Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

CASEM > High Yield 1 > Flashcards

High Yield 1 Flashcards

1
Q

What info to obtain in focus history in Emergency?

A

Age and sex of patient, mechanism of injury, injury sustained, signs and symptoms, treatment so far

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

How to manage bleeding in long bones ?

A

Immobilise and splint

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

How to approach unconscious pt

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Causes of decreased LOC

A

Hyponatremia
Hypothermia
Hyperthermia
Hypovolemia
Hypoglycemia
Infection
Stroke

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Most common form of hyponatremia

A

Dilutional

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Describe the causes of hyponatremia in an endurance athlete

A

D/t excess water, sodium loss during sweating, activity induced release of ADH

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Why do neurological sx occur in hyponatremia?

A

D/t cerebral edema (exercise associated hyponatremic encephalopathy)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

When do symptoms of hyponatremia occur?

A

If sodium is <125 or if loss if abrupt (10% fall in 24hr period)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Hx questions for ?hyponatremia

A

Food + water intake
NSAIDs, SSRIs, diuretics, APs + amiodarone use

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Sx of hyponatremia

A

Mild = dizziness, HA, vomiting, cramping
Mod = confusion, inability to concentrate, swollen hands + feet, bloating
Severe = delirium, szs, resp distress, pulmonary edema, coma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

RF for hyponatremia

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What to assess on physical of hyponatremia

A

Vitals
Weight
Fluid status - BP, skin turgor, edema, pulmonary exam
Mental status

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Investigations for ?hyponatremia

A

Na <135
CBC, lytes, BUN, Cr, glucose, LFTs, PTT, INR
ABGs
Correct serum sodium for hyperglycemia if present

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

DDx for hyponatremia

A

Hypovolemia, hypothermia, hyperthermia, hypoglycemia
MI
Adrenal crisis
CHF
AKI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Management of Mild hyponatremia (>130)

A

monitor, fluid restrict - will likely self correct w/ urination
Fluid restriction is CI in rhabdomyolysis

Do not D/C until able to urinate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Management of Moderate hyponatremia

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Management of severe hyponatremia

A

ABCs
Supine w/ legs elevated
give 100ml bolus 3% saline IV and repeat after 10 mins if no response, transfer to hospital.
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 well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

How long can hyponatremia occur for after exercise?

A

Can occur up to 24hrs after prolonged exercise

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

How to prevent hyponatremia

A

Educate participants
Drink dictated by thirst
Reduce availability of fluids
Monitor weight before + after race - if weight gained, reduce fluid intake

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Sx - heat exhaustion

A

Hot, thirsty, cramps
Fatigue
N/V
Dizziness, syncope

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Sx - heat stroke

A

Prev hx of heat exhaustion
Irritability, confusion
CNS sx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Physical exam findings for heat exhaustion

A

Normal or elevated temp <40
Flushed skin
Profuse sweating
Cold, clammy skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Physical exam findings for heat stroke

A

Confusion, ataxia
Temp >40
Tachycardia, SOB, hypotension
Hot skin +/- sweating

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Investigations for ?heat exhaustion/ stroke

A

ECG
Lytes
Blood gas
Blood sugar (normal fasting/ before meals = 4-7)
Kidney function
Coagulation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Risk factors for heat stroke

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

DDx for heat exhaustion

A

Dehydration
Electrolyte abnormality
CV disease
Exercise associated collapse
CNS lesion
Thyroid abnormality
Infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Management of heat stroke/ exhaustion

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Complications of heat stroke

A

End organ failure
Death
Szs
CV collapse
ARDS
Liver failure
Kidney failure
Rhabdomyolysis
DIC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Prevention of heat exhaustion in future

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

RTP for heat stroke

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

RTP for heat exhaustion

A

Exhaustion - 24-48hrs can return to activity, gradually increase intensity + volume

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Superficial vs deep frostbite

A

Superficial - partial or complete freeze of skin
Deep - involvement of skin + underlying tissue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

RF for hypothermia

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

RF for frostbite

A

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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Sx Frostbite

A

Skin that is erythematous, swollen or waxy, white, yellow, blue/ purple
Blisters
Numbness +/- pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Sx of Hypothermia

A

Shivering, confusion, amnesia, dysarthria, ataxia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Physical exam findings in hypothermia

A

Loss of deep tendon reflexes
Loss of shivering
Muscle rigidity
Cardiac arrhythmias
Dilated pupils
Reduced LOC
Hypotension
Reduced RR
Tachycardia initially then bradycardia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

how to do body temp in hypothermia

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Physical exam findings in frostbite

A

Neurovascular status
Pliability of tissue - soft tissue = more likely superficial frostbite, hard tissue = more likely deep

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Investigations in frostbite/ hypothermia

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

DDx for Frostbite

A

frostnip, trench foot, chilblains, raynauds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

DDx for Hypothermia

A

metabolic abnormalities, alcohol ingestion, head injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Management of Frostbite

A

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 within 6-24hrs of rewarming may decrease amputation rate
IV iloprost administered up to 48hrs after rewarming may decrease amputation rate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

management of Hypothermia

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Prevention in future of cold injury

A

Event planning based on temperature
Proper clothing inc hats, mittens, multiple layers
Avoid alcohol
Recognise signs + sx of hypothermia + get to shelter

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Complications of hypothermia

A

Cardiac arrhythmias
Electrolyte + acid-base disorders
DIC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Complications of frostbite

A

Amputation
Premature closure of epiphysis in young athletes
Autonomic dysfunction of affected extremity
Permanent cold sensitivity + susceptibility to cold injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

RF for drowning

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Sx following drowning

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Management following drowning

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Complications following drowning

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Prevention of drowning

A

Parental supervision
Swimming lessons
Pool fencing
Lifeguards
Restricted swimming areas w/ proper signage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

What is epilepsy?

A

2 unprovoked szs that occur >24hrs apart

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

What is status epilepticus?

A

One continuous sz lasting >5 mins or 2 or more szs where there is no full return to consciousness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Sx + hx questions for ?sz

A

Change in muscle tone
Convulsions
Decreased LOC
Staring spells
Bladder or bowel incontinence
Postictal confusion
Todd paralysis
Collateral hx
Prev seizures + head injuries

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Physical exam for ?sz

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Causes of szs

A

Alcohol w/d
AV malformation
Hypoglycemia
Hyponatremia
Fever
Hepatic failure
Substance use or w/d
Intracranial swelling
Brain tumor
Posttraumatic sz
Stroke
Syncope
Uremia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Management of szs

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

When to refer szs to neuro

A

First time unprovoked sz
Initiation of anti-convulsant
For outpt EEG

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

RTP for szs

A

Should be based on probability of sz occurring, sz type, usual timing of sx occurrance, SE of anticonvulsant meds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Prevention of szs

A

Exercise may decrease sz frequency
Sufficient + regular sleep
Limiting alcohol intake
Exercise at high altitudes can cause hypoxia + induce szs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

What qs to ask on hx of ?anaphylaxis, and what sx?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

RF for anaphylaxis

A

Prev allergic reaction to same allergen
Coexisting atopic dz, particularly poorly controlled asthma
Older age at first reaction to food allergy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

Physical signs of anaphylaxis

A

Bronchospasm, layngeal edema
Hypotension, arrhythmias
Urticaria, angioedema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

DDx for ?anaphylaxis

A

PE
MI
Airway obstruction
Asthma
Tension pneumothorax
Vasovagal collapse
Septic shock
Hereditary angioedema
Pheochromocytoma
Carcinoid syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

Management of anaphylaxis - sideline

A

Support ABCs
Remove trigger

Epi
0.3mg epi pen in adult or 0.15mg in child
If only 1:1000 available, administer 0.5mg IM in adult or 0.3mg in child
Repeat every 5 mins if sx continue for 3-4 doses
WADA requires emergency TUE afterwards if using epinephrine

Place pt supine and elevate legs
Ventolin if bronchospasm present

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

Management of anaphylaxis - ED

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

Complications of anaphylaxis

A

DIC
Szs
Death

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

Prevention of anaphylaxis

A

Avoidance of allergen
Immunotherapy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

