tag:blogger.com,1999:blog-87761071489731661642024-03-13T16:48:23.581-04:00PEMTweetsA site devoted to education in Pediatric Emergency MedicineBrad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.comBlogger37125tag:blogger.com,1999:blog-8776107148973166164.post-8958828075261282742012-08-12T14:41:00.003-04:002012-08-12T14:41:50.869-04:00PEMTweets Blog has moved<span style="font-size: x-large;">Go and check out the blog at the new home</span><br />
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<a href="http://www.pemcincinnati.com/blog"><span style="font-size: x-large;">www.pemcincinnati.com/blog</span></a></h2>
<br />Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-52792739533430809342012-07-27T10:28:00.000-04:002012-07-27T10:28:19.588-04:00Acute testicular/scrotal pain<br />
<h2>
<span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;">History & Physical Exam</span></h2>
<div class="MsoNormal" style="margin-bottom: 0in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><o:p></o:p></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Pain? Acute onset suggests torsion, epididymitis, or torsion of the appendix testis/epididymis<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Trauma?<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Change in size? Valsalva = hydrocele<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Sexually active? Epididymitis in adolescents<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Difficulty voiding? Think mass, cord lesion, UTI<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Flank pain or hematuria? Referred pain from a kidney stone<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Abdominal pain, nausea/vomiting? Torsion<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Setting the stage<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Get a chaperone if you or patient are uncomfortable<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Have the patient stand if possible<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">If you suspect a varicocele examine the patient supine as well<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Respect the patient’s privacy!<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Don’t forget to examine the;<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Inguinal folds<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Penis and urethra<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Pubic hair<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Testicular position (left is lower)<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Testicular lie</span></li>
</ul>
</ul>
<h2>
<span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;">Testicular torsion</span></h2>
<div class="MsoNormal" style="margin-bottom: 0in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><o:p></o:p></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Surgical emergency!<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">The testicle twists on the spermatic cord<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Venous compression then…<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Edema of testicle and cord then…<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Arterial occlusion then…<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">1/4000 males < age 25<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Bimodal - neonatal and puberty<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">65% between ages 12-18 years<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Likely due to increasing testicle volume<o:p></o:p></span></li>
</ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;"><span style="text-indent: -0.25in;">Bell clapper deformity</span><span style="text-indent: -0.25in;">Testis is not fixed to the tunica vaginalis posteriorly and i</span><span style="text-indent: -0.25in;">t is free to rotate and is at increased risk of torsion.</span><span style="text-indent: -24px;">Incidence is approximately 1/125 and u</span><span style="text-indent: -24px;">sually present bilaterally.<span style="background-color: black;"><br /></span></span></span></li>
<li><span style="background-color: black; color: white; font-family: Arial, Helvetica, sans-serif; text-indent: -0.25in;">Presentation</span></li>
<ul>
<li><span style="background-color: black; color: white; font-family: Arial, Helvetica, sans-serif; text-indent: -0.25in;">Abrupt onset of pain <12 hours</span></li>
<li><span style="background-color: black; color: white; font-family: Arial, Helvetica, sans-serif; text-indent: -0.25in;">Associated N/V, lower abdominal pain</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif; text-indent: -0.25in;"><span style="color: white;"><span style="background-color: black;">In a retrospective review only 8% had pain prior to this episode (Kadish, 1998)</span></span></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Exam<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Edema of scrotum<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Testis – tender and slightly elevated, may have a horizontal lie<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Cremaster reflex is absent<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Torsion is ideally a clinical diagnosis<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">If suspected tell your Attending and call Urology ASAP<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Ultrasound<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Sensitivity 69-100%<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Specificity 77-100%<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Nuclear medicine scans are very sensitive and specific – but not readily available<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Surgery<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">If viable – detorsion of affected testis and fixation (orchiopexy) of both testis<o:p></o:p></span></li>
</ul>
</ul>
<div class="MsoListParagraphCxSpFirst" style="margin-bottom: 0in; text-indent: -0.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 7pt;"> </span><b><span style="font-size: large;">Viability rates<o:p></o:p></span></b></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0in 1in; text-indent: -0.25in;">
<b><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Within 4-6 hours 100%<o:p></o:p></span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0in 1in; text-indent: -0.25in;">
<b><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">12-24 hours 20%<o:p></o:p></span></b></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 0in 1in; text-indent: -0.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><b><span style="font-size: large;">>24 hours 0%</span></b><br /><br /><o:p></o:p></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Sequelae<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Males may have increased risk of infertility even when viable de-torsed testis is left in scrotum because of immune-mediated injury to contralateral testis<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Other studies have failed to show that anti-sperm antibodies are present<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Intermittent torsion<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">80% have bell clapper deformity<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Pain is brief and resolves quickly (minutes)<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Eaton et al, 26% had nausea and vomiting, 21% pain awakened patient from sleep<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Neonatal torsion<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">A topic that could have its own talk<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Many cases occur in utero</span></li>
</ul>
</ul>
<h2>
<span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;">Torsion of the appendix testis and appendix epididymis</span></h2>
<div class="MsoNormal" style="margin-bottom: 0in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><o:p></o:p></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Vestigial structures<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Appendix testis: Müllerian system<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Appendix epididymis: Wolfian system<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">They torse easily<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Boys 7-12 years of age<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Pain is usually less severe<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">The ‘blue dot sign’ is the pathognomonic physical finding<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Due to infarction/necrosis of the appendix<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">A reactive hydrocele may also be seen<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Diagnosis<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Usually clinical if you see a ‘blue dot sign’<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Get an Ultrasound in cases where you can’t r/o torsion<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Management<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Analgesics<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Rest<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Scrotal support<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">The pain typically resolves in 5-10 days</span></li>
</ul>
</ul>
<h2>
<b><span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;">Epididymitis</span></b></h2>
<div class="MsoNormal" style="margin-bottom: 0in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><o:p></o:p></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Etiology<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Sexually active? Chlamydia, gonorrhea, E.coli, viruses<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Prepubertal? Viruses, E. coli, mycoplasma<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Presentation<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Pain and swelling localized to the epididymis<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Testis has a normal lie<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">50% have scrotal edema<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">The scrotum is sometimes red<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Cremaster reflex is present<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Positive ‘Prehn sign’ (not reliable)<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Patient may have dysuria<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">The work-up<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Clinical exam<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Ultrasound<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Urinalysis<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Obtain in <u>ALL</u> patients with suspected epididymitis<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">STD testing<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Get gc/chlamydia DNA of urine if sexually active<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Syphilis and HIV testing<o:p></o:p></span></li>
</ul>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Prepubertal boys<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Antibiotics are NOT always indicated<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Treat if.. Pyuria >3-5 wbc, positive U/C, or underlying UTI risk factors - TMP/SMX or Cephalexin for 10 days<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Teenagers (Pro-Tip: think about STDs)<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Ceftriaxone 250mg IM x1 then doxycyline 100mg bid x10 days<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">For enterics AND negative STD…<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">10 days of ofloxacin 300mg bid or levofloxacin 500mg qday<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: 0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Tx also includes rest, NSAIDs, and scrotal elevation</span></li>
</ul>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-6443054011532372012012-07-17T07:35:00.001-04:002012-07-17T07:35:41.986-04:00 Academic Life in Emergency Medicine: Trick of the Trade: Converting % to mg/mLGreat quick tip here!<br />
<br />
<a href="http://academiclifeinem.blogspot.com/2012/07/trick-of-trade-converting-to-mgml.html?spref=bl"> Academic Life in Emergency Medicine: Trick of the Trade: Converting % to mg/mL</a>:<br />
<br />
It's as simple as adding a zero - Seriously!Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-74300989091940716272012-07-06T12:33:00.001-04:002012-07-19T16:21:10.556-04:00Ouch my eye! Ocular injuries in the pediatric ED<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">Here are some highlights from Eileen Murtagh-Kurowski's talk on ocular injuries on 7/6/12</span><br />
<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="background-color: black; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;"><span style="color: white;">Before moving on check out the PEM</span><b><span style="color: red;">SHORT</span><span style="color: white;">/CUTS</span></b><span style="color: white;"> video on using the Panoptic Ophthalmoscope</span></span><br />
<span style="color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;"><a href="http://www.vimeo.com/pemcincinnati/panoptic" style="background-color: black;">www.vimeo.com/pemcincinnati/panoptic</a></span><br />
<span style="background-color: black;"><span style="color: white;"><br /></span></span><br />
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<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">
Corneal abrasions</span></h3>
