New Site

I have changed to a new blog:

http://ecc-education.blogspot.com

Please check it out!!!

I was just reviewing chemical sedation in the ED and after considering the many options I am still very partial to the tried and true B52: Benadryl 50 mg, Haldol 5 mg, Ativan 2 mg.

I've been using CHADS2...Anyone using CHA2DS2-VASc?

"A newer risk score to determine stroke risk in atrial fibrillation patients called CHA2DS2-VASc may provide a more accurate risk assessment."

Clinical calculators

We recently updated our EMR with some new clinical calculators.  My job was to help implement, explain, advocate, and ultimately educate my partners about these tools.  Here is one of the pictures I used to make a very important point:

Clinical calculators are tools.  They can be very helpful tools, but they must be used intelligently, or BAD THINGS can happen.

Chance Fracture

Chance Fracture of the Spine

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- Discussion:
    - Chance frx & posterior ligament rupture (variant of flexion distraction injury pattern) may
          present w/ minor anterior vertebral compression;
          - in Chance frx, the anterior column fails in tension (along w/ the middle and posterior columns),
                 where as flexion distraction fracture involve compression of the anterior column and
                 distraction of the middle and posterior columns;
    - approx 1/2 of pts w/ flexion distraction injury pattern have primarily ligamentous rupture;
          - rupture usually includes interspinous ligament, ligamentum flavum, facet capsule, posterior
                 annulus, and thoracodorsal fascia;
    - whether the injury is purely ligamentous or includes a fracture thru vertebral body, all three columns
          rupture in distraction (tension);
    - often these are misdiagnosed as a compression frx;
          - the occurance of a traumatic compression fracture in a young patient (following MVA) should
                 raise the possibility of a Chance fracture;
          - either good quality AP view is necessary to rule out posterior element injury, or a CT scan is
                 required (if the AP view remains equivocal);

- Exam:
    - seldom assoc w/ neurologic compromise unless
    - abdominal injuries are common and occur in upto 50-60% of patients;
    - references:
          - The epidemiology of seatbelt associated injuries.
                 PA Anderson et al.  J. Trauma. Vol 31. 1991. p 60-67.

- Radiographs:
    - significant translation on lateral;
    - anterior wedging may be minimal;
    - often only a portion of the vertebral body will be involved (half ligamentous and half bony injury);
    - look for frx line extending thru spinous process, lamina, pedicles, & portion of the vertebral body;
    - often the AP view will best show the posterior element injury (lamina frx will appear as a "lazy W")  

- CT Scan: is often ordered to help make the diagnosis;

   

- Non Operative Treatment:
    - Chance Frx may initially be unstable, but after 2 weeks there will be sufficient bony healing
           to allow fitting for an orthosis;
           - patients w/ partial vertebral body involvement (half bony injury and half ligamentous injury)
                  may be candidates for non operative treatment is alignment is acceptable;
    - candidates for non operative treatment should have less than 15 deg of kyphosis;
    - patients should be fitted for a custom molded hyperextension orthosis;
    - fractures below L3 may require the addition of a thigh extension;

- Indications for Operative Treatment:
    - w/ Ligamentous Chance Injury, soft tissue healing is unreliable, and about
           half of all patients treated non operatively will have poor outcomes;
           - progressive kyphosis is one of the major complications w/ non-op Rx;

Afferent Pupillary Defect

Marcus Gunn pupil (relative afferent pupillary defect)

is a medical sign observed during the swinging-flashlight test^[1] whereupon the patient's pupils constrict less (therefore appearing to dilate) when a bright light is swung from the unaffected eye to the affected eye.

The affected eye still senses the light and produces pupillary sphincter constriction to some degree, albeit reduced.

The most common cause of Marcus Gunn pupil is a lesion of the optic nerve (proximal to the optic chiasm) or severe retinal disease. It is named after Scottish ophthalmologist Robert Marcus Gunn.^[2]


  Look for an afferent pupillary defect (RAPD - also known as Marcus Gunn Pupil) by:

a.       The Swinging Flash Light Test

b.      The pupils must react to light in order to perform the test

c.       Not a test of the pupil per se—but we do the test when we look at the pupil

d.      Tests the optic nerve function

e.       Relies on a difference between the two optic nerves—one must be different from each other

 

 

Subperiosteal Abscess

Bilateral ethmoidal sinusitis with subperiosteal abscess of the left medial wall.