9.27.18 Conference Summary

M&M - Dr. Andrew Schaub

Penetrating Neck Trauma

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  • ‘Penetrating’ = violation of platysma; assume injury to deeper structures

  • Zones

    • Zone 1: highest mortality, often requires median sternotomy

    • Zone 2: most accessible —highest rates of injury, best prognosis

    • Zone 3: often treated as primary head injury, difficult to access injuries

  • ‘Hard’ signs of neck injury

    • Expanding hematoma, air bubbling, severe active bleeding, shock, absent radial pulse, airway obstruction, neuro deficit, hematemesis

    • Emergently to OR (delay only for securing unstable airway)

  • ‘Soft’ signs of neck injury

    • Oropharyngeal blood, sob, dysphonia, dysphagia, chest tube air leak, stable hematoma, bruit/thrill, subcutaneous emphysema

    • Conservatively managed but need rapid eval for vascular/aerodigestive injury

      • Zone II: CTA, gastrograf/EGD/esophogram, +/- bronch, serial exams

      • Zone I & III: usually more institutional/provider dependent

  • Emergent management

    • Consider early airway intervention; anticipate difficulty, be ready for cric

      • Consider smaller ETT size to avoid injury to structures

        • Minimize BVM to avoid dissection of air

        • Disregard C-spine immobilization unless high likelihood of direct spinal injury

        • Consider awake intubation or use of ketamine

      • Do not probe wounds — may dislodge clots and worsen bleeding

      • Establish vasc access on contralateral side

Ischemic Colitis

  • Most common form of GI ischemia with high mortality

  • Continuum of ischemia: mucosal/submucosal injury = non-necrotic —> transmural injury = necrotic 

  • Most pts have transient ischemia/nongangrenous colitis and can be conservatively managed

  • Angiography has low utility; most commonly small vessel, nonocclusive disease 

  • If necrotic/gangrenous: need emergent OR + vanc/zosyn (+fluconazole if above ligament of tritz

  • Subtypes

    • Occlusive: arterial emboli most common, vascular disease, hypercoagulable, etc

    • Non-occlusive: associated with low flow states, certain drugs, incl cocaine, colonic obstruction

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  • Risk factors for gangrenous colitis: many… diabetes, heart failure, peripheral arterial disease are most common

  • Cocaine-induced ischemic colitis is very rare though not well studied

  • Cocaethylene: cocaine + ethanol; significantly higher mortality compared to cocaine alone

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Pancreatitis

  • Pancreatic inflammation leading to autodigestion of tissue, edema, potential loss of function

  • Causes: numerous.. gallstones, alcohol, high triglycerides most common

  • Dx requires 2 of following: abd pain c/w pancreatitis, lipase +/- amylase >3x normal, findings on abd imaging

  • Ranson’s criteria to assess severity

  • Complications: most common include necrosis, splenic/portal vein thrombosis, pseudocyst/abscess

  • Who needs imaging?

    • CT not routinely recommended if characteristic pain + enzyme 3x nl

    • however, CT recommended if enzymes lower than 3x limit normal or to differentiate from other intraabd cause

Peds Curriculum: Antibiotics in the ED - Dr. Amy Edwards, Peds Infectious Disease

  • URIs

    • up to 50% caused by rhinovirus

    • 2/3 with URI have abnormal middle ear pressure

    • In kids with URI, 5-19% develop AOM and 6-13% develop bacterial sinusitis

  • AOM

    • Bacteria: Strep pneumo, non-typeable hflu, moraxella

    • When to treat?

      • age <6 months: mandatory

      • 6-23 months: encouraged

      • >2 years: optional

    • Antibiotics:

      • Oral: amoxillin, augmentin, cefpodoxime, bactrim

        • Augmentin over amoxicillin if: bilateral AOM, beta lactam in last 30 days, concurrent conjunctivitis (suggests nontypeable hflu)

      • IM/IV therapy: ceftriaxone, ampicillin

      • Pen allergy - levaquin, clindamycin

  • Sinusitis

    • Bacteria: strep pneumo, nontypeable hflu, moraxella

    • Antibiotics: (**need to cover nontypeable hflu)

      • Oral: augmentin, cefpodoxime, levofloxacin

      • IV/IM: unsayn, ceftriaxone, cefotaxime, levofloxacin

  • Pneumonia

    • Age <5 yrs

      • Bacteria: Strep pneumo, Hib, non-typeable hflu, moraxella, staph aureus, group A strep (atypicals less common)

      • Antibiotics:

        • Oral: amoxicillin, cefpodoxime

        • IV: ampicillin, ceftriaxone

    • Age > 5 yrs

      • Bacteria: strep pneumo, mycoplasma pneumonia, chlamydia pneumonia

      • Antibiotics:

        • Oral: azithromycin (1st line but developing resistance), amoxicillin, levofloxacin

        • Uncomplicated non-IUC: ampicillin, ceftriazone, azithromycin, levofloxacin

        • Complicated non-ICU: ampicillin or ceftriaxone + azithromycin

        • Complicated ICU: vanc + ceftriaxone + azithromycin (or vanc + levo if allergic)

  • UTI

    • Bacteria: e.coli by far the most common, followed by klebsiella

    • Antibiotics:

      • Oral: amoxicillin, cefdinir, cephalexin, bactrim (avoid in infants), cipro

      • IV: ampicillin (most penicillins), ceftriaxone, meropenum, ciprofloxacin, macrobid (for older kids with no upper tract penetration)

  • Acute abdomen

    • Bacteria: gram neg (ecoli), gram pos (enterococcus), anaerobes

    • Antibiotics: zosyn, meropenum (no enterococcus coverage), amp+gentimicin+flagyl, cipro+flagyl

  • Impetigo

    • Bacteria: Group A strep (rarely MSSA)

    • Antibiotics:

      • Oral: cephalexin, amoxicillin (but no MSSA), clindamycin

      • IV: cefazolin, clindamycin, vancomycin

    • If lesion is small, you can use topical abx (mupirocin)

  • Folliculitis

    • Bacteria: staph aureus, CONS, pseudomonas (if recent hot tub)

    • Antibiotics (oral): clindamycin, bactrim

      • If recent hot tube exposure: treat with ciprofloxacin (pseudomonas/staph aureus)

  • Cellulitis

    • Bacteria: GAS, if purulence think staph aureus

    • Antibiotics:

      • Oral: cephalexin, augmentin, clindamycin

      • IV: cefazolin, clindamycin, vancomycin

    • Poorly defined borders compared to very well-demarcated erysipelas

  • Abscess

    • Bacteria: staph aureus, GAS, group G&C strep

    • Best treatment: I&D

    • Antibiotics

      • Oral: clindamycin, bactrim, linezolid

      • IV: vanc, clindamycin

  • Necrotizing fascitiis

    • Bacteria: GAS, staph aureus, clostridium, pseudomonas, vibrio

    • IV antibiotics: zosyn + clinda + vanc (allergy: meropenum, cipro+flagyl)

  • Bone and joint infections

    • General:

      • Bacteria: MRSA, GAS, kingella

      • IV antibiotics: nafcillin, cefazolin, vancomycin, clindamycin

    • Sickle cell

      • Bacteria: salmonella, staph auresua

      • IV antibiotics: ceftriaxone+vanc, cefepime+vanc, zosyn+vanc

    • Age <3 months

      • Bacteria: GBS, staph aureus

      • IV abx: cefotaxime+vanc

Super Track Series: Nail Complaints - Dr. Leyya Suleman-Civis

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Paronychia

  • Inflammation of lateral and/or proximal nail folds

  • Due to repetitive trauma, manicuring, nail biting, frequent water immersion etc

  • Bacterial: usually staph aureus or GAS

  • Non-bacterial: meds including chemo, ARV, retinoids, etc

  • Treatment:

    • Abscess: I&D (abx if immunocompromised — Keflex or Bactrim/clinda/doxy for MRSA)

    • No abscess: warm soaks with chlorhexidine/betadine, topical abx

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Felon

  • Abscess in pulp of fingertip

  • Severe pain, erythema, swelling

  • Risk factors: septic arthritis, flexor tenosynovitis, osteomyelitis, ischemic necrosis — need xray

  • Treatment: I&D (may need OR drainage)

    • Make incision on ulnar side for digits 2-4, radial side for thumb/5th digit

    • If superficial, can make midline/longitudinal incision over pulp

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Herpetic Whitlow

  • Pain/swelling/erythema with cluster of vesicles

  • Commonly seen in healthcare workers

  • Treatment: acyclovir (obtain viral cultures)

  • Do NOT I&D

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Ingrown Nails

  • Lateral folds vs proximal folds (retronychia)

  • Result of improper trimming/external pressure

  • Nail plate breaks into nail fold, causing pain & inflammation

  • Treatment:

    • Mild: mechanical separation of nail/nail fold using cotton wedge, Epsom salt soaks, push nail fold away from nail and apply corticosteroid

    • Moderate-severe: digital block and cut away involved nail and debride; keep site clean; antibiotics only if diabetic, immunocompromised, PVD

    • May need ablation if recurrent

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Subungal hematoma

  • Blood collection between nail and nailbed

  • Treatment:

    • Drain (trephination) if painful or >50% nailbed involved; otherwise can monitor

    • Remove nail/repair nailbed if nail partially avulsed or nail fold disrupted

  • Blood collection between nail and nailbed

  • Treatment:

    • Drain (trephination) if painful or >50% nailbed involved; otherwise can monitor

    • Remove nail/repair nailbed if nail partially avulsed or nail fold disrupted

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Nail Trauma

  • Assess for injury beyond nail/nailbed, obtain xrays, neurovascular exam, assess for tendon injury (ROM at DIP)

  • Management: digital block —> gently remove nail, keep intact —> irrigate nailbed —> replace nail into nailfold and suture in place (use nonadherent material if nail unavailable)

Power (Half) Hour with Dr. Lauren McCafferty

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Case #1: Angioedema

  • Histamine vs bradykinin-mediated etiology

  • ACE inhibitors can cause bradykinin-mediated angioedema even after many years of taking

  • Always consider NP scoping patients with signs of angioedema; even if normal-appearing posterior oropharynx, they may have laryngeal edema/airway compromise (‘skip lesions’)

  • Angioedema-related epiglottitis tends to be non-erythematous, boggy, watery appearance in contrast to cherry red appearance in infectious epiglottitis

  • Consider early airway management especially in the community

  • Treatment dependent on cause

    • Remove/avoid offending agent if allergy or ACE-inhibitor induced

    • Allergy: H1/2 blockers, steroids, epi if severe

    • ACEi angioedema

      • Often fails to respond to steroids, H1/2 blockers, epi

      • Icatibant (bradykinin antag) not shown to improve outcomes

      • May consider FFP in resistant cases

    • Hereditary: C1 esterase inhibitor

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Case #2: SBO

  • Ultrasound findings

    • Bowel diameter > 2.5 cm

    • Fluid-filled bowel with ‘to-and-fro’ peristalsis

    • Thickened bowel wall with prominent plicae circulares

    • Free fluid surrounding bowel loops = poorer prognosis

  • Management

    • Surgery consult, NPO, supportive care +/- NGT for decompression