Common causes of anaphylaxis

A

Food most common causative agent in kids
Meds most common causative agent in adults
Other causes: venom, latex, vaccines

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

Hx questions for lacerations

A

Assess blood loss
Weakness, numbness, tingling
NSAIDs, ASA, antiplatelets, blood thinners
Tetanus
Determine potential for FB

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

Physical exam for lacerations

A

Nerve + motor function
Pulses distal to laceration
Cap refill

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

Management of lacerations

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
74
Q

Qs to ask on hx of epistaxis

A

Timing, frequency, severity
Quantify amount of blood loss
Trauma?
Bleeding conditions
Use of intranasal cocaine
Meds - ASA, anticoagulants, intranasal steroids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
75
Q

Initial management of epistaxis

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
76
Q

Persistent epistaxis despite initial management

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
77
Q

Complications of packing for epistaxis

A

Septal hematomas, abscesses, pressure necrosis, sinusitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
78
Q

After car for epistaxis

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
79
Q

MOI EDH

A

Temporal skull # causing bleeding of middle meningeal artery is most common

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
80
Q

MOI acute SDH

A

MVA, falls, assaults

81
Q

Sx of EDH

A

Lucid interval - altered consciousness then improvement then deterioration

82
Q

Physical for head trauma

A

Neuro exam - serial
GCS
Examine skull for #

83
Q

Management of intracranial trauma

A

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

84
Q

Hx questions for concussion

A

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

85
Q

Physical exam for ?concussion

A

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

86
Q

Imaging for ?concussion

A

CT head if concern of structural damage
X-ray if concern of associated injuries (facial #, C-spine)

87
Q

DDx for concussion

A

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

88
Q

Management of concussion

A

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

89
Q

Time frame for recovery

A

Simple concussion resolves within 10 days with appropriate post concussion rehab
80% get better in 7-10 days

90
Q

When to Send to ED for concussions

A

C-spine tenderness, ↑HA, ↓LOC, ↑tiredness or confusion, lateralizing weakness, Sz, persisting vomiting

91
Q

Complications of concussion

A

> 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

92
Q

What is post concussion syndrome?

A

Continued concussion sx after 3 mo
Occurs in up to 30% of injuries

93
Q

Return to school plan after concussion

A

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

94
Q

Return to play protocol for concussion

A

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

95
Q

What is an exertional HA, what are the types?

A

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

96
Q

Hx qs for headache

A

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

97
Q

PEH vs cough headache

A

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

98
Q

Physical exam for HA

A

Neuro exam
Head & Neck Exam inc fundoscopy
Evaluate for meningismus
SCAT Card if concern of concussion

99
Q

Ix for HA

A

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

100
Q

DDx for HA

A

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

101
Q

Management of exertional HA

A

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

102
Q

What are the RF/ triggers for effort/ exertional HAs?

A

High altitude
Hot weather
Dehydration
Extreme exercise
Alcohol and caffeine consumption

103
Q

What are the associated conditions w/ exertional HAs?

A

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)

104
Q

Symptoms of cervicogenic HA

A

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

105
Q

Physical exam findings of cervicogenic HA

A

Reduced C spine range of motion
Symptoms on palpation of head or neck
Anaesthetic blockade abolish pain

106
Q

Sx + hx for eye trauma

A

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

107
Q

Physical for eye trauma

A

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

108
Q

Types of ocular injury + which are vision threatening + typical sx associated

A

Subconjunctival hemorrhage (reddened, painless)
Conjunctival laceration (pain, redness)
Corneal abrasion (pain + FB sensation)
Eyelid contusion or laceration
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)

109
Q

Management of eye trauma

A

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

110
Q

Management of Corneal abrasion

A

Treat w/ chloramphenicol 0.5% ointment q2hrs x2 days then q4H x3 days + padding of eye
Topical cyclopegics for photophobia (2% homadropine)

111
Q

RTP after orbital #

A

Noncontact sport - 2 wks
Contact sport - 4-6 wks

112
Q

Indications for immediate referral to ophthalmologist

A

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

113
Q

When to refer eyelid lacerations?

