KW-PEM1CSV Flashcards
When can you close a dog bite? (What does the wound look like, and what level of risk is it)
If the wound is superficial without presence of significant crush injury or tissue loss, primary closure is the best approach for cosmetic outcomes. (=low risk)
Which is most common and also THE WORST: ischemic vs non ischemic priaprism?
Ischemic
Whats the prob with ischemic (low flow priaprism)?
impaired relaxation
and
paralysis of smooth muscle
What’s the time cutoff to define PRIAPRISM?
> 4 hrs
What 2 tests can help determine priaprism type?
penile blood gas (acidotic = ischemic)
Doppler
pH = 7.25, PCO2 >/=60 what kind of priaprism is this?
Ischemic
When does penile damage occur?
@ 6 hrs
What rx for priaprism can you offer while u wait for Urology?
Physical activity
urination
Fluid
Ejaculation
ICE (except if SCD)
Pain management
What is Urology’s procedure?
Aspiration and Irrigation
In Priaprism, whats engorged and whats flaccid?
Cavernosum = ENGORGED
Glans and Spongiosum = Flaccid
What medication reccs are there for priaprism treatment?
1) AUA reccs phenylephrine
2) if < 10 yo, then epi in dilute soln
3) If these dont work, then surgical shunt
Whats the procedure
Injection at 2-3 o’clock midshaft of corpus callosum
Removal of 3-5 ml aliquots of blood until detumescence / red blood
Irrigation with normal saline
What are the consult indications for PARAphimosis
Answ
- Penile necrosis –dark color, firmness, elasticity
- Evidence of blood flow compromise
- Complete urinary obstruction
- Unsuccessful manual reduction
otherwise attempt MANUAL REDUX
What happens in penile fx?
Rupture of tunica albuginea (the layer surrounding cavernosum)
AKA “eggplant deformity”
What must you eval for in penile fx?
Urethral rupture
What is the treatment for penile fx?
URGENT/EMERGENT repair
-surgical
What is the treatment for zipper entrapment?
1) Mineral Oil extraction
2) Cut zipper cloth
3) Cut the median bar of the fastner
For girls with STRADDLE injuries—what is the common injury location? Why is this important?
Anterior/lateral to hymen
if hymen or posterior fourchette involved—>think of abuse
When should you consult for straddle injuries?
-Vaginal bleeding, large vaginal / vulvar lacerations
•Large testicular / scrotal hematoma; testicular rupture, torsion, dislocation, avulsion
•Scrotal laceration through the Dartos layer
•Concern for urethral disruption
Most torsion is due to ____ rotation
Medial
De-torse by lateral rotation (360-270 deg) “open the book”
What are the time delay cutoffs for testicle loss at 90%, 50% and 10%?
<6 hrs: 90% survival of teste
12 hrs: 50%
>24 hrs: < 10%
Tenderness of testicle that is POSTERIOR and SUPERIOR =
Epidymitis
spermatic cord twisting, altered testicular blood flow, increased size, altered echotexture
Torsion
swelling & structural heterogenicit
Epididymitis & TAT
Label the following
A) Dartos/fascia and skin
B) Tunica Albuginea
C) T. Vaginalis
D) Spermatic Cord
B
C
D
A
When do you need to discuss surgery for Hematocele?
> 5cm or expanding US (bc testicle may suffer comrpession)
What’s the formula for expected bladder capacity?
(Age + 2) x 3
What are common Urinary retention etiologies?
Urinary RTN is >12 hrs without UOP WITH enlarged bladder
UTI –urethritis and urethral edema
•Constipation –mechanical obstruction by distended rectum
•Medications –i.e.anticholingerics, sympathomimetics
•Neurologic disease –MS, myasthenia gravis, GBS, spina bifida, spinal cord disease (etiology in 3-17% of AUR cases)
•Urethral obstruction –paraphimosis, imperforate hymen, urethral stone
•Uretheralspasm
What are the 4 components of a complex febrile seizure?
Focality
>15 min
Occcur 2 or more times in 24 hrs
Todd Pareisis or other deficits present
Who gets imaging in febrile seizure?
Focal seizure
Neonates with seizures
Afebriles with seizure < 3
When should a patient return back to baseline following seizure (afebrile)?
2-3 hrs
What is 2nd line management for status epi? (> 4wks of age)
If seizures continue for 10 min after at least two injectons of benzos…
Then..give
Keppra
phenytoin/fospheny
Valproate
Define Status Epi
Lasts > 5 min
OR
Back to back seizures not allowing for postictal states
When do you consider pyridoxine rx for status epi?
