence of trauma or a wound does not rule out the possibility
exam should differentiate swelling of the olecranon bursa (increased pain in terminal flexion) from joint effusion (increased pain at terminal extension)
-look for erythema or warmth over the olecranon bursa, which would raise the suspicion for septic bursitis
-septic bursitis is ruled out if there is no warmth or erythema.  If the diagnosis is unclear, fluid can be aspirated and sent for cell count, gram stain, culture, and crystal analysis
-septic bursitis may lead to bacteremia, sepsis, and permanent bursa damage
-tx with antiStaph abx +/- MRSA coverage depending on risk factors

Gout
-tx: Relief should begin at 24 hours after NSAID therapy and NSAIDs should be continued for 24 hours after symptoms resolve. Colchicine is dosed at 0.5-0.6mg PO q1-2h until pain is controlled, 3 tabs have been taken within 3 hours, or 10 tablets within 24 hours.

Fracture blisters
= from the initial shearing injury, not from the cast
-fracture blisters should prompt contact with the treating orthopedist because they frequently overlie sites of planned internal fixation or surgical incisions
-for any pt presenting with pain in a casted or splinted limb, must remove it to examine the limb

Subungual hematoma
-usu due to nailbed laceration
-do NOT confuse subungual hematoma with Kaposi sarcoma or melanoma (verify a history of trauma)
-wipe with chlorhexidine and trephinate with cautery to relieve pain and prevent pressure necrosis
-underlying fracture is not a contraindication to trephination

Compartment syndrome
pain with passive stretch of a muscle in the suspected compartment, which is more sensitive and specific than the other findings. The affected area will be exquisitely tender and may be tense, hard, or firm
-levels >30mmHg or within 30mmHg of the diastolic blood pressure are suggestive of compartment syndrome.

Open fracture
-If the wound is >10cm with loss of bone coverage and severe soft tissue injury, an aminoglycoside should be added to cover for gram-negative organisms.
-Significant contamination of the wound, either by dirt, soil, gravel, or any other outside material warrants anaerobic coverage (specifically clostridium perfringens) with a penicillin (other options include metronidazole or clindamycin if PCN allergic)

Peds

Iliac avulsion fracture – Advise rest, ice, and NSAIDS. When in bed, a position that avoids tension on the affected muscle should be advised. The patient can bear weight as tolerated with crutches for additional comfort. Refer for a routine orthopaedics follow-up. Athletic activities can resume when the patient is able to participate without pain.

Torus fracture (ex: distal radius) consists of immobilization in a short arm cast for 2-3 weeks with orthopedic evaluation one week

Be wary of diagnosing sprains in children with tenderness near a growth plate. Rather, immobilize with a splint and refer to orthopedics for repeat films in 7-10 days to ensure you don’t miss a Salter-Harris type I or V fracture (esp if history of axial load).

Osteochondritis Dissecans (rare) = a subchondral bony lesion of an articular surface. A piece of cartilage with attached subchondral bone becomes detached, either partially or completely, resulting in a loose body in the joint space. Pts are young and athletic (children age 11-13 or adults age <30) with knee, elbow, or ankle pain. Leads to significant morbidity. Pts have intermittent clicking, locking, and pain and swelling; it is a repetitive use injury and may be exacerbated by trauma. May have a positive Wilson’s test in which the knee is internally rotated and extended from 90 degrees. A positive test is increased pain at 30 degrees or if pain is relieved by external rotation. Wilson’s sign (walking with the knee externally rotated to avoid impingment of the fragment on the condyle) may also be present. Comparison views of the opposite knee are suggested, both to ensure that the lesion seen isn’t an anomalous ossification center (also may be bilateral). Knee immobilizer, NWB, f/u with ortho.
Screen Shot 2018-01-27 at 7.46.35 PM.png

Fractures of distal radial and ulnar shafts (“both bone” fracture)
-look for tense compartments and skin breaks (open fractures common)
-eval for supracondylar humerus fractures, which creates a ‘floating elbow’ requiring surgical management
-assess radial head alignment to prevent a ‘missed Monteggia’ fracture pattern
-Incomplete (greenstick)* and complete fractures with minimal or no displacement/angulation can be managed with a sugar-tong or long-arm splint.
-If using a long-arm splint, hand positioning depends on location of the fractures.

  • Fractures of the distal third should be splinted in with the hand pronated, midshaft fractures with the hand in neutral, and proximal third fractures with the hand in supination to reduce rotational deformity.

Those with significant angulation (greater than 10 degrees), displacement, or shortening require closed reduction performed in the emergency department. Reduction is performed in a similar manner to that of Colles fractures; finger traps are applied and gravity used to distract the fracture fragments, followed by closed reduction and immediate splinting (same rules as above). Older children typically require only hematoma block, while younger children will require conscious sedation. Due to their excellent remodeling abilities and functional outcomes, children rarely require surgical intervention for uncomplicated forearm shaft fractures

*greenstick/incomplete fx = cortical disruption and periosteal tearing on the convex side of angulation with plastic deformation and intact periosteum on the concave side
-in isolated ulnar shaft fx, evaluate for Monteggia fracture by checking for radial head tenderness which may indicate that the radial head has spontaneously reduced
-In infants, up to 30 degrees of angulation is acceptable. In children less than 10 years old, no reduction is needed for angulation less than 10 degrees.
-For volarly angulated fracture, the fracture is manipulated with the forearm in pronation. In a dorsally angulated fracture, it is manipulated with the forearm in supination. Place ulnar greenstick fractures in a long arm splint

Metaphyseal corner fractures (bucket-handle fractures) of femur (Type II Salter-Harris) – suspect child abuse! (esp if infants & toddlers)
-exam: unable to bear weight. The knee is often held in flexion secondary to hamstring spasm. May be knee effusions and soft tissue swelling
-other fractures suspicious for child abuse: rib fractures, humeral fractures and skull fractures
-place in long leg splint, NWB, with prompt orthopedic referral for operative repair (esp if displaced)
child abuse: long bone fractures in nonambulatory infants, scapula fractures, rib fractures (normally very pliable and resistant to breaks unless large force applied), sternal fractures, skull fracture, and multiple fractures in various stages of healing

Spiral fracture of distal tibia (Toddler fracture)
-NOT child abuse (unless proximal tibia involved)
-weak force fracture due to rotational component in mechanism of injury
-may not be seen initially on xray – consider ultrasound
-NWB, long leg cast