A

If they involve lid margins or lacrimal duct or if suspicion of penetrating injury

114
Q

hat does a subconjunctival hemorrhage without a posterior border of bleeding indicate?

A

Can be associated w/ intracranial bleed or orbital roof #

115
Q

Cause, sx, Ix + treatment of hyphaemia

A

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.

116
Q

Cause, sx, Ix + treatment of retinal injury

A

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

117
Q

When to suspect blowout #

A

Tenderness of orbital margin, reduced upward eye movement, double vision, nose bleed, reduced sensation in cheek

118
Q

Management of FB in eye

A

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

119
Q

Hx qs in nasal trauma

A

Check for concussion
Epistaxis
Prev facial/ nasal #

120
Q

Physical for nasasl trauma

A

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

121
Q

Reduction of nasal trauma

A

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

122
Q

Management of nasal hematoma

A

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

123
Q

Management of CSF leak in nasal trauma

A

Persistent rhinorrhea should raise suspicion for cribriform damage + CSF leak
CT + ENT referral urgently

124
Q

Complications of nasal trauma

A

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

125
Q

Sx + management + RTP of nasal hematoma

A

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

126
Q

How long do nasal #s take to heal?

A

3-6 wks

127
Q

What is cauliflower ear + how to treat?

A

Hematoma between skin and perichondrium - can become fibrotic within 2 wks. Use ice + compression and aspirate hematoma

128
Q

RTP for nasal #

A

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

129
Q

Hx qs for dental trauma

A

Pain
Temperature sensitivity
Color changes
Inability to chew
Force + velocity of injury
Past dental hx

130
Q

Classes of dental #

A

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)

131
Q

Physical in dental trauma

A

Head + neck exam
Palpate mandible, zygoma, TMJ, mastoid
Check jaw movement
Chin laceration - think C spine!
Intraoral exam - teeth, tongue, gums, buccal mucosa

132
Q

Imaging - when is it needed + what type, in context of dental trauma

A

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

133
Q

Management of dental trauma

A

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

134
Q

Prevention of dental trauma

A

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

135
Q

Primary + secondary survey in ?C spine injury

A

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

136
Q

Management of C spine injury - sideline

A

Stabilise C spine
Remove helmet
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

137
Q

XR views for C spine #

A

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)

138
Q

How to measure C spine collar

A

Measure neck height from jaw line to trap using flat hand

139
Q

What nerve root + peripheral nerve is responsible for shoulder abduction?

A

C5 - axillary

140
Q

What nerve root + peripheral nerve is responsible for elbow flexion?

A

C5-6 - musculocutaneous

141
Q

What nerve root + peripheral nerve is responsible for elbow extension?

A

C6-7 - radial

142
Q

What nerve root + peripheral nerve is responsible for wrist extension?

A

C6-7 - radial

143
Q

What nerve root + peripheral nerve is responsible for wrist flexion?

A

C7-8 - median

144
Q

What nerve root + peripheral nerve is responsible for finger flexion?

A

C8 - median

145
Q

What nerve root + peripheral nerve is responsible for finger extension?

A

C8 - radial

146
Q

What nerve root + peripheral nerve is responsible for finger abduction?

A

T1 - ulnar

147
Q

What nerve root + peripheral nerve is responsible for hip flexion?

A

L2-3 - femoral

148
Q

What nerve root + peripheral nerve is responsible for knee extension?

A

L3-4 - femoral

149
Q

What nerve root + peripheral nerve is responsible for ankle dorsiflexion?

A

L4-5 peroneal

150
Q

What nerve root + peripheral nerve is responsible for hip extension?

A

L4-5 gluteal

151
Q

What nerve root + peripheral nerve is responsible for knee flexion?

A

L5-S1 - sciatic

152
Q

What nerve root + peripheral nerve is responsible for ankle plantar flexion?

A

S1-2 - tibial

153
Q

Cervical dermatomes

A
154
Q

Lower leg dermatomes

A
155
Q

Spinal cord injury at C1-4: sx, care needs

A

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

156
Q

Spinal cord injury at C5: sx, care needs

A

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

157
Q

Spinal cord injury at C6: sx, care needs

A

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

158
Q

Spinal cord injury at C7: sx, care needs

A

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

159
Q

Spinal cord injury at C8: sx, care needs

A

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

160
Q

Spinal cord injury at T1-T5: sx, care needs

A

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

161
Q

Spinal cord injury at T6-T12: sx, care needs

A

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

162
Q

Spinal cord injury at L1-5: sx, care needs

A

Loss of function in hips + legs
Little voluntary control of bowel or bladder
May need wheelchair or braces

163
Q

Spinal cord injury at S1-S5: sx, care needs

A

Loss of function in hips + legs
Little voluntary control of bowel or bladder
Most can walk

164
Q

Complications of spinal cord injury (C spine injury)

A

Spinal “shock” = transient areflexia, flaccid paralysis, anesthesia - resolves with time
Neurogenic shock = hypotension, bradycardia

165
Q

Types of spinal cord injury

A

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

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

166
Q

Canadian C spine rules

A

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

167
Q

When are Canadian C spine rules not applicable?

A

GCS <15
Age <16
Unstable vitals
Known vertebral dz
Acute paralysis
Pregnant
Prev C spine surgery

168
Q

Management of C spine #

A

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

169
Q

Common mechanism + MOI of spinous process #

A

Avulsion type injuries from contraction of trapezius, rhomboid minor, serratus posterior
MOI = forced flexion of neck (football, weight lifters)

170
Q

What are transverse # from high energy traumas associated with?

A

Visceral injuries, commonly to spleen + liver

171
Q

Common MOI for lumbar transverse proces #

A

Direct trauma

172
Q

Associated # with L4 + L5 transverse process #

A

L4 = acetabular #
L5 = pelvic ring injuries

173
Q

Workup if transverse process # identified on imaging

A

Abdo CT d/t risk of visceral, abdo + other ortho injuries

174
Q

What to examine in FU for cervical spine #

A

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)

175
Q

Hx Ankylosing spondylitis

A

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

176
Q

Physical exam for Ankylosing spondylitis

A

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)

177
Q

Ix for Ankylosing spondylitis

A

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

178
Q

DDx of AS

A

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)

179
Q

What are the types of spondyloarthritis?

A

AS
Reactive arthritis
Arthritis w/ IBD
Arthritis w/ psoriasis
Unspecified spondylitis

180
Q

ROME criteria for AS

A

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

181
Q

Management of AS

A

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

182
Q

Hx for spinal stenosis

A

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

183
Q

Physical for spinal stenosis

A

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

184
Q

DDx for spinal stenosis

A

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

185
Q

Management of spinal stenosis

A

NSAIDs
Lumbar support
Epidural steroid injection
Acupuncture
Multilevel decompressive laminectomies
PT
- Core strengthening, good posture and flexibility can slow progression

186
Q

Neurogenic vs vascular claudication

A

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

187
Q

Complications of spinal stenosis

A

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

188
Q

What is spondylolysis, cause, RF

A

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

189
Q

Hx of spondylolysis

A

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

190
Q

Physical for spondylolysis

A

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

191
Q

Ix for spondylolysis

A

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

192
Q

Management of spondylolysis

A

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

193
Q

DDx of spondylolysis

A

Spinal stenosis
Tumor
Scoliosis
Disc dz/ herniation
Spondylytic dz
Vertebral #
Osteoid osteoma or other malignancy
Reactive arthritis
AS
Vertebral osteomyelitis
Lumbar sprains + strains
Pyelonephritis

194
Q

Complications of spondylolysis

A

Spondylolisthesis

195
Q

What is Spondylolisthesis

A

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

196
Q

Hx of spondylolisthesis

A

Insidious onset LBP, can be intermittent
Can have radicular symptoms

197
Q

Imaging for spondylolisthesis

A

AP + lateral XR
Standing may worsen apparent slippage
Bone scan w/ SPECT

198
Q

Management inc RTP of spondylolisthesis

A

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

199
Q

RF for spondylolisthesis

A

Family history
Sports with extreme spinal motion, especially repetitive hyper extension
Growth spurts
An atomic variations like spina bifida, scoliosis, increased lumbar lordosis

CASEM (13 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions