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503 Cards in this Set

  • Front
  • Back
  • 3rd side (hint)
What is the universal goal of surgical intervention in the spine and the extremities?
To provide painless musculoskeletal function.

p. e-51
What are the (5) post operative complications, pertaining to devices, MC seen in the ED following ortho repair?
1. implant failure
2. loss of fixation
3. nonunion
4. malunion
5. infection

p. e-51
Musculoskeletal infections present differently than other body tissues. They present with severe pain, pressure (abscess/pyarthrosis) or with a draining sinus tract. However, they are often lacking in what two otherwise common symptoms?
1. fever
2. sepsis

p. e-51
It is often, when plates/screws/devices are in place following ortho surgery, for the "fracture line to be visible" beyond what time?
> 1 yr

p. e-51
What is the most common "early" complication following orthopedic internal fixation procedure with plates and screws?
Infection

p. e-51
What is required of deep wound infections following orthopaedic device placement?
Surgical Debridement

p. e-51
What is a late complication of plate and screw device placement in ortho surgery?
Non-union of a fracture

p. e-51
- it may be related to a deep chronic infection.
After ortho implant,plates and screws, are removed- how long are the bones susceptible to fx?
3 months

p. e-51
What is the MC implant used to treat femoral and tibial shaft fractures?
single, intramedullary rod

p. e-51
rigidity of the fracture immobilization is less than that with plates and screws, so fx healing is results in less visible callus formation
Why are flexible intermedullary rods seldom used in the slower healing, elderly population?
Because flexible rod fixation is less stable than rigid intramedullary nailing

p. e-51
Why are flexible intramedullary rods more favorable in the pediatric population?
Because they avoid the cumbersome nature of external fixation

p. e-51
What is more common than infection, in open fractures, secured with intermedullary rods?
Hardware failure

p. e-56

- open fx treated with intermedullary rods have higher nonunion rates than closed fx...
Nails and screws can cause significant discomfort in ortho devices, when left in too long or if they back out of the bone. What three locations in the body is this most common?
- distal femur
- proximal tibia
- distal tibia

p. e-56
Percutaneous pins, often used in the small bones of the hand and foot add stability, has a common complication...what is it?
pin tract infection

p. e-58
infx MC resolves after pin removal, but this should be done by ortho doc
Also needed: oral abx
What is common with percutaneous pins and easily detected by radiography?
Pin migration and breakage

p. e-58
What is external fixation MC used for?
Stabilization of the pelvis or extremity

p. e-61
- this may occur while life or limb threatening surgery is performed, or as staged tx in polytrauma.

- read bottom paragraph, left column, p. e-61
If a superficial pin tract infx is suspected, with external fixation, what can be done to treat it?
- oral abx
- releasing the skin around the pin with a scapel, after adequate analgesia

p. e-61
deep infx, call ortho
Post-operative infection of ligamentous reconstruction can be a catastrophic, early complication. Though rare, how does it present?
- increased pain and low-grade fever

p. e-62
- this can actually jeopardize graft stability
What is the MC complication of ligamentous grafts (soft tissue stabilizing implants)?
loss of fixation

p. e-65
How is the diagnosis of a failed soft tissue-to-bone procedure made?
clinically

p. e-65
- radiographs are often normal
MRI can be used as well
If soft tissue graft surgery was performed less than 6 weeks prior to patients arrival with pain, what should be done with the physical examination?
It should be defered to the Orthopedist to perform- because the graft may not have healed completely to the bone

p. e-65
What is the success rate and "years to follow-up" on total knee and hip arthroplasties (replacement)?
1. >90% success rate
2. 15-20 yrs to follow-up

p. e-65
Of all joint arthroplasties, which is the most reliable "operations in all surgery", such that >90% of pts will not suffer any complications in the first 10 yrs.
Total knee arthroplasty

p.e-66
What is ALWAYS sacrificed by the patient in total knee arthroplasty?
Anterior cruciate ligament

p. e-66
What 4 things should be suspected when a patient presents with a new onset of periprosthetic pain?
1. Dislocation
2. Periprosthetic fracture
3. Implant loosening
4. Infection

p. e-76
Dislocation of prosthetic surgical device will be 2/2 what three things?
1. trauma
2. improper limb position
3. insufficient soft tissue stabilization

p. e-76
Surgical orthopedic prosthetic implants may dislocate...what should not be done w/o first discussing with orthopedist?
Relocation...
-because many of today's implants are modular (snap together in the operating room)

p. e-76
- disassemply of modular prosthesis has been reported, during closed reduction
What is the MC long term complication of arthoplasty?
implant loosening

p. e-76
MC this will not present to the ED, 2/2 to the insidious nature of onset
A 60 y/o R hand dominant Male patient presents with intractable shoulder pain, worsened with movement in all directions. Surgeries: Appendectomy , and arthroplasty. Medications: Percocet, BiDil and Coreg.NKDA. Additionally, labs obtained from check in are reported as elevated WBC's, an elevated CRP and ESR. Blood cultures were obtained and radiograph was negative for acute finding?
Infection of joint arthroplasty

p. e-76
You suspect that a patient has an infection of an orthopedic prosthesis- in the knee. You know that the patient needs antibiotics. What two things should be done prior to administration?
- Aspiration of the joint
- Call the orthopedist (they may not want to to, or may wish to do it themselves). It is possible for an aseptic implant to be infected by needle aspiration

p. e-76
What should joint aspiration fluid labs include?
- cell count
- gram stain
- culture
- crystal analysis

p. e-76
Why is knowing if a patient has a history of prosthetic joint debridement important?
Because this has a prognostic indication on whether the patient has an infection in the prosthesis, stage one or simple debridement is associated with higher rates of infx

p. e-76
What is the MC joint arthroplasty to dislocate?
the hip

p. e-76
The prosthesis are often modular and therfore, great care should be used during relocation
What upper extremity arthroplasties have more frequent complications than any other commonly replaced joint?
Elbow

p. e-78
A patient presents to the ER with pain in the left shoulder. You do not suspect infection, however, suspect that the prosthetic has "slipped" out and become dislocated from glenoid fossa. Anterior and posterior views, while difficult were obtained. The patient is unable to tolerate the axillary view 2/2 to pain. What view may then be obtained?
Velpeau View

p. e-76
What is the term for "spinal cord compression?
Myelopathy

p. e-76
- nerve root=radiculopathy
Patients with halos, an external fixator for cervical spine fx's/arthrodesis healing, may develop pin tract infections, however, they may also have loose screws. Why is it imperative not to tighten or manipulate these?
risk skull penetration and or meningitis

p. e-80
Patients with Halo devices are prone to falls and pin dislodgement. Why?
Because of the head fixation- they cannot look down...

p. e-80
A patient presents following thoracolumbar fixation and has pain and drainage from the site of the procedure. A colleague notes that the patient has no temperature, and the CBC, the only lab ordered, upon check in was NML. He states that this must be a superficial abscess and not related to the surgery. Do you agree with this? If not, what other labs may you choose that may be more helpful?
I don't agree...actually, the temperature and WBC's do not have to be up...
What you need instead is: ESR, CRP, and the additional indicated sxs, which are more helpful as the WBC"s and Temp are often NML.

p. e-81
Patient recently had a spinal procedure, though a poor historian as to the type of procedure and intent, is able to tell you that they "heard a pop" and felt an intense rush of pain. What's up with that?
Harrington-type hook implant- prone to dislodging.

-e-81
call neurosurg after lateral rad film
What is the reason for disk surgery?
restore and maintain motion

p. e-84
This actually reduces the risk of adjacent disease
A patient had a disk replacement and reports following a slip in his garage, without direct trauma, and subsequent surge of pain after a "pop" and electricity down both legs. What is the "salvage procedure", if revision is not an option?
fusion

p. e-84
A patient presents following thoracolumbar fixation and has pain and drainage from the site of the procedure. A colleague notes that the patient has no temperature, and the CBC, the only lab ordered, upon check in was NML. He states that this must be a superficial abscess and not related to the surgery. Do you agree with this? If not, what other labs may you choose that may be more helpful?
I don't agree...actually, the temperature and WBC's do not have to be up...
What you need instead is: ESR, CRP, and the additional indicated sxs, which are more helpful as the WBC"s and Temp are often NML.

p. e-81
Patient recently had a spinal procedure, though a poor historian as to the type of procedure and intent, is able to tell you that they "heard a pop" and felt an intense rush of pain. What's up with that?
Harrington-type hook implant- prone to dislodging.

-e-81
call neurosurg after lateral rad film
What is the reason for disk surgery?
restore and maintain motion

p. e-84
This actually reduces the risk of adjacent disease
A patient had a disk replacement and reports following a slip in his garage, without direct trauma, and subsequent surge of pain after a "pop" and electricity down both legs. What is the "salvage procedure", if revision is not an option?
fusion

p. e-84
T/F: Any single break in the pelvic ring will cause pelvic instability.
False. A single break in the pelvic ring will yield a stable injury without significant risk of displacement. An injury with two breaks in the ring is unstable with risk of displacement.

p. 1841
There are three portions that make of the acetebulum: Which is the chief weight bearing surface?
Iliac portion, or superior dome

p. 1842
There are three portions that make of the acetebulum: Which is thin and therfore easily fractured?
inner wall, consisting of the pubis

p. 1842
There are three portions that make of the acetebulum: Which is posterior aspect?
thick ischium

p. 1842
The pelvis is EXTREMELY vascular. What vessels run along the SI joints?
iliac arteries and venous trunks

p. 1842
What is the sensivity of a pelvic examination in blunt force trauma in a patient is alert and awake?
Very Sensitive

p. 1842
You are examining a patient who sustained multiple injuries in a MVA. Performing the physical examination, you suspect that the patient has a pelvic fracture and may be unstable- what should you be cautious about doing?
Should not perform excessive movements of unstable fx's. This could produce further injury and additional blood loss.

p. 1842
What is "Earle's sign" and "Destot sign"?
Earle's sign: Tenderness along the fx line during a rectal exam
Destot sign: hematoma over the scrotum

p. 1842
Why perform a rectal examination in blunt trauma patient?
1. superior, posterior displacement of the prostate
2. rectal injury
3. abnormal bony prominence or large hematoma
4. if fracture, may have tenderness along the fracture line

p. 1842
What is safely assumed when assessing pelvic instability?
1. intra-abdominal injury
2. retroperitoneal injury
3. gynecologic injury
4. urologic injury

- it should be investigated thoroughly to be disporven

p. 1843
T/F regarding pelvic injury in trauma: Asx individuals who are alert and oriented do not require routine radiographs.
True

p. 1843
What is more sensitive than plain films in the detection of pelvic fractures?
CT scan

p. 1843
T/F: Plain films rarely change the management of plan of stable patients with pelvic pain following blunt trauma.
True

p. 1843
What is the gold standard for evaluating pelvic injuries?
CT scan

p. 1843
- Read Next slide it is bold phrase in book...
Compared to CT, pelvic radiographs have a sensitivity of only 64% to 78% for identifying pelvic fractures in blunt trauma patients.
You are performing a contrast abdominal pelvic CT and see extravasation on the study...the trauma CT tech says they have seen this before and you should not overreact, stating, "it could be fake. CT is not perfect". What do you think?
While not perfect, the contrast extravasation on CT is 80-90% sensitive for detecting arterial bleeding.
Ignore the crazy freakshow...and take care of the patient.

p. 1843
Get an interventional radiologist involved...angiographic embolization can control hemorrhage in >90% of arterial pelvic injuries.
What should be considered early in hemodynamically unstable patient with pelvic fx and no evidence of other source of bleeding.
Angiography
What is defined, by the text, as the most clinically useful means to classify pelvic fractures?
Young-Burgess Classification System

p. 1844
What are the three main pelvic fracture patterns defined by the Young-Burgess Classification system?
1. Lateral compression
2. Anterior-posterior compression
3. Vertical Shear

p. 1844
What is the MC?
Lateral compression, accounting for half
What type of pelvic fracture accounts for 1/4 of the injury patterns and is the second MC type?
AP compression, also referred to as the "open book" fracture

p. 1844
An prisoner is brought to you by the police, following a foot chase and jump off of a bridge. The patient appears to be in real pain and refuses to walk. Patient is unable to lie still 2/2 to pain and is HoTn and Tachycardic...you suspect from a pelvic fx. What type is likely?
Vertical Shear

p. 1844
Open reduction and internal fixation is a must
What LC fracture is treated with bedrest, pain control and protective weight bearing?
Type I

p. 1844, Table 269-1
What LC fracture is "Crescent iliac wing" fx on side of impact?
Type II

p. 1844, Table 269-1
What LC fx is LC-1 or LC-II, with contralateral open book fx?
Type III

p. 1844, Table 269-1
What APC fracture is mere widening of the symphisis pubis?
Type I AP fx

p. 1844, Table 269-1
What AP fracture type is widened anterior SI joint, disrupted anterior SI sacrotuberous, and sacrospinous ligaments, intact posterior SI ligaments
Type II AP fx

p. 1844, Table 269-1
What AP fracture type is a complete disruption of SI joint, with lateral displacement, disrupted anterior SI sacrotuberous, and sacrospinous ligaments, disrupted posterior SI ligaments
Type III AP fx

p. 1844, Table 269-1
Tx is open reduction internal fixation
T/F: Acetabular fx's are seenly commonly with other injuries, such as femur, hip fractures and dislocations, and knee injuries.
True

p. 1846
What are the acetabular/pelvic views: AP film, 45-degree iliac oblique and 45-degree obturator oblique view combined called?
Judet views

p. 1846
What is the more sensitive than plan films in the detection of acetabular views?
CT

p. 1846
T/F: Retroperitoneal bleeding is inevitable complication of pelvic fractures, and up to 4Liters of blood can be accommodated in this space until vascular pressure is overcome and tamponade occurs.
True

p. 1847
What is the most common source of bleeding in the pelvis?
MC slow venous bleed

- only 10-15% are arterial

p. 1847
What pelvic fx MC found in fall or direct trauma in elderly, exercise-induced stress fx in young or pregnant women?
single ramus of pubis or ischium

p. 1847
- local pain and tenderness; may have inability to ambulate
+ analgesia and crutches
What is the least common pelvic fx and MC pain with hamstring movement?
Ischium body

p. 1847
- tx'd with donut cushion, crutches
You were with a friend who runs track who was recently seen for a pelvic fracture. She states that the doctor told her that her pelvic fx occured when she "forcefully flexed her sartorius muscle". She states that when she lifts her legs for stretching it hurts (she tries to show you in a flexed and abducted position- groin stretch), but can't 2/2 pain. What was fractured?
Avulsion fx of the Ant/Superior iliac spine

p. 1847
You were playing soccer when you were in high school and went to perform a serious kick, but in turn felt pain in your groin. Any time you flexed your hip it hurt like crazy. You stopped immediately and and you friends took to the hospital, where you were dx with what pelvic fx?
Avulsion fx of the Ant/Inferior iliac spine

p. 1847
This pelvic fracture occurs when one forcefully flexes the hamstrings?
Ischial tuberosity

p. 1847
Should a pelvic fx result in arterial damage, it will typically from one of the many branches of what artery?
Internal iliac

p. 1847
A patient is brought to you from a trauma. There is certain pelvic instability and they are a hot mess...what do you do to stabilize the pelvis: by reducing volume and stabilizing fracture ends, using just the resources on the trauma bed?
tie the bed sheet around the pelvis

p. 1847
You perform a FAST exam on a patient with a pelvic fx, who is unstable, what do you do with a result showing: + free intraperitoneal fluid?
Arrange an immediate laparotomy

p. 1847- next slide
However, do not assume just because of pelvic instability that it must be the source. Everything else must be reasonably entertained.
Open reduction, internal fixtion of pelvic fx's MC have to occur within what time?
Within 5-14 days

p. 1847
What effect can the following have on C1-C2 vertebrae as well as the odontoid process: ankylosing spondylitis, rheumatoid arthritis, psoriatic spondyloarthropathy?
can damage the transverse ligament, damaging the C1-C2- placing this at risk as well as erosion of the odontoid process.

p. 1885- read next!
Subluxation can occur spontaneously or from a trivial trauma.
Night pain...quick what are you thinking?
Malignancy

p. 1885
Night sweats and fever...quick what are you thinking?
Infection

p. 1885
Morning stiffness...quick what are you thinking?
Arthritis

p. 1885
What is the name of the examination: where the patients head is extended, and laterally rotated and axial pressure applied. The purpose of the test is reproduction of radicular sxs.
Spurling's Test

p. 1885
What is the abduction relief sign?
Having the patient place the hand of the affected upper extremity (radicular sxs) on top of his or her head to obtain pain relief. This indicates soft disk protrusion as source of radicular pains.

p. 1885
Why should one auscultate the carotid and subclavian arteries for bruits, as well as palpation of the temporal arteries as it pertains to neck pain?
1. (carotid arteries)- cerebral insufficiency may be a source of neck/back pain
2. (subclavian arteries)- thoracic outlet and vascular steal syndromes
3. (temporal arteries)- examined for inflammatory cause of neck or back pain

p. 1885
Early cervical myelopathy's can only be determined when the examiner knows to look for them. What are some of those 8 indicated findings?
1. hyperreflexia
2. + babinski
3. clonus
4. gait disturbances
5. sexual and bladder dysfunction
6. lower extremity weakness
7. impaired hand movement
8. upper and lower extremity spasticity

p. 1885
What is the central cord examination, when the the patient's head is placed into flexion and then experiencesan electrical shock sensation radiating down spine and extremities.
Lhermette Sign

p. 1885
What sign is used to support upper motor neuron disease, by flicking the middle finger and a + test finding elicited when the thumb jerks into flexion.
Hoffman's sign

p. 1885
What is indicated in the patient's who have neck pain with neurologic signs or symptoms regardless of the plain film findings?
MRI

P. 1886
A patient reports to the ER several hours after being rearended by an idiot going to fast...running into the back of their motionless car. THe patient states that she had ben expecting some discomfort in her neck, but since that time has also felt a "deep, achy pain"...like a "numbing sensation in left arm and weakened grip". What 3 things should be considered in this...
1. brain Injury
2. spinal cord injury
3. carotid or vertebral artery dissection

p. 1886
You want a patient to have an MRI for bone or disk margin destruction concerns, what if the MRI cannot be done...what study can/should you get?
CT myeolography

p. 1886
What is the most Devastating complication of hyperflexion-hyperextension injury?
Central Cord Syndrome

p. 1887
Patient states that she had been in an accident prior to her arrival, finds it weird that she is having difficulty with hoarseness and dysphagia...what's up with that?
Severe blunt trauma or laryngeal injury...investigate further

p. 1887
Where is the disk space effected if: pain is felt in neck and scalp, sensory abnormality in the scalp?
C1-C2

p. 1887
Where is the disk space effected if: pain is felt in the neck, shoulder, and upper arm and sensory abnormality is felt in the shoulder?
C4-C5

p. 1887
Where is the disk space effected if: pain is felt in the neck, shoulder, upper medial scapular region, proximal forearm, thumb and index finger. Sensory deficit middle finger, forearm.
C5-C6

p. 1887
Where is the disk space effected if the pain is felt: neck, posterior arm, dorsum proxiomal forearm, chest, medial third of the scapula, and middle finger
C6-C7

p. 1887
What is the disck space effected if: pain is felt in the neck, posteriorarm, ulnar side fo the forearm, medial inferior scapular border, medial hand, ring and little fingers?
C7-T1
Patient comes to see you with c/o insidious development of difficult swallowing. No hx of trauma. No fever, chills, sweats, weight loss. No N/V/D. No change in appetite. No reported changes in hx: GERD, etc. No hx of lung CA. No hx of EtOH, Tobacco or ilicit drug use. Only hx: DDD and Rx: Mobic, NKDA. No concerns for achalasia or pancoast tumor on recurrent laryngeal nerve. What bony anamoly may be a factor?
Anterior body, cervical osteophyte formation.

p. 1886
T/F: Metastatic CA should be in the differential for neck pain, even if no reported hx of CA. First appearance of CA may be that of spinal cord compression.
True

p. 1887
Lung, breast, and prostate CA as well as lymphoma and multiple myeloma may involve the cervical spine and cause neck pain.
Where do most cases of epidural cord compression from CA occur?
Thoracic spine

p. 1887
10% in cervical spine, though the risk of multiple sites is prevelant as well
What is the gold standard in the detection of spinal metastatic dz and cord compression?
MRI

p. 1888
What is commonly confused with radiculopathy, but patients more commonly complain of: neck, scapula and shoulder pain, and pain not limited to dermatomal pattern; and NML neurologic examination. MC patients will have trigger points of pain identified on palpation of head, neck, shoulder, and scapular region.
Myofascial pain syndrome

p. 1888
T/F: Temporal arteritis is an inflammatory cause of neck pain.
True

p. 1888
What should be considered in an anti-coagulated patient or a patient with hemophilia- and experiences: neck pain followed by sxs of cord compression...
epidural hematoma.

p. 1888
What is the ideal tx for whiplash injuries?
Treatment should consist of: maintaining motion as tolerated coupled with analgesics and muscle relaxants

p. 1888
What are the indications for hospital admission in patients with cervical radiculopathy?
- acute or progressive symptoms
- signs of myelopathy
- progressive upper extremity weakness, especially in the C7 distribution
- intractable radicular pain unresponsive to maximal outpatient treatment

p. 1889
T/F: Patients in the acute phase of cervical radiculopathy, have no proven benefit with medrol dose pack.
False, may actually be useful.

p. 1889
What type of back pain is characterized by a duration < 6 weeks?
Acute

p. 1889
What type of back pain is characterized by duration 8-12 weeks?
Subacute

p. 1889
What type of back pain is characterized by > 12 weeks sxs?
Chronic

p. 1889
What is the most likely source of back pain in those < 18, >50 y/o?
Tumor or Infection

p.1889
patients < 18 are more likely to suffer from what back dz's and > 50 more likely to suffere from what back effects?
1. <18...higher incidence of congenital and bony defects, spondylolysis, spondylolisthesis, and scheurmann kyphosis
2. >50 are more likely to suffer from fractures, spinal stenosis, and intra-abdominal processes that cause back pain- such as an abdominal aortic aneurysm

p. 1889
Back pain: what do systemic sxs of fever, chills, night sweats, malaise, and undesired weightloss suggest (3)?
1. infx
2. systemic rheumatologic conditions
3. malignancy

p. 1889
What risk factors contribute to infection in the back (7)?
1. recent bacterial infx, skin abscesses, UTI, pneumonia
2. recent GI/GU procedure
3. immunocompromised status
4. hx IV drug use
5. hx alcoholism
6. hx of renal failure
7. hx of DM

p. 1889
PARTICULARLY IV DRUG USE...substantial risk of spinal infx
An elderly gentleman reports to the ER having been in the hospital for a rx pick up, states he has felt "weird" today. Then within a minute, felt a sudden onset of back pain. He admits to hx of CAD, HTN, DM, Hyperlipidemia and MI x 2 in the past. Persists in smoking, occasional drink (daily). No exercise, and no recent activity changes or trauma. However, the pain in back is suddenly more intense...he looks pale, in shock and suddenly collapses unresponsive. (Unlikely chance of survival even in your ER). What is it?
Ruptured Abdominal Aortic Aneurysm

P. 1889
- additional things that can cause intense back pain:
Pancreatitis
Nephrolithiasis
Posterior lobe PNA
Renal infarct
What kind of back pain is MC described as: dull, achy, worse with movement, improved with rest and lying still?
Benign

p. 1889
What type of back pain is MC worse with valsalva, coughing or sitting, but improved with lying down in supine position?
Suspicious for Disk Herniation.

p. 1889
If a patient has a hx of back pain and urinary incontinence(acute or chronic), but an otherwise normal hx and evaluation, measure the post-void residual volume at the bedside with U/S or Urinary catheter. What volume would suggest a neurologic compromise?
A large post-void residual volume of > 100 mL indicates overflow incontinence, which in the setting of low back pain suggests neurologic compromise and an epidural compression syndrome.

p. 1889
You perform a leg raise on a patient, and at 70 degrees, the patient reports symptoms in his glute and low back. Your attending, observing your exam reports this as a + test. Do you agree?
No, radicular sxs should be produced by this examination. Glute and low back is not +

p. 1889
Finish the following: The straight leg raise test is____ to ____ sensitive for L4-L5 or L5-S1 herniated disk.
68-80%

p. 1890
What is it called when a patient experiences radicular pain down the affected leg when lifting the asx leg?
Crossed Straight Leg Raise test

p. 1890
Specific for nerve root compression, not very sensitive though
T/F: All patients with low back pain should have a rectal examination.
False...but should be performed on all those with neurologic complaints or findings on PE.

p. 1890
Why? Because one needs to examine rectal/sphincter tone and sensation, the presence of prostatic masses, as well as rectal masses and to r/o perirectal abscesses.
What is the definitive imaging study in most patients with emergent back pain?
MRI

p. 1890
What imaging study for back pain is most useful for the evaluation of vertebral fractures, facet joints, and posterior elements of the spine?
CT scan

p. 1890
You want to provide a patient an NSAID, such as motrin, for his back pain because you believe it can help. Yet wonder about his risk of GI bleed. Is there anything you can give him to help, so that the motrin may be provided as well?
Misoprostol or Prilosec

p. 1891
What is the most appropriate initial treatment for back pain in those with a higher risk of adverse effects from NSAIDs...elderly and those with renal dz.
Tylenol- montherapy or with NSAID

p. 1891
If NSAIDs are used for acute back pain, what is the time limit you should give for duration?
1-2 weeks...they are only of proven benefit in the acute phase

p. 1891
T/F: Steroids are of benefit in non-specific back pain when used in the acute phase, first 48 hrs.
False, of no proven benfit.

p. 1891
What should be done for a patient with no risk factors for serious disease in history or physical examination, other than sciatica?
Treat conservatively, no need for further diagnostic tests in the ER

p. 1891
T/F: NSAID treatment in disk herniation is just as effective in the treatment of non-specific back pain.
False, ineffective in disk/sciatica

p. 1891
Steroids and Injection steroids are also of very little proven benefit
T/F: Epidural steroid injections has shown benefit in sx relief and reduction in surgical need.
False. There has been limited sx relief and has never reduced the need for surgery

p. 1891
Infact, MC radicular back pain sxs will improve (80%) in 6 weeks. Surgery is encouraged when the following three are met:
1. def. evidence of disk herniation- per imaging
2. herniation exists within context of clinical picture and neuro deficits
3. conservative tx for 4-6 weeks fails to produce improvement.
What back pain MC occurs in the 6th decade of life, is worsened by erect posture and prolonged standing; being relieved by forward flexion as well as rest. Sxs MC located in the lower back.
Spinal stenosis

p. 1892
Neurogenic claudication, what is this?
It is sxs, associated with spinal stenosis, that are worsened by erect posture and predictably relieved by lying down and/or forward flexion.

p. 1892
Surgery reduces pain, but has no impact on function
What is epidural compression syndrome?
A collective term encompassing spinal cord compression, cauda equina, conus medullaris

p. 1892
Urinary Retention >500 mL alone or in combination with two of the three additional findings are important predictors of MRI confirmed cauda compressions. What are the three things?
1. b/l sciatica
2. subjective urinary retention
3. rectal incontinence

p. 1892
What is the most common finding in cauda equina syndrome?
Urinary incontinence w or w/o retention

p. 1892
You suspect that someone has epidural compression syndrome, esp due to a tumor, what is done for the patient even beofre confirmatory testing?
Dexamethasone 10 mg IV

p. 1892- see Nxt!
After this is given, get emergent MRI- of the entire spine
Why is dexamethasone given to patients with suspected epidural compression syndromes?
Given in an attempt to minimize progression of the compression, edema, and the resultant neurologic damage. The studies may take several hours to obtain and damage is often irreversible.

p. 1892
read last paragraph, for awesome FYI, second column regarding compression syndromes, just prior to the transverse myelitis section.
A patient presents to the ER with sxs of back pain and b/l motor and sensory disturbances as well as autonomic disturbances that progressed slowly over days to weeks, to about the level of the L4 distribution. He states that he was sure it would get better, but on-line resources indicate that he may die w/o tx. no recent camping, travel and no recent medications or immunizations. States that he is having difficulty with voiding. + hx of SLE. You suspected epidural compression syndrome, but MRI is normal. What do you think- what is it, what is the tx?
1. Transverse Myelitis

2. Treatment includes corticosteroids and plasma exchange- at the direction of a neurologist.

p. 1892-1893
Transverse myelitis is going to appears c/w epidural compression syndromes, but MRI will either show a spinal cord swelling or NML findings.
- call the neurologist. to discuss the admission
- perform a lumbar puncture to further examine, and assist in the dx. MC: spinal fluid will show lymphocytosis and elevated proteins.
What three infections/complications of the spine are rare, but serious causes of back pain?
Spinal Infections:
1. vertebral osteomyelitis
2. diskitis
3. spinal epidural abscess

p. 1893
What are the (5) risk factors associated with spinal infections.
1. immunocompromise
2. recent invasive procedure
3. spinal implants and devices
4. injection drug use
5. skin abscesses (can't tell if this is skin abscesses or skin abscesses in association with IV drug use)

p. 1893
What process most commonly displays bony destruction, irregularity of the vertebral end plates and disk space narrowing on plain film?
Vertebral Osteomyelitis

p. 1893
36 y/o M patient, known to the nurses as a junky who is notoriously drug seeking. Brought in with back pain > 3 months. VSS, however, Temp 101.5. Denies recent illnesses, but admits to just not feeling well over all. + hx of IV drug and marijuana use, tho says remote. Cigs: 1/2 ppd. EtOH: none- as he is in rehab. Feels warm, + TTP over vertebral bodies, to percussion. CBC: NML, ESR elevated. Blood cultures obtained. You order a plain film of back...but are certain at this time the patient has...
Vertebral Osteomyelitis

p. 1893,
- this is confirmed further an plain film. What does it show?
bony destruction, irregularity of veterbal end plates, and disk space narrowing.
A patient reports to you with neck and back pain, which has been wakening them from sleep. States that this is not improved with attempts to rest and with analgesics. + Fever. PE c/w reported concerns and the patinet has elevated ESR and NML WBC's. Whatcha think'n?
Diskitis

p. 1893
What presents with the classic triad of:
1. severe back pain
2. fever
3. neurologic deficits
spinal epidural abscess

p. 1893
The stages of epidural abscess varies from 1-30 days. What stage is the following:
back pain at the level of the affected spine
stage 1

p. 1893
The stages of epidural abscess varies from 1-30 days. What stage is the following:
nerve root pain radiating from the involved spinal area
stage 2

p. 1893
The stages of epidural abscess varies from 1-30 days. What stage is the following:
motor weakness and sensory deficit as well as bladder and bowel dysfunction
stage 3

p. 1893
The stages of epidural abscess varies from 1-30 days. What stage is the following:
paralysis
stage 4

p. 1893
What are the risk factors for epidural abscess (10)
1. injection drug use
2. immunocompromise
3. alcohol abuse
4. recent spine procedure
5. distant site infection
6. diabetes
7. indwelling catheter
8. recent spine fx
9. chronic renal failure
10. Cancer

- presence of 1 or more was 98% sensitive for an abscess.
- ESR is elevated >90% of pts

p. 1893
You suspect a spinal infection in the patient you are examining. What diagnostic study is the "gold standard"?
MRI

p. 1893
What is the treatment for:
1. epidural abscess
2. diskitis
3. vertebral osteomyelitis
Always, discuss with neurosurgeon
1. Epidural abscess- emergent eval and tx by neurosurgeon
2. diskitis- long term abx, surgery is not necessary unless cord compression or instability
3. vertebral osteomyelitis- primarily medical, with IV abx for 6 weeks; followed by 4-8 weeks of oral abx. However, as above, consult with neurosurg prior to tx.

p. 1893
What is the target organism when treating spinal infections?
Staph Aureus

p. 1893
There are three groups of patients with neck and back pain, who have a history of cancer. What group is someone with symptoms of neck and back pain with nerve findings, present and appears stable for days? But what is that individual has involvement of more than one nerve root?
Originally Stage I
Then, Stage II

- stage three is someone with neck or back pain, w/o neurologic sxs.

p. 1893
T/F: The findings of a normal plain film do not exclude the presence of epidural metastases.
True

p. 1893
What are the four joints of the shoulder?
1. Glenohumeral
2. Acromioclavicular
3. Scapulothoracic
4. Sternoclavicular

p. 1894
What is the primary source of mobility of the upper extremity?
The deltoid muscle...along with the pec muscle

p. 1894
What four muscles make up the rotator cuff?
- supraspinatous
- infraspinatous
- teres minor
- subscapularis

p. 1894
What muscle provides internal rotation of the arm, and is the only muscle that attaches to the anterior aspect of the scapula?
Subscapularis

p. 1894
How many bursa are in the shoulder? How many are clinically significant?
1. 8
2. 1- subacromial bursa

p. 1894
What is the termused to describe conditions associated with repetitive overhead use; affecting subacromial bursitis, rotator cuff tendonitis, supraspinatous tendonitis, and painful arc syndrome.
Impingement Syndrome

p. 1895
18 y/o athlete comes to see you 2/2 to complaints of shoulder pain. States that he is a tennis player and weightlifter as well as qtr back. States that the pain is a "dull ache" over the anterolateral shoulder. Worse with sports and improved with rest. What is it?Is it reversible?
Stage 1 Impingement syndrome- reversible edema and hemorrhage about the rotator cuff
- yes, reversible.

p. 1895
A 34 y/o M patient you have seen a few weeks ago and told to take NSAIDs and d/c their current exercise regimen 2/2 to shoulder pain is back. You are not surprised to hear, he has not d/c'd the exercise program. No states that the pain is: recurrent, chronic, "aching pain"., worse with daily activities as well as vigorous activities, and night pains as well. What is it?
Stage 2 impingement syndrome- this is characterized by advancement of the edema and hemorrhage to tendonitis as well as fibrosis of the rotator cuff and bursa.

p. 1895
What stage of imingement syndrome is characterized by: rotator cuff tears, ruptures of the long head of the bicepsand subacromial spurs.
Stage 3

p. 1895
Patient with disuse atrophy of the right shoulder, 2/2 to "months" of shoulder pain. Ache- worse at night esp when laying on it. Or when they brush their hair or put their shoulders behind their head to recline. States that the pain radiates to mid humerous and feels like an ache and stiffness. What is it?
Impingement syndrome

p. 1895
Reminder on shoulder examinations: p. 1895

recall: Obriens, Hawkins, Neers. How to isolate the supraspinatous, infraspinatous and tere minor...etc.
Regardless of the stage of impingement syndrome, a conservative tx program should include what 7 things?
1. Relative rest and activity modification
2. Medication to reduce pain and inflammation
3. Cryotherapy- application of ice
4. Gentle range of motion
5. Stretching and strengthening
6. Corticosteroid injections
7. Follow-up

p. 1896
T/F: Partial thickness tears of the rotator cuff often require surgery, for mechanical restroation.
False: Partial thickness will often heal with conservative mgt
Full thickness requires surgery

p. 1897
T/F: Often rotator cuff injuries are insidious in sx manifestation. Gradual progressive pain, MC worse at night- then persistent. Pain is often diffuse or lateral shoulder. As the pain progresses, weakness does as well. Intensity and duration of sxs increase and are less responsive to usual treatments. Dysfunction increases until it impairs work, recreation, and NML daily activities.
True

p. 1897
What test is used to assess for complete rotator cuff tears and is sensitive and specific in experienced hands.
Rent Test

p. 1897
What should dx of an acute rotator cuff tear depend on?
clinical examination findings.

- no radiograph findings are dx of an acute rotator cuff tear

p. 1897
What are the most sensitive modalities for detecting rotator cuff tears (3)
-MRI
-U/S
-Arthography
What is the self-limiting condition characterized by calcium crystal deposition within one or more tendons of the rotator cuff.
Calcific tendonitis

p. 1897
47 y/o F is evaluated in the ER by you 2/2 shoulder pain, worse when resting such as relaxing or trying to sleep at night. "It feels lie when I move my arm like this [abduction] it sometimes catches". You obtain a radiograph and see calcific changes over the shoulder. What is it? What is the pathophysiology behind the pain?
-calcific tendonitis- this is believed 2/2 to microtraumas, age, tissue hypoxia.
- pain- occurs when the calcium is reabsorbed. It is during the resorptive phase that the patient endorses "incapacitating" pain- 2/2 vascular proliferation, formation of granulation tissue, and calcium crystal extravasation into the subacromial bursa. MC lasts for 1-2 weeks and is self limted. Patients may have some "postcalcific period" pains as well- this can last for "months".

p. 1898
MC pain at rest, worse with movement as well as at night. Often the patient holds limb across chest, reluctant to move it.
What is the most common complication of calcific tendonitis?
Adhesive Capsulitis

p. 1898
You see a shoulder film of someone with shoulder pain. Non-acute. The patient reports hx of a large rotator cuff tear. The radiograph shows a narrowing of acromiohumeral space <7 mm. Additionally, you see some calcium deposits that appear more hazy than the last film a few weeks ago...though the location is the same. The patient states that the surgery for the rotator cuff is pending, but this pain is different. Why?
-the space < 7 mm in the acromiohumeral space is c/w with a large rotator cuff tear he is aware of, HOWEVER, the calcium deposits "more hazy" than in the past means that the patient is going through the "painful" calcium reabsorptive phase of his existing calcific tendonitis as well.

p. 1898 (7mm section 1897)
Don't know if this could happen in terms of sxs, however, this is from the text otherwise.
How often is non-operative mgt for calcific tendonitis successful?
>90%

p. 1898
What shoulder anamoly is associated with post-menopause, DM, thyroid disease, pulmonary neoplasms, and autoimmune disorders.
Adhesive Capsulitis

p. 1898
There are four statges associated with adhesive capsulitis, which is the following:
Occurs around 2-3 months, marked by acute synovial inflammation and limitation of shoulder movement 2/2 pain.
Stage 1

p. 1898
There are four statges associated with adhesive capsulitis, which is the following:
occurs about months 3-9, decreased motion of the shoulder, from capsular thickening, scarring and chronic pain.
Stage 2.

p. 1898
There are four statges associated with adhesive capsulitis, which is the following:
ocurring months 9-15, less pain, but associated with fibrotic capsule and significant decrease in motion
Stage 3

p. 1898
There are four statges associated with adhesive capsulitis, which is the following:occurs at ~month 15, associated with minimal pain and progressive improvement in the ROM of the shoulder.
Stage 4

p. 1898
Pain in this shoulder problem is not produced with palpation. however, limited movement with active and passive movement. Pain feels like an "ache" and stiffness in the shoulder and arm.
Adhesive Capsulitis

p. 1898-1899
What is a SLAP lesion of the shoulder?
S-superior L-labrum A-anterior P-posterior.
- this is the site where the glenoid labrum may be torn near the long head of the biceps insertion.

p. 1899
What test is diagnostic for SLAP lesion?
Biceps load test II...with the patient reclining supine, elevate their arm to 120 degrees and externally rotate to its maximal point, with the elbow at 90 degrees of flexion and forearm supinated. Patient is asked to flex the elbow...if pain is pronounced by the patient, the test is positive.
If pain is pronounced by the examiner, then he's just a wuss

p. 1899
- what is the most accurate diagnostic radiographic test?
MRArthrography
What is the extrinsic differential for shoulder pain?
- cervical spine
- brachial plexus injury
- axillary artery thrombosis
- subscapular nerve injury
- thoracic outlet syndrome
- pancoast tumor miscellaneous thoracoabdominal disorders

p. 1900
What is the MC source of pain that is referred to the shoulder?
Neck

p. 1900
What is a source of shoulder atrophy, shoulder pain as well as weakness but is NOT the shoulder? (occuring often w/weeks of injury)
Brachial Plexus Injury

p. 1900
- what is similar, but is not injury, but believed viral in nature?
Brachial Plexus Neuritis.

Refer to neurologist- though rare and often self-limiting
What is the most serious vascular anomaly causing shoulder pain?
thrombosis of the axillary artery

p. 1900
- this can be a result of: repetitive stress from heavy lifting- which can compress the intimal lining of the axillary artery, predisposing the artery to thrombosis.
A tumor, mass that may compress the brachial plexus against the chest wall and causes shoulder pain. The patient often reports local or radicular pain and a sense of "fullness" in the supraclavicular fossa.
Pancoast Tumor

p. 1900
What are the major nerves w/in the thigh?
Sciatic and femoral nerves.

p. 1991
Referred pain from the hip, where does it often travel (5)?
- buttocks
- thigh
- groin
- knee
- foot

p. 1901
What must be considered in the elderly patient, with a appropriate (cardiac) risk factors and hip pain that is not otherwise explained by the hx and PE, preexisting problems w/in the joint?
Expanding abdominal aortic aneurysm.

p. 1901
Name two surgeries that may be a source of maralgia paresthetica?
Appendectomy and hysterectomy

p. 1902
Patient 30 y/o M c/o pain in the medial thigh and groin. + hx of pelvic practure few weeks ago. States that the pain is worse with movement.
obturator Nerve entrapment

p. 1902- can occur in atheletes
A patient with this nerve entrapment syndrome will often c/o pain in groin, scrotum or labrum with hyperextension of the hip.
Ilioinguinal nerve entrapment"

p. 1902
What is the following syndrome: pain in the buttock and hamstring, made worse by sitting, climbing stairs, or squatting. There may be a palpable, tender mass over the musculature of the low back on the ipsilateral aspect. Additionally, pain is also produced by hip flexion and internal rotation.
Piriformis Syndrome

p. 1902
What muscle in the low back is susctible to infection 2/2 it's rich blood supply and proximity to overlying retroperitoneal lymphatic channels.
Psoas Muscle

p. 1902
What are the organisms MC associated with psoas abscess?
Staph Aureus= MC, 80%
Additionally, P. Aeruginosa, Serratia Marcescens, H. Aphrophilus, Proteus Mirabilis, and enteric pathogens.

p. 1902
Patient presents with abdominal pain, which radiates to the the hip, flank. Is limping to ambulate and has a fever. Admittedly this has been over the last few days-week. C/o Nausea, weight loss and malaise. What do they have? How will you confirm? How will you treat?
1. Psoas Abscess
2. PE, flex ipsilateral leg against resistance..."psoas test" and obtain CT confirm
3. Abx and surgical consultation for debridement.

p. 1902
What is the largest bursa of the hip region?
Iliopsaos bursa

p. 1903
"Weaver's bottom" is the nickname of the inflammtory version of this bursitis, which is common in sedentary individuals. Bursa lies just over the ischial tuberosity and is subject to direct trauma irritation.
Ischiogluteal bursitis

p. 1903
This bursa lies just deep to the site of the three tendon insertion, medial aspect of the tibia- below the knee joint, but above the MCL and medial femoral condyle. Common in obese women with OA, runners and overuse syndromes. Can be confused with Medial meniscal or MCL ligament injury.
Pes Anserine

p. 1903-1904
What is the cause of carpet layer's knee, nun's knee or housemaids knee; caused by repetitive healing on hard surfaces. Presents as an effusion over the inferior pole of the knee, +TTP. Can be a common site of septic bursitis.
Prepatellar bursitis

p. 1904
What is pellegrini-steida disease?
ossification of the proximal portion of the MCL. Presenting as a palpable mass, TTP; which commonly reults from injury.

p. 1904
Why are steroids injected in to tendons, when attempting to treat bursitis of the knee, a bad idea.
THese injections can cause weakness and lead to rupture.

p. 1904
A patient with hx of bursitis and hx of immunocompromise, what should be done for tx.
- IV abx
- consult with ortho, consider admission:
a. serial drainage, if refractory
b. consider surgical intervention

p. 1904
What is the name of the condition of which a "snapping sound" is heard and "popping sensation" is felt as the Iliotibial band slips over the greater trochanter?
Coxa Saltans

p. 1904
- in atheletes this is MC associated with inflammation of the band and the bursa. THe patient can cause the snap with flexion and extension of the hip.
What is the measurement at the junction of a line drawn from anterior superior iliac spine to the central patella, and a second line drawn from central patella to the tibial tubercle.
Q angle

p. 1905
What is a NML q angle?
15 degrees

p. 1905
> 20 is abnormal, and increases the risk of patellar subluxation
What knee pain is MC insidious and non-radiating...anterior knee pain. Pain may be worsened by prolonged flexion of knee, such as air flights. Pain can occur with walking as well as climbing stairs. Crepitus may be present, suggesting inclusion of DJD.
Patella Femoral Syndrome

p. 1905
Plica is rare folds of redundant connective tissue, MC discovered how?
MRI or arthroscopy

p. 1906
What causes pain in the posterior lateral aspect of the knee, worsened when running down hill. +TTP over the proximal, posterior tibia, along lateral joint line.
Popliteus Tendonitis

p. 1906
Of the following treatments for patellar tendnitis, jumper's knee, which of the following treatments are contraindicated:
- rest
- NSAIDs
- cryotherapy
- steroid injection
- brace wear
- complete immobilization
- steroid injection and complete immobilization

p. 1906
T/F: Osteonecrosis, is a compromise in blood supply- a bone infarction. The cause can be trauma that is significant acutely or occult and due to repetitive injury.
True

p. 1907
You suspect that a DM patient has osteomyelitis. Using the ESR, what value will give you a sensitivity of >83-92%
>70 mm/h

p. 1908
What confirms the dx of osteomyelitis?
Bone bx

p. 1908
A DM patient comes to see you 2/2 to an ulceration that appears infected. The ulcer is > 2cm round, and using a sterile instrument, you probe the depth of the wound and discover it reaches to the bone. You obtain an ESR. Your student is with you and asks you why you ordered the ESR and what you think it is. Your response?
You suspect that this is osreomeylitis. ESR> 70 will provide some support 2/2 sensitivity. However, need to call ortho anyhow- this is their patient.

p. 1908
What is the MC organism for osteomyelitis?
Staph A. (As always)

p. 1908
What is the likely causative organism for Osteomyelitis in the following patient and how would you treat them:

Elderly, Hematogenous spread of organism
Staph A, including MRSA as well as gram Neg

p. 1909
Treatment on next slide
Vacomycin + Zosyn or imipenem
What is the likely causative organism for Osteomyelitis in the following patient and how would you treat them:

Sickle Cell Patient
Salmonella, gram negs

p. 1909
Treatment on next slide
Cipro, consider vanc- as Staph A is becoming more common
What is the likely causative organism for Osteomyelitis in the following patient and how would you treat them:

DM patient, or vascular insufficiency
Polymicrobial: S. Aureus, Strep Agglectiae, S. Pyogenes, + coliforms and anerobes

p. 1909
Treatment on next slide
Vanc + Zosyn or Imipenem
What is the likely causative organism for Osteomyelitis in the following patient and how would you treat them:

Injection drug user
Staph A (MRSA possible) as well as Pseudomonas

p. 1909
Treatment on next slide
Vanc
What is the likely causative organism for Osteomyelitis in the following patient and how would you treat them:

Developing Nations
Mycobacterium TB

p. 1909
Treatment on next slide
Look it up if needed
What is the likely causative organism for Osteomyelitis in the following patient and how would you treat them:

Newborn
Staph A (including MRSA) and Gram Negs, Group B strep

p. 1909
Treatment on next slide
Vanc + Ceftazidime
What is the likely causative organism for Osteomyelitis in the following patient and how would you treat them:

Children
Staph A (MRSA)

p. 1909
Treatment on next slide
Vanc + Ceftazidime
What is the likely causative organism for Osteomyelitis in the following patient and how would you treat them:

Postoperative with or without retained orthopedic hardware
Staph A, Coagulase + Staph

p. 1909
Treatment on next slide
Vanc
What is the likely causative organism for Osteomyelitis in the following patient and how would you treat them:

Human Bite
Strep or Anaerobic

p. 1909
Treatment on next slide
Zosyn or Imipenem
What is the likely causative organism for Osteomyelitis in the following patient and how would you treat them:

Animal Bite
Pasteurella Multicida and Eikenella

p. 1909
Treatment on next slide
Cefuroxime, Zosyn or Imipenem
A 50 y/o M reports "locking in his joint", with pain and swelling. no fever, or systemic evidence of infection. No erythema. No hx of gout. Patient does not appear toxic. X-ray of the joint shows evidence of calcification and intrarticular bodies in a joint with associated DJD. What is it?
Synovial Osteochondromatosis

p. 1909
What occurs in middle age males and pregnant females in the 3rd trimester, with hip pain and resolves w/in 6-12 months time?
Transient Osteoporosis of the hip

p. 1909- take precautions against hip fractures until then
patient with hip pain. Serum level of alk phos elevated. X-ray shows narrowed joint space and minmal hypertrophy on film. it is the result of overactive breakdown and bone reformation is chronic in nature?
Paget's Dz

p. 1909
What is the leading cause of ICU admission following an acute rheumatic disease flare?
Infection

p. 1911
A patient says she is sent by her rheumatolgist to your ER 2/2 to her sore throat and "tenderness when you touch here" (point to her cartilaginous structures of her throat). C/o pain worse when she swallows and speaks; also c/o globus hystericus as well as hoarsenss, dyspnea and cough. you observe a hoarse voice and upper airway stridor. What is the likely culprit for this patient? What do you do?
Cricoarytenoid Joint Arthritis (caused by her autoimmune syndrome)
Provide high dose steroids and abxs

p. 1911
See Chart p. 1912- Table 279-3...Read whole thing just before the test!!!
Tracheomalacia, explain it. What is the best airway mgt strategy for them?
Relapsing polychondritis can cause inflammation, destruction, and collapse of tracheobronchial cartilage- which can result in airway obstruction.
Non-invasive ventilation is preferred, if possible. However, 2/2 tracheal stenosis if invasive ventiliation is needed: use a small tube.

p. 1913
Subglottic stenosis, can cause an acute upper airway obstruction; patients may have an inability to clear tracheobronchial secretions. It often requires surgical intervention and may be the first presenting sign of what disease?
Wegener's Granulomatosis

p. 1913
What are some upper airway considerations in rheumatic disease regarding "airway safety"? ()
1. ET intubation is regarded as difficult, anticipate the need for adjunctive airways. Consider early the fiberoptic scope as well as the cricothyroidotomy (if airway is secure but risk is expected, take to the operating room- its safer)
2. RA and Ank.Sponylitis patients have risk for TMJ, making mouth opening difficult
3. patients with RA and ank. spndyloarthritis have a 1/4 risk of atlantoaxial instability-caution with neck hyperextension.
4. those with scleroderma are risky because often have difficulty opening their mouth, however, 2/2 to their skin changes, surigcal airway is also difficult.

p. 1913
Respiratory arrest has been reported in SLE patients, why?
1. angioedema is a risk in this patients.
2. also, lower respiratory systemic 2/2 to phrenic nerve involvement

p. 1913
Respiratory arrest has been reported in RA patients; why?
due to the cervicomedullary compression associated with rheumatic atlantoaxial dislocation.

p. 1913
Respiratory arrest has been reported in Sjogren's Syndrome, why?
Hypokalemia 2/2 to the distal renal tubular acidosis

p. 1913
What are the disease states that according to the text are associated with AH (alveolar hemorrhage)? There are seven.
1. SLE
2. Antiphospholipid Syndrome
3. Systemic Vasculitis
4. Wegener's Granulomatosis
5. Dermatomyositis/polymyositis
6. Microscopic Polyangitis
7. Systemic Sclerosis

p. 1914
Prognosis for this is poor when:
- delayed recognition
- > 60 y/o
- ESRD
- cardiovascular comorbidity
Patient 60 y/o M presents with abrupt onset of SOB, fever, and cough. States that it happened today. No recent surgeries. no hx of DVT, PE. Seen for HTN, DM, and W.Granulomatosis. Takes lisinopril, Metformin, Janunuvia, as well as prednisone. A colleague suggests a CT Angio r/o PE. However, you suspect another cause...just prior the patient getting apneic and going into respiratory arrest. What did you suspect? What is the patients prognosis?
- Alveolar Hemorrhage
- not a good prognosis.

p. 1914
What is the classic triad of alveoplar hemmorrhage?
1. hemoptysis
2. pulmonary infiltrates on pCXR
3. rapid fall in hgb

p. 1914
T/F: Systemic Rheumatic Disease is a "new" risk factor for coronary atherosclerosis.
True

p. 1915- read next slide!
- IN fact they are more likely to have unrecognized MI and sudden death, having a higher risk than unaffected individuals, yet they are less lieky to undergo invasive evaluation and treatment.
What is the risk for a MI in premenopausal patients with SLE?
50 times greater than those who do not have SLE

p. 1915
Rhythm disturbances are common as well; esp: Complete AV block as well as Ventricular arrythmias.
What heart anomaly is a common extrarticular manifestation of disease in ankylosing spondyloarthropathies?
Valvular Heart Disease

p. 1916
Aortitis is common with vasculitis, and may lead to aortic aneurysms- which can later rupture or dissect. What are the three provided by the text most likely to do this?
1. giant cell arteritis
2. Takayasu Arteritis
3. Behcets Disease

p. 1916
Any part of the aorta can be involved by the inflammation of behcet's, however, which area of the aorta is more likely to be problematic?
Abdominal Aorta

p. 1916
Takayusu aortitis cause vessel occlusive (arterial anrrowing) and/or what additional sxs?
Neurologic sxs or syncope- related to subclavian steal syndrome

p. 1916

- additionally, this can also cause: ACS, Mesenteric Ischemia, peripheral artery ischemia...(Takayusu)
Superficial and deep vein thrombosis can be caused by?
Behcet's Disease

p. 1916
- it is caused by vessel inflammation and not peripheral embolism
Vessel thrombosis (artery or vein); peripheral gangrene, ACS, renal artery thrombosis, sagittal sinus thrombosis, TIA, and budd chiari syndrome due to hepatic vein thrombosis are caused by what two vascuilitic conditions?
SLE and Antiphospholipid

p. 1916
What is the primary organ involved in catastrophic antiphospholipid syndrome?
Kidney

p. 1916
- then lungs
- CNS
- heart
and skin (livedo reticularis)
What is the tx for antiphospholipid syndrome?
IV heparin
High dose glucocorticoids
IV immunoglobulins
Plasma Exchange

p. 1916 (However, mortality remains high)
T/F: Those who have RA will have typically developed an neck discomfort from the posterior to the anterior aspect of their neck to throat, harolding atlantoaxial instability; so definately caution if this hx is known.
False- made this whole thing up. In fact it is MC clinically silent, so use caution in every patient with RA when extending the neck.

p. 1916
What is scleroderma renal crisis?
Develops early in the course of systemic sclerosis, MC w/in the first four years. Abrupt and rapid deterioration in renal fxn herolded by HA, visual disturabances, and hypertensive encephalopathy- renal disease is the MC cause of death in systemic sclerosis

p. 1917
- the important thing for treatment: effective, prompt blood pressure control. ACEI are the drug of choice for this.
What occurs in the kidney's of 30% of patients with Sjogren's Syndrome?
Distal Renal Tubular Acidosis

p. 1917
Characterized by: hyperchloremic metabolic acidosis, low bicarb and hypokalemia.
What is the MC GI manifestation reported in rheumatic illnesses?
Hemorrhage

p. 1917
What are the GI manifestations for those who suffer from systemic Rheumatic Diseases?
- ischemia
- infarction
- perforation
- vascular rupture
- infx
- hemorrhage

p. 1917
What is common in several systemic rheumatic diseases...(epigastric pain)
acute pancreatitis

p. 1917
What are the three ways that systemic rheumatic disease make patients susceptible to infx?
1. disease itself results in immunicompromise
2. treatment for the disease results in immunicompromise
3. disease can cause anatomic changes in the body that predispose a patient to infx.

p. 1917
High procacitonin are sensitive, though not specific for what two sources of infx? Why are they particularly not specific in the vasculitis patient?
- bacterial and fungal infx's
- procalcitonin can be mildly elevated in the presence of immunologic disorders

p. 1918
Why is septic arthritis an ortho emergency in systemic rheum conditions?
it can be joint and life threatening.

-remember that these patients are immunosuppressed too...so they are at risk for opportunistic infx: Candida, Pneumocystis Jiroveci, Legionella, Mycobacterium TB.

p. 1918
A patient is wheeled to you , profoundly obtunded and bradycardic, c/o coldness and not feeling well. HoTn and d-stick is 38mg/dL. She has no hx of CNS disease or DM. She has a hx of RA for which she had been on a prednisone taper, as well as Azo for her bladder infx and pseudophed for congestion. What do you think you could do now to help this patient?
-High dose steroid. (100 mg hydrocortisone perhaps)

-p. 1918
Young boy is brought in by his mother, states that he had been seen following URI sxs, then admitted for some rash on his legs, abdominal pain and then something with his labs. "Now he's complaining about this...is he OK?". The boy seems shy about talking about it, but appears uncomportable in his groin and genitals. What do you do, what is it, and what caused it?
- order u/s- r/o torsion
- orchitis
- Henoch Schonlein Purpura- vasculitis
IV drug users present with deep space infections and abscesses frequently. These infections can be caused by direct innoculum from the needle and from the skin, but also hematogenous spread from bacterial endocarditis. What are the organisms (2) indicated in the text as likely sources?
1. Staph Aureus
2. Gram Neg organisms

p. 1920
MC the saliva of human bites is polymicrobial. What are the organisms (if u dare try) and what is it treated with?
S. Anginosis, Fusobacterium nucleatum, S. Aureus, Eikenella Corredens, and Prevotella Melaninogenica

tx: Augmentin or Moxifloxicin

p. 1920
Cat and Dog bites, to the hand, typically cause a nasty infx, rapidly progressive cellulitis that quickly becomes suppurative. DANG, what organism causes this?
Pasteurella Multocida

p. 1920,
PCN susceptible. (Give augmentin)
FYI: DM patients are immunocompromised, therefore may be suscptible to: Candida and/or Mycobacterium
Additionally, immunocompromised patients from asplenia, may be at risk for progressive and fatal infections
What is done to tx an individual who has systemic sxs and a hand infx?
parenteral abx and admission

p. 1920
T/F: With the exception of cellulitis, all other hand infections are surgical issues that must be managed using accepted surgical principles.
True

p. 1920
T/F: IF in a hand infx there is a collection of pus, drain it. However, paronychia and felon are the only infxs of this type that can be drained in the ER. All others need OR.
True

p. 1920
- after drained. Elevate the hand, this reduces inflammation and prevents the extension of the infection
Broad spectrum abx's are of course a must
There are four abx's that MRSA is currently susceptible to, in the book. What are they
1. bactrim
2. linezolid
3. doxycycline
4. vancomycin

p. 1920 (however, local sensitivity is always changing)
You are examing a patient that was turned over to you at change of shift. You were told that the patient was to be discharged, following an x-ray. You note that the patient has gross cellulitis however, is also unable to move the digit and cannot tolerate palpation of the deep structures of the hand. What do you do?
Start parenteral abx therapy and call the ortho hand surgeon

p. 1921
FYI: the MC organisms are MRSA and strep pyogenes.
You are seeing a kid who works at the fish department at the local grocery store. He has a dreadful case of cellulitis on his hands. What are the possible organisms? What should be done to tx?
- organisms: Vibrio Vulnificus, Klebsiella Pneumoniae, Strep Group A, S. Aureus, and Enterobacter species.

- tx with Doxy and Ceftazidime, via admission to the hospital.

p. 1921
Don't forget to remove rings from the fingers of these jokers
What is an immunization you do not want to forget in hand infx's...well in all infx's really?
Td.

p. 1921
Failure to recognize this form of tenosynovitis will lead to a loss of fxn of the effected digit and possibly the entire hand.
Flexor Tenosynovitis

p. 1921
What are the four cardinal Kanavel Signs of Flexor Tenosynovitis?
1. percussion tenderness- TTP over the entire length of the flexor tendon sheath
2. uniform swelling- symmetric finger swelling along the length of the tendon sheath
3. Intense pain- intense with passive extension
4. Flexion posture- flexed posture of the involved digit at rest, to minimize the pain

p. 1921
MC associated with penetrating trauma, tho the patient may be unaware that the injury ever occurred.
You are seeing a patient with what you suspect is flexor tenosynovitis. There is sponatnoeus d/c from the site of innoculation. He was treated a few weeks ago for an STI, after selling himself to support his IV drug habit. What do you do with the drainage, and what organisms are you concerned about and tx provided.
1. gram stain AND cx the d/c
2. Neisseria Gonnorrhea and MRSA are the organisms
3. Rocephin and Vanc (May also throw on Zosyn for this guy but that's me)

- and no Euthanasia is not a treatment or an option. However, calling the Hand surgeon is...I recommend this (the surgeon).

p. 1921
When performing an examination of the volar surface of the hand for an infx, what four things is the palpation examination looking for?
1. elicit tenderness
2. examine for induration
3. examine for fluctuance
4. examine for sensory evaluation

p. 1922
Why does flexion of the flexor tendon of the digits produce significant pain in the hand in the presence of hand infxs?
Because the compartments are continguous with the flexor tendons of the hand.

p. 1922
An idiot comes to see you in the ER, breaking the first rule of fight club. He got his but kicked...however, he got one good punch in, with his right fist..but is bleeding from this (amongst other injuries). Assuming the other injuries are OK...what should be done with this well open laceration, though sensation and movement is spared?
1. x-ray to r/o fracture as well as retained FB
2. irrigation and cleaning of the wound
3. prophylactic abx
4. call the hand surgeon to discuss and at minimim arrange f/u.

p. 1923
What is a subcutaneous pyogenic infx of the pulp space of the distal finger or thumb?
Felon

p. 1923
Often the finger pad is "swollen and tense"; with a palpable fluctuance. Digital block is performed, incised. Gram stain and cx are performed. Abx provided.
When making an incision for a felon, on the fat pad, why should you avoid the distal "finger tip"?
Incision into the distal aspect, the finger tip would likely cause instability and loss of sensation.

p. 1923
What incisions used for felon are never used any more?
1. fishmout
2. hockey stick
3. through and through

p. 1923
what is used now is the: unilateral longitudinal and longitudinal volar approach
Most felons have significant cellulitis- that should be tx'd with abx
A colleague is examining a patient and gets the instruments to perform an incision for a felon. You decide to examine it too, having never seen this before. You observe erythema with overlying vesicles, and a site that is indurated by not tense. What is this? Should he cut it?
It is a herpetic whitlow
No, he should not cut it, this will cause a seconday infection and prolong the failure of this to heal.

p. 1923
Your colleague comes back with the supplies. You discuss it, but he disagrees. Is there anything you can do to prove your case?
unroof the vesicle and send it off for Tzank smear...


you'll be glad you did, you are right!
Tensosynovitis in the flexor sheath, over years scars or inflames and forms nodules, that often catch when the finger is forced into extension from flexion proximal to the A-1 pully. Surgical division of the pulley is curative. What is this disorder?
Trigger Finger

p. 1924
What would you discover on an examination for carpal tunnel that would make you immediately contact the hand surgeon, emergently?
Presence of median nerve motor dysfunction

p. 1925
What is caused by fibroplastic changes of the subcutaneous tissues of the palmar surface of the hand and fingers. 4-5 decade of life, and has a genetic component.
Dupuytren's Contracture

p. 1925
What is the most concerning diagnosis of acute joint pain and consideration of septic arthritis?
Whether it is due to bacterial sources.

p. 1926
What are common joint d/o's with a migratory pattern? (5)
- gonoccocal arthritis
- acute rheumatic fever
- lyme disease
- viral arthritis
- systemic lupus erythematous

p. 1926
What are some risk factors for non-gonoccocal septic arthritis?
- Injection Drug Use
- DM
- RA
- Prosthetic joint: knee/hip
- Immunosuppression, HIV
- >80 y/o
- skin ulcer and/or infx
- hemophilia
- hypogammaglobinemia
- malignancy
- hemodialysis
- liver dz
- EtOHism
- steroid therapy

p. 1926
What are some risk factors for gonoccocal septic arthritis?
- menses
- pregnancy
- complement deficiency
- HIV infx
- SLE
- IV drug use

p. 1926
When considering septic/non-septic arthritis, what is the most useful diagnostic tool at your disposal?
Synovial Fluid Anaylsis

p. 1927
- observe Table 281-4
all fluid should be evaluated with:
cx
gram stain
leukocyte count
wet prep for crystals
you suspect septic arthritis in your patient, why do you want: lyme titer, RF, ANA, and repeat synovial fluid aspirate (even blood cx and ESR)- since this does not aid you acutely?
For follow-up

p. 1927
When preparing to perform an arthrocentesis of the joint site, you cleans the area with povidone-iodine, but a friend reminds you to wipe with alcohol. Why?
To prevent the iodine from being tracked into the space- which can cause a chemical irritation and sterilize the aspiration sample.

p. 1928
Why is septic arthritis the most important diagnostic consideration in acute joint pain?
Because bacterial infection and the subsequent inflammatory response can destry and joint in a matter of days

p. 1929
What are the common findings associated with bacterial, non-gonoccal septic arthritis?
1. Joint pain
2. joint swelling
3. fever

- present in > 50% of patient

p. 1930
However, there is no "clinical pattern" that all have to possess for this
21 y/o M presents to you with a "red, hot" ankle. He used a friends crutches as he was unable to bear weight. He seems anxious and though wearing a sock and tolerating touch to sensation, seems to have an aversion to the remainder of your clinical exam ie. he cries when you suggest you are going to move it. What has to be at the very top of your differential?
Septic joint


p. 1930
You attempt an arthrocentisis of a joint, and the lab loses the specimen. The examine, though suggesting it, is not the most impressive septic joint you've ever seen. What do you do?
Admit the patient.
if septic arthritis cannot be excluded after eval and aspirate, admit.

p. 1930
If aspirate is +, you must call ortho to discuss
What is the MC cause of septic arthritis in adolscents and young adults?
Gonoccocal Arthritis

p. 1930
Typically there is a prodromal phase in which there are migratory joint sxs and tenosynovitis, pain and swelling settle into one or more joints.
Where else do you need to obtain cultures, when you suspect that the patient has gonococcal arthritis; since the cx from joint aspirate are usually of little yield?
Let the patients sexual hx guide you and get cx's from:
- pharynx
- urethra
- cervix
- rectum
get these prior to administerinf abx's as these may be the only sources of value

p. 1930
Which causes more joint destruction: gonococcal or non-gonococcal septic arthritis?
Non-gonococcal

-therefore surgical correction for gonococcal is rarely needed.

p. 1930
What is the MC cause of inflammatory joint disease in men > 40 y/o?
Gout

p. 1931
The two MC crystalline agents:
- gout (Uric Acid)
- pseudogout (calcium pyrophosphate)
Crystals are seen in polarizing microscope, drawn from joint aspirate
When are serum uric acid levels useless in dx Gout?
30% of patients will have a NML level at the time of a flare.

p. 1931
No evidence of gout, uric acid or phosphate during pseudogout.
You are looking through a microscope at joint aspirate and see:
Blue colored, needle shaped crystals. What is it?
Uric Acid

p. 1931
You are looking through a microscope at joint aspirate and see:
Yellow colored, romboid shaped objects. What is it?
Calcium Pyrophasphate (Pseudogout)

p. 1931
What is the treatment of gout and pseudogout? For how long? Who does not get this medicine?
1. NSAIDs (Indomethacin)
2. 1 week
3. Renal disease patients (Renal Insufficiency)

p. 1931
What is an alternative for tx in patients with gout and pseudogout with a hx of NML renal function?
Colchicine

p. 1931
What are the three MC causes of viral arthritis?
1. Parvovirus B19
2. Rubella
3. Hepatitis B

p. 1931
What is the MC involved joint from Hep B?
Knee

p. 1931
Hep C is polyarticular

HepB: signs and sxs: fever, lymphadenopathy, then joint pains, and jaundice
Treatment for Lyme dz is given for 3-4 weeks. What are the 4 recommended abx?
-doxycycline
- Pen G
- Amoxicillin
- Rocephin

p. 1932
T/F: Traumatic hemiarthrosis has a high association ligamentous injury as well as intrarticular fx. Aspiration will often provide relief and increase range of motion. Immobilize and ice. Spontaneous hemiarthrosis often occurs 2/2 known bleeding disorders (Hemophilia) and should never be done.
False.
By and large the state is true, except for the absolute contrindication to aspiration for relief. While contraversial, in very large effusions this is acceptable, as long as the factor is replaced.

p. 1932
What causes an acute, asymmetric oligoarthritis w/in 2-6 weeks after an infectious illness.
Reiter's Syndrome, AKA, Reactive Arthritis

p. 1932
The classic triad of conjunctivitis, urethritis, and arthritis needn't be present for this to occur.
While chlamydia or Ureaplasma
Also can be postdysentery: salmonella, shigella, yersnia, campylobacter, e-coli, and clostridia.
T/F: Antibiotics are the cornerstone of reactive arthritis.
False, NSAID's are. Abx's are not regarded as useful.

p. 1932
You note on the PE of a patient complaining of "weird thing" in my elbow, a swollen callosed process protruding from the olecronon process. Non-TTP and no limitation of movement. Is it infected? What is it?
No, this is non-infected bursitis. That fact that it has no impact on movement non-TTP supports no infx in nature. Treat by elimination of the cause and NSAIDs

p. 1932
Where are the two MC sites of septic bursitis?
- prepatellar bursa and olecronon bursa

p. 1932
Septic bursitis, what are the sxs associated with this?
- fever, pain: mild to severe, with an overlying cellulitis...

- aspiration, if able, can be both diagnostic and therapeutic.

p. 1933
T/F: all calluses should be treated.
False, calluses are protective and should not be treated if no pain.

p. 1933
What are calluses that grow out, but then are pushed inward by continued pressure?
Corns

p. 1934
These can be soft and/or hard
Hard corns are over dry surfaces
Soft corns are over moist surfaces- such as between the toes.
pain or painless
You are examining a persons foot, and are unable to decipher corn vs war 2/2 to the loss of dermatoglyphics. You then decide to par it down. Does not bleed. What is it?
Corn

p. 1934
What is characterized by inflammation, swelling or infection of the medial or lateral aspect of the toenail?
Onychocryptosis (Ingrown Toenail)

p. 1934
What can occur in patients who have an ingrown nail with underlying diabetes or arterial insufficiency, cellulitis, ulceration, and necrosis?
Gangrene

p. 1934
What are the four types of retrocalcaneal bursitis?
1. non-inflammatory
2. inflammatory
3. Suppurative
4. Calcified

p. 1935
What is the MC cause of heel pain?
Plantar fasciitis

p. 1935
What is the purpose of the plantar aponeurosis?
Anchoring the skin to the bone
MC: self-limited, with 80% healing with in 12 months (spontaneously)
What is a compression neuropathy of the posterior tibial nerve that causes foot and heel pain?
Tarsal Tunnel Syndrome

p. 1935 (posterior tibial nerve courses inferior to the medial malleolus)
What is a + tinel sign for tarsal tunnel syndrome?
Tapping into the site of the inferior aspect of the medial malleolus induces pain into the medial and lateral aspects of the plantar surface of the foot.

p. 1935
Pain can be caused by dorsiflexion as well as eversion of the foot. May obtain MRI and NCT (EMG)
What are some common causes of peroneal nerve entrapment? (7)
1. recurrent ankle sprains
2. soft tissue masses
3. trauma
4. chronic biomechanical malalignment
5. edema
6. ski boots
7. tight fitting footwear

p. 1935
What are the sxs associated with peroneal nerve entrapment?
dorsal and medial foot pain (as the peroneal nerve courses under the inferior extensor retinaculum, medial aspect of foot, figure 282-3), as well as sensory hypoesthesia at the first web space

p. 1935- pain is worsened with activity and relieved with rest. Night time pain is common
Ganglion- what is that...
MC a benign cystic mass...MC synovial "outpouch". Can appear gradually or suddenly. MC firm and non-tender. This is a clinical dx, though in some cases may take u/s or MRI.

p. 1936
When an individual sustains a laceration to their tendon in their foot, what position should the foot be placed in for healing if it is the following:
If extensor tendon laceration?
Dorsiflexion

p. 1936
When an individual sustains a laceration to their tendon in their foot, what position should the foot be placed in for healing if it is the following:
If flexor tendon laceration?
Plantar flexion (Equinus)

p. 1936
What are two drugs implicated as risky for the development of spontaneous rupture of the achilles, tibialis anterior, and posterior tibialis tendon rupture?
1. corticosteroids (chronic)
2. fluoroquinolones (tho' check the literature on this, I heard that this was being debunked)

p. 1936
You are evaluating a 45 y/o M CMSgt, who was running on the soccer field when he felt a surge of pain in his heel and collapsed. States it was a forceful punch. Difficulty with ambulation. You feel a palpable defect and perform a Thompson Test, and elicit no movement. How do you treat?
Splint into Equinus
Provide pain mgt
Call ortho to arrange further mgt

p. 1936
T/F: Anterior tibialis tendon ruptures have varying degrees of foot drop in 40 y/o patients, w/a palpable defect distal to the ankle joint in the tendon. This is common and fixed with surgery
False...while the first half is true, it is an uncommon and does not usually require surgery

p. 1936
Patient reports to you following an ankle injury, direct blow, during "recreation" (she does not wish to go into details)...states that the pain is over the left, lateral malleolus, and frequent, annoying, uncomfortable "clicking" when she walks. What is it Doctor? How is it treated? X-ray reveals no acute osseous abnormality
1. disruption of the peroneal retinaculum
2. surgery

p. 1937
Patient reports to you following an ankle injury, direct blow, during "recreation" (she does not wish to go into details)...states that the pain is over the left, lateral malleolus, and frequent, annoying, uncomfortable "clicking" when she walks. What is it Doctor? How is it treated? X-ray reveals no acute osseous abnormality
1. disruption of the peroneal retinaculum
2. surgery

p. 1937
What is common in the third interspace of the foot, MC in women, ages 25-50 y/o, with pain located in the metatarsal head, with pain described as "burning, cramping, or aching". The pain is worse with ambulation, resolved with rest as well as removal of the shoes. Dx is often made clinically, though one can use NCTests. Tx is wide toed shoes, good metatarsal head supports and off loading inserts. Local glucocorticoid injections can sometimes be curative. If conservative mgt fails...surgery.
Morton's Neuroma.

p. 1937
how many compartments are there in the foot?
9

p. 1937
Which is more likely to cause a compartment syndrome in the foot, crush injuries or penetrating injuries?
Crushh injuries

p. 1937
have been reported to have occurred in the following:
- foot/ankle fractures
- burns
- contusions
- bleeding disorders
- postischemic swelling after arterial injury/thrombosis
- venous obstruction
- exercise
- prolonged pressure to affected area.
You perform intracompartment pressure assessment on foot with suspected compartment syndrome. Using a Stryker STIC device, you determine that the difference in the compartment pressure and the reported diastolic pressure is < 30. What do you do?
Immediate fasciotomy.

p. 1937
You are evaluating an african american male, who reports that he had been told to examine his feet. He noted a lesion on his feet that his Dr told him was fungal 2/2 his DM. However, numerous different tx options have failed to resolve it over the past couple of months. DM is controlled with A1C 6%. No additional acute complications. No pain. Atypical, pigmented well circumscribed lesion on the platar surface of the foot. Some superifical desquamation. No excoriations, no calor, rubor or dolor. No satellite eruptions. With the exception of Hyperkeratotic toe nails, some scat onychomycosis otherwise NML. Sensation is maintained throughout. What should you be thinking?
Malignant Melanoma

p. 1937
What is a serious allergic condition that is rapid in onset and may result in death?
Anaphylaxis

p. 177
There exists clinical criteria that suggests a likelihood of anaphylaxis; what are the three?
1. Acute onset of illness- with involvement of the skin and/or mucosal tissue (hives/urticaria, pruritis, flushing and swollen lips, tongue) associated with the following: respiratory compromise, reduced BP, or organ dysfunction (hyptonia, syncope, incontinence)
2. Two or more of the following, that occurs rapidly s/p exposure: involvement of skin and/or mucosal tissue, respiratory compromise, reduced BP, and persistent GI sxs- cramps, vomiting
3. Anaphylaxis- when a patient is exposed to known allergen and develops hypotension

p. 178, Table 27-1
What is the difference in the two terms?
Anaphylactic and Anaphylactoid...and what is the final pathway?
Anaphylaxis is the term associated with IgE mediated events where as Anaphylactoid is the term associated with non-IgE mediated events (does not require a sensitizing exposure).
The final pathway is Anaphylaxis- which a a canopy term for both

p. 177
What is a hypersensitivity reaction?
Hypersensitivity is the term used to describe an inappropriate immune response to a generally harmless antigen
Anaphylaxis is the most dramatic and severe of hypersensivity reactions.

p. 177
Anaphylaxis is a continuum...can begin as a minor hypersensitivity reaction...and can quickly become anaphylaxis
What are some common causes of anaphylaxis rxns?
1. foods
2. medications
3. insect stings
4. allergen immunotherapy injections

p. 177
T/F: while there are common sources, any agent that is able capable of producing a sudden degranulation of mast cells or basophils can produce anaphylaxis.
True

p. 178
What are the Top 2, MC causes of anaphylactic reactions?
1. Beta-Lactam abx's (400-800 deaths per yr)

2. Hymenoptera stings (100 deaths per yr)

p. 178
What are some common associated sxs of anaphylaxis?
- abdominal pain or cramping
- nausea
- vomiting
- diarrhea
- bronchospasm
- rhinorrhea
- conjunctivitis
- dysrhythmias
and/or
- HoTn

p. 178
A 34 y/o F is brought into the ED by her spouse, in extremis. Appears to be frightened, tachypneic with increased work of breathing and "agonal respirations". As you grab the airway cart and ready to "manage the case". You hear him telling the staff that "she began feeling itchy, she got flush and broke out in hives...then started complaining of feeling a lump in her throat...she said her chest was tight and she started coughing and dry heaving and just got worse". What is this? What is the most important drug for this patient?
- Anaphylaxis
- Epinephrine

p. 178-

Suggestion:Oh, and do still intubate...have alternatives available, esp crich...but prevent this, by dropping her now. Ketamine and Succ...
T/F: The faster the onset of sxs, in anaphylaxis, the worse the sxs.
True

p. 178
You see a patient who appears to have had a mild anaphylactic reaction. The patient appears to have improved and has been observed for 3 hrs. The charge nurse says, "can we let this heiffer go, I need the bed?". (while not addressing the derogatory reference to the patient, what is your response)
No, there is a biphasic risk associated with this (Anaphylaxis), that remains unclear. After the initial sxs abate, there is a risk of recurrence...via mediators in the body occurring 4-8 hrs following the initial event (beginning to start 3-4 hrs after). The patient should be admitted...call medicine.

p. 178
What are the clinical manifestations of anaphylaxis, regarding body systems, of the following:

respiratory system
rhinitis, pharyngeal edema, laryngeal edema, bronchospasms, and dyspnea

p. 179
What are the clinical manifestations of anaphylaxis, regarding body systems, of the following:

cardiovascular system
dysrhythmias, collapse, cardiac arrest

p. 179
What are the clinical manifestations of anaphylaxis, regarding body systems, of the following:

skin
Pruritis, urticaria, angioedema, flushing

p. 179
What are the clinical manifestations of anaphylaxis, regarding body systems, of the following:

GI system
Nausea, emesis, cramps, diarrhea

p. 179
What are the clinical manifestations of anaphylaxis, regarding body systems, of the following:

Eyes
pruritis, tearing, redness

p. 179
What are the clinical manifestations of anaphylaxis, regarding body systems, of the following:

GU System
urgency, cramps

p. 179
What is the single most important step in the treatment of even a suspect anaphylactic reaction?
Administration of Epinephrine

p. 179- next slide
ABC's: (Epinephrine, IV fluids, and Oxygen)
- Vital signs
- IV Access
- Oxygen administration
- Cardiac Monitoring
- pulse oximetry
THis is an ER, all this crap should be happening at once.
You are examining a patient with difficulty breathing/shortness of breath, and the patient has obvious swollen lips (appears c/w angioedema); they open their mouth and have slightly swollen tongue and uvula, with faint, but audible stridor. What would you do next?
Intubate...
- failure to intubate early may lead to complete airway obstruction

p. 179
A patient is believed to be in anaphylaxis 2/2 to eating some food with peanuts...you have provided the Epi as wll as oxygen, etc. A friend recommends GI lavage to get the junk out. Whatcha think?
Not recommended for food allergens...

p. 179
What receptors does epinephrine work on?
Alpha and Beta receptors

-p.179- next question, How is alpha and beta receptor activation for epi helpful?
Epinephrine works on:

Alpha rectors causing: reduces mucosal edema and membrane leakage, treats HoTn

Beta-receptors causing: bronchodilation and controls mediator release
What is the first drug and primary drug used in anaphylaxis, that is regarded as the most underused?
Epinephrine

p. 179
When is IM version of epinephrine acceptable for anaphylaxis?
In patients without any sign of cardiavascular collapse or compromise

p. 179
What is the dose of IM epi for anaphylaxis and how frequently can it be given?
0.3-0.5 mg (0.3-0.5mL of the 1:1,000 dilution)- repeat q 5-10 min based on response or relapse

p. 179: read next slide
Many ED's have adopted the use of the EpiPen 0.3 mg for adults and EpiPen Jr 0.15 mg for children- for convenience, patient safety, and accurate dosing.
Why is caution advised when using epinephrine in someone taking betablockers? (do not rush to answer, think about this).
- because the betablockade will allow for unopposed beta adrenergic stimulation, leading to severe Hypertension.

p. 179
How should a patient be provided epinephrine, when they are in cardiovascular compromise or collapse?
Institute IV infusion...

Initially, epinephrine, 100 mcg (0.1 mg) IV should be given as 1:100,000 dilution. This can be done by placing epinephrine 0.1 mg of the 1:1,000 in a syringe with 10cc Normal Saline, and providing as an IV bolus over 5-10 minutes (1-2 cc/min), of course titrating to effect. If the patient is refractory to the initial bolus, than an epinephrine infusion should be started by placing epi 1 mg (1mL of the 1:1,000 dilution), in 500 mL of 5% dextrose in water or NS and administer at a rate of 1 to 4 mcg/min (0.5 to 2 mL/min), titrate to effect.

p. 179
A patient has become HoTn 2/2 to their anaphylaxis...and of course is tachy. You suspect shock...OK smart guy, what type?
Distributive Shock

- Good Job!!
-p. 179
What are the second line treatments for anaphylaxis? (4)
1. Corticosteroids
2. Antihistmines
3. Asthma Medications
4. Glucagon

p. 179
T/F: All patients with anaphylaxis should get corticosteroids.
True

p. 179
-Methylprednisolone 80-125 mg IV (preferred in elderly)
-Hydrocortisone 250-500 mg IV
We know that every patient in anaphylaxis gets an H1 and H2 blocker. Who does not get cimetidine?
- elderly 2/2 SE profile
- multiple comorbidity patients: interferes with metabolism of too many medications
- renal or hepatic impairment patients
- those patients of who anaphylaxis is complicated by their betablocker- as cimetidine will delay absorption of betablcoker and force it to linger

p. 180
Magnesium in bronchospasm patients, we know this relaxes smooth muscle, but really early on in severe asthma attack?
Yes, it improves pulmonary function and reduces admissions

p. 180. How is it dosed?
3 gm IV over 30 minutes in adults

25-50 mg/kg in children
What should be given to patients, believed to be in anaphylaxis, with HoTn that is refractory to fluids as well as epinephrine? How is it dosed?
Glucagon
1 mg IV q 5 min, until HoTn resolves, followed by an infusion 5-15 mcg/min

p. 180
SE: N/V, dizziness, HYPOkalemia, and hyperglycemia
T/F: Someone who had received Epinephrine as a treatment in the ED for anaphylaxis, may be safely discharged from the ED, after a reasonable period of observation.
True.

p. 180
- not something I would do, I would call, the hospitalist or something and let them decide.
You are d/c'ing a patient who had a hypersensitivity/allergic reaction and is taking a beta-blocker for HTN tx. You are uncertain as to the source of his anaphylactic contact, but at this time does not appear to be his BP med. What should you do?
D/c the Beta-blocker and place patient on something else...any patient with hx of anaphylactic rxn should nbot be on a betablocker.

p. 181
Magnesium in bronchospasm patients, we know this relaxes smooth muscle, but really early on in severe asthma attack?
Yes, it improves pulmonary function and reduces admissions

p. 180. How is it dosed?
3 gm IV over 30 minutes in adults

25-50 mg/kg in children
What should be given to patients, believed to be in anaphylaxis, with HoTn that is refractory to fluids as well as epinephrine? How is it dosed?
Glucagon
1 mg IV q 5 min, until HoTn resolves, followed by an infusion 5-15 mcg/min

p. 180
SE: N/V, dizziness, HYPOkalemia, and hyperglycemia
T/F: Someone who had received Epinephrine as a treatment in the ED for anaphylaxis, may be safely discharged from the ED, after a reasonable period of observation.
True.

p. 180
- not something I would do, I would call, the hospitalist or something and let them decide.
You are d/c'ing a patient who had a hypersensitivity/allergic reaction and is taking a beta-blocker for HTN tx. You are uncertain as to the source of his anaphylactic contact, but at this time does not appear to be his BP med. What should you do?
D/c the Beta-blocker and place patient on something else...any patient with hx of anaphylactic rxn should nbot be on a betablocker.

p. 181
T/F: Though not an IgE mediated reaction, corticosteroids and antihistamines for angioedema caused by ACEI are of clinical benefit.
False, there have been no proven benefit
- still give, as angioedema is a clinical dx and u have no way of knowing this is the actual cause.

p. 181
Hypersensitivity reactions to foods is becoming increasingly common. No one knows why. What kind of rxn is it?
IgE mediated reaction to the proteins, not the additives.

p. 181
MC food sources: dairy products, eggs, nuts, shellfish
What are the following sxs c/w: swelling and itching of the lips, mouth and pharynx; as well as nausea, abdominal cramps, vomiting, as well as diarrhea.
food allergy

p. 182
What do the following have in common: Bactrim (septra), Lasix, Glipizide, HCTZ, Silver Sulfadiazine, Bumetanide, and Celebrex, as well as Mafenide Acetate?
products that contain: sulfonamides

p. 182
The ability of a drug to cause an allergic rxn is depedent of what?
It's ability to bind to tissue proteins

p. 182
PCN has been associated with fatal rxns. Of fatal drug rxns, PCN was implicated in >75% of the cases. <25% exhibited a rxn prior. What route is more than 2x's greater risk of causing this...
IV route

p. 182
What is the PCN cross-reactivity to Cephalosporins?
7%

p. 182
People who have had a significant, life threatening allergic reaction to PCN, should not receive PCN or_____.
Cephalosporins

p. 182
What is characterized by: malaise, arthralgias, arthritis, pruritis, urticaria eruptions, fever, adenopathy, and hepatospleenomegaly. It takes 1-2 weeks following exposure of a drug, and several weeks to resolve?
Serum Sickness

p. 182
Developmental Attributes of neonates and infants (0-9months):

- response to pain
pain is perceived at the time it is inflicted
Pain may affect future neurodevelopment

-p. 265
Developmental Attributes of neonates and infants (0-9months):

- abstraction
No ability for abstraction; unable to conceptualize cause and effect, outcome or benefit

No concept of time, so no anticipation, thus no anxiety

-p. 265
Developmental Attributes of neonates and infants (0-9months):

- psychological development
No stranger anxiety

-p. 265
Why is parental presence and even participation important in the preparation for painful procedures, in the toddler age group (10-36 months)?
Because this age group is prone to stranger anxiety and perceived threat of separation from parent may cause significant distress

p. 265
Examine the patient with the parents first, sitting in their lap, etc.
This age prefers to make their own decisions, so involve them as much as reasonably possible
What strategy is effective in gaining support for your examination in a school aged (4-10 yrs) patient?
Winning them over...

p. 265
What are the five rational approaches to anxiolysis and analgesia, and sedation in children?
1. patient factors (developmental and anxiety)
2. procedure factors (degree of pain)
3. Physician Skill
4. Nursing Skill
5. ED resources

p. 266
T/F: There are pharmacologic and non-pharmocologic strategies of anxiolysis.
True

p. 266
non-pharmacologic: parental presence.
What is the dose of Midazolam? What is the onset of action?
- 0.5mg/kg PO
- 20 minutes

p. 266

(0.1 mg/kg IV; can be given 0.2 mg/kg intranasally)
Oral Midazolam (versed) has a longer half life than IV
Why should family members of patients who receive oral midazolam be warned about safety, as apposed to IV administration.
Should be protected from falls and injury, as coordination may be impaired for several hours after discharge...2/2 to relatively longer 1/2 life.

p. 266
A child was provied intransal versed and began crying and throwing fits, which you initially thought was an emergence reaction. However, soon seetles and falls asleep...good, until a little too asleep and now apneic. You provide the flumazenil...and the patient responds and you save the day. However, a short while later the patient goes apneic again. What is up?
Flumazenil has a shorter half life and wore off prior to the versed...remeber intransal has a longer half life than IV

p. 266
What are the two common topical anesthetics for closed skin?
EMLA and LMX

p. 266
What are some open wound topical anesthetics?
LET (Lidocaine, epinephrine and tetracaine)- apply to the surface and then to cotton swab left in wound for 20 minutes.

p. 266
When mixing bicarb to lidocaine to reduce burning, what is the appropriate ratio of: bicard to lido?
1:4 (mL's)

p. 266
What about analgesia in infants? How is this best accomplished?
oral sucrose 25% on pacifier dipped into solution just before the procedure

p. 267
What is the youngest age and dose for Ketoralac?
FDA approved for 24 months of age and older...

1 mg/kg IM, 0.5 mg/kg IV

p. 267
What are two important factors to recognize in children with regard to appropriate analgesia?
1. children do not respond to pain in the same way as adults. They may be sitting quiet, but if they have a fx, tx this.

2. Children require more opiates proportionate to their weight than do adults

p. 267
What is the appropriate dose of morphine for kids?
0.1-0.3 mg/kg...

p. 267
however, choose the appropriate therapy for needs... (next slide)
example:
- Fentanyl has shorter half life and less histamine response than synthetic variations of opiates
- Hydropmorphone has higher potency than morphine and may be useful for ongoing pain
T/F: Demerol (Meperidine), safe in kids, tho admittedly falling out of vogue.
False- never safe in children

p. 267
What are three routine procedures that will not require routine procedural sedation?
1. short, non-painful diagnostic studies (CT)
2. Ultrashort painful procedures (reduction of nurse maids elbow or subluxed patella)
3. Painful procedures for which adequate analgesia can be provided w/o sedation (simple lac repair or LP)

p. 267
What are some indications for procedural sedation? (4)
1. very painful procedures of any length (fx reduction)
2. moderately painful, protracted procedures (I&D abscess)
3. Extreme anxiety or developmental barriers when attempts at anxiolysis have failed.
4. Need for complete motionlessness (eyelid lac repair, in toddler)

p. 267
What should always be available at the bedside when procedural sedation is provided?
Resuscitation equipment

p. 267
What is the following ASA classification?

Healthy patient w/o systemic dz
ASA I

p. 268
What is the following ASA classification?

Patient with mild systemic dz
ASA II

p. 268
What is the following ASA classification?

Patient with severe systemic disease
ASA III

p. 268
Class III or higher, may not be appropriate for procedural sedation in the ED
What is the following ASA classification?

Patient with severe systemic disease posing a threat to life
ASA IV

p. 268
Class III or higher, may not be appropriate for procedural sedation in the ED
What is the following ASA classification?

Moribound patient who cannot survive w/o surgery
ASA V

p. 268
Class III or higher, may not be appropriate for procedural sedation in the ED
What is the appropriate Mallampati score for the following airway:

Full view of the uvula, tonsilar arches, and posterior oropharynx
Grade I

p. 268
What is the appropriate Mallampati score for the following airway:

partial occlusion of the posterior oropharynx, superior tonsilar arches and the inferior aspect of the uvula(maybe)
Grade II

p. 268
What is the appropriate Mallampati score for the following airway:

Almost complete occlusion of the posterior oropharynx, base of the uvula visible.
Grade III

p. 268
What is the appropriate Mallampati score for the following airway:

Complete overlap of tongue and soft palate (no visualization of the posterior oropharynx at all)
Grade IV

p. 268
What complication does the patient with Trisomy 21 and Pierre-Robin pose?
- Down's child: larger tongue and absence of the transvere ligament
- Pierre-Robin: Micrognathia

p. 268
T/F: There is a large risk of aspiration in the ER during conscious sedation, since the patient has not fasted in preparation, however, it is often a necessary risk when weighting patient pro's and con's.
False. Ther is no risk of aspiration outside of the ER with regard to fasting. A large-scale report fromm the Pediatric Sedation Research Consortium, which documented only 1 in 30,037 peds sedations outside of the operating room.
- the single case, child ate >8 hrs prior
- vomiting can occur.
ie. THERE IS NO evidence to support a need for fasting prior to sedation in the ED

p. 268
What is the SECOND MC sedation agent used in the ED, and is a dissociative anesthetic related to phencyclidine?
Ketamine

p. 268
- while: short half life, poses little risk for resp and cardiac depression
- it is emetogenic, therefore raises intraoccular and possibly intracranial pressure
Ketamine appears to be a "threshold agent". What does that mean?
Means that a "small amount" does not cause a "little sedation", but rather at a certain dose threshold sedation occurs.

p. 268
subdissociative doses <1 mg/kg, can provide analgesia w/o sedation
Midazolam is often given with ketamine to reduce emergence reactions- there is little benefit in this. However, how may it be helpful?
1. muscle relaxation
2. antiemesis

p. 268
What is the MC procedural sedation used in pediatric ER medicine?
Propofol

p. 268
Weakness: No analgesia!! so analgesia will need to be provided with general anesthetic
T/F: Caution when providing opiates with ketamine, these added effects could cause unnecessary risks.
False, at least one study determined no risk to combined therapies. in fact this is commonly practiced in the ED

p. 268
- however, propofol and ketamine by themselves or inconcert with another agent (such as fentayl) are superior in their effectiveness and safety profile
Which is more sedating: Ketamine or Propofol
Ketamine

p. 268
Barbituates such as Pentobarbital and Methohexital have been used for rad procedures but have three notable drawbacks?
1. HoTn
2. Respiratory Depression
3. Long recovery time

p. 268
What agent can be used for "hypnosis", not analgesia, providing sedation, with minimal cardiopulmonary risks and perhaps even cerebral perfusion benefit?
Etomidate

p. 270
What medications are indicated in the text as DO NOT USE for pediatric procedural sedation?
-chloral hydrate
- demerol
- phenergan
- chlorpromazine (promethazine)

p. 270*
How long should children be monitored following sedation?
Until they have returned to their defined baseline.

p. 270 (However, d/c criteria, next slide)
1. Stable Vital Signs: including BP and Pulse Ox
2. Return to baseline mental status
3. