410C Quiz 1: sensitive exam, MSK, IV injections/fluids Flashcards
When should you release the tourniquet when taking blood?
after the flash, before you use the tubes
Shoulder Joints
- Contains the scapula, humerus, clavicle, glenohumeral joint, acromioclavicular joint
- glenohumeral is the actual shoulder joint
- scapulothoracic joint is in the back → important for impingement injuries
Rotator Cuff General info
- consists of SITS: supra spinatus, infra spinatus, teres minor, sub scapularis
- impingement syndrome → most important muscle = supra spinatus muscle b/c it passes beneath the acromion
Y view of the shoulder
- aka transcapular view b/c it shoots down the body of the scapula
- used to look for impingement
- gets a good look at the acromion
- used to assess the acromion
What is the grashey view?
Shoulder film
no overlap of the humerus and glenoid
- Used to see the glenohumeral joint
Xray of (lateral & AP) Elbow vs radial-capitellar view
-
Xray Elbow:
- cannot see the radial head that well
-
XR Elbow Radiocapitellar View:
- if suspect elbow fracture (usually a radial head fracture) → need to order a radiocapitellar view
- better view of the radial head
Posterior vs Anterior Fat Pads in the Elbow
- Anterior can be normal
-
Posterior is always Pathological
- indicative of a fracture
Galeazzi Fracture vs Monteggia Fracture
“Gruesome Murder”
- Galeazzi: Radial fracture, ulnar dislocation (distal)
- Monteggia: Ulnar fracture, radial dislocation (proximal)
Torus/Buckle Fracture
- AP of the wrist
- kids bones are covered with a very thick, fibrous periosteum
- torus, buckle, and greenstick are all the same thing
- **Only found in children → check for open growth plate
Salter Harris Classification
Pelvis Fractures
Super serious, major trauma!!
look for associated injuries
- anticipate large blood loss
- up to 9-15 units of blood in unstable fractures
- external and internal iliac arteries are present anterior
- femoral artery, profunda and circumflex artery are present posterior
- tx:
- admission
- look for associated injuries → vessel/bladder/nerve/head trauma/ cervical spine injuries
- Manage blood loss
- often surgical
- **side note: pelvis & ankle are a ring so if there is one fracture it is still stable, but two make it unstable!!!
Garden Classification of Hip Fractures
Names of Different Fractures
What do you do if you see a tibial plateau fracture?
if both side → need CT
could be due to MVA
need neurovascular exam ASAP
check hgb & HCT asap
give blood prn
check for compartment syndrome!
Mortise Joint
- the medial malleolus of the tibia forms the top of the mortise joint
- can order a mortise view -→ can see both sides
- spaces in the mortise joint should be equal ~1mm
- if there is a difference in the spaces = displaced ankle
Lisfranc Injury
- VERY BAD, takes significant trauma
- Can’t miss
- usually requires surgery to repair
- and often has residual issues after surgery
Phalangeal Fractures
Most are not problematic except the great toe
- can often be reduced & taped
- use postop shoe or split
- great toe will often require surgery
Jones Fracture
- Proximal 5’th metatarsal diaphysis fracture
- Pain over the lateral border of the forefoot, especially with weight-bearing
- The fracture is believed to occur as a result of significant adduction force to the forefoot with the ankle in plantar flexion
- The area has a poor blood supply
- Treatment: Walking boot/cast, RICE, surgery for displaced fractures. Requires 6 weeks of non-weight bearing
What should you never do with a fresh fracture?
put the pt in the cast → you need to splint then refer
What films do you need to order for a shoulder dislocation?
Axillary View and AP view before AND after reduction
If pt fell on their arm in full extension what film do you need to order?
Grashey view
What is the most important muscle for impingement?
Supraspinatus
If pt has impingement syndrome what film do you always order & why?
Y film → b/c if you don’t order Y view you might not know that the acromion is a type III which requires surgery and that is why the injury isn’t resolving → not enough anatomical space for the supraspinatus tendon
If pt comes in for a fall on their hand with positive snuffbox tenderness what film should you order and why?
Scaphoid view b/c this is a scaphoid fracture until proven otherwise
What size angiocath is most appropriate for: IV maintenance fluids vs blood infusion
IV maintenance fluids: 20g
Blood infusion: 18g
Why do we use a saline flush on extension tubing and a saline lock?
ensuring extension tubing is patent
prevent an air embolism
How long should you leave the tourniquet in place?
no longer than 1-2 minutes at a time
How often does the CDC recommend changing the peripheral IV site?
72-96 hours
Calculating Body Water
- BW = 60% of body weight
- ICF = ⅔ of body water
- ECF = ⅓ of body water
- ¾ of ECF = interstitium
- ¼ of ECF = plasma
Osmolality Definition & normal values
-
Definition:
- solute or particle concentration of a fluid
- Normal range: 280-295 mOsm/kg
-
Symptomatic when numbers are:
- >320-330 mOsm/kg or <265 mOsm/kg
How to calculate osmolality?
2x (sodium) + glucose/18 + BUN/2.8
Conditions that cause Hypovolemia
Conditions that Cause Hypervolemia
Renin-Angiotensin System
What is the most common maintenance fluid?
D5W ½ NS
How to Tx Volume Overload
IV Cath size and flow rates
5% albumin vs 25% albumin
- if 1 liter of 5% albumin is given, all will stay in intravascular space because its too large to cross the cell membrane
- 1000mL → 1000mL
- if 100mL of 25% albumin is given, it will draw 5x its volume into the intravascular compartment
- 100mL → 500mL
Types & Cross
Blood is taken from the pt and typed and then crossed with a donor blood to look for agglutination/rxn
- takes 45min -1 hour → so ACT EARLY!
- type & cross is only good for 48-72hrs so may need a new one
- how much do you ask for? 2-6 units
- use O- is you cannot wait (often the case!)
when do you give blood?
if Hgb of 7 without active bleed
if hgb of 9-10 with active bleed
How much increase in hgb from packed red blood cells?
- expect increase of 1gm/dl in Hgb (3%) in HCT from a unit (325-350ml) of PRBCs
When do you start adding FFP, Cryo & platelets?
after 4 units of packed red blood cells
may be needed sooner based on findings → check fibrinogen, platelet count, ACT, INR
if FFP isn’t thawed it may reduce effectiveness of coagulation factors (due to the cold)
What fluids are okay to bolus?
Normal Saline
Normosol R
Lactated Ringer’s
PLasma-Lyte 148
Maintenance Fluids rates and additions
Potassium Repletion Infusion Rates
What is pelvic pain in a woman < 50yo until proven otherwise?
ectopic pregnancy
What does the sexual history include?
- Gender identity
- sexual orientation
- social hx
- GU & Genital ROS
- GYN hx → pregnancies, deliveries, menarche etc
6 Ps of Sexual History
- Partners
- Practices
- Protection from STIs
- Past Hx of STIs
- Pregnancy Intention
- (Pleasure)