<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">Can only be diagnosed reliably with fluorescin under a Wood's lamp (black light). It may be advantageous to use tetracaine during the instillation of fluorescin. Otherwise saline will suffice. Fluorescin is safe to instill in any eye - even in an open globe. Please let your patients know that the tetracaine will burn during instillation. The treatment generally consists of topical antibiotics - I'll ask the parent which type (erythromycin ointment or polytrim drops) they would prefer. Generally corneal abrasions will heal well in less than a week, antibiotics can help reduce the already low risk of infection.</span><br />
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<a href="http://www.eyedoctom.com/EyeInfo/Images/CornealAbrasion.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;"><img border="0" src="http://www.eyedoctom.com/EyeInfo/Images/CornealAbrasion.jpg" /></span></a></div>
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<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">
Foreign bodies</span></h3>
<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">Everting the top eyelid can allow you to visualize a foreign body which is usually behind the upper lid. Removal of material adherent to the inside of the upper lid can be done with a cotton swab, flush with saline, or needle nose forceps. Removing a foreign body off of the surface of the eye can be done (delicately) with an 18 Guage needle to 'flick' it off of the eye. Topical antibiotics are always appropriate.</span><br />
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<a href="http://www.tedmontgomery.com/the_eye/eyephotos/pics/ConjunctivalForeignBody.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;"><img border="0" height="240" src="http://www.tedmontgomery.com/the_eye/eyephotos/pics/ConjunctivalForeignBody.jpg" width="320" /></span></a></div>
<span style="background-color: black;"><span style="color: white;"><br /></span></span><br />
<h3>
<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">Abnormally shaped pupil</span></h3>
<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">A pupil that is not a circle is bad. This generally indicates that the ciliary muscles of the iris have been disrupted/compromised. This can be due to direct trauma or an open blow.</span><br />
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<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">Traumatic iritis</span></h3>
<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">Look for the patient with decreased visual acuity and extreme light sensitivity.</span><br />
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<a href="http://eyepathologist.com/images/Kl25016.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;"><img border="0" height="320" src="http://eyepathologist.com/images/Kl25016.jpg" width="320" /></span></a></div>
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<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">Hyphema</span></h3>
<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">Blood in the anterior chamber will create a meniscus like effect. These occur usually due to ocular trauma. The biggest risk is of acute angle closure glaucoma. The treatment is bed rest - for patients with a a hyphema >25-50% of the anterior chamber admission might be warranted. Rebleeding can occur - and the risk extends into and in some cases beyond the second or third day.</span><br />
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<a href="http://www.kellogg.umich.edu/theeyeshaveit/trauma/images/hyphema.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;"><img border="0" height="234" src="http://www.kellogg.umich.edu/theeyeshaveit/trauma/images/hyphema.jpg" width="320" /></span></a></div>
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<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">The open globe</span></h3>
<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">Generally fluorescin adheres to epithelium. Fluorescin that 'flows' is generally floating on the aqueous material. This is AKA Seidel's sign. The classic 'tear drop' shaped pupil is an important finding to recognize.</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPs9zKVXBDGkS98h-zKAAg0CUB27fxIaDh3r1YQDnt7kU26m1N_DDrwYQQ8BfJwrJBT9HGtzQJINR5_M8DLk2xuQAUJ_2_YiAtF1y_DS0H0zv09q6SWZxyXKz1icCBTdaZrMjZ_92lB1k/s1600/teardrop.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;"><img border="0" height="272" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPs9zKVXBDGkS98h-zKAAg0CUB27fxIaDh3r1YQDnt7kU26m1N_DDrwYQQ8BfJwrJBT9HGtzQJINR5_M8DLk2xuQAUJ_2_YiAtF1y_DS0H0zv09q6SWZxyXKz1icCBTdaZrMjZ_92lB1k/s320/teardrop.jpg" width="320" /></span></a></div>
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<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">
Uveitis and hypopyon</span></h3>
<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">White fluid in the anterior chamber - similar to a hyphema - is a hypopyon which can be infectious or inflammatory.</span><br />
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<a href="http://medicalpicturesinfo.com/wp-content/uploads/2011/09/Hypopyon-3.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;"><img border="0" height="217" src="http://medicalpicturesinfo.com/wp-content/uploads/2011/09/Hypopyon-3.jpg" width="320" /></span></a></div>
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<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">General pearls</span></h3>
<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">1. The visual acuity is the vital sign of the eye</span><br />
<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">2. Always ask patients with eye infections whether or not they wear contacts</span><br />
<span style="background-color: black; color: white; font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">3. Use the panoptic ophthalmoscope for a much better view of the retina and fundus</span>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-35624272201504542172012-06-06T23:05:00.003-04:002012-06-06T23:05:45.773-04:00To scan or not to scan - my thoughts<span style="font-family: Arial, Helvetica, sans-serif;">If you recall from my previous post we were considering when to get a head CT on a pediatric patient with a closed head injury, and specifically how to approach this with the family. In general I find that its best to be honest and discuss the criteria outlined in the Kuppermann article. Even if there is a parental <i>expectation</i> of a getting a head CT even before you enter the room, I've found that most parents understand where your coming form when you approach things in a straightforward and honest manner. They just want what's best for their kid - scan or not after all.</span><div>
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<div>
<span style="font-family: Arial, Helvetica, sans-serif;">But what about those parents that still demand a scan for their child who is making shadow puppets with the otoscope light? First, it's important to address their concerns honestly and without pretension. Find out what they are worried about. Perhaps they had a family member who died in a car crash. Or just had an experience where "the doctors missed something." It's also important to remember that we aren't perfect diagnostic machines. Parents do know their children best. And on the flip side, if a situation seems fishy, especially in cases of suspected non accidental trauma, go ahead and get the scan.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;">The bottom line is that you should be familiar with how to explain the current evidence to your patients, and to openly acknowledge the risks, benefits, and parental concerns. Even with zero of the predictors for clinically important traumatic brain injury, there is still a 0.5% chance that the kid has a head bleed - even if they look perfect. Every parent - including this one - views their kid as one in a million.</span></div>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com2tag:blogger.com,1999:blog-8776107148973166164.post-87139051661757089262012-06-04T13:53:00.000-04:002012-06-04T15:18:46.282-04:00To scan or not to scan - that is not the (only) question<span style="font-family: Arial, Helvetica, sans-serif;">Inspired by the cadre of closed head injuries that I saw in a recent shift I figured I'd launch phase 2.0 of The PEMTweets website with a discussion about how we manage closed head injuries in children. The issue I'll be addressing here is not one of when to scan or not to scan - that is an important decision that is now well supported by existing literature. Instead, allow me to focus on how we communicate our decision to an anxious family. </span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">So, if you haven't already done so , go ahead and read the seminal Lancet 2009 article.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><a href="http://www.sciencedirect.com/science/article/pii/S0140673609615580">Kuppermann - Lancet, 2009</a></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">OK, welcome back... I ended up seeing three patients, all of whom presented by smacking their heads on hard surfaces. I've changed their names and ages to protect the innocent, and to avoid the wrath of Hungry Hungry HIPAA. </span><br />
<br />
<ol>
<li><b style="font-family: Arial, Helvetica, sans-serif;">The first patient was a school aged male whose bike failed him, and whose helmet was hanging in his garage. He ended up introducing his occiput to the pavement, though his recollection of this event was foggy at best. His sensorium was mired in the same fog.<br /></b></li>
<li><b><span style="font-family: Arial, Helvetica, sans-serif;">The second was an infant, who despite her mother's best efforts, wriggled free from her arms and fell to the concrete below. The baby cried immediately, and aside from the large hematoma on her forehead, looked great.<br /></span></b></li>
<li><b><span style="font-family: Arial, Helvetica, sans-serif;">Sensing a theme, you might wager that the third cranium contacted concrete in a concussive cacophony (sorry about the alliteration). It did, but 2 days ago. A visit to an urgent care, and a 'medical' neighbor later - had filled the family with enough information to seek care at my ED as they wondered whether or not their robust toddler needed a head CT.</span></b></li>
</ol>
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">There is a delicate balance between managing the anxieties and expectations of a parent, when they are (justly so) legitimately worried about their child's well-being. Perhaps they are a medical professional themselves, and armed with just enough (mis)information to make them worry more than they should. Or maybe, they consulted Dr. Google, or worse, Dr. facebook in that back alley clinic that would make Dr. Nick Riviera of the Simpson's blush.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">Go ahead and think for a moment about whether or not you would order a head CT on each patient (I know you are thinking about the decision to scan in each, as your natural medicine brains will not allow you to avoid pursuing a diagnoses). But, hopefully this post will instead stimulate you to think about another very important question. Namely, how do you summarize the literature for an anxious, perhaps tearful family, and how do you communicate your recommendations to them, given the evidence that suggests when to scan, in the face of mounting concerns about the exposure to ionizing radiation.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">Check out the next post where I'll share my thoughts. until then I'm interested in seeing what all of you are thinking.</span><br />
<br />
<br />Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-384742213301873412012-05-29T13:30:00.000-04:002012-05-29T13:30:00.625-04:00Video laryngoscopy with the GlideScopeCheck out this video detailing the use of the GlideScope for endotracheal intubation
<iframe src="http://player.vimeo.com/video/40230199" width="500" height="281" frameborder="0" webkitAllowFullScreen mozallowfullscreen allowFullScreen></iframe>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com3tag:blogger.com,1999:blog-8776107148973166164.post-22285518352583166882012-05-29T13:00:00.000-04:002012-05-29T13:00:07.576-04:00Video laryngoscopy with the Stroz C-MACHere is a video detailing use of the Storz C-MAC system for video laryngoscopy
<iframe src="http://player.vimeo.com/video/40230198" width="500" height="281" frameborder="0" webkitAllowFullScreen mozallowfullscreen allowFullScreen></iframe>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-92192711905416891842012-05-29T12:10:00.000-04:002012-05-29T12:10:00.399-04:00Final Leaderboard Update<span style="font-family: Arial, Helvetica, sans-serif;">Thanks to all who participated! As announced at today's Noon Conference, the winner of the 2012 #PEMTwitterTriviaContest was...</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif; font-size: x-large;"><a href="http://twitter.com//Bedingaj">@Bedingaj</a></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><img src="http://twittertoolsbook.com/wp-content/uploads/2012/02/twitter-trophy.jpg" />
</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">Coming in at 2nd place we found</span><br />
<a href="http://twitter.com/paulbunchmd"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-large;">@paulbunchmd</span></a><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">Followed by the 3rd place finisher</span><br />
<a href="http://twitter.com/MarlinaLovett"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-large;">@MarlinaLovett</span></a><br />
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<br />Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-61965626535972328382012-05-29T10:51:00.000-04:002012-05-29T11:04:45.868-04:00Introduction to Video LaryngoscopyCheck out this video as a follow up to last week's lecture on RSI and video laryngoscopy by Gary Geis.
<iframe src="http://player.vimeo.com/video/40230200" width="500" height="281" frameborder="0" webkitAllowFullScreen mozallowfullscreen allowFullScreen></iframe>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-11776823440093649262012-05-26T21:44:00.000-04:002012-05-26T21:44:16.372-04:00Spinal cord injury syndromes<div>
<b><span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;">Central cord syndrome</span></b></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;">Incomplete spinal cord injury</span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;">Weakness in the arms with relative sparing of the legs with variable sensory loss</span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;">Ischemia, hemorrhage, or necrosis involving the central portions of the spinal cord</span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;">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.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div>
<b><span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;">Anterior cord syndrome</span></b></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Associated with flexion type injuries to the cervical spine</span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;">Damage to the anterior portion of the spinal cord and/or anterior spinal artery</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Below the level of injury motor function, pain sensation, and temperature sensation are lost</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Touch, position and vibration are intact</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
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<b><span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;">Posterior cord syndrome</span></b></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;">Posterior portion of the spinal cord and/or posterior spinal artery</span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;">Loss of proprioception and epicritic sensation (e.g. stereognosis, graphesthesia) below the level of injury</span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;">Motor, pain, and sensitivity to light touch are intact</span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
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<b><span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;">Brown-Séquard syndrome</span></b></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;">Hemisectioned or lateral injury side (penetrating trauma)</span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;">Ipsilateral side loss of motor function, proprioception, vibration, and light touch</span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;">Contralateral side loss of pain, temperature, and crude touch sensations</span></div>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-8497421409653260792012-05-26T13:32:00.000-04:002012-05-26T13:32:36.846-04:00NEXUS and Canadian C-spine rule: When to get films<span style="vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: Arial, Helvetica, sans-serif;">Think about what you do in the ED? Do you recognize how following studies have impacted your practice?</span></span><br />
<b><span style="vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: #6fa8dc;"><br /></span></span></span></b><br />
<b id="internal-source-marker_0.16639357502572238"><span style="vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: #6fa8dc;">National Emergency X-Radiography Utilization Study</span><span style="font-weight: normal;"><br class="kix-line-break" />Multicenter, prospective, observational study of patients with blunt trauma for whom cervical spine X-rays were obtained.</span></span></span></b><br />
<b style="font-weight: normal;"><span style="vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></b><br />
<b style="font-weight: normal;"><span style="vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: Arial, Helvetica, sans-serif;">Get C-spine films if:</span></span></b><br />
<br />
<ul>
<li><b style="font-weight: normal;"><span style="vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: Arial, Helvetica, sans-serif;">Patients with abnormal neurologic examination</span></span></b></li>
<li><b style="font-weight: normal;"><span style="vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: Arial, Helvetica, sans-serif;">Distracting or painful injury (like a femur fracture)</span></span></b></li>
<li><b style="font-weight: normal;"><span style="vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: Arial, Helvetica, sans-serif;">Depressed or altered mental status</span></span></b></li>
<li><b style="font-weight: normal;"><span style="vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: Arial, Helvetica, sans-serif;">Intoxication</span></span></b></li>
<li><b style="font-weight: normal;"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="vertical-align: baseline; white-space: pre-wrap;">Midline cervical tenderness should get an X-Ray </span></span></b></li>
</ul>
<br />
<span style="font-family: Arial, Helvetica, sans-serif;"><b style="font-weight: normal;"><span style="color: #1155cc; vertical-align: baseline; white-space: pre-wrap;"><a href="http://www.nejm.org/doi/full/10.1056/NEJM200007133430203">http://www.nejm.org/doi/full/10.1056/NEJM200007133430203</a></span></b>
</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<b><span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;">Canadian C-spine rule</span></b><br />
<b style="font-weight: normal;"><span style="font-family: Arial, Helvetica, sans-serif;">A prospective cohort study in Canada evaluating patients with head or neck trrauma.</span></b><br />
<b style="font-weight: normal;"><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></b><br />
<b style="font-weight: normal;"><span style="font-family: Arial, Helvetica, sans-serif;">Radiography in high risk factors</span></b><br />
<br />
<ul>
<li><b style="font-weight: normal;"><span style="font-family: Arial, Helvetica, sans-serif;">Dangerous mechanism</span></b></li>
<li><b style="font-weight: normal;"><span style="font-family: Arial, Helvetica, sans-serif;">Paresthesias</span></b></li>
</ul>
<br />
<b style="font-weight: normal;"><span style="font-family: Arial, Helvetica, sans-serif;">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.</span></b><br />
<br />
<ul>
<li><b style="font-weight: normal;"><span style="font-family: Arial, Helvetica, sans-serif;">Simple rear-end MVC</span></b></li>
<li><b style="font-weight: normal;"><span style="font-family: Arial, Helvetica, sans-serif;">Sitting position in the ED</span></b></li>
<li><b style="font-weight: normal;"><span style="font-family: Arial, Helvetica, sans-serif;">Ambulatory at any time since injury</span></b></li>
<li><b style="font-weight: normal;"><span style="font-family: Arial, Helvetica, sans-serif;">Delayed onset neck pain</span></b></li>
<li><b style="font-weight: normal;"><span style="font-family: Arial, Helvetica, sans-serif;">Absence of midline C-spine tenderness</span></b></li>
</ul>
<div>
<a href="http://jama.jamanetwork.com/article.aspx?volume=286&issue=15&page=1841"><span style="font-family: Arial, Helvetica, sans-serif;">http://jama.jamanetwork.com/article.aspx?volume=286&issue=15&page=1841</span></a>
</div>
<br />
<b style="font-weight: normal;"><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></b>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-28260728448858244402012-05-25T21:00:00.000-04:002012-05-25T21:00:00.648-04:00Pop! goes the appendix<b id="internal-source-marker_0.16639357502572238"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="vertical-align: baseline; white-space: pre-wrap;"><span style="color: #6fa8dc;">Perforation is more likely in younger kids because:</span></span><br /><span style="font-weight: normal; vertical-align: baseline; white-space: pre-wrap;">1. More thin walled appendix, predisposing to early perforation</span><br /><span style="font-weight: normal; vertical-align: baseline; white-space: pre-wrap;">2. Younger children can’t communicate as well, resulting in prolonged symptoms before diagnosis</span><br /><span style="font-weight: normal; vertical-align: baseline; white-space: pre-wrap;">3. The level of suspicion for appendicitis is lower in younger age groups</span><br /><span style="font-weight: normal; vertical-align: baseline; white-space: pre-wrap;"></span><br /><span style="vertical-align: baseline; white-space: pre-wrap;">Pro-Tip:<span style="font-weight: normal;"> 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.</span></span></span></b>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-41374586221818226282012-05-25T15:00:00.000-04:002012-05-25T15:00:02.870-04:00Pediatric Appendicitis Score<br />
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<span style="font-family: Arial; font-size: 12pt; font-weight: bold;"><span style="color: #6fa8dc;">Pediatric
Appendicitis Score</span></span></div>
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<span style="font-family: Arial; font-size: 12pt; font-weight: bold;"><br /></span></div>
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<span style="font-family: Arial; font-size: 12pt;">(1
point) anorexia</span></div>
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<span style="font-family: Arial; font-size: 12pt;">(1
point) fever</span></div>
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<span style="font-family: Arial; font-size: 12pt;">(1
point) nausea/vomiting</span></div>
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<span style="font-family: Arial; font-size: 12pt;">(1
point) migration of pain</span></div>
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<span style="font-family: Arial; font-size: 12pt;">(2
points) pain with cough, </span><span style="font-family: Arial; font-size: 12pt;">percussion, or hopping</span></div>
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<span style="font-family: Arial; font-size: 12pt;">(2
points) RLQ tenderness</span></div>
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<span style="font-family: Arial; font-size: 12pt;">(1
point) Leukocytosis (</span><span style="font-family: Arial; font-size: 12pt;">WBC > 10,000)</span></div>
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<span style="font-family: Arial; font-size: 12pt;">(1
point) Left shift </span><span style="font-family: Arial; font-size: 12pt;">(ANC >6750)</span><br />
<span style="font-family: Arial;"></span><br />
<br />
<ul>
<li><span style="font-family: Arial;">10 point scale incorporating history, physical and lab components</span></li>
<li><span style="font-family: Arial;">Initial study (Samuels, 2002) with N = 1170</span></li>
<li><span style="font-family: Arial;">Prospective cohort age 4-15 with abdominal pain suggestive of appendicitis</span></li>
<li><span style="font-family: Arial;">Cutoff of >=6 provides 1.00 sensitivity and 0.92 specificity</span></li>
<li><span style="font-family: Arial;">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)</span></li>
</ul>
<br />
<br />
<ul>
<li><span style="font-family: Arial;">Validation studies have shown better performance at the ends of the spectrum (using 2 cutoffs)</span></li>