In kids less than 1 yrs of age with refractory seizures
and
Isoniazid overdose
Dose for pyridoxine deficiency:
100 mg
For isoniazid OD: 70 mg/kg IV to start
What is the 3rd line/step in Status epi?
if lasting > 30 min despite benzos, 2nd line rx (KPFV)
then..
give continuous infusion of midaz, propofol, or pentobarb
What imaging is best to eval spinal epi abscess
MRI with IV gadolinium is the imaging method of choice for spinal epidural abscess and is superior to CT scan alone.
What is the treatment for congenital syphillis in newborn?
Treatment with aqueous penicillin G IV for 10-14 days is the preferred treatment for congenital syphilis
What are the features of Leimierre’s?
recent head or neck infection, internal jugular vein septic thrombophlebitis and the isolation of anaerobic pathogens, usually Fusobacterium necrophorum .
What is PID treatment?
Ceftriaxone IM and doxycycline PO. More specifically, this patient should receive ceftriaxone 250 mg IM (single dose) and oral doxycycline 100 mg BID for 14 days.
What is the treatment for rabies exposure?
After local wound care, concurrent active and passive prophylaxis with rabies immune globulin (RIG) and rabies vaccine are indicated. Rabies vaccine should then be repeated on days 3, 7 and 14.
So give vax on Day 0, 3, 7, 14
What is the arm sequelae of compartment syndrome (forearm)
Volkmann’s contracture of the hand (i.e. “claw hand”). Forearm ischemic contracture is due to brachial artery injury and injury to the anterior interosseous branch of the median nerve. This affects the flexor digitorum profundus and the flexor pollicis longus, which leads to muscle contraction and scarring, and ultimately clawing of the fingers.
Forearm ____ contracture is due to _____ artery injury and injury to the anterior interosseous branch of the ___nerve.uestion…
ischemic
brachial
median
What structures are impacted in VOLKMAN’S CONTRACTURE
This affects the flexor digitorum profundus and the flexor pollicis longus, which leads to muscle contraction and scarring, and ultimately clawing of the fingers.
Hip pain, limp,good passive ROM, antalgic gait, no hx of fever
Get bilat hip XRAYS to eval for Legg-Calve-Perthes (LCP)
ddx includes transient synovitis
needs f/u
What is Leggs Calves Perthes?
osteonecrosis of the capital femoral epiphysis
including a small dense proximal femoral epiphysis and widening of the articular cartilage. In some patients, a subchondral fracture can be seen, which can be from a stress fracture after minor trauma, and may be the etiology of acute worsening of symptoms
What are the XR findings in Leggs Calve P.?
a small dense proximal femoral epiphysis and widening of the articular cartilage.
In some patients, a subchondral fracture can be seen, which can be from a stress fracture after minor trauma, and may be the etiology of acute worsening of symptoms
Walking age (just beginning), no pain with range of motion, but has limited abduction of the left hip and slight asymmetry of thigh muscles and labial folds
Consider:
developmental dysplasia of the hip
These findings are c/w…
abnormal hip abduction, abnormal gluteal/thigh/labial folds, and limb-length inequality
What is the work up (age dep) for <4-6 mos, >4-6mos
developmental dysplasia of the hip
US for < 4-6 mos (femoral epiphysis is NOT ossified)
XR for >4-6 mos
** follow up with an orthopedic surgeon once the diagnosis is made
Most common pathogen for septic joint, all ages
Staph Aureus
Synovial fluid WBC of (>/<) ______ cells per mm 3 is concerning for bacterial septic arthritis, although Lyme disease and noninfectious causes of arthritis (e.g., juvenile idiopathic arthritis) can also have elevated WBC in this range, while tuberculosis and Brucella infections may have lower WBC counts.
Synovial fluid WBC of >50,000 cells per mm 3 is concerning for bacterial septic arthritis,
** Lyme disease and noninfectious causes of arthritis (e.g., juvenile idiopathic arthritis) can also have elevated WBC in this range, while tuberculosis and Brucella infections may have lower WBC counts.
Septic Joint Empiric abx: Everyone, Neonates, >2mo up to 5 yrs, >5 yrs, sexually active
Treat with: Clindamycin alone
-S. aureus is the most common organism found in this condition for all age groups.
Neonates:Vanc, Cefotaxime
-group B streptococcus and Gram-negative bacilli are also causative organisms and should be treated with vancomycin and cefotaxime.
> 2mos-5 yrs: Clinda, +/- CTX
-still, clindamycin is recommended for empiric treatment and ceftriaxone should be added only if 1) the Gram stain is negative for Gram-positive cocci; 2) or the culture is positive for K. kingae; or 3) if the child is ill appearing
> 5 yrs: Clinda
- S. aureus and group A streptococcus would also be covered with clindamycin.
sexually active adolescents: CTX + Clinda
-Neisseria gonorrhoeae should also be considered as a causative organism; therefore, ceftriaxone, in addition to clindamycin, is recommended for empiric treatment .
Switch to an oral form for the duration of treatment, usually 2-3 more weeks.
