High Yield 1 Flashcards
What info to obtain in focus history in Emergency?
Age and sex of patient, mechanism of injury, injury sustained, signs and symptoms, treatment so far
How to manage bleeding in long bones ?
Immobilise and splint
How to approach unconscious pt
Primary Survey
Airway - responsiveness? patent?
Breathing - look, listen, feel
No breathing, pulse felt
Rescue breaths 1 every 6s
No breathing, no pulse
Chest compressions + RB 30:2
AED
Breathing - RR, sats
Circulation
CRT, HR, BP
Assess for sources of bleeding - long bones
Hemorrhage control
Disability
PEARL
Glucose
Movement + sensation x4 limbs
Exposure
Occult injuries
Medic alert bracelet
Keep pt warm
Causes of decreased LOC
Neuro:
Stroke
Infection
CV:
MI
Cardiomyopathy
Hypovolemia
Resp:
PE
Metabolic:
Hyponatremia
Hypothermia
Hyperthermia
Hypoglycemia
Benign:
exercise induced collapse
Most common form of hyponatremia
Dilutional
Describe the causes of hyponatremia in an endurance athlete
D/t excess water, sodium loss during sweating, activity induced release of ADH
Why do neurological sx occur in hyponatremia?
D/t cerebral edema (exercise associated hyponatremic encephalopathy)
When do symptoms of hyponatremia occur?
If sodium is <125 or if loss if abrupt (10% fall in 24hr period)
Hx questions for ?hyponatremia
Food + water intake
NSAIDs, SSRIs, diuretics, APs + amiodarone use
Sx of hyponatremia
Mild = dizziness, HA, vomiting, cramping
Mod = confusion, inability to concentrate, swollen hands + feet, bloating
Severe = delirium, szs, resp distress, pulmonary edema, coma
RF for hyponatremia
High heat, humidity, excess water stations at event, inexperienced athletes, females, older age, CF gene, high fluid intake, SIADH, use of NSAIDs prior to or during event, longer race time, high or low BMI
What to assess on physical of hyponatremia
Vitals
Weight
Fluid status - BP, skin turgor, edema, pulmonary exam
Mental status
Investigations for ?hyponatremia - sideline + in ED
Na <135, glucose
Correct serum sodium for hyperglycemia if present
CBC, lytes, BUN, Cr, glucose, LFTs, PTT, INR
ABGs
DDx for hyponatremia
Hypovolemia, hypothermia, hyperthermia, hypoglycemia
MI
Adrenal crisis
CHF
AKI
Management of Mild hyponatremia (>130)
monitor, fluid restrict - will likely self correct w/ urination
Fluid restriction is CI in rhabdomyolysis
Do not D/C until able to urinate
Management of Moderate hyponatremia
ABCs
Supine w/ legs elevated
hypertonic oral fluids (4 cubes bullion in 4oz water = 9% saline solution OR 3 salts packs in half cup gatorade = 3% saline solution)
Restrict all other oral fluids until pt is able to void
Do not D/C until able to urinate
Management of severe hyponatremia
ABCs
Supine w/ legs elevated
give 100ml bolus 3% saline IV and repeat after 10 mins if no response, transfer to hospital. Can give up to 3 boluses
Alternatively can give IV bicarb ampule (50ml of 8.4% NaHCO3)
Goal is 1-2meQ/L/hr increase in Na level
If AMS present, give high flow O2 also
How long can hyponatremia occur for after exercise?
Can occur up to 24hrs after prolonged exercise
How to prevent hyponatremia
Educate participants
Drink dictated by thirst
Reduce availability of fluids
Monitor weight before + after race - if weight gained, reduce fluid intake
Sx - heat exhaustion
Hot, thirsty, cramps
Fatigue
N/V
Dizziness, syncope
Sx - heat stroke
Prev hx of heat exhaustion
Irritability, confusion
CNS sx
Physical exam findings for heat exhaustion
Normal or elevated temp <40
Flushed skin
Profuse sweating
Cold, clammy skin
Physical exam findings for heat stroke
Confusion, ataxia
Temp >40
Tachycardia, SOB, hypotension
Hot skin +/- sweating
Investigations for ?heat exhaustion/ stroke
ECG
Lytes
Blood gas
Blood sugar (normal fasting/ before meals = 4-7)
Kidney function
Coagulation
Risk factors for heat stroke
Young or old
Dehydration
Increased body fat %
Overmotivation
Heat exhaustion on prev day / cumulative heat load
Heat + humidity
Poor acclimatization
Inappropriate clothing
Equipment (pads, helmets)
Sickle trait
Supplements/ drugs - cocaine, amphetamine, ephedra, BB, diuretics, CCB, TCAs, antihistamines
Concurrent illness - viral illness, cardiac dz
DDx for heat exhaustion
Dehydration
Electrolyte abnormality
CV disease
Exercise associated collapse
CNS lesion
Thyroid abnormality
Infection
Management of heat stroke/ exhaustion
Fast cooling ASAP
Ice tub, move to cool environment, remove excess clothing, apply ice bags to neck, axilla + groin
Supine position w/ legs elevated
Replace fluids + electrolytes - PO or IV
Monitor rectal temp every few mins - remove from ice bath when temp is 38.9
Observe athletes for an hour after temp returns to normal
If unstable or if still symptomatic after 1 hr of cooling, transfer to hospital
Complications of heat stroke
End organ failure
Death
Szs
CV collapse
ARDS
Liver failure
Kidney failure
Rhabdomyolysis
DIC
Prevention of heat exhaustion in future
Pre + post exercise hydration, increase electrolyte intake (mainly sodium)
Acclimatise (takes 10-14 days)
Appropriate clothing
Graduated training
Manage heat exhaustion on preceding days effectively
Provide shade, ice water, misting fans
Modify time, intesnity + exposure during hot/ humid weather
Gear up in stages
Manage “tough” culture (i.e. player pride, tough coaches)
Optimise sleep, no alcohol
Cold tubs before and after exercise
RTP for heat stroke
Stroke
7 days rest or until asymptomatic + labs returned to normal
FU 1 wk
Begin gradually increasing training in cool environment over 2 week period
Gradually increase heat acclimatization
Return to comp 2-4 wks after 2 wks asymptomatic training + acclimatization
RTP for heat exhaustion
Exhaustion - 24-48hrs can return to activity, gradually increase intensity + volume
Superficial vs deep frostbite
Superficial - partial or complete freeze of skin
Deep - involvement of skin + underlying tissue
RF for hypothermia
Cold temp, wind chill, prolonged exposure, high altitude
Wet clothing
Immersion in water
Fatigue
Low body fat
Alcohol use
Extremes of age
Underlying medical conditions - sickle anemia, peripheral vascular disease, diabetes, szs, hypothyroidism
RF for frostbite
Cold temp, wind chill, prolonged exposure, high altitude
Wet clothing
Immersion in water
Prior cold injury
Petroleum or oil lubricants
Constrictive clothing or shoes
Smoking
Vasospastic disorders (Raynauds)
Sx Frostbite
Skin that is erythematous, swollen or waxy, white, yellow, blue/ purple
Blisters
Numbness +/- pain
Sx of Hypothermia
Shivering, confusion, amnesia, dysarthria, ataxia
Physical exam findings in hypothermia
Loss of deep tendon reflexes
Loss of shivering
Muscle rigidity
Cardiac arrhythmias
Dilated pupils
Reduced LOC
Hypotension
Reduced RR
Tachycardia initially then bradycardia
how to do body temp in hypothermia
Core body temp
Esophageal has greatest accuracy but only to be used when pt airway is secure
If not secure, use epitympanic
Oral temp inadequate for diagnosis
Rectal temp not advised until in warm environment to reduce further cold exposure
Physical exam findings in frostbite
Neurovascular status
Pliability of tissue - soft tissue = more likely superficial frostbite, hard tissue = more likely deep
Investigations in frostbite/ hypothermia
MRI or technetium 99 bone scan for frostbite severity + prognosis
ECG to assess for arrhythmias (AFib, VF, prolonged PR, QRS + QT intervals, J waves)
Lytes, VBG
DDx for Frostbite
frostnip, trench foot, chilblains, raynauds
DDx for Hypothermia
metabolic abnormalities, alcohol ingestion, head injury
Management of Frostbite
Avoid thawing until no further risk of refreezing
Immerse affected part in 37-39 degrees
Remove wet clothing
Rehydration w/ warmed fluids
Avoid rubbing skin
Monitor + treat concurrent hypothermia
In ED
Debride white blisters, apply topical aloe vera
Blood blisters - apply topical aloe vera
Consider tetanus prophylaxis
NSAIDs unless CI
Intra-arterial plasminogen activator (alteplase) within 6-24hrs of rewarming may decrease amputation rate
IV iloprost administered up to 48hrs after rewarming may decrease amputation rate
management of Hypothermia
Remove wet clothing
Blankers, dry clothing, move to warm environment
Heating pad, hot water bottle to torso - monitor BP d/t risk of hypotension from rapid rewarming
Hot drinks
In ED
Continuous cardiac monitoring
Active internal + external rewarming
Monitor electrolytes
Severe cases in young, otherwise healthy pts may need cardiopulmonary bypass
Prevention in future of cold injury
Event planning based on temperature
Proper clothing inc hats, mittens, multiple layers
Avoid alcohol
Recognise signs + sx of hypothermia + get to shelter
Complications of hypothermia
Cardiac arrhythmias
Electrolyte + acid-base disorders
DIC
Complications of frostbite + in adults + kids
Amputation
Premature closure of epiphysis in young athletes
Autonomic dysfunction of affected extremity
Permanent cold sensitivity + susceptibility to cold injury
RF for drowning
Male age
Young age
Low income
Unattended children
Alcohol or drug use
Limited swimming ability
Trauma
Risky behaviour
Shallow water blackout (intentional hyperventilation)
Exacerbation of existing conditions (szs, cardiac dz, syncope)
Hypothermia
Panic/ anxiety
Sx following drowning
Respiratory (can occur up to 8 hrs after drowning)
Increased RR, wheezing, cough, SOB
Bronchospasm
Neuro (d/t cerebral edema + raised ICP - can be up to 24hrs after injury)
Confusion, myoclonic jerks, szs
Management following drowning inc management for hypoxic brain injury
ABCs
C spine precautions
O2 15L via NRB
Foil blanket (consider removing wet clothing if possible)
Transfer to ED
NG tube for stomach decompression
Monitor for electrolyte abnormalities
Suspected hypoxic brain injury - hyperventilation, head elevation, diuretics + muscle relaxants
Monitor for min 8 hrs for pts with resp sx following drowning
Can be d/c when normal vitals, normal mentation, improving or resolved resp sx, normal lung sounds, normal CXR
Complications following drowning
CV
Arrhythmia (tachycardia, bradycardia, AFib, PEA, asystole)
Cardiac ischemia (d/t takotsubo cardiomyopathy, coronary artery spasm, hypothermia, hypoxia)
Hypothermia
Hypovolemia d/t cold diuresis (vasoconstriction to direct blood to core organs, central volume receptors sense fluid overload, decreased ADH, increase urine production)
Atypical PNA
Metabolic acidosis (hypoxia + hypoperfusion)
Rhabdomyolysis
Acute tubular necrosis
DIC
Prevention of drowning
Parental supervision
Swimming lessons
Pool fencing
Lifeguards
Restricted swimming areas w/ proper signage
What is epilepsy?
2 unprovoked szs that occur >24hrs apart
What is status epilepticus?
One continuous sz lasting >5 mins or 2 or more szs where there is no full return to consciousness
Sx + hx questions for ?sz
Change in muscle tone
Convulsions
Decreased LOC
Staring spells
Bladder or bowel incontinence
Postictal confusion
Todd paralysis
Collateral hx
Prev seizures + head injuries
Physical exam for ?sz
Temp
Assess for focal neurological deficits (if present, think trauma or tumor)
Meningismus signs
Papilledema (think raised ICP)
Tongue biting
Injuries that could have occurred during seizures
Causes of szs
Alcohol w/d
AV malformation
Hypoglycemia
Hyponatremia
Fever
Hepatic failure
Substance use or w/d
Intracranial swelling
Brain tumor
Posttraumatic sz
Stroke
Syncope
Uremia
Management of szs
General
Support ABCs
If in setting of trauma, stabilize C spine
Protect pt from injury
Keep pt in lateral recovery position
Transfer to ED if no known sz disorder
Meds
Check blood sugar
Intra-buccal, nasal or IM benzo (midaz 10mg)
If no success, repeat 5 mins later
Longterm:
If no reversible cause found, start regular med
Levetiracetam, phenytoin, valproic acid
May need monitoring
When to refer szs to neuro
First time unprovoked sz
Initiation of anti-convulsant
For outpt EEG
RTP for szs
Should be based on probability of sz occurring, sz type, usual timing of sx occurrance, SE of anticonvulsant meds
Prevention of szs
Exercise may decrease sz frequency
Sufficient + regular sleep
Limiting alcohol intake
Exercise at high altitudes can cause hypoxia + induce szs
What qs to ask on hx of ?anaphylaxis, and what sx?
Prev hx of anaphylaxis
Time between exposure + sx
Sx:
Allergic type mediated by IgE
Acute onset (mins - hours)
Skin or mucosal tissue involvement: lip, throat, tongue swelling, hives, itching, flushing AND:
Resp compromise (SOB, wheezing, stridor, hypoxia)
CV (hypotension, syncope, incontinence)
GI (abdo pain, vomiting)
May have hx of less severe reaction previously on exposure
Exercise induced anaphylaxis
Occurs in response to physical exertion
Cold urticaria
Reproducible, rapid onset of erythema, pruritus, edema after exposure to cold
RF for anaphylaxis
Prev allergic reaction to same allergen
Coexisting atopic dz, particularly poorly controlled asthma
Older age at first reaction to food allergy
Physical signs of anaphylaxis
Bronchospasm, layngeal edema
Hypotension, arrhythmias
Urticaria, angioedema
DDx for ?anaphylaxis
PE
MI
Airway obstruction
Asthma
Tension pneumothorax
Vasovagal collapse
Septic shock
Hereditary angioedema
Pheochromocytoma
Carcinoid syndrome
Management of anaphylaxis - sideline
Support ABCs
Remove trigger
Epi
1 in 1000 (usual concentration for IM dosing in anaphylaxis)
0.5mg in adult or 0.3mg in child
Repeat every 5 mins if sx continue for 3-4 doses
1 in 10,000 is the concentration usually used for IV dosing, i.e. in ACLS
WADA requires emergency TUE afterwards if using epinephrine
Place pt supine and elevate legs
Ventolin if bronchospasm present
Management of anaphylaxis - ED
Continuous cardiac monitoring + vitals until stable
May need aggressive volume resuscitation
IV fluids +/- vasopressors for hypotension
In volume refractory hypotension, may need continious IV epi
Antihistamines for cutaneous sx
Diphenhydramine 50mg IV for adults or 1-2mg/kg slow IV pump for kids
Steroids may decrease chance of having a biphasic reaction
Methylprednisone for severe reactions
125mg IV for adults
1-2mg/kg IV for kids (max dose 80mg)
Prednisone for mild reactions
60mg PO adults
4-8mg/kg IV kids
Complications of anaphylaxis
DIC
Szs
Death
Prevention of anaphylaxis
Avoidance of allergen
Immunotherapy
Common causes of anaphylaxis
Food most common causative agent in kids
Meds most common causative agent in adults
Other causes: venom, latex, vaccines
Hx questions for lacerations
Assess blood loss
Weakness, numbness, tingling
NSAIDs, ASA, antiplatelets, blood thinners
Tetanus
Determine potential for FB
Physical exam for lacerations
Nerve + motor function
Pulses distal to laceration
Cap refill
Management of lacerations
ABCs
Examine
Explore for FB
Remove devitalized tissue
Assess injury to underlying structures
Irrigation
Clean w/ soap + water
Remove FB
Irrigate w/ clean tap water
Debride wound edges
Closure
Close all wounds except puncture wounds that can’t be irrigated
Local anesthetic
Close w/ surgical tape, staples, glue or sutures
Dressing
Non stick dressing until staples or sutures are removed
Meds
Tetanus
Vaccine needed if: last tetanus shot >5 yrs ago in dirty wound or >10 yrs in clean wound or not received full tetanus primary 5 dose series
Abx for open #, exposed tendon, exposed joint
Qs to ask on hx of epistaxis
Timing, frequency, severity
Quantify amount of blood loss
Trauma?
Bleeding conditions
Use of intranasal cocaine
Meds - ASA, anticoagulants, intranasal steroids
Initial management of epistaxis
Sit in upright position, leaning forward
Blow nose to remove clots + FB
Examine
If no source identified, refer to ENT
In trauma:
Assess for deformity
Palpate bony structures
Evaluate EOM + stability of teeth
Evaluate for concussion
Apply LA + vasoconstrictior (Afrin - lido w/ epi + oxymetazoline)
Pinch nose against septum continuously for 15 mins
Cold compress
Persistent epistaxis despite initial management
If not stopping - may need cautery
LA first
Silver nitrate x10s
Do not cauterize both sides of septum in same session to reduce risk of septal perforation
If still not stopping, consider packing
Nasal tampon, lubricated
Leave in place for 1-5 days
If >24hrs, give abx to prevent toxic shock syndrome
If posterior bleed, refer to ENT +/- balloon insertion
Complications of packing for epistaxis
Septal hematomas, abscesses, pressure necrosis, sinusitis
After car for epistaxis
Refrain from heavy lifting, blowing or picking nose
No alcohol
Nasal saline rinses
FU w/ PCP to investigate underlying cause
If recurrent epistaxis, should have XR + nasal endoscopy to r/o neoplastic lesion
MOI EDH
Temporal skull # causing bleeding of middle meningeal artery is most common
MOI acute SDH
MVA, falls, assaults
Sx of EDH
Lucid interval - altered consciousness then improvement then deterioration
Physical for head trauma
Neuro exam - serial
GCS
Examine skull for #
Management of intracranial trauma
Once C spine cleared, elevate head of bed to 30 degrees
Maintain systolic BP >100
Main temp between 36-38
Consider sz prophylaxis w/ phenytoin
If signs of increased ICP, consider mannitol or hypertonic saline
Refer to neurosurg
If above measures not working, could consider drilling burr holes
Hx questions for concussion
State you would use a SCAT card to ask about symptoms
Get collateral from parent or coach
Mechanism of injury
Protective equipment (helmet, mouth guard, neck guard)
LOC? If yes how long, Amnesia? Szs?
Current symptoms? Improving or worsening? Aggravating factors
Sensory sx
Physical symptoms (HA, dizzy, n/v, gait unsteadiness, slow to respond, slurred speech, HA with exertion, seeing stars, visual disturbance, ringing in ears)
Cognitive symptoms (confusion, amnesia, disorientation, poor concentration, memory disturbance, feeling dinged or dazed, sleep/ wake issues)
Emotional symptoms (depression, moodiness, irritable, personality or behavioral change)
Past Hx of Concussion (#, dates, length of recovery, sx, LOC, ER, MD, CT/MRI, time off sports)
Work/ school functioning
Physical exam for ?concussion
C spine exam
BESS
3 tests lasting 20s each
Feet together
Single leg stance on non dominant foot
Heel toe tandem stance with non dominant behind
SCAT 6
Imaging for ?concussion
CT head if concern of structural damage
X-ray if concern of associated injuries (facial #, C-spine)
DDx for concussion
Subdural hematoma
Epidural hematoma
Intraparenchymal hemorrhage
Second impact syndrome (cerebral edema + raised ICP following 2nd impact to head after prev unhealed concussion)
Trauma induced migraine
C spine injury
Management + general advice for concussion
Immediate
No return to play on same day or if symptomatic
Monitor for deterioration (focal neuro deficit, declining mental status or LOC, uncontrolled vomiting)
Advice
Avoid noisy areas with excessive stimulation, avoid bright lights (sunglasses)
Tylenol for HA but avoid NSAIDs
Avoid alcohol & drugs
Healthy nutrition, regular sleep pattern
Continue to participate in team functions & activities to maintain a connection to the team, avoid isolation
Rest 24-48 hrs
Adjunctive therapy
Consider PT/massage for the neck + vestibular sx
Osteopath for craniosacral treatment
Psychologist especially if prolonged symptoms and struggling with depression, grief, sense of loss, anxiety
Regular Follow-up
Concussion time frame for recovery
Simple concussion resolves within 10 days with appropriate post concussion rehab
80% get better in 7-10 days
When to Send to ED for concussions
C-spine tenderness, ↑HA, ↓LOC, ↑tiredness or confusion, lateralizing weakness, Sz, persisting vomiting
Complications of concussion
> 3 concussions increases risk of injuries, mental illness, slowed + prolonged recovery, SU + early Alzheimers
Complex has longer lasting symptoms >10days or recurrence of symptoms with exertion
Post concussion syndrome
What is post concussion syndrome?
Continued concussion sx after 3 mo
Occurs in up to 30% of injuries
Return to school plan after concussion
Stage 1 - complete mental + physical rest, no school
Once sx free x24 hrs, move to stage 2
Stage 2 - return to school w/ academic accommodations
Limit tech use
No tests, PE, band or chorus
Avoid heavy backpacks
Rest at home
Once sx free x24 hrs, move to stage 3
Stage 3 - increase workload gradually, full time school if possible, light aerobic activity
Once sx free x24 hrs, move to stage 4
Stage 4 - resume normal school activities
Return to play protocol for concussion
Stage 1 - complete mental + physical rest, no school
Once sx free x24 hrs, move to stage 2
Stage 2 - light aerobic exercise (walking, swimming, cycling)
HR <70% - 15 mins
Once sx free x24 hrs, move to stage 3
Stage 3 - sport specific exercise
Simple drills, no impact activity
HR <80% - 45 mins
Once sx free x24 hrs, move to stage 4
Stage 4 - no contact training
Complex drills, resistance training
HR <90% - 60 mins
Once sx free x24 hrs, move to stage 5
Stage 5 - full contact practice
Once sx free x24 hrs, back to full practice + play
What is an exertional HA, what are the types?
2 types: primary exercise headache (PEH) + “weight lifters headache” (form of primary cough headache)
Primary exercise headache = lasts longer, results from more sustained intense exercise, not associated w/ valsalvas
Weight lifters headache = short lasting, results from Valsalva
Hx qs for headache
Screen time: Computer use, TV, video games
Aggravated by dehydration, heat, fatigue, extreme exercise
R/O RF: confusion, disorientation, szs, numbness or focal weakness, amnesia, speech impairment, visual changes, N/V
Personal + family hx of migraines, bleeding disorders or blood clots
PEH vs cough headache
PEH
Brought on by exercise
Bilateral, throbbing, can turn into migraine if pt is susceptible
Lasts from 5min-24hrs
Cough headache
Induced by exercises like lifting, bending over
Often occipital/ neck region
Lasts only minutes
Sharp or stabbing
Physical exam for HA
Neuro exam
Head & Neck Exam inc fundoscopy
Evaluate for meningismus
SCAT Card if concern of concussion
Ix for HA
CT head if any focal neuro signs or concern for lesion or stroke
MRI head if thinking weight lifters HA
Ottawa SAH Rule for HA
New, severe, atraumatic HA reaching maximum intensity within 1 hr should be evaluated w/ CT + LP if CT normal and high suspicion remains
DDx for HA
Migraine
Concussion
External compression HA (eg. Swimming goggles, mask squeeze)
SAH
High altitude HA
Cervicogenic HA
Tension HA
Tumor
TMJ (especially with diving)
Cervical artery dissection
Viral illness
AVM
Management of exertional HA
Avoid provoking activity
NSAIDs for treatment or prevention
Indomethacin or ergotamine can be used prior to activity or propranolol for prevention long term
Diary of symptoms & triggers
Consider PT/massage for the neck
Healthy nutrition, regular sleep pattern
Avoid caffeine & Etoh
Avoid exercising in extreme temperatures (hot and cold)
Sudden severe HA w/ exercise - go to ED
What are the RF/ triggers for effort/ exertional HAs?
High altitude
Hot weather
Dehydration
Extreme exercise
Alcohol and caffeine consumption
What are the associated conditions w/ exertional HAs?
50% of pts w/ PEH have personal or fam hx of migraine
50% of pts with cough headache have a space occupying lesion of posterior fossa (usually Chiari type 1 malformation)
Symptoms of cervicogenic HA
Unilateral headache with neck, shoulder and arm pain
Starting in neck and spreading to head
Triggered by neck movement
Associated with nausea, vomiting, dizziness, blurred vision, photophobia
Physical exam findings of cervicogenic HA
Reduced C spine range of motion
Symptoms on palpation of head or neck
Anaesthetic blockade abolish pain
Sx + hx for eye trauma
MOI - penetrating trauma (velocity, type of material, size)
Diplopia, blurred vision, photophobia
Flashing lights, floaters
Pain
C spine pain, LOC, HA
Prev facial/ nasal #
Facial protection
Glasses/ contacts
Prior vision issues
Tetanus status
Physical for eye trauma
Remove contacts
CN exam inc visual acuity, EOM + sensation to skin
Impaired downward gaze - inferior rectus or oblique muscle entrapment
Pupil exam inc light response
Examine head, scalp, face, orbital area
Palpate orbital rim
External eye structures - conjunctiva, cornea (blood, swelling, FB)
Use fluorescein + cobalt blue light - abrasions will appear green
IOP with Tono-Pen
Fundoscopy - defer if vision significantly abnormal (as ophtho will do)
Red reflex
Slit lamp
Assess cornea, anterior chamber, iris, lens
If unavailable, use pen light to look for hyphema, laceration + shrunken appearing globe
Evert upper eyelid
Typical sx associated with:
subconjunctival hemorrhage
conjunctival laceration
corneal abrasion
corneal laceration
globe rupture
hyphema
retinal detachmenet
orbital rim #
Subconjunctival hemorrhage (reddened, painless)
Conjunctival laceration (pain, redness)
Corneal abrasion (pain + FB sensation)
Corneal laceration (severe pain, sensitivity to light, blurred vision, vision threatening)
Globe rupture (vision loss, pain, eye deformity, vision threatening)
Hyphema (blurred vision, light sensitivity, vision threatening)
Retinal detachment (floaters, flashes, dark curtain, vision threatening)
Orbital rim # (impaired upward gaze)
Management of eye trauma
No RTP
Systemic analgesics (no NSAIDs)
Consider patching for comfort
Elevate head at least 30 degrees at all times, pt should not lie flat
Cold packs x48 hrs
Nasal decongestants, avoid blowing nose or valsalva movements
Refer to ophtho
Tetanus shot if abrasions
Management of Corneal abrasion
Treat w/ chloramphenicol 0.5% ointment q2hrs x2 days then q4H x3 days + padding of eye
Topical cyclopegics for photophobia (2% homadropine)
RTP after orbital # (contact + non contact sports)
Noncontact sport - 2 wks
Contact sport - 4-6 wks
Sx that would indicate immediate referral to ophthalmologist
Severe eye pain, persistent blurred or double vision, persistent photophobia suspected penetrating injury, embedded foreign body, hyphema, marked impaired visual activity, loss of parts of visual field
When to refer eyelid lacerations?
If they involve lid margins or lacrimal duct or if suspicion of penetrating injury
hat does a subconjunctival hemorrhage without a posterior border of bleeding indicate?
Can be associated w/ intracranial bleed or orbital roof #
What is hyphema, sx, complications + treatment
Blood accumulating in anterior chamber from ruptured iris vessels. Can be microscopic and only visualised on slit lamp. Can be associated w/ increase in IOP. Optic atrophy + secondary hemorrhage can occur. Treatment is relative rest, eye patch.
Cause, sx, Ix + treatment of retinal injury
Can be from direct blow to eye or back of head, or from straining. Central retinal damage causes blurred vision. Sx can include sudden increase in flashes or floaters. Refer to optho
When to suspect blowout #
Tenderness of orbital margin, reduced upward eye movement, double vision, nose bleed, reduced sensation in cheek
Management of FB in eye
Assess for eyelid laceration
Topical anesthetic (tetracaine) if no globe perforation suspected
Irrigate eye, if superficial FB can use cotton tipped applicator to try and remove
If deep or penetrating; place hard shield over eye + refer to ophtho
Hx qs in nasal trauma
Check for concussion
Epistaxis
Prev facial/ nasal #
Physical for nasasl trauma
Nasal deformity
Nasal obstruction
Periorbital swelling + ecchymosis
Palpate nasal bones for deformity + crepitus
Palpate all bony structures of face inc teeth
Ring test (collect fluid from nose onto filter paper - if a clear ring of CSF diffuses out beyond central area of blood = CSF leak)
Visualise anterior septum w/ nasal speculum or otoscope
Probe w/ finger or cotton tip, feeling for swelling, fluctuance, widening of septum
Blood clots adjacent to septum should be evacuated
Hematomas are soft and compressible
Ensure absence of CSF leak
Hematoma appears as a bluish red bulge from septum to nasal vestibule or as asymmetric mucosal fold
Control bleeding w/ direct pressure + topical decongestants or cautery in order to adequately visualise septum
Septal hematomas do not shrink w/ decongestants
Reduction of nasal trauma
Reduction
If nose grossly displaced consider immediate reduction
Most cases require referral to specialist within 3-7d for reduction (open or closed)
May not need reduction of non displaced
Defer surgical tx until cessation of “high risk” activities
Management of nasal hematoma
If hematoma present, needs needle aspiration or sharp I+D following by suction of clot
Place drain/ wick if abscess suspected
Bilateral anterior nasal packing to prevent recurrence x2-4 days
Systemic abx w/ clindamycin or amox-clav
Management of CSF leak in nasal trauma
Persistent rhinorrhea should raise suspicion for cribriform damage + CSF leak
CT + ENT referral urgently
Complications of nasal trauma
Hematoma (usually from an inferior blow)
Hematoma can lead to pressure necrosis or abscess
Cartilage destruction, collapse of nasal dorsum or saddle nose deformity can occur
Sx + management + RTP of nasal hematoma
Sx: epistaxis, nasal deformity/ swelling, ecchymosis, pain, difficulty breathing through one/ both nostrils
Can occur up to 14 days after trauma
Close FU needed w/ ENT
Children should be followed for 1 yr for cartilagenous changes
RTP once nasal packing removed
How long do nasal #s take to heal?
3-6 wks
What is cauliflower ear + how to treat?
Hematoma between skin and perichondrium - can become fibrotic within 2 wks. Use ice + compression and aspirate hematoma
RTP for nasal # (no contact, potential contact eg football, combat sports)
No contact 1-2 wks
RTP w/ nasal protective device for another 4 wks following initial trauma
Extended to 6 wks if surgery needed
10-12 wks for combat sports
Hx qs for dental trauma
Pain
Temperature sensitivity
Color changes
Inability to chew
Force + velocity of injury
Past dental hx
Classes of dental #
1 = enamel fracture only
Chipped tooth feels rough, may go unnoticed
2 = enamel + dentin #
Exposure of yellow dentin
Pain w/ exposure of dentin to air, touch, cold
3 = enamel, dentin + pulp
Dental emergency (within 3 hrs)
Exposure of red-pink pulp
4 = root #
Dental emergency (within 3 hrs)
Physical in dental trauma
Head + neck exam
Palpate mandible, zygoma, TMJ, mastoid
Check jaw movement
Chin laceration - think C spine!
Intraoral exam - teeth, tongue, gums, buccal mucosa
Imaging - when is it needed + what type, in context of dental trauma
XRs
Maxillary or mandibular teeth injury = 2x periapical views at different angles, lateral anterior view
If SOB, hemoptysis or missing tooth = CXR
Mandibular or condylar # = panoramic XR
Negative XRs may be repeated 1-2 days later
Post reduction views also needed
Management of dental trauma
Analgesia - 1ml lidocaine into buccal mucosa over injured tooth; avoid oral meds initially d/t risk of swallowing blood + fragments of teeth
Locate all teeth or tooth fragments, handle only by crown
Irrigate with sterile saline or milk
Replant tooth ASAP unless pt obtunded (firmly reinsert tooth into socket then get pt to bite gently on gauze to set tooth in)
Transport immediately to dental office or ED w/ on call dentist
Place nonimplantable teeth or fragments in milk, sterile saline solution (can last up to 6 hrs)
Forceful blow: Luxated tooth should be repositioned to the original site using firm finger pressure/bite on sterile gauze and splinted with aluminum foil prior to dental referral - should be splinted for 2-4wks
Enamel chip fractures are not painful and require non-urgent dental referral - fragment may be reattached with bonding or resin
5-10 days of abx (penicillin or clindamycin) in case of exposed pulp or avulsion
Tetanus
Soft/ liquid diet for a timeP
Prevention of dental trauma
Properly fitted custom made mouth guard, consider bimaxillary guard which covers upper + lower teeth but make breathing + speech difficult
Face masks in hockey + football
Rinse mouth guard w/ antiseptic mouth wash
Regular dental check ups
Primary + secondary survey in ?C spine injury
Primary Survey
C spine - pain at rest? Tenderness?
Airway - ask pt’s name, MOI (is airway patent?)
Breathing - check BP, HR, RR, sats, temp, glucose
Circulation - HR, CRT
Secondary survey
Head + neck - GCS, PEARL, EOM, TM, movement + sensation x4 limbs, strength (flex/ ex wrists + ankles), palpate skull + facial bones
Chest: inspection, auscultation, palpation, hematoma
Abdomen: inspection, auscultation, palpation
Palpate every bone
Roll and palpate C-L spine and check rectal tone
Pelvic stability
Check helmet
Management of C spine injury - sideline, wearing helmet
Stabilise C spine
Remove helmet - 1 person holding C spine ant-posteriorly, one person removes helmet + then places rolled up towel or block under head
Realign head into neutral position - if causing any pain, muscle spasm or neuro signs, immobilise head in position found. Hold manual inline stabilization
Realign spinal column into neutral position
Stabilize on RSB
Once on board, convert to external stabilisation with head blocks
XR views + what they show for C spine #
AP (vertebral bodies + intervertebral spaces)
Lateral (zygapophyseal joints, soft tissue structures, spinous processes)
Odontoid (C1 + C2)
Oblique (intervertebral foramina)
Swimmer’s view (C7-T1 junction)
How to measure C spine collar
Measure neck height from jaw line to trap using flat hand
What nerve root + peripheral nerve is responsible for shoulder abduction?
C5 - axillary
What nerve root + peripheral nerve is responsible for elbow flexion?
C5 - musculocutaneous
What nerve root + peripheral nerve is responsible for elbow extension?
C7 - radial
What nerve root + peripheral nerve is responsible for wrist extension?
C6-7 - radial
What nerve root + peripheral nerve is responsible for wrist flexion?
C6-7 - median
What nerve root + peripheral nerve is responsible for finger flexion?
C8 - median
What nerve root + peripheral nerve is responsible for finger extension?
C7 - radial (posterior interosseous)
What nerve root + peripheral nerve is responsible for finger abduction?
T1 - ulnar
What nerve root + peripheral nerve is responsible for hip flexion?
L2-3 - femoral
What nerve root + peripheral nerve is responsible for knee extension?
L3-4 - femoral
What nerve root + peripheral nerve is responsible for ankle dorsiflexion?
L4 deep peroneal
What nerve root + peripheral nerve is responsible for hip extension?
L5 inferior gluteal
What nerve root + peripheral nerve is responsible for knee flexion?
S1 - sciatic
What nerve root + peripheral nerve is responsible for ankle plantar flexion?
S1 - tibial
Cervical dermatomes
Lower leg dermatomes
Spinal cord injury at C1-4: sx, care needs
Paralysis in hands, arms, trunk, legs
May be unable to breathe, cough or control bladder or bowels
Ability to speak can be impaired
Requires 24/7 care
Spinal cord injury at C5: sx, care needs
Can raise arms + bend elbows
Paralysis of wrists, hands, trunk, legs
Can speak + use diaphragm
Breathing weakened
Needs assistance w/ ADLs but can move in power wheelchair
Spinal cord injury at C6: sx, care needs
Nerves affect wrist extension
Paralysis in hands, trunk, legs
Able to bend wrists back
Can speak + use diaphragm
Breathing weakened
Can move in and out of bed + wheelchair w/ assistive equipment
May be able to drive adaptive vehicle
Little voluntary control of bowel or bladder
Spinal cord injury at C7: sx, care needs
Nerves control elbow extension and some finger extension
Most can straighten arm and have normal movement of shoulders
Can do most ADLs solo
May be able to drive
Little voluntary control of bowel or bladder
Spinal cord injury at C8: sx, care needs
Nerves control some hand movement
Should be able to grasp + release objects
Can do most ADLs solo
May be able to drive
Little voluntary control of bowel or bladder
Spinal cord injury at T1-T5: sx, care needs
Nerves affect muscles, upper chest, mid back + abdo muscles
Arm + hand function normal
Injuries affect trunk + legs
Likely use manual wheelchair
Can stand in standing frame, may be able to walk w/ braces
Spinal cord injury at T6-T12: sx, care needs
Nerves affect muscles of trunk
Normal upper body movement
Fair to good control + balance of trunk in seated position
Should be able to cough
Little voluntary control of bowel or bladder
Can stand in standing frame, may be able to walk w/ braces
Spinal cord injury at L1-5: sx, care needs
Loss of function in hips + legs
Little voluntary control of bowel or bladder
May need wheelchair or braces
Spinal cord injury at S1-S5: sx, care needs
Loss of function in hips + legs
Little voluntary control of bowel or bladder
Most can walk
Complications of spinal cord injury (C spine injury)
Spinal “shock” = transient areflexia, flaccid paralysis, anesthesia - resolves with time
Neurogenic shock = hypotension, bradycardia
Describe the 5 types of spinal cord injury + sx associated
Complete cord injury
Reduced sensation + power at next caudal level to injury and absent sensation + power in levels below
Acute - areflexia, flaccid muscle tone, priapism in males, urinary retention + bladder distension
Incomplete spinal cord injury
Various degrees of motor + sensory function, sensory function usually more preserved
Level of injury determined by finding lowest segment of cord with power >3 bilaterally, with intact sensation + power (5/5) above this level
Central cord syndrome
Occurs after trauma in setting of pre-existing cervical spondylosis
Greater motor impairment in upper compared with lower extremities, bladder dysfunction, variable sensory loss below level of injury
Anterior cord syndrome
Lesions that affect anterior ⅔ of spinal cord and spare dorsal column
Bilateral paralysis/ weakness below level of lesion, bilateral loss of pain + temp sensation below level of injury but intact touch, vibration + proprioception below level of injury
Brown-Sequard syndrome
Hemisection to ½ of spinal cord resulting in paralysis and loss of proprioception on ipsilateral side as injury and loss of pain and temp sensation on contralateral side of lesion
Canadian C spine rules
High risk factor present?
Age >65, extremity paraesthesias or dangerous mechanism (fall from >3ft, axial load injury, high speed MVC, bike collision, motorized recreational vehicle)
if yes - needs imaging
If no:
Low risk factor present?
Sitting position in the ED, ambulatory at any time, delayed (not immediate onset) neck pain, no midline tenderness. Simple rearend motor vehicle collision (MVC)
If not - needs imaging. If yes - able to actively rotate neck 45 degrees left + right?
If yes - C spine cleared
If not - needs imaging
When are Canadian C spine rules not applicable?
GCS <15
Age <16
Unstable vitals
Known vertebral dz
Acute paralysis
Pregnant
Prev C spine surgery
Management of C spine # + RTP
Short term rest
Cryotherapy within 36-48hrs can be helpful
Protection against flexion with an orthosis for 4-6 wks
RTP once # is healed and pt has full painless ROM and no neuro deficits
Common mechanism + MOI of spinous process #
Avulsion type injuries from contraction of trapezius, rhomboid minor, serratus posterior
MOI = forced flexion of neck (football, weight lifters)
What are transverse # from high energy traumas associated with?
Visceral injuries, commonly to spleen + liver
Common MOI for lumbar transverse proces #
Direct trauma
Associated # with L4 + L5 transverse process #
L4 = acetabular #
L5 = pelvic ring injuries
Workup if transverse process # identified on imaging
Abdo CT d/t risk of visceral, abdo + other ortho injuries
What to examine in FU for cervical spine #
Physical
Inspection (wasting? asymmetry? cervical lordosis?)
Palpation (prominent vertebrae = C7, occipital region, trapezius, levator scapulae)
ROM - flexion (Add extra pressure), extension, then flexion + extension w/ rotation, lateral rotation, side flexion (pain = brachial plexus injury)
Spurlings test (radicular pain) - look to side of pain, move neck into extension + then apply axial load
Neurological assessment
Sensation to lateral deltoid (C5), thumb (C6), middle finger (C7), little finger (C8), medial elbow (T1)
power - deltoid (C5), biceps (C5), wrist extension (C6), triceps (C7), claw grip (C8), fingers splayed (T1)
Reflexes - biceps jerk (C5), brachioradialis (C6), triceps (C7)
Hx Ankylosing spondylitis
Commonly presents in young adulthood, males>females
Chronic, progressive
Pain, morning stiffness >30mins in SI + lumbar region that improves w/ exercise but persists at rest
Peripheral arthritis (shoulder, knee, hands, wrist, feet)
Enthesopathy (iliac crest, ischial tuberosity, greater trochanter, patella, calcaneus/Achilles, tibial tubercle, vertebral bodies)
Iritis
Pulmonary involvement
Constitutional sx like weight loss, fever, malaise, night sweats, night pain, n/v
Physical exam for Ankylosing spondylitis
Spinal exam
Peripheral joint exam + major entheses (calcaneus, patella, tibial tubercle)
Eye exam
Skin exam (signs of psoriasis)
Decreased cervical motion (tested w/ occiput to wall test)
Increased thoracic kyphosis
Decreased chest expansion
Decreased lumbar motion (Schober test <5cm)
Ix for Ankylosing spondylitis
XR SI joint + lumbar spine
MRI to evaluate early inflammatory changes before structural changes are seen on XR
HLA-B27 - 90-95% of patients with AS have HLA-B27
CRP or ESR
Rheumatologic work-up (RF, ANA, dsDNA, complement, ESR) - these will be negative
DDx of AS
Mechanical LBP
Myofascial LBP
SI joint dysfunction
Degenerative disc dz
Herniated nucleus pulposus
Spondylolysis
Discitis
Scoliosis
Multiple myeloma, bony mets, facet joint arthropathy
Fibromyalgia, osteomyelitis, discitis, osteoporosis w/ compression #
Vertebral #, lumbar sprain/ strain, visceral organ dz (AAA, pyelo, kidney stones, PID)
What are the types of spondyloarthritis?
AS
Reactive arthritis
Arthritis w/ IBD
Arthritis w/ psoriasis
Unspecified spondylitis
ROME criteria for AS
Ankylosing spondylitis is present if bilateral sacroiliitis is associated with any single criterion:
Low back pain and stiffness for more than 3 months
Pain and stiffness in the thoracic region
Limited motion in the lumbar region
Limited chest expansion
History of evidence of iritis or its sequela
Management of AS
Patient should be encouraged to return to their normal activities of daily living as soon as symptoms permit
Activity modification & education on proper lifting techniques
Lifelong regular physical activity & exercises, healthy body weight, pool exercises to avoid stiffness & pain
Breathing exercises for lung capacity
Medications
NSAIDS - try 2 before moving on. Monitor for GI SE, kidney and hepatic failure
TNFi (infliximab, adalimumab) - try 2 before moving on to DMARD. Increased risk of infection - screen for HIV, TB and hepatitis, no live vaccines during treatment
DMARDs (sulfasalazine, pamidronate)
Interleukin 17a inhibitor (secukinumab)
Corticosteroid injections
Physiotherapy, core program, postural exercises
Massage
Refer to Rheumatologist
Refer to Ophthalmologist if sx of iritis (anterior uveitis in 20% of patients with temporal association with peripheral arthritis)
Surgery
Hx for spinal stenosis
Chronic LBP, buttocks, legs, worsening over time
Burning, cramping
Standing or walking upright increases sx
Unable to walk for long periods but can bike for much longer
Relieved by sitting down/ leaning forward/ walking uphill
Radiating pain into groin/ testes
R/o cauda equina
Physical for spinal stenosis
Spinal exam
Broad based gait
Abnormal Romberg’s
Flexion relieves pain, extension worsens
Femoral nerve stretch might be positive if stenosis is at L3/4
Straight leg raise usually negative
Examine vascular lower limbs
DDx for spinal stenosis
Vascular claudication
Space occupying lesion
Scoliosis
Disc dz/ herniation
Spondylitic dz
Multiple myeloma
Bony mets
Arthritis
Fibromyalgia
Osteomyelitis
Discitis
Pyelonephritis
Compression #
Paget’s dz
Lumbar sprain/ strain
Management of spinal stenosis
NSAIDs
Lumbar support
Epidural steroid injection
Acupuncture
Multilevel decompressive laminectomies
PT
- Core strengthening, good posture and flexibility can slow progression
Neurogenic vs vascular claudication
Neurogenic - worse w/ standing, can walk variable distances, improved w/ change of position, improves after ~10 mins
Vascular - can walk a set distance, improves w/ stopping, improves after ~2 mins
Complications of cervical stenosis in athletes
Athletes with cervical stenosis are at increased risk of quadriplegia and should not do contact or collision sports - need to be referred to spinal specialist
What is spondylolysis, cause, RF
Stress # of pars interarticularis
Cause: repeated hyperextension +/- rotation (gymnastics, cricket, volleyball, tennis, throwing sports)
Most common cause of back pain in athletes
Commonly L5 and L4
Males > females
Hx of spondylolysis
Usually asymptomatic, found incidentally
Insidious LBP
Pain with running + jumping, no pain sitting
Pain w/ landing from dismount
Pain worse w/ bending and lateral flexion
Physical for spondylolysis
Spinal exam
Tender to palpate
Pain with extension
Ipsilateral back pain when pt stands on one leg and hyperextends back
May feel step off when palpating spinous processes if significant listhesis is present
Ix for spondylolysis
XR
Bone scan +/- CT (SPECT) - can show if lesion is improving or worsening but high radiation dose
MRI - good for assessing pars defects + nerve root compression, needed if ?cauda equina but unable to determine if lesion is improving or worsening
Management of spondylolysis
Cessation of sports x3mo for symptomatic young pts
Bracing (controversial - could be used if initial rest fails)
Positive XR but negative bone scan means lesion is chronic and does not need bracing
Boston brace
Surgery
Indicated if rest + brace x6mo has not worked or for cases w nerve compression
Direct repair of bilateral pars defects or posterolateral fusion
Restricted lumbar extension +/- rotation
Core + lumbar strengthening when pain free
DDx of spondylolysis
Spinal stenosis
Tumor
Scoliosis
Disc dz/ herniation
Spondylytic dz
Vertebral #
Osteoid osteoma or other malignancy
Reactive arthritis
AS
Vertebral osteomyelitis
Lumbar sprains + strains
Pyelonephritis
Complications of spondylolysis
Spondylolisthesis
What is Spondylolisthesis + what typically can cause it?
Slippage of one vertebra on another (usually L5 on S1)
Associated w/ bilateral pars defects (usually familial predisposition)
Usually L5 on S1
Rarely from athletic overuse injuries
May be secondary to breakdown of bilateral pars defects, congenital, due to degenerative disease or trauma
Hx of spondylolisthesis
Insidious onset LBP, can be intermittent
Can have radicular symptoms
Imaging for spondylolisthesis
AP + lateral XR
Standing may worsen apparent slippage
Bone scan w/ SPECT
Management inc RTP of spondylolisthesis
Low grade slips = rest x3mo +/- modified Boston brace (3-6mo)
Grade 3 or higher - refer to surgeon for consideration
High grade slippage >50% or high slip angle >55 degrees or slip progression may warrant surgery
Nerve compression warrants surgery
Decompressive laminectomy w/ fusion
rest + core strengthening
Hamstring stretches
Core strengthening
Water therapy
Pelvic tilt exercises
No high speed or contact sports (grade 3 + 4)
RTP if pain free >3mo w/ extension after bracing
RF for spondylolisthesis
Family history
Sports with extreme spinal motion, especially repetitive hyper extension
Growth spurts
An atomic variations like spina bifida, scoliosis, increased lumbar lordosis
What is the ideal HbA1c level for participating in competitive sports in adults and adolescence?
Less than 7% for adults and less than 7.5% for adolescents
What is the ideal blood glucose level prior to exercise in a type one diabetic?
6.6 to 10
When should a type one diabetic postpone exercise, based on high glucose labs?
Blood sugar over 13.9 and ketones in urine
Blood sugar over 16.5
Describe the consensus statement on youth early specialisation in sport
Should participate in free, unstructured play to improve motor skill development
Youth should be encouraged to participate in a variety of sports
Children who participate in more hours of sport per week than their age, or who spend more than 16 hours per week in intense training, should be closely monitored for burnout, overuse injury and overtraining
Youth can benefit from strength and conditioning
Youth specialising in a single sport should have neuromuscular training to reduce injury risk
What are the concerns with early specialisation?
Social isolation, dependence, burnout, manipulation, overuse injury, compromised growth and maturation
What are the physiological differences in women compared to men?
Less lean body mass
Higher body fat composition
Wider pelvis, increased inward slant of femur and knee more medial
Lower maximum cardiac output and VO2 max
Higher cardiac work and index, higher exercising heart rate
Lower blood volume and hemoglobin
What medical issues + complications in exercise do women face more than men?
Pain and discomfort in breasts
Urogenital symptoms (particularly in cycling)
Urinary incontinence
Hypermobility
PatelloFemoral pain syndrome
ACL injuries
Anaemia
Menstrual dysfunction and contraception
RED-S
Pregnancy
Describe the IOC transgender guidelines
Those are transition from female to male are eligible to compete in the male category without restriction
Those are transition from male to female are eligible to compete in a female category under the following conditions :
Athlete has declared that her gender identity is female, the declaration cannot be changed for minimum four years
The total testosterone has been below 10 for at least one year prior to her first competition
Describe pre-race strategies ahead of an endurance event to enhance safety
Schedule at a time of year and day when environmental conditions will not adversely affect health
Discuss criteria at which the medical director should have authority to cancel race based on weather conditions, ie using a wet bulb globe temperature
Plan the course so that the finish area is large enough to accommodate finishes, Medical and Emergency vehicles
First aid stations along the route 3-5km apart
Pre-participation screening and qualification standards
Pre-race seminars to educate athletes on training, nutrition, fluids, dangers
Past medical history on registration forms
What common medications can cause altered mental status?
Benzos
Anti-convulsants
Narcotics
First generation antihistamines
Antiemetics
Tricyclic antidepressants
Lithium
Fluoroquinolone antibiotics
Antiarrhythmics
Muscle relaxant
Corticosteroids
Decongestants
What are the differences between growing and adult bones?
Periosteum is thicker in children and has considerable healing potential
Articular cartilage of growing bone is thicker in children and can remodel
The junction between the epiphyseal plate and metaphysis in children is vulnerable to disruption
Tendon attachment sites (apophyses) are cartilagenous plates that are relatively weak and are predisposed to avulsion injuries
Children tend to suffer incomplete fractures (green stick)
A valgus force to the thumb causes what injury in adults vs children?
Adults: sprain of UCL
Children: fracture of proximal phalangeal physis (usually salter-harris type 3)
A valgus force to the thumb causes what injury in adults vs children?
Adults:
Children:
A hyperflexion injury to the distal IPJ of finger causes what injury in adults vs children?
Adults: mallet finger (extensor tendon injury)
Children: # of distal phalangeal epiphysis (salter harris type 2 or 3)
A punching injury to the hand causes what injury in adults vs children?
Adults: # of metacarpal head
Children: # of metacarpal epiphysis (salter harris type 2)
A fall directly on point of shoulder causes what injury in adults vs children?
Adults: AC sprain
Children: # of middle 1/3 of clavicle epiphysis
An acute flexor muscle strain or extensor strain in the thigh/ hip causes what injury in adults vs children?
Adults: quad or hamstring strain
Children: apophyseal avulsion of AIIS or ischial tuberosity
An abduction + external rotation force to the shoulder causes what injury in adults vs children?
Adults: dislocated shoulder
Children: # of proximal humeral epiphysis (salter harris type 1 or 2)
An acute injury to the knee causes what injury in adults vs children?
Adults: meniscal or ligament injury
Children: # distal femoral or proximal tibial epiphysis, avulsion of tibial spine
An acute inversion injury to the ankle causes what injury in adults vs children?
Adults: lateral ligament sprain
Children: salter harris 1 or 2 # of tibia or fibula
An overuse injury at the heel causes what injury in adults vs children?
Adults: achilles tendonopathy
Children: sever’s disease
What is the management + potential complications of a distal radial # in kids?
cast immobilisation x4 wks
growth disturbance
What is the management + potential complications of a supracondylar # of elbow in kids?
sling x3 wks
vascular compromise of brachial artery, median nerve damage, malalignment
What is the management + potential complications of a distal fibular # in kids?
cast, non wt bearing x4-6 wks
growth disturbance up to 18mo later
What is the management + potential complications of a distal tibial # in kids?
cast, non wt bearing x4-6 wks
premature closure of physis can lead to angulation + leg length discrepancy
What is the management + potential complications of a distal femur # in kids?
anatomical reduction
long leg cast x4-6 wks
growth discrepancies - must be monitored closely
What are the RF for concussion?
Migraines
Female
Children + teens
Hx of concussion
ADHD, learning disabilities, mood disorders
What is Scheuermann Kyphosis?
structural hyperkyphosis of the thoracic or thoracolumbar spine that occurs due to abnormal vertebral growth during adolescence. It is the most common cause of hyperkyphosis in teenagers
Sx of Scheuermann Kyphosis
Rigid thoracic hyperkyphosis that does not correct with extension (unlike postural kyphosis)
Possible compensatory lumbar lordosis.
Mid back pain, worse with prolonged standing or activity.
Stiffness
RF for Scheuermann Kyphosis
Teens
Fam hx
Males
High mechanical stress on the spine (e.g., athletes in rowing, gymnastics, weightlifting)
Physical exam for Scheuermann Kyphosis
Kyphosis that does not correct with active extension
Ix for Scheuermann Kyphosis
XR
Management of Scheuermann Kyphosis
Physio
Bracing (for significant curves)
NSAIDs for pain
Surgery if severe
Sx of popliteal artery entrapment
Exertional leg pain
Cramping, tightness or fatigue of leg w/ exertion
Sx resolve w/ rest
As it progresses, can get paresthesias in foot
What is popliteal artery entrapment?
popliteal artery is compressed due to an abnormal relationship with surrounding muscles, usually the gastrocnemius or popliteus. This can lead to vascular insufficiency, particularly in young athletes.
RF for popliteal artery entrapment
Young, active people
Males
Repetitive lower limb motion (runners, cyclists)
Congenital/ anatomic variations of muscle
Muscular hypertrophy
Physical for popliteal artery entrapment
Palpate popliteal and posterior tibial pulse + dorsalis pedis at rest and with active foot movements.
Maneuvers to provoke symptoms:
Ankle dorsiflexion + active plantarflexion → loss of pulse.
Knee flexion + passive dorsiflexion → reproduction of symptoms.
Compare pulses bilaterally (asymmetry may be a clue)
Dx of popliteal artery entrapment
Doppler US
CT angio
Angiography
Management of popliteal artery entrapment
Activity modification
Physio
Surgery for muscle resection if sx persist