<li><span style="font-family: Arial;">Validated prospectively and retrospectivelyIn ages > 1</span></li>
<li><span style="font-family: Arial;">Using various combinations of cutpoints</span></li>
<li><span style="font-family: Arial;">High risk scores (> 7) had a specificity of 95-98%</span></li>
<li><span style="font-family: Arial;">Low risk scores (<3) had a negative predictive value of 98%</span></li>
<li><span style="font-family: Arial;">Moderate risk scores indicated the need for further imaging</span></li>
<li><span style="font-family: Arial;">Use of the PAS would have decreased the need for imaging</span></li>
</ul>
<br />
</div>
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<span style="font-family: Arial, Helvetica, sans-serif;">
</span></div>
</div>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-52461361549969339112012-05-25T10:26:00.001-04:002012-05-25T10:26:04.547-04:00Leaderboard Update - Day 18<span style="font-family: Arial, Helvetica, sans-serif;">We are closing in on the conclusion of the #PEMTwitterTriviaContest. The leader board as of this morning...</span><div>
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">1st <b id="internal-source-marker_0.3319909747224301" style="font-weight: normal;"><a href="https://twitter.com/#!/Bedingaj"><span style="background-color: whitesmoke; color: #66c1c1; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">@</span><span style="background-color: whitesmoke; color: #009999; font-weight: bold; vertical-align: baseline; white-space: pre-wrap;">Bedingaj</span></a></b></span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">2nd <b id="internal-source-marker_0.3319909747224301" style="font-weight: normal;"><a href="https://twitter.com/#!/paulbunchmd"><span style="background-color: whitesmoke; color: #66c1c1; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">@</span><span style="background-color: whitesmoke; color: #009999; font-weight: bold; vertical-align: baseline; white-space: pre-wrap;">paulbunchmd</span></a><span style="background-color: whitesmoke; color: #333333; vertical-align: baseline; white-space: pre-wrap;"> </span></b></span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">3rd <b id="internal-source-marker_0.3319909747224301" style="font-weight: normal;"><a href="https://twitter.com/#!/MarlinaLovett"><span style="background-color: whitesmoke; color: #66c1c1; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">@</span><span style="background-color: whitesmoke; color: #009999; font-weight: bold; vertical-align: baseline; white-space: pre-wrap;">MarlinaLovett</span></a><span style="background-color: whitesmoke; color: #333333; vertical-align: baseline; white-space: pre-wrap;"> </span></b></span></div>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-21996498286818181992012-05-23T20:23:00.000-04:002012-05-23T20:23:45.062-04:00Do it FAST!<span style="font-family: Arial, Helvetica, sans-serif;">FAST is a Focused Assessment with Sonography for Trauma that utilizes bedside ultrasound to rapidly identify intraperitoneal pericardial hemorrhage in trauma patients.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">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.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">Here are the locations for FAST</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;"><b>Perihepatic</b></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><img src="http://www.trauma.org/archive/radiology/images/ruqpatient.jpg" /><img src="http://www.trauma.org/archive/radiology/images/fastruqexpl.jpg" /> </span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;"><b>Perisplenic</b></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><img src="http://www.trauma.org/archive/radiology/images/luqpatient.jpg" /></span><br />
<span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;"><b>Pelvis</b></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><img src="http://www.trauma.org/archive/radiology/images/pelvpatient.jpg" /> </span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;"><b>Pericardium</b></span><br />
<img src="http://www.trauma.org/archive/radiology/images/pericpatient.jpg" /><img src="http://www.trauma.org/archive/radiology/images/posperic.jpg" /> <br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">Images courtesy of Trauma.org - This is a great overview of FAST - <a href="http://www.trauma.org/archive/radiology/FASTfast.html">Check it out here</a></span>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-65549262493795272762012-05-23T11:11:00.000-04:002012-05-23T11:11:15.920-04:00Clavicle fractures - to fix or not to fix<span style="font-family: Arial, Helvetica, sans-serif;">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.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">Outpatient Orthopedic referral is recommended for:</span><br />
<br />
<ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Patients with a completely displaced clavicle
fracture, which is defined as displacement greater than one bone width.</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">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</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Comminuted fracture</span></li>
</ul>
<br />
<br />
<div jquery16204515749007962277="285">
<span style="font-family: Arial, Helvetica, sans-serif;">Emergent referral is required for:</span></div>
<div jquery16204515749007962277="285">
</div>
<ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;">open
fractures</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">neurovascular compromise</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">tenting of the skin (skin stretched
tautly over a displaced fracture)</span></li>
</ul>
<br />
<div jquery16204515749007962277="285">
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div jquery16204515749007962277="285">
<span style="font-family: Arial, Helvetica, sans-serif;">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.</span></div>
<div jquery16204515749007962277="285">
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div jquery16204515749007962277="285">
<span style="font-family: Arial, Helvetica, sans-serif;">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.<br /><br /><a href="http://www.ncbi.nlm.nih.gov/pubmed/18803979">http://www.ncbi.nlm.nih.gov/pubmed/18803979</a></span></div>
<div jquery16204515749007962277="285">
<br /></div>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-24154751185754703192012-05-22T19:01:00.001-04:002012-05-22T19:01:17.499-04:00Kocher Criteria: Helping to differentiate septic hip versus transient synovitis<b id="internal-source-marker_0.5713169584050775"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="background-color: white; color: #414b56; font-weight: normal; vertical-align: baseline; white-space: pre-wrap;">Kocher criteria for a child with a painful hip, suspected to have septic arthritis:</span><br /><span style="background-color: white; color: #414b56; font-weight: normal; vertical-align: baseline; white-space: pre-wrap;">1) non-weight-bearing on affected side </span><br /><span style="background-color: white; color: #414b56; font-weight: normal; vertical-align: baseline; white-space: pre-wrap;">2) sedimentation rate greater than 40 mm/hr </span><br /><span style="background-color: white; color: #414b56; font-weight: normal; vertical-align: baseline; white-space: pre-wrap;">3) fever </span><br /><span style="background-color: white; color: #414b56; font-weight: normal; vertical-align: baseline; white-space: pre-wrap;">4) WBC >12,000 </span><br /><span style="background-color: white; color: #414b56; font-weight: normal; vertical-align: baseline; white-space: pre-wrap;"></span><br /><span style="background-color: white; color: #414b56; font-weight: normal; vertical-align: baseline; white-space: pre-wrap;">Criteria met and probability child has septic arthritis</span><br /><span style="background-color: white; color: #414b56; font-weight: normal; vertical-align: baseline; white-space: pre-wrap;">4/4 -- 99%</span><br /><span style="background-color: white; color: #414b56; font-weight: normal; vertical-align: baseline; white-space: pre-wrap;">3/4 -- 93%</span><br /><span style="background-color: white; color: #414b56; font-weight: normal; vertical-align: baseline; white-space: pre-wrap;">2/4 -- 40%</span><br /><span style="background-color: white; color: #414b56; font-weight: normal; vertical-align: baseline; white-space: pre-wrap;">1/4 -- 3%</span><br /><span style="font-weight: normal; vertical-align: baseline; white-space: pre-wrap;"></span><br /><a href="http://jbjs.org/article.aspx?Volume=86&page=1629"><span style="color: #1155cc; font-weight: normal; vertical-align: baseline; white-space: pre-wrap;">http://jbjs.org/article.aspx?Volume=86&page=1629</span></a></span></b>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-81502005493716405882012-05-21T23:23:00.000-04:002012-05-21T23:23:57.675-04:00Ow my elbow! A bit about supracondylar fractures of the humerus<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxvZydJZJBDkfpUC8GepMePoJ05negOedp11UOICzMU1r0Q6nmtngr08zuVBGTmdR3QPE4eNPGAFDfWFkgNbTtUtlIBJAndvyXC2rmPB0y-slGplvyX17wFd5gEpOhcdkqz9T_2AXl2eJ_/s1600/Type+1+supracondylar.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxvZydJZJBDkfpUC8GepMePoJ05negOedp11UOICzMU1r0Q6nmtngr08zuVBGTmdR3QPE4eNPGAFDfWFkgNbTtUtlIBJAndvyXC2rmPB0y-slGplvyX17wFd5gEpOhcdkqz9T_2AXl2eJ_/s1600/Type+1+supracondylar.png" /></a><strong><span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;">Type I</span></strong><br />
<span style="font-family: Arial, Helvetica, sans-serif;">Nondisplaced or minally displaced fracture</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">On the lateral view: anterior humeral line remains intact but a posterior fat pad sign may be present</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><b>Treatment</b></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">Treated w/ immobilization in long arm posterior splint w/ elbow flexed and outpatient Ortho follow up</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<br />
<br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEinFg0fFqBmL25_p1nmrHneGKbiDIb0zJuAU2VHQU2Yt5Sw855EBOWiTDH4BciLKRt5s-kRSS9YvzeaZsxlxRZwn3YPU7Ruy780oymgOyJbgTaS5HGBkL4tvpc6WWWvmZjJnMOmyi6anauo/s1600/sc_2.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="266" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEinFg0fFqBmL25_p1nmrHneGKbiDIb0zJuAU2VHQU2Yt5Sw855EBOWiTDH4BciLKRt5s-kRSS9YvzeaZsxlxRZwn3YPU7Ruy780oymgOyJbgTaS5HGBkL4tvpc6WWWvmZjJnMOmyi6anauo/s320/sc_2.jpg" width="320" /></a><br />
<b><span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;">Type II</span></b><br />
<span style="font-family: Arial, Helvetica, sans-serif;">Posterior cortex remains intact, making it a greenstick fracture technically</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><strong>Treatment:</strong></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">Require adequate reduction</span><span style="font-family: Arial, Helvetica, sans-serif;"> </span><span style="font-family: Arial, Helvetica, sans-serif;">and percutaneous pinning</span><span style="font-family: Arial, Helvetica, sans-serif;"> in many instances</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">Consult Ortho immediately</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1PlZKE6TKBiX3xVzGZ70ZsGSxL5S5_oZ77IOObO8Un96SduXuxrJogbYHZGViPlMeMkWMdVystuShPHqeyW4yd69aS27w71VnT7K-Hr7iVdEyMRGN1oVRmNMIrojRaDPrOJ0K6-5b_pCL/s1600/Supracondylar-Fracture+3.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="215" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1PlZKE6TKBiX3xVzGZ70ZsGSxL5S5_oZ77IOObO8Un96SduXuxrJogbYHZGViPlMeMkWMdVystuShPHqeyW4yd69aS27w71VnT7K-Hr7iVdEyMRGN1oVRmNMIrojRaDPrOJ0K6-5b_pCL/s320/Supracondylar-Fracture+3.jpg" width="320" /></a><b><span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;"><br /></span></b><br />
<b><span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;">Type III</span></b><br />
<span style="font-family: Arial, Helvetica, sans-serif;">Displaced with no cortical contact</span><br />
<b><span style="font-family: Arial, Helvetica, sans-serif;">Treatment</span></b><br />
<span style="font-family: Arial, Helvetica, sans-serif;">Immediate Ortho consult - This will need to go to the OR in most instances</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-35386575155251496812012-05-21T08:00:00.000-04:002012-05-21T08:00:05.201-04:00Day 15 Leaderboard<span style="font-family: Arial, Helvetica, sans-serif;">There's a change at the top of the #PEMTwitterTriviaContest Leaderboard, as <span id="internal-source-marker_0.7224101775791496"><a href="https://twitter.com/#!/Bedingaj"><span style="background-color: whitesmoke; color: #66c1c1; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">@</span><span style="background-color: whitesmoke; color: #009999; vertical-align: baseline; white-space: pre-wrap;">Bedingaj</span></a> has surged ahead with an impressive weekend stint. There's still plenty of time to catch up though, with competitors hot on her tail.</span></span><div>
<span style="font-family: Arial, Helvetica, sans-serif;"><span><br /></span></span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><b><span>1st: </span><a href="https://twitter.com/#!/Bedingaj"><span style="background-color: whitesmoke; color: #66c1c1; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">@</span><span style="background-color: whitesmoke; color: #009999; vertical-align: baseline; white-space: pre-wrap;">Bedingaj</span></a></b></span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><b><span>2nd: </span><span id="internal-source-marker_0.7224101775791496"><a href="https://twitter.com/#!/paulbunchmd"><span style="background-color: whitesmoke; color: #66c1c1; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">@</span><span style="background-color: whitesmoke; color: #009999; vertical-align: baseline; white-space: pre-wrap;">paulbunchmd</span></a><span style="background-color: whitesmoke; color: #333333; vertical-align: baseline; white-space: pre-wrap;"> </span></span></b></span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><b><span>3rd: </span><span id="internal-source-marker_0.7224101775791496"><a href="https://twitter.com/#!/MarlinaLovett"><span style="background-color: whitesmoke; color: #66c1c1; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">@</span><span style="background-color: whitesmoke; color: #009999; vertical-align: baseline; white-space: pre-wrap;">MarlinaLovett</span></a><span style="background-color: whitesmoke; color: #333333; vertical-align: baseline; white-space: pre-wrap;"> </span></span></b></span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;"><span><br /></span></span></div>
<div>
<span style="font-family: Arial, Helvetica, sans-serif;"><span>In the hunt:<br /><div>
@GreggKottyan<span class="Apple-tab-span" style="white-space: pre;"> </span></div>
<div>
@ziggy7652</div>
<div>
@preetir85</div>
<div>
@TarekAlsaied</div>
<div>
@amyocon24</div>
<div>
@dbailey4</div>
<div>
@7hillsandariver</div>
<div>
@AnotherLynLee</div>
</span></span></div>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-60414330642397444362012-05-18T15:34:00.000-04:002012-05-18T15:34:38.709-04:00One pill can kill!<span style="font-family: Arial, Helvetica, sans-serif;"><b>These medicines could potentially be fatal in a single dose to a 10kg toddler</b></span><br />
<ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Benzocaine</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Camphor</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Chloroquine</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Clonidine</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Cyclic antidepressants</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Diphenoxylate/atropine (Lomotil)</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">LIndane</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Methadone (and other opioids)</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Methyl salicylate (oil of wintergreen)</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Oral hypoglycemics</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Quinidine</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Propranolol</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Theophylline</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Thioridizine</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Verapamil</span></li>
</ul>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-13247176558025046382012-05-17T21:44:00.000-04:002012-05-17T21:44:06.672-04:00Suturing and tetanus prophylaxis<br />
<div class="WordSection1">
<div class="MsoNormal" style="text-align: left;">
<b><span style="font-family: Calibri, sans-serif; font-size: 16pt;"><span style="color: #6fa8dc;">Suturing Guidelines</span><o:p></o:p></span></b></div>
<div class="MsoNormal" style="text-align: left;">
<span style="font-family: Calibri, sans-serif;">For
Uncontaminated, Uncomplicated Lacerations<o:p></o:p></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</div>
<div class="WordSection2">
<div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">LET
</span></b><span style="font-family: Calibri, sans-serif;">(Lidocaine-Epinephrine-Tetracaine)</span><b><span style="font-family: Calibri, sans-serif;"><o:p></o:p></span></b></div>
<div class="MsoNormal">
<span style="font-family: Calibri, sans-serif;">-
Works in ~ 30 minutes<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Calibri, sans-serif;">-
Use only on broken skin (won’t work on intact skin)<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Calibri, sans-serif;">-
Don’t use on mucous membranes (risk of toxicity)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 8.1pt; text-indent: -8.1pt;">
<span style="font-family: Calibri, sans-serif;">- CAUTION
with fingertips, toes, penis, nose, or pinna b/c of epi<o:p></o:p></span></div>
<div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">EMLA
</span></b><span style="font-family: Calibri, sans-serif;">(Eutectic Mixture of Local Anesthetic)</span><b><span style="font-family: Calibri, sans-serif;"><br />
ELA-max</span></b><b><span style="font-family: Calibri, sans-serif;"><br />
</span></b><span style="font-family: Calibri, sans-serif;">Use
only on intact skin (NOT on lacerations!) <b><o:p></o:p></b></span></div>
<div class="MsoNormal">
<span style="font-family: Calibri, sans-serif;">ELA-max
works in 30 minutes, EMLA takes an hour<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Calibri, sans-serif;">OK
to use on areas of distal circulation because no epi<o:p></o:p></span></div>
</div>
<div class="WordSection3">
<div class="MsoNormal">
<span style="font-family: Calibri, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Lidocaine
<o:p></o:p></span></b></div>
<div class="MsoNormal">
<span style="position: relative; z-index: 251657728;"><span style="height: 2px; left: -1px; position: absolute; top: -25px; width: 730px;"><img height="2" src="file:///C:/Users/SOBI4H/AppData/Local/Temp/msohtmlclip1/01/clip_image001.gif" v:shapes="Line_x0020_13" width="730" /></span></span><span style="font-family: Calibri, sans-serif;"><o:p></o:p></span></div>
</div>
<span style="font-family: Calibri, sans-serif;"><br clear="all" style="mso-break-type: section-break; page-break-before: auto;" />
</span>
<br />
<div class="WordSection4">
<div class="MsoNormal">
<span style="font-family: Calibri, sans-serif;">1%
lidocaine = 10 mg/ml<br />
2% lidocaine = 20 mg/ml<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Calibri, sans-serif;">Max
dose - lidocaine WITH epi = 7 mg/kg (up to 280 mg)<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Calibri, sans-serif;">Max
dose - lidocaine WITHOUT epi = 4 mg/kg (up to 280 mg)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 6.0pt; text-indent: -6.0pt;">
<span style="font-family: Calibri, sans-serif;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 6.0pt; text-indent: -6.0pt;">
<span style="font-family: Calibri, sans-serif;">w/ epi DO NOT
use on fingertips, toes, penis, nose, pinna<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 99.9pt; text-indent: -99.9pt;">
<br /></div>
<div class="MsoNormal" style="margin-left: 99.9pt; text-indent: -99.9pt;">
<span style="font-family: Calibri, sans-serif;">To buffer
with bicarb: 1:10 solution with 8.4% sodium bicarbonate<br />
(9ml of lidocaine + 1ml bicarb)<o:p></o:p></span></div>
</div>
<span style="font-family: Calibri, sans-serif;"><br clear="all" style="mso-break-type: section-break; page-break-before: auto;" />
</span>
<br />
<div class="MsoNormal">
<br /></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-yfti-tbllook: 480;">
<tbody>
<tr>
<td style="background: #BFBFBF; border-right: solid windowtext 1.0pt; border: solid windowtext 1.5pt; mso-background-themecolor: background1; mso-background-themeshade: 191; mso-border-alt: solid windowtext 1.5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div align="center" class="MsoNormal" style="text-align: center;">
<b><span style="font-family: Calibri, sans-serif;">Location<o:p></o:p></span></b></div>
</td>
<td style="background: #BFBFBF; border-bottom: solid windowtext 1.5pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: solid windowtext 1.5pt; mso-background-themecolor: background1; mso-background-themeshade: 191; mso-border-bottom-alt: 1.5pt; mso-border-color-alt: windowtext; mso-border-left-alt: .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: .5pt; mso-border-style-alt: solid; mso-border-top-alt: 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 192.0pt;" width="256"><div align="center" class="MsoNormal" style="text-align: center;">
<b><span style="font-family: Calibri, sans-serif;">Percutaneous (Skin)<o:p></o:p></span></b></div>
</td>
<td style="background: #BFBFBF; border-bottom: solid windowtext 1.5pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: solid windowtext 1.5pt; mso-background-themecolor: background1; mso-background-themeshade: 191; mso-border-bottom-alt: 1.5pt; mso-border-color-alt: windowtext; mso-border-left-alt: .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: .5pt; mso-border-style-alt: solid; mso-border-top-alt: 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.0in;" width="192"><div align="center" class="MsoNormal" style="text-align: center;">
<b><span style="font-family: Calibri, sans-serif;">Deep (Dermal)<o:p></o:p></span></b></div>
</td>
<td style="background: #BFBFBF; border-left: none; border: solid windowtext 1.5pt; mso-background-themecolor: background1; mso-background-themeshade: 191; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 113.4pt;" width="151"><div align="center" class="MsoNormal" style="text-align: center;">
<b><span style="font-family: Calibri, sans-serif;">Days to removal<o:p></o:p></span></b></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<b><span style="font-family: Calibri, sans-serif;">(percutaneous only)<o:p></o:p></span></b></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: .5pt; mso-border-color-alt: windowtext; mso-border-left-alt: 1.5pt; mso-border-right-alt: .5pt; mso-border-style-alt: solid; mso-border-top-alt: 1.5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Scalp<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 192.0pt;" width="256"><div align="center" class="MsoNormal" style="text-align: center;">
<b><span style="font-family: Calibri, sans-serif;">Staples</span></b><span style="font-family: Calibri, sans-serif;">
or<o:p></o:p></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">5-0/4-0
Prolene/Ethilon<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.0in;" width="192"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">4-0
Vicryl/Chromic Gut<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-bottom-alt: .5pt; mso-border-color-alt: windowtext; mso-border-left-alt: .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: 1.5pt; mso-border-style-alt: solid; mso-border-top-alt: 1.5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 113.4pt;" width="151"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">7-10<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Ear<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 192.0pt;" width="256"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">6-0
Prolene/Ethilon – SEE NOTE*<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.0in;" width="192"><div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 113.4pt;" width="151"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">5-7<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Eyelid<o:p></o:p></span></b></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 336.0pt;" width="448"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">7-0/6-0
Prolene/Ethilon. If low on lid,
consult Ophtho.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 113.4pt;" width="151"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">5-7<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Eyebrow<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 192.0pt;" width="256"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">6-0/5-0
Prolene/Ethilon<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.0in;" width="192"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">5-0
Vicryl/Chromic Gut<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 113.4pt;" width="151"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">5-7<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Nose<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 192.0pt;" width="256"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">6-0
Prolene/Ethilon - SEE NOTE*<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.0in;" width="192"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">5-0
Vicryl/Chromic Gut<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 113.4pt;" width="151"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">5-7<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Lip<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 192.0pt;" width="256"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">6-0
Prolene/Ethilon<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.0in;" width="192"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">5-0
Vicryl/Chromic Gut<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 113.4pt;" width="151"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">5-7<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Oral
mucosa<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 192.0pt;" width="256"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">---<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 2.9pt 0in 2.9pt; width: 2.0in;" width="192"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif; letter-spacing: -0.3pt;">4-0 or 5-0 Vicryl/Chromic Gut<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 113.4pt;" width="151"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">---<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Tongue<o:p></o:p></span></b></div>
</td>
<td colspan="3" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 449.4pt;" width="599"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">Suture
if significant step-off or through and through laceration<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Other
face/<o:p></o:p></span></b></div>
<div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">forehead<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 192.0pt;" width="256"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">6-0
Prolene/Ethilon – SEE NOTE*<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.0in;" width="192"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">5-0
Vicryl/Chromic Gut<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 113.4pt;" width="151"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">4-5<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Trunk<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 192.0pt;" width="256"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">5-0/4-0
Prolene/Ethilon<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.0in;" width="192"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">3-0
Vicryl/Chromic Gut<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 113.4pt;" width="151"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">8-10
(Chest/Abd)<o:p></o:p></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">12-14
(Back)<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Extremities<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 192.0pt;" width="256"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">6-0/5-0/4-0
Prolene/Ethilon<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.0in;" width="192"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">4-0
Vicryl/ Chromic Gut<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 113.4pt;" width="151"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">8-10<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Hand<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 192.0pt;" width="256"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">6-0/5-0
Chromic<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.0in;" width="192"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">5-0
Vicryl/ Chromic Gut<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 113.4pt;" width="151"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">8-10;
10-12 (tip)<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 2.9pt 0in 2.9pt; width: 101.4pt;" width="135"><div class="MsoNormal" style="margin-left: 2.5pt;">
<b><span style="font-family: Calibri, sans-serif;">Extensor tendon<o:p></o:p></span></b></div>
</td>
<td colspan="3" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 449.4pt;" width="599"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">Refer
to plastic surgeon<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Foot/sole<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 192.0pt;" width="256"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">4-0/3-0
Prolene/Ethilon<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.0in;" width="192"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">4-0
Vicryl/ Chromic Gut<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 113.4pt;" width="151"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">12-14<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Vagina<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 192.0pt;" width="256"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">---<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.0in;" width="192"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">4-0
Vicryl/Chromic Gut<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 113.4pt;" width="151"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">---<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Scrotum<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 192.0pt;" width="256"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">---<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.0in;" width="192"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">5-0
Vicryl/Chromic Gut<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 113.4pt;" width="151"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">---<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.5pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: 1.5pt; mso-border-color-alt: windowtext; mso-border-left-alt: 1.5pt; mso-border-right-alt: .5pt; mso-border-style-alt: solid; mso-border-top-alt: .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 101.4pt;" width="135"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Penis<o:p></o:p></span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.5pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-bottom-alt: solid windowtext 1.5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 192.0pt;" width="256"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">5-0
Prolene/Chromic<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.5pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-bottom-alt: solid windowtext 1.5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.0in;" width="192"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">---<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.5pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 113.4pt;" width="151"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">7<o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal">
<span style="font-family: Calibri, sans-serif;">*Consider
use of Fast Absorbing Gut (5-0/6-0) on Ear, Eyelid, Eyebrow, Nose, Lip and Face
if anticipated difficulty with suture removal (Note: follow up still required
for wound evaluation)<o:p></o:p></span></div>
<div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">NOTE:</span></b><span style="font-family: Calibri, sans-serif;"> If cartilage involved, strongly consider
plastic surgery consult. Always treat with
antibiotics <o:p></o:p></span></div>
<div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">NOTE:</span></b><span style="font-family: Calibri, sans-serif;"> If human/animal bite, cleanse, dress, treat
with antibiotics, and follow-up with Plastics.
If tendons are involved, start antibiotics and consult Plastics. See ‘Bugs and Drugs’ section (page 63-64) for
specific treatment guidelines. <o:p></o:p></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<div class="MsoNormal" style="text-align: left;">
<b><span style="font-family: Calibri, sans-serif;"><span style="color: #6fa8dc; font-size: large;">Tetanus administration</span><o:p></o:p></span></b></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: none; margin-left: 5.4pt; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-yfti-tbllook: 480;">
<tbody>
<tr>
<td style="border-right: solid windowtext 1.0pt; border: solid windowtext 1.5pt; mso-border-alt: solid windowtext 1.5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 1.0in;" width="96"><div class="MsoNormal">
<span style="font-family: Calibri, sans-serif;">Immunization history<o:p></o:p></span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.5pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: solid windowtext 1.5pt; mso-border-bottom-alt: 1.5pt; mso-border-color-alt: windowtext; mso-border-left-alt: .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: .5pt; mso-border-style-alt: solid; mso-border-top-alt: 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.25in;" valign="top" width="312"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Dirty,
Tetanus prone</span></b><span style="font-family: Calibri, sans-serif;">: >6 hrs since injury;
stellate or avulsion injury; missile, crush, burn, frostbite; >1 cm deep;
devitalized /contaminated.<o:p></o:p></span></div>
</td>
<td colspan="2" style="border-left: none; border: solid windowtext 1.5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 239.4pt;" valign="top" width="319"><div class="MsoNormal">
<b><span style="font-family: Calibri, sans-serif;">Clean,
Non-tetanus prone</span></b><span style="font-family: Calibri, sans-serif;">: ≤6 hours since injury; linear injury; sharp surface (glass,
knife); ≤1 cm deep; No devitalized or contaminants<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border: none; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 1.0in;" valign="top" width="96"><div class="MsoNormal">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.5pt; border: none; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 117.0pt;" valign="top" width="156"><div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.5pt; border: none; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 117.0pt;" valign="top" width="156"><div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.5pt; border: none; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" valign="top" width="160"><div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.5pt; border: none; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" valign="top" width="160"><div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.5pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; padding: 0in 5.4pt 0in 5.4pt; width: 1.0in;" valign="top" width="96"><div class="MsoNormal">
<br /></div>
</td>
<td style="background: #BFBFBF; border-bottom: solid windowtext 1.5pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-background-themecolor: background1; mso-background-themeshade: 191; mso-border-alt: solid windowtext 1.5pt; mso-border-left-alt: solid windowtext 1.5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 117.0pt;" valign="top" width="156"><div align="center" class="MsoNormal" style="text-align: center;">
<b><span style="font-family: Calibri, sans-serif;">TdaP (Adacel)<o:p></o:p></span></b></div>
</td>
<td style="background: #BFBFBF; border-bottom: solid windowtext 1.5pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-background-themecolor: background1; mso-background-themeshade: 191; mso-border-bottom-alt: 1.5pt; mso-border-color-alt: windowtext; mso-border-left-alt: .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: .5pt; mso-border-style-alt: solid; mso-border-top-alt: 1.5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 117.0pt;" valign="top" width="156"><div align="center" class="MsoNormal" style="text-align: center;">
<b><span style="font-family: Calibri, sans-serif;">TIG<o:p></o:p></span></b></div>
</td>
<td style="background: #BFBFBF; border-bottom: solid windowtext 1.5pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-background-themecolor: background1; mso-background-themeshade: 191; mso-border-bottom-alt: 1.5pt; mso-border-color-alt: windowtext; mso-border-left-alt: .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: .5pt; mso-border-style-alt: solid; mso-border-top-alt: 1.5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" valign="top" width="160"><div align="center" class="MsoNormal" style="text-align: center;">
<b><span style="font-family: Calibri, sans-serif;">TdaP (Adacel)<o:p></o:p></span></b></div>
</td>
<td style="background: #BFBFBF; border-bottom: solid windowtext 1.5pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-background-themecolor: background1; mso-background-themeshade: 191; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" valign="top" width="160"><div align="center" class="MsoNormal" style="text-align: center;">
<b><span style="font-family: Calibri, sans-serif;">TIG<o:p></o:p></span></b></div>
</td>
</tr>
<tr>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: .5pt; mso-border-color-alt: windowtext; mso-border-left-alt: 1.5pt; mso-border-right-alt: .5pt; mso-border-style-alt: solid; mso-border-top-alt: 1.5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 1.0in;" valign="top" width="96"><div class="MsoNormal">
<span style="font-family: Calibri, sans-serif;">Unknown or <3 doses<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 117.0pt;" width="156"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">Yes<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 117.0pt;" width="156"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">Yes<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" width="160"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">Yes<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; mso-border-bottom-alt: .5pt; mso-border-color-alt: windowtext; mso-border-left-alt: .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: 1.5pt; mso-border-style-alt: solid; mso-border-top-alt: 1.5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" width="160"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">No<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 18.4pt; mso-yfti-irow: 4; mso-yfti-lastrow: yes;">
<td style="border-bottom: solid windowtext 1.5pt; border-left: solid windowtext 1.5pt; border-right: solid windowtext 1.0pt; border-top: none; height: 18.4pt; mso-border-bottom-alt: 1.5pt; mso-border-color-alt: windowtext; mso-border-left-alt: 1.5pt; mso-border-right-alt: .5pt; mso-border-style-alt: solid; mso-border-top-alt: .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 1.0in;" valign="top" width="96"><div class="MsoNormal">
<span style="font-family: Calibri, sans-serif;">3 or more doses<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.5pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 18.4pt; mso-border-alt: solid windowtext .5pt; mso-border-bottom-alt: solid windowtext 1.5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 117.0pt;" width="156"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">No,
unless >5 yrs since booster<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.5pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 18.4pt; mso-border-alt: solid windowtext .5pt; mso-border-bottom-alt: solid windowtext 1.5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 117.0pt;" width="156"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">No<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.5pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 18.4pt; mso-border-alt: solid windowtext .5pt; mso-border-bottom-alt: solid windowtext 1.5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" width="160"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">No,
unless >10 yrs since booster<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.5pt; border-left: none; border-right: solid windowtext 1.5pt; border-top: none; height: 18.4pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 119.7pt;" width="160"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Calibri, sans-serif;">No<o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal">
<br /></div>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-60779215218417504922012-05-16T20:00:00.000-04:002012-07-27T10:16:28.420-04:00Overview of Acute Scrotal/Testicular Pain<h2>
<span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;">History
& Physical Exam</span></h2>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><o:p></o:p></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level1 lfo1; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Pain? Acute onset
suggests torsion, epididymitis, or torsion of the appendix
testis/epididymis<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level1 lfo1; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Trauma?<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level1 lfo1; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Change in size? Valsalva
= hydrocele<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level1 lfo1; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Sexually active? Epididymitis
in adolescents<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level1 lfo1; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Difficulty voiding? Think
mass, cord lesion, UTI<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level1 lfo1; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Flank pain or hematuria? Referred pain from a kidney stone<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level1 lfo1; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Abdominal pain, nausea/vomiting? Torsion<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level1 lfo1; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Setting the stage<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level2 lfo1; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Get a chaperone if you or patient are uncomfortable<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level2 lfo1; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Have the patient stand if possible<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level2 lfo1; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">If you suspect a varicocele examine the patient supine as well<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level2 lfo1; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Respect the patient’s privacy!<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level1 lfo1; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Don’t forget to examine the; <o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level2 lfo1; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Inguinal folds<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level2 lfo1; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Penis and urethra<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level2 lfo1; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Pubic hair<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level2 lfo1; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Testicular position (left is lower)<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l4 level2 lfo1; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Testicular lie</span></li>
</ul>
</ul>
<h2>
<span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;">Testicular
torsion</span></h2>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><o:p></o:p></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l6 level1 lfo2; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Surgical emergency!<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l6 level1 lfo2; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">The testicle twists on the spermatic cord<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l6 level2 lfo2; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Venous compression then…<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l6 level2 lfo2; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Edema of testicle and cord then…<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l6 level2 lfo2; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Arterial occlusion then…<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l6 level1 lfo2; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">1/4000 males < age 25<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l6 level2 lfo2; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Bimodal - neonatal and
puberty<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l6 level2 lfo2; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">65% between ages 12-18 years<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l6 level2 lfo2; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Likely due to increasing testicle volume<o:p></o:p></span></li>
</ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;"><span style="text-indent: -0.25in;">Bell clapper deformity</span><span style="text-indent: -0.25in;">Testis is not fixed to the tunica vaginalis
posteriorly and i</span><span style="text-indent: -0.25in;">t is free to rotate and is at increased risk
of torsion.</span><span style="text-indent: -24px;">Incidence is approximately 1/125 and u</span><span style="text-indent: -24px;">sually present bilaterally.<br /></span></span></li>
<li><span style="background-color: white; font-family: Arial, Helvetica, sans-serif; text-indent: -0.25in;">Presentation</span></li>
<ul>
<li><span style="background-color: white; font-family: Arial, Helvetica, sans-serif; text-indent: -0.25in;">Abrupt onset of pain <12 hours</span></li>
<li><span style="background-color: white; font-family: Arial, Helvetica, sans-serif; text-indent: -0.25in;">Associated N/V, lower abdominal pain</span></li>
<li><span style="background-color: white; font-family: Arial, Helvetica, sans-serif; text-indent: -0.25in;">In a retrospective review only 8% had pain
prior to this episode (Kadish, 1998)<br /></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l0 level1 lfo3; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Exam<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l0 level2 lfo3; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Edema of scrotum<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l0 level2 lfo3; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Testis – tender and slightly elevated, may have a horizontal lie<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l0 level2 lfo3; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Cremaster reflex is absent<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l0 level1 lfo3; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Torsion is ideally a clinical diagnosis<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l0 level2 lfo3; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">If suspected tell your Attending and call Urology ASAP<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l0 level1 lfo3; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Ultrasound<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l0 level2 lfo3; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Sensitivity 69-100%<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l0 level2 lfo3; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Specificity 77-100%<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l0 level1 lfo3; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Nuclear medicine scans are very sensitive and specific – but not
readily available<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l0 level1 lfo3; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Surgery<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l0 level2 lfo3; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">If viable – detorsion of affected testis and fixation (orchiopexy)
of both testis<o:p></o:p></span></li>
</ul>
</ul>
<div class="MsoListParagraphCxSpFirst" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-add-space: auto; mso-list: l7 level1 lfo7; tab-stops: list .5in; text-indent: -.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;">§<span style="font-size: 7pt;"> </span><b><span style="font-size: large;">Viability rates<o:p></o:p></span></b></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: .0001pt; margin-bottom: 0in; margin-left: 1.0in; margin-right: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l2 level2 lfo8; text-indent: -.25in;">
<b><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Within 4-6 hours 100%<o:p></o:p></span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: .0001pt; margin-bottom: 0in; margin-left: 1.0in; margin-right: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l2 level2 lfo8; text-indent: -.25in;">
<b><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">12-24 hours 20%<o:p></o:p></span></b></div>
<div class="MsoListParagraphCxSpLast" style="margin-bottom: .0001pt; margin-bottom: 0in; margin-left: 1.0in; margin-right: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l2 level2 lfo8; text-indent: -.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><b><span style="font-size: large;">>24 hours 0%</span></b><br /><br /><o:p></o:p></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l1 level1 lfo4; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Sequelae<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l1 level2 lfo4; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Males may have increased risk of infertility even when viable
de-torsed testis is left in scrotum because of immune-mediated injury to
contralateral testis<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l1 level2 lfo4; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Other studies have failed to show that anti-sperm antibodies are
present<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l1 level1 lfo4; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Intermittent torsion<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l1 level2 lfo4; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">80% have bell clapper deformity<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l1 level2 lfo4; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Pain is brief and resolves quickly (minutes)<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l1 level2 lfo4; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Eaton et al, 26% had nausea and vomiting, 21% pain awakened patient
from sleep<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l1 level1 lfo4; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Neonatal torsion<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l1 level2 lfo4; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">A topic that could have its own talk<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l1 level2 lfo4; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Many cases occur in utero</span></li>
</ul>
</ul>
<h2>
<span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;">Torsion of
the appendix testis and appendix epididymis</span></h2>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><o:p></o:p></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level1 lfo5; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Vestigial structures<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level2 lfo5; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Appendix testis: Müllerian
system<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level2 lfo5; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Appendix epididymis: Wolfian
system<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level1 lfo5; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">They torse easily<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level2 lfo5; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Boys 7-12 years of age<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level2 lfo5; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Pain is usually less severe<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level1 lfo5; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">The ‘blue dot sign’ is the pathognomonic physical finding<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level2 lfo5; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Due to infarction/necrosis of the appendix<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level2 lfo5; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">A reactive hydrocele may also be seen<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level1 lfo5; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Diagnosis<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level2 lfo5; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Usually clinical if you see a ‘blue dot sign’<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level2 lfo5; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Get an Ultrasound in cases where you can’t r/o torsion<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level1 lfo5; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Management<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level2 lfo5; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Analgesics<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level2 lfo5; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Rest<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level2 lfo5; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Scrotal support<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l5 level2 lfo5; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">The pain typically resolves in 5-10 days</span></li>
</ul>
</ul>
<h2>
<b><span style="color: #6fa8dc; font-family: Arial, Helvetica, sans-serif;">Epididymitis</span></b></h2>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><o:p></o:p></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level1 lfo6; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Etiology<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Sexually active? Chlamydia, gonorrhea, E.coli, viruses<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Prepubertal? Viruses, E. coli, mycoplasma<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level1 lfo6; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Presentation<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Pain and swelling localized to the epididymis<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Testis has a normal lie<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">50% have scrotal edema<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">The scrotum is sometimes red<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Cremaster reflex is present<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Positive ‘Prehn sign’ (not reliable)<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Patient may have dysuria<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level1 lfo6; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">The work-up<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Clinical exam<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Ultrasound<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Urinalysis<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level3 lfo6; tab-stops: list 1.5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Obtain in <u>ALL</u> patients with suspected epididymitis<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">STD testing<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level3 lfo6; tab-stops: list 1.5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Get gc/chlamydia DNA of urine if sexually active<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level3 lfo6; tab-stops: list 1.5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Syphilis and HIV testing<o:p></o:p></span></li>
</ul>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level1 lfo6; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Prepubertal boys<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Antibiotics are NOT always indicated<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Treat if.. Pyuria >3-5 wbc, positive U/C, or underlying UTI risk
factors - TMP/SMX or Cephalexin
for 10 days<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level1 lfo6; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Teenagers (Pro-Tip: think about STDs)<o:p></o:p></span></li>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">Ceftriaxone 250mg IM x1 then doxycyline 100mg bid x10 days<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">For enterics AND negative STD…<o:p></o:p></span></li>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level2 lfo6; tab-stops: list 1.0in;"><span style="font-family: Arial, Helvetica, sans-serif;">10 days of ofloxacin 300mg bid or levofloxacin 500mg qday<o:p></o:p></span></li>
</ul>
<li class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-list: l3 level1 lfo6; tab-stops: list .5in;"><span style="font-family: Arial, Helvetica, sans-serif;">Tx also includes rest, NSAIDs, and scrotal elevation</span><o:p></o:p></li>
</ul>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-21006668524652658362012-05-16T07:30:00.000-04:002012-05-16T08:06:18.900-04:00Day 8 Leaderboard<span style="color: black; font-family: Arial, Helvetica, sans-serif;">As Day 8 of the #PEMTwitterTriviaContest dawns there is a logjam at the top of the Leaderboard with a deadlock in 2nd place. Other competitors - there is still plenty of time to make your move.<br /><br />1. </span><a href="https://twitter.com/#!/MarlinaLovett" id="internal-source-marker_0.3053111803267582"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: black;"><span style="background-color: whitesmoke; color: #66c1c1; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">@</span><span style="background-color: whitesmoke; color: #009999; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: underline; vertical-align: baseline;">MarlinaLovett</span></span></span></a><span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: black;"><span style="background-color: whitesmoke; color: #333333; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span><br />2. </span></span><a href="https://twitter.com/#!/Bedingaj" id="internal-source-marker_0.3053111803267582"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: black;"><span style="background-color: whitesmoke; color: #66c1c1; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">@</span><span style="background-color: whitesmoke; color: #009999; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: underline; vertical-align: baseline;">Bedingaj</span></span></span></a><span style="color: black; font-family: Arial, Helvetica, sans-serif;"> and </span><a href="https://twitter.com/#!/paulbunchmd" id="internal-source-marker_0.3053111803267582"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: black;"><span style="background-color: whitesmoke; color: #66c1c1; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">@</span><span style="background-color: whitesmoke; color: #009999; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: underline; vertical-align: baseline;">paulbunchmd</span></span></span></a><br />
<span style="color: black; font-family: Arial, Helvetica, sans-serif;">3. </span><a href="https://twitter.com/#!/GreggKottyan" id="internal-source-marker_0.3053111803267582"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: black;"><span style="background-color: whitesmoke; color: #66c1c1; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">@</span><span style="background-color: whitesmoke; color: #009999; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: underline; vertical-align: baseline;">GreggKottyan</span></span></span></a><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: black;">Close behind are<strong> <span style="background-color: transparent; color: black; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><a href="http://twitter.com/ziggy7652">@ziggy7652</a>, <span style="background-color: transparent; color: black; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><a href="http://twitter.com/dbailey4">@dbailey4</a>, <a href="https://twitter.com/#!/7hillsandariver"><span style="background-color: whitesmoke; color: #66c1c1; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">@</span><span style="background-color: whitesmoke; color: #009999; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: underline; vertical-align: baseline;">7hillsandariver</span></a><span style="background-color: whitesmoke; color: #333333; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><span style="background-color: transparent; color: black; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">, <a href="http://twitter.com/AnotherLynLee">@AnotherLynLee</a>, <span style="background-color: transparent; color: black; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><a href="http://twitter.com/preetir85">@preetir85</a>, <span style="background-color: whitesmoke; color: #66c1c1; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">@</span><span style="background-color: whitesmoke; color: #009999; font-family: Calibri; font-size: 13px; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: underline; vertical-align: baseline;">TarekAlsaied</span></span></span></span></span></span></strong></span></span>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0tag:blogger.com,1999:blog-8776107148973166164.post-86443819107149838622012-05-15T21:30:00.000-04:002012-05-15T21:30:01.166-04:00Prognotic factors in sickle cell disease<span style="font-family: Arial, Helvetica, sans-serif;">Three prognostic factors have been associated with worse outcome in sickle cell disease:</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">1.) Dactylitis in infants younger than age 1 year</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">2.) Hemoglobin level less than 7 g/L</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">3.) Leukocytosis in the absence of infection</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">These worse outcomes include <span style="background-color: white; text-align: left;">death, risk of stroke, high pain rate, recurrent acute chest syndrome.</span></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">Check out the article here: <a href="http://www.nejm.org/doi/full/10.1056/NEJM200001133420203">http://www.nejm.org/doi/full/10.1056/NEJM200001133420203</a></span>Brad Sobolewskihttp://www.blogger.com/profile/02142508760496519882noreply@blogger.com0