Saturday, May 26, 2012

Spinal cord injury syndromes

Central cord syndrome
Incomplete spinal cord injury
Weakness in the arms with relative sparing of the legs with variable sensory loss
Ischemia, hemorrhage, or necrosis involving the central portions of the spinal cord
May be seen in recovery from spinal shock due to prolonged swelling around or near the vertebrae, causing pressure on the cord. Can be transient or permanent.

Anterior cord syndrome
Associated with flexion type injuries to the cervical spine
Damage to the anterior portion of the spinal cord and/or anterior spinal artery
Below the level of injury motor function, pain sensation, and temperature sensation are lost
Touch, position and vibration are intact

Posterior cord syndrome
Posterior portion of the spinal cord and/or posterior spinal artery
Loss of proprioception and epicritic sensation (e.g. stereognosis, graphesthesia) below the level of injury
Motor, pain, and sensitivity to light touch are intact

Brown-Séquard syndrome
Hemisectioned or lateral injury side (penetrating trauma)
Ipsilateral side loss of motor function, proprioception, vibration, and light touch
Contralateral side loss of pain, temperature, and crude touch sensations

NEXUS and Canadian C-spine rule: When to get films

Think about what you do in the ED? Do you recognize how following studies have impacted your practice?

National Emergency X-Radiography Utilization Study
Multicenter, prospective, observational study of patients with blunt trauma for whom cervical spine X-rays were obtained.

Get C-spine films if:

  • Patients with abnormal neurologic examination
  • Distracting or painful injury (like a femur fracture)
  • Depressed or altered mental status
  • Intoxication
  • Midline cervical tenderness should get an X-Ray

Canadian C-spine rule
A prospective cohort study in Canada evaluating patients with head or neck trrauma.

Radiography in high risk factors

  • Dangerous mechanism
  • Paresthesias

Assess range of motion in low-risk factors. If none of the following are present and the patient can actively rotate 45 degrees to left and right, then C-spine films may not be needed.

  • Simple rear-end MVC
  • Sitting position in the ED
  • Ambulatory at any time since injury
  • Delayed onset neck pain
  • Absence of midline C-spine tenderness

Friday, May 25, 2012

Pop! goes the appendix

Perforation is more likely in younger kids because:
1. More thin walled appendix, predisposing to early perforation
2. Younger children can’t communicate as well, resulting in prolonged symptoms before diagnosis
3. The level of suspicion for appendicitis is lower in younger age groups

Pro-Tip: In addition, appendicitis can progress to peritonitis quicker in infants, because they have a less well developed omentum, and thus cannot contain infection as well.

Pediatric Appendicitis Score

Pediatric Appendicitis Score

(1 point) anorexia
(1 point) fever
(1 point) nausea/vomiting
(1 point) migration of pain
(2 points) pain with cough, percussion, or hopping
(2 points) RLQ tenderness
(1 point) Leukocytosis (WBC > 10,000)
(1 point) Left shift (ANC >6750)

  • 10 point scale incorporating history, physical and lab components
  • Initial study (Samuels, 2002) with N = 1170
  • Prospective cohort age 4-15 with abdominal pain suggestive of appendicitis
  • Cutoff of >=6 provides 1.00 sensitivity and 0.92 specificity
  • Logistic regression to determine best fit of diagnostic variables for sum of true-positive and true-negative results (total joint probability for a single cutoff)

  • Validation studies have shown better performance at the ends of the spectrum (using 2 cutoffs)
  • Validated prospectively and retrospectivelyIn ages > 1
  • Using various combinations of cutpoints
  • High risk scores (> 7) had a specificity of 95-98%
  • Low risk scores (<3) had a negative predictive value of 98%
  • Moderate risk scores indicated the need for further imaging
  • Use of the PAS would have decreased the need for imaging

Leaderboard Update - Day 18

We are closing in on the conclusion of the #PEMTwitterTriviaContest. The leader board as of this morning...

1st @Bedingaj

Wednesday, May 23, 2012

Do it FAST!

FAST is a Focused Assessment with Sonography for Trauma that utilizes bedside ultrasound to rapidly identify intraperitoneal pericardial hemorrhage in trauma patients.

It is indicated in abdominal trauma patients who are hypotensive and/or who are unable to provide a reliable history. It is an adjunct to the primary survey (ABCs). In adults a positive FAST (blood in the abdomen/pericardium) means a trip to the OR for laparotomy. In children small amount of intraperitoneal blood is not as significant as in adults, and many can be managed conservatively.

Here are the locations for FAST





Images courtesy of - This is a great overview of FAST - Check it out here

Clavicle fractures - to fix or not to fix

In children 10 years of age and under 90% of clavicle fractures occur in the middle third, 60 percent of which are nondisplaced. Above age 10, the majority are displaced (as in adults). immobilization with sling and swathe for 3-4 weeks is generally sufficient for most uncomplicated fractures.

Outpatient Orthopedic referral is recommended for:

  • Patients with a completely displaced clavicle fracture, which is defined as displacement greater than one bone width.
  • Shortening greater than 18 mm in males and 14 mm in females because of the risk of significant morbidity, including local tenderness, numbness, pain when lying on the affected side, impaired range of motion, impaired strength, and cosmetic abnormalities
  • Comminuted fracture

Emergent referral is required for:
  • open fractures
  • neurovascular compromise
  • tenting of the skin (skin stretched tautly over a displaced fracture)

An open fracture should be suspected anytime there is a break in the skin near a fracture site. After puncturing the skin during the initial injury, fractured bone ends often retract under the skin and cannot be seen with simple inspection. If respiratory compromise or hemodynamic instability exists, serious injury to intrathoracic or other structures should be suspected and immediately addressed. proximal third clavicle fractures are generally associated with more significant trauma, and have a higher potential for internal injuries.

Traditionally the management his followed the dictum "If both ends of the bone are in the same room, then sling and swathe alone is sufficient." New evidence has suggested otherwise.There may be advantages to repairing select medial fractures in the OR. See this article for more information.

Tuesday, May 22, 2012

Kocher Criteria: Helping to differentiate septic hip versus transient synovitis

Kocher criteria for a child with a painful hip, suspected to have septic arthritis:
1) non-weight-bearing on affected side
2) sedimentation rate greater than 40 mm/hr
3) fever
4) WBC >12,000

Criteria met and probability child has septic arthritis
4/4 -- 99%
3/4 -- 93%
2/4 -- 40%
1/4 --  3%

Monday, May 21, 2012

Ow my elbow! A bit about supracondylar fractures of the humerus

Type I
Nondisplaced or minally displaced fracture
On the lateral view: anterior humeral line remains intact but a posterior fat pad sign may be present
Treated w/ immobilization in long arm posterior splint w/ elbow flexed and outpatient Ortho follow up

Type II
Posterior cortex remains intact, making it a greenstick fracture technically
Require adequate reduction and percutaneous pinning in many instances
Consult Ortho immediately

Type III
Displaced with no cortical contact
Immediate Ortho consult - This will need to go to the OR in most instances

Day 15 Leaderboard

There's a change at the top of the #PEMTwitterTriviaContest Leaderboard, as @Bedingaj has surged ahead with an impressive weekend stint. There's still plenty of time to catch up though, with competitors hot on her tail.

1st: @Bedingaj
2nd: @paulbunchmd

In the hunt: