Podcast #210: Bear Mauling

Author: Jared Scott M.D.

Educational Pearls:

  • Bear mauling is not a common issue in the ED.
  • The Ursus americanus (black bear) is the most common in Colorado, but Ursus arctos horribilis (grizzly bear) attacks are more frequent because they are more aggressive.
  • Head and neck lacerations are the most common injuries. Complications include infection and long term PTSD.
  • Most bear attacks are defensive in nature.
  • If a bear attacks you – lay face down and cover your neck with your hands.

References: Frank RC, Mahabir RC, Magi E, Lindsay RL, de Haas W. Bear maulings treated in Calgary, Alberta: Their management and sequelae. The Canadian Journal of Plastic Surgery. 2006;14(3):158-162. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2539044/

Podcast #204: Thoracotomy

Author: Aaron Lessen M.D.

Educational Pearls:

 

  • Thoracotomy is a potentially life-saving procedure. However, outcomes are often poor and the procedure itself poses many risks to provider and patient.
  • Chance of surviving a thoracotomy when there is no cardiac activity on ultrasound is 0%.
  • Performing a thoracotomy is unlikely to benefit patients with no cardiac activity on ultrasound or patients that lost vital signs greater than 10 minutes before starting the procedure.
  • A thoracotomy is maximally beneficial in patients with a penetrating chest injury that occurred less than 10 minutes before the procedure.

 

References: K. Inaba et al, “FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy: A Prospective Evaluation” Ann. of Surgery, 2015. https://www.ncbi.nlm.nih.gov/pubmed/26258320

 

Podcast #192: Back Fat Hernia

Author: Jared Scott M.D.

Educational Pearls:

  • There are two anatomical triangles on the back, the inferior lumbar triangle and the superior lumbar triangle.
  • Herniation occurs whenever something moves to a place where it is not supposed to be, often through a fascial weakness.
  • A “back hernia” can happen when the contents of of the abdominal cavity herniate into the back, usually through the superior lumbar triangle. This is also known as a Grynfeltt-Lesshaft hernia.
  • Back hernias can be traumatic or congenital.
  • These hernias are typically treated surgically.

References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959346/

 

Podcast #191: Blunt Cervical Trauma

Author: Chris Holmes M.D.

Educational Pearls:

  • Mechanism of injury involves hyperextension/hyperflexion
  • Pathophysiology: inside of the arteries in the neck becomes disrupted, similar to a dissection. This is thrombogenic and leads to cerebral infarction
  • Neurologic deficit is common.
  • Other risk factors include facial fracture and cervical-spine fracture.
  • Treat with anticoagulation – aspirin or other antiplatelet agents are appropriate.
  • Increase clinical suspicion when patient presents with neurological deficit and has a negative CT.

References: https://www.east.org/education/practice-management-guidelines/blunt-cerebrovascular-injury

 

Podcast #179: Concussions

b3a1b8b3-ea78-4c07-bbc8-8db303511de8Run Time: 1 minutes

Author: Aaron Lessen M.D.

Educational Pearls:

  • Patients with concussions are frequently seen in the ED, and generally are given good home health care precautions.
  • A new study for post concussion management looked at driving performance after a concussion.
  • The study showed that 48 hours after symptoms had resolved, patients who were diagnosed with a concussion did worse on a standard performance test than people without a concussion.

Link to Podcast: http://medicalminute.madewithopinion.com/concussions/

References: http://psycnet.apa.org/journals/neu/24/4/493/

http://emedicine.medscape.com/article/92095-overview

Podcast #174: Cervical Spine

8a7dc42a-f8b2-43c0-b61b-0beac1397e14Run Time:  5 minutes

Author: Dylan Luyten M.D.

Educational Pearls:

  • Cervical spine immobilization is a big change in the EMS protocol over several years.
  • Cervical collars were developed for rehabilitation after neck or spine surgery, but became a tool for prehospital treatment of undifferentiated trauma patients that may or may not have injured the neck.
  • There is no real evidence that the cervical collar prevents secondary spinal cord injury.
  • The problem is that these patients may not even exist. The forces to injure the cervical spine – transect the bones or tear ligaments – are so great the it is unlikely that the cervical spine was not also injured during the initial trauma.
  • Deterioration of a patient with a possible cervical spine injury are likely due to increasing edema and ischemia in the spinal cord.
  • The cervical collar does not diminish the force on the neck even with restriction of movement.

Link to Podcast: http://medicalminute.madewithopinion.com/the-cervical-spine/

References: http://www.jems.com/articles/print/volume-40/issue-2/patient-care/why-ems-should-limit-use-rigid-cervical.html

Podcast #168: GSW with Neurogenic Shock


9f97856c-43b7-48c2-8b2f-b915b1ba4316Run Time:  4 minutes

Author: Aaron Lessen M.D.

Educational Pearls:

  • Some of the main causes of hypotension in a trauma patient are hypovolemia, hemorrhagic shock, tension pneumothorax, and cardiac injury (including pericardial effusion). However; a patient with a gunshot wound presents to the ED with a SBP in the 90s, a HR in the 120s, 300mL of fluid from the chest tube, and on a dopamine drip, which is unusual for a trauma patient.
  • After a neurologic exam was performed on the patient, the patient was unable to move his lower extremities. The patient was sent to CT scan which showed that the bullet traversed from the right clavicle to the T12 vertebral body.
  • Another cause of shock in a trauma patient is Neurogenic shock, where the spinal cord loses sympathetic tone causing the blood vessels to dilate.
  • Treatment of neurogenic shock is different than other causes of shock in trauma. Usually early IV fluids and vasopressors are used for blood pressure support until the sympathetic nervous system responds. Classically Levophed is used, but other patients may respond better to other vasopressors.
  • Neurogenic shock is a diagnosis of exclusion. Other causes of traumatic shock that need more aggressive treatment should be considered first before jumping to treating neurogenic shock.

Link to Podcast:  http://medicalminute.madewithopinion.com/gsw-with-neurogenic-shock/#

References: http://www.jems.com/articles/print/volume-39/issue-11/features/assessment-and-treatment-spinal-cord-inj.html

http://www.cdc.gov/TraumaticBrainInjury/index.html

Podcast #166: Subdural Hematoma

00c86def-a234-422b-a345-2431643f87c8Run Time: 6 minutes

Author: Peter Bakes M.D.

Educational Pearls:

  • There are 3 layers of tissue between skull and brain – the dura which is adhered to the skull, the arachnoid, and the pia which is adhered to the brain.
  • There are bridging veins between the pia-arachnoid space, when these rupture the blood accumulates under the dura between the arachnoid space, usually in the temporal lobe, but can occur anywhere, resulting in a subdural hematoma.
  • Acute SDH: manifests as a hyperintense on imaging in the first 2 days, and manifests as an isodense from 2-14 days.
  • Chronic SDH: greater than 14 days manifest as hypodense.
  • Any SDH greater than 5mm is considered for surgical intervention if the patient is symptomatic, and any SDH greater than 10mm or with significant midline shift, regardless of symptoms are surgically treated.
  • A craniotomy (remove skull and put it back) is performed to evacuate the hematoma.
  • A craniectomy (remove skull and don’t put it back) is performed if the patient has underlying tissue damage and expected interval swelling.
  • Chronic SDH are only treated with trephination (poke a hole in it) if the patient is significantly symptomatic, in case there is a future need to perform a craniotomy.

Link to Podcast: http://medicalminute.madewithopinion.com/subdural-hematoma/

References: http://neurosurgery.ucla.edu/acute-subdural-hematomas

Podcast #148: Knee Dislocation

4ecce1c5-678a-4ad3-be1e-06469ce3fd90Run Time:  4 minutes

Author: Samuel Killian M.D.

Educational Pearls:

  • A true knee dislocation and a patellar dislocation are slightly different conditions. A true knee dislocation is the translation of the femur and the tibia – described as anterior/posterior, posterior/anterior, medial/lateral.
  • Knee dislocations occur after a high force blow to the leg.
  • 50% of the time the knee can be self-reduced or naturally reduced prior to presentation to the ED. Otherwise the knee dislocation is totally obvious.
  • The big concern with a knee dislocation is vascular or nerve injury.
  • Popliteal artery injury occurs approximately 50% of the time. Normally this is evaluated by feeling for pulses, assessing discoloration, but 10% of cases can have normal pulses with serious injury.
  • Patients with popliteal artery injury may need emergent revascularization surgery if there are hard signs of vascular injury.
  • If a patient has no hard signs of vascular injury then ABI (ankle-brachial index) is used to assess the likelihood of injury – ABI of >.9 then there is 95% sensitivity for no significant arterial injury, ABI of <.9 then it is highly likely that there is significant arterial injury.
  • 30% of knee dislocations have peroneal nerve injury, which presents as numbness in 1st web space or trouble with dorsal flexion, however this may be hard to assess due to the patient’s pain.

Link to Podcast: http://medicalminute.madewithopinion.com/knee-dislocation/

References: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC535529/

Podcast #145: Eye Injuries

acbd2571-f80b-492c-b937-5b9ab347ceb2Run Time: 3 minutes

Author: Jared Scott M.D.

Educational Pearls:

  • Patient profile: sustained blunt trauma to the face. On eye exam the left pupil is eccentric pulled to the side and vertically oriented, and there is a large dark space lateral to the iris.
  • This patient has Iridodialysis: localized separation or tearing away from the iris from the ciliary body.
  • Smaller separations are usually asymptomatic, but larger separations have vision loss, photophobia, and diplopia because light is not entering the pupil normally and additional light is entering the lense from the side of the iris.
  • Iridodialysis usually results from blunt trauma to the face including boxing, airbag deployment, high pressure water jets, etc.
  • Patients with large defects may go to surgery, where the surgeon slides the iris over and sutures it in place w/ 10-0 prolene.
  • Most patients have an associated hyphema – If the hyphema is very large the patient goes to the OR for a wash out.

Link to Podcast: http://medicalminute.madewithopinion.com/eye-injuries/

References: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4759894/