Retroperitoneal Organs
Physical Exam Findings
Symptoms 1. Most common presenting complaint = abdominal pain; then leg/hip pain; back pain 2. Can have femoral neuropathy, iliopsoas spasm Traumatic RPH
Spontaneous RPH
Management - controversial Zone I - concern for vascular injury - likely OR Zone II & III - ?pulsatile, ?expanding - determines intervention Packing vs arterial embolization - majority of traumatic RPH are venous in nature CORE CONCEPTS: - RPH is a rare diagnosis with significant mortality - see keep on your differential! - Undress your adult patients too - look for Fox's sign, etc - Most common presenting symptom: abdominal pain, then leg or back pain - Seen more commonly in elderly and those on anticoagulation, but 1/3 of pts who presented with spontaneous RPH were not on anticoagulation
1 Comment
The Return ED Visit
"BB" Shot to Right Groin...
- Bullet embolism is extremely rare. - Requires multidisciplinary management. - Consider possibility if missile lays next to major vessels or bullets are found in unexpected locations. - Venous more common than arterial FLU 1st presentation - viral symptoms. 2nd presentation - viral symptoms. 3rd presentation (within 24 hours) - SHOCK with Resp Failure
Tamiflu is not magic...
CORE CONCEPTS
Special Circumstances:
1. Spearing injury - duodenal injuries, rectus injury with hernia, pancreatic injury - handlebar, ski pole, - duodenal hematoma- CT with oral contrast - pancreatic injury - get lipase (usually presents in delayed fashion) 2. Seatbelt sign - Ecchymosis / Bruises ... not just abrasions - get CT, give good return precautions or have them come back for check 3. Geriatric - VS misleading, abdominal exam insensitive, lactate > 2( sensitive to occult shock) - liberal role for CT - low threshold for admit PECARN Rules: get CT if, - Abdominal wall trauma, seatbelt sign - GCS< 14 - Tenderness - Chest wall trauma - Intoxication, - Hematuria - Elevated LFT - Painful distracting injury Finger Infections - Paronychia- disruption of nail fold/ plate, mixed flora + staph - erythema swelling tender, can extend into eponychium - tx- warm soaks, po abx, I&D - Felon- infection of hyponychium, progressing to pulp - tx- soaks, elevation, abx; surgical- incision options for i&d - may use transverse incision here, must disrupt all septae, - wick/drain that is changed at 24hrs, - abx- iv in ed - Flexor Tenosynovitis- infx of synovial sheath around flexor tendon, - mechanism is penetrating injury, may be direct spread from other area; - s. aureus; - kanaval signs - flexed posturing, pain with passive extension, fusiform swelling of digit; TTP over palmar aspect of digit - tx- early- admit, obs, abx but will usually go to OR Nail Bed Injuries - get an xray, 50%with tuft fracture - repair: removal of plate, elevate proximal nail fold if needed; wash out; closure 5-0 chromic, 4-0 nylon for surrounding skin - protection of repair- native nail is ideal, or silicone, aluminum; secure with suture; protect scaring of nail fold down Tip Amuptations - Preserve fxnal length, durable coverage - <1cm squared can be healed by 2ndary intention; 4-5 weeks to heal, pain control, abx, tetanus; - Find digital nerves, pull out, trim to avoid neuromas. - Exposed bone- need rongeurs, bone cutters, take joint surface off - If you close primarily, space out sutures - Dressings non-circumferntial, loose2x2, cast padding, bias Finger Dislocations - palmar dislocation - recreated deformity then volar force - no splint needed, buddy tape - volar dislocations - hyperflex, dorsally reduce, splint in extension Pneumococcal Meningitis with HUS Usually serotypes outside of 13-valent vaccine If you suspect, initial treatment with: - Cefotaxime 300 mg/kg/day IV (max 12g/day) in 3 doses OR - Ceftriaxone 100mg/kg/day IV (max 4g/day) in 2 doses PLUS - Vancomycin 60mg/kg/day IV (max 4g/day) in 4 doses Pneumococcal HUS Recognize classic triad: - Microangiopathic hemolytic anemia - Thrombocytopenia - Acute Kidney Injury Sources: - PNA - 70% - Meningitis - 20-30% - Others - Otitis, sinusitis, bacteremia - Not like STEC-HUS - Needs Tx with Abx - Pneumococcal leads to higher M&M Hemoptysis from 5-yr old retained GSW Delayed Pulmonary Hemorrhage from FB - Up to 30 yrs latency reported - Present with intermittent hemoptysis Complications: - Pulm Art or Aortic Pseudoaneurysm - AVMs with R -> L shunts - Embolization - arterial or venous Massive Hemoptysis No universal definition - "Is this life threatening?" Initial ED Management - ID bleeding lung and position dependently - A - Establish airway (8-0 ETT or bigger for bronchoscope) - B - Ensure good gas exchange on vent - C - Stop bleeding! Restore volume, give PRBCs, reverse coagulopathy,etc... Regular Wide Complex Tachycardia
- Consider VT until proven otherwise!!! - 80% is VT by numbers - Algorithms to differentiate SVT are difficult to remember - If you treat for VT, won't harm SVT - Nodal blockers for SVT can send VT into VF -- PLACE PADS with Adenosine! A great analysis of EP and Cardiologist failure in applying Brugada to electrophysiologically proven VT. Two fantastic talks from the ever-salient @amalmattu - VT vs SVT with Aberrancy - Adenosine Sensitive VT Dens fracture > Type I: Extends through the tip of the dens > Type II: Extends through the base of the dens - unstable > Type III: Extends through vertebral body of axis - can be unstable Geriatric Trauma - Falls - leading cause of injury - Frequently fail to mount a tachycardic response TB meningitis
> If lymphocytic meningitis, likely not viral if low glucose - LOW GLUCOSE IS NOT NORMAL FOR VIRAL MENINGITIS > Absence of fever doesn't exclude TB > Cranial nerve 6 = most common nerve palsy in meningitis Chronic Acetaminophen Toxicity - Can't use nomagram with chronic ingestions - NAC - replenished and maintains glutathione stores - also thought to have a role in free radical scavenging; IV or PO acceptable - If unknown ingestion time and LFTs or APAP elevated Impact - Head injury is the #1 killer the trauma patient To scan or not to scan? Cost Issues - Head CT = $2700 Occult Injury Issues
If GCS = 14, 10-20% + head CT If GCS 13 = 20-30% + head CT So, if GCS is not 15... risk increases substantially. 2 classes of head trauma patients:
New Orleans Head CT rule - goal was to identify all patients with abnormal scan.
Canadian Head CT rule - looking for clinically significant findings - more specific
Use with caution in drunk folks! Anticoagulation is the Enemy! IMAGE ALL ANTICOAGULATED HEAD TRAUMA -- Much higher mortality in anticoagulated patients when compared to age matched controls Plavix vs Coumadin? -- Observational study of adult ED patients with blunt head trauma on coumadin vs plavix -- higher risk of immediate bleed in plavix -- important - 60% of people with bleeds had GCS 15 and 70% had no LOC Delayed Bleeds? -- Risk of delayed bleed relatively small; -- People with negative head CT who are THERAPEUTICALLY anticoagulated can be DC'ed home -- People who are supra-therapeutic likely need observation. Blood in the Brain is Bad. Airway management - want to minimize increased ICP RSI > Lidocaine - theoretically is supposed to attenuate cough reflex but hasn't been proven to change outcomes > Sucyincholine - can use without concern of worsening ICP from fasiculations > Ketamine - is ok to use in ICP - good literature that ketamine can help with ICP and avoids risk of hypotension that can occur with etomidate (don't use if has history of obstructive hydrocephalus) - use 1-2mg/kg Ventilator settings - RR of 12 Mannitol: 1g/kg (0.5g/kg - 1.5g/kg) - some evidence higher doses are more effective. The Primary damage has been done... your job is to Prevent Secondary Injury
IMPENDING HERNIATION (and briefly in conjunction with other measures); endpoint 30 mm Hg d. Steroids, narcan, hypothermia - none has been proven to work * No fantastic evidence in people on ASA with head trauma* QUICK HIT CORE CONCEPTS
***Mortality in trauma increases dramatically with increased age, inc 7% mortality for each year over 65 in trauma ***Liver disease is the worst premorbid condition for trauma ***Standard trauma assessment is inadequate in elderly, particularly vital signs insensitive ***Falls: 10% significant injury, in geraitric population cervical spine fractures common ***Have decreased cardiac output, may not be able to mount adequate tachycardic response, may have occult shock. Have consideration for peri-traumatic MI both prior to trauma or stress of trauma causing MI ***Pulmonary issues: Decreased reserve, increased risk ARDS and atelectasis, CO2 narcosis ***CNS: High risk of subdural, clouded by questionable baseline mental status ***Renal: Often baseline poor GFR, CT Contrast can cause significant injury ***Trauma triage poor in elderly: Age >55 should be at a trauma center ***CMC TRAUMA ACTIVATION for geriatrics ATC 1:: Age >65: HR>100, SBP<110 ALERT:: Age >65 involved in MVC or fall from height ***MANAGEMENT Airway: Increased aspiration risk. Consider dentures. Consider high cervical spine risk and maintain proper imobilization. Consider increased response to induction agents: decreased your dose. Breathing: Decreased reserved, rapid desaturation. Use passive oxygenation. Use ETCO2. Consider increased risk of rib fractures. Circulation: Decreased response to catechols, on beta blockers; may not mount tachycardia appropriately. Consider RELATIVE hypotension. --Journal trauma study shows HR >90 and SBP <110 significant increased in mortality Disability: Central cord syndrome more common in elderly, may have "Hand burning", will have upper extremity weakness and capelike paresthesia ***SHOCK INDEX HR/Systolic blood pressure Normal less than 0.6, realistic threshold <0.8 More sensitive than HR or BP alone Even better: Shock index * Age should be <50 ***If concerned about fluids, use repeated small boluses (250ml) ***Anemia: Follow serial hemoglobins and transfuse early. Transfusion threshold controversial, starting thinking about it around 8 or persistent hypotension ***History: Keep in mind precipitating events, syncope in 10-15% of geriatric fall/MVC ***Identify blood thinner use!! Coumadin, plavix, ASA, Anti 10A, anti thrombin ***CAREFUL chest exam: Must identify rib fractures, flail chest; XRAY low sensitivity for these. Traumatic aortic dissection often does not have external signs of injury. ***Abdomen: Geriatric may NOT develop peritonitis despite significant intraabdominal injury ***LABS: Always get lactate; highly predictive of bad outcome >2 admit, >3 ICU, >4 call chaplain. (40% mortality in lact >4) Upgrade to ATC 2 if INR >2 or Lactate >2.5 ***ECG Routine in geriatric trauma ***Careful with opiates in elderly, start low doses ***Head trauma: 80% mortality if GCS<8 Any anticoagulation with head trauma = scan ***Anticoag reverse> Coumadin, see protocol Antithrombin: May try FFP but pretty much screwed Anti Xa: PCCC may be beneficial (see protocol for dosing) ***Rib fractures: Risk of atelectasis, resp faulire, pneumonia Admit if >3 rib fx. Consult if 1 or more if frail, live alone, any concern really ***Elderly aorta Eggshell appearance distant from border of aorta may indicate dissection (Egg shell or Halo sign) ***Pelvic fx mortality 50% if hypotension, 90% if open. Eval for hemoperitoneum and aortic rupture ***Burns.. Baux index: Mortality = age + TBSA. Age >50 with bad burns, = burn center **BEWARE Cold and quiet, elderly trauma patient! HIGH YIELD CONCEPTS:
- Bifacet dislocation - Type II odontoid fracture - Hangmans fracture - distraction & rotation injury - posterior element of C2 gets fractured & spondylolisthesis of axis - Flexion Teardrop - most serious of all Cspine fractures For Cranial Imaging:
For Cervical Imaging:
For Abdominal Injury:
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