Finger Felon Management:
1st: digital block,
2nd: I/D (palmar or lateral surface of the finger in the area of greatest fluctuance)
* The septae should not be divided as iatrogenic complications can occur, including skin sloughing, unstable fat pad, permanent sensory nerve damage with chronic pain and/or hypesthesia, and significant scarring
Felon complications
Osteomyelitis of the distal phalanx. septic arthritis, or suppurative flexor tenonsynovitis
The deep septal attachments in the finger pad within which the infection is contained are distal to the DIP joint, so infection spread to this structure and possible subsequent chronic arthritis are uncommon.
Why is it uncommon for bacteria to spread past distal phalanx in a felon?
The deep septal attachments in the finger pad within which the infection is contained are distal to the DIP joint, so infection spread to this structure and possible subsequent chronic arthritis are uncommon.
Abscess in the deep pulp space of the distal finger
Felon
*clinical dx, don’t need labs
refusal to walk, difficulty sitting upright, hip pain and/or abdominal pain, less than 25% have fever
discitis
Identify condition
Legg Calve Perthes
Discitis: Order the following test in order of sensitivity CT, MRI, XR, Bone Scan
Bone scan is the most sensitive and would show increased uptake at the level of the involved disc.
MRI can best differentiate discitis from vertebral osteomyelitis.
CT is less sensitive in demonstrating discitis.
Spine x-rays are usually normal initially, but then may demonstrate intervertebral disc space narrowing after 2-3 weeks
Bone Scan> MRI> CT> XR
Leggs Calve P. exam (maneuver) findings
restricted range of internal rotation and abduction
defect of the pars interarticularis of the vertebral body, which can occur due to an acute traumatic event or may develop more insidiously
Spondylolysis
-Most commonly L5-S1 = “anterior translation of L5 on S1”
Sinding-Larsen-Johansson
a traction apophysitis at the inferior pole of the patella at the infrapatellar tendon
SCFE
capital femoral epiphysis is displaced from the femoral neck through the physeal plate
=condition affecting the femoral head epiphysis
SCFE sx
chronic history of intermittent pain in the groin, medial thigh, or knee
knee b/c of referred pain down obturator
How do you dx SCFE?
The diagnostic test of choice for this condition is x-rays of the hips (AP and frog-leg views) = ED DXIC TEST OF CHOICE
which demonstrate displacement of the femoral neck from the acetabular wall, physeal plate widening, irregularity and decreased epiphyseal height in the center of the acetabulum.
SCFE Complications
Without early and appropriate surgical pinning, major complications of this condition include:
chondrolysis (acute dissolution of the articular cartilage) and osteonecrosis.
*Follow-up x-rays may demonstrate osteonecrosis with a subchondral lucency, fracture, sclerosis, or collapse of the femoral head, and cyst formation
Risk Factors in Sickle Cell for avasc necrosis
Hemoglobin (Hgb) SC disease compared to Hgb SS disease.
Other risk factors include a high baseline hematocrit and a history of frequent or severe pain crises.
Some pain with internal rotation of the right hip. When you passively flex the right hip, the thigh abducts and externally rotates, Atrophy of the thigh and gluteal muscle may be apparent from disuse with chronic symptoms.
SCFE exam findings
How do you estimate Severity in SCFE
Using the Klein line
What is this photo a depiction of
Klein line in SCFE
1) Evaluate the line along the superior margin of the femoral neck. This radiographic measurement, the Klein line, or Klein’s line, demonstrates the degree of displacement of the femoral head epiphysis from the femoral neck, which is found in the diagnosis of slipped capital femoral epiphysis.
With normal anatomy, this line intersects the lateral aspect of the epiphysis. With progressive displacement, this line may not intersect the epiphysis at all. Although the femoral head metaphysis may appear more laterally displaced from the acetabular wall, this measurement may not give the degree of displacement.
True/False: There are sclerotic changes in SCFE
Sclerotic changes and effusions are not seen with SCFEs
What are the KOCHER Criteria?
“There are just a FEWw Kocher”
They risk stratify a child with suspected septic arthritis using the following factors:
1) non-weight bearing on the affected side;
2) ESR > 40 mm/hr;
3) presence of fever; and
4) serum WBC > 12,000/mm 3 .
What are the associated probabilities for KOCHER criteria
With 4/4 criteria the probability of septic arthritis is 99%;
3/4= 93%,
2/4= 40%;
1/4= 3%; and
0/4=0.2%.
When should you perform athrocentesis for septic jt eval?
If the degree of clinical suspicion for a bacterial septic hip is high, it should be performed to obtain
synovial fluid for culture, Gram stain, and WBC.
If the fluid is purulent with a high WBC count or a positive Gram stain, operative intervention is necessary
When do you start abx in septic jt?
Empiric antibiotics would not be routinely given until synovial fluid cultures were obtained by aspiration or operative washout.
Symptoms: pain, swelling after activity, chronic
XRAY: crescentic-shaped defect within the subchondral bone of the distal left femur
consistent with osteochondritis dissecans
osteochondritis dissecans management hierchy
1st: conservative with rest
if no improvement
2nd: Casting for immobilization and non-weight bearing restrictions
Septic Joint due to suspected Lyme: management
- 8 years or older is oral doxycycline for 1 month.
-< 8 years, the preferred treatment is with oral amoxicillin for 1 month.
There is no indication for parenteral antibiotics or operative drainage for Lyme arthritis.…
DDx of Bony Tumor in femur with findings:lytic lesion with a thin cortex due to cortical destruction in the distal right femur
Ewing sarcoma, osteosarcoma, aneurysmal bone cysts
**specific diagnosis can’t be made on the x-ray, orthopedic follow-up with advanced imaging will be necessary.
Osgood Schlatter Dz
- apophysitis of the tibial tubercle caused by repetitive stress on the patellar tendon by overuse.
-The repetitive stress causes a series of microavulsions of the secondary ossification center and underlying cartilage of the patella.
The x-ray demonstrates a tibial tubercle avulsion fracture that can be associated with Osgood-Schlatter disease. n
-
What maneuvers can be used to dx O.Schlatter dz?
The diagnosis can be confirmed on PE with localized tenderness of the tibial tubercle. Maneuvers that stress the patella tendon elicit pain (e.g., patient in prone position flexes knee so heel contacts the buttocks).
What is complex regional pain syndrome type I (CRPS1
previously referred to as reflex sympathetic dystrophy.
This is a disorder characterized by pain, abnormal sensation and irregularities of the circulation.
This condition may develop after minor trauma, but not in all cases.
xrays aren’t needed to dx condition
When should Breast Milk Jaundice disappear?
Jaundice should be gone by 12 weeks
What are the nerves supplying A-G
A: Median only
B. Ulnar only
C. Median
D. Radial only
E.Median
F. Ulnar
G. Radial
The musculocutaneous nerve provides anesthesia for the ______.
Forearm
Where is the best posoition for a penile nerve block
2 and 10 position
What amts of lido and concentration are used for neonate and older kid penile block?
neo: 0.8 ml of 1 %
older: 1-4 ml of 1%
- hear a pop when passing thru buck fascia
What is the taping procedure of a “sucking chest wound”?
A temp occlusive dressings function as one-way flutter valves (until a thoracostomy tube can be placed at a site distant from the wound.)
The occlusive dressing material should be impervious to air, thin and flexible, unlikely to adhere to the skin, and pliable enough to allow air to flow underneath when applied over the wound.
- two or three 4 x 4 gauze sponges with an overlying covering of petrolatum gauze. The dressing is then applied over the chest wall with 1 to 2 inch margins beyond the wound edge, and then securely taped on 3 sides of the dressing with the nondependent edge left open.
Where do you put in a needle (thoracostomy)?
2 nd intercostal space at the midclavicular line.
Which splint:
unstsable forearm or wrist fracture
Sugar Tong
Which splint:metacarpal and proximal phalangeal fractures.
Gutter
Which splint:metacarpal and proximal phalangeal fracture of thumb
thumb spica is a gutter splint adapted for the thumb
Which splint: stable forearm fx
colles splints provide volar support , alternative for older children.
Which splint: stable injuries at or near the elbow.
Long arm
What are the steps for a successful IO placement?
1) IO needle should remain in the bone without support. Firm seating of the IO needle in the bone is the first indication of correct placement.
2) Aspiration of the bone marrow typically follows, providing additional evidence of correct placement of the IO needle and also providing blood that may be used for laboratory assays.
- If aspiration of bone marrow is unsuccessful, advancing the needle is not indicated, as it may result in puncturing both cortices.
3) After the firmly-seated needle is aspirated, with or without blood return, the next step should be infusion of saline through the IO needle.
-If the saline infuses without resistance or soft tissue fluid extravasation, this provides additional confirmation that IO placement is correct even if bone marrow aspiration was not successful.
What is the position for proper pigtail placement
Above the 5 th rib, anterior axillary line.
Appropriate placement for insertion of a pigtail thoracostomy catheter is between the anterior axillary and midaxillary lines in the 4 th to 6 th intercostal spaces.
Insertion at this location minimizes risk to blood vessels, muscle, and breast tissue.
*The ideal insertion site is to go above the inferior rib at the intercostal space to avoid injuring the neurovascular bundle.
When less invasive respiratory options have failed in patients with upper airway obstruction, what are your two choices? Which should be tried first?
Percutaneous transtracheal ventilation and surgical cricothyrotomy
Percutaneous transtracheal ventilation should always be considered first due to its ease, quicker procedural time and fewer complications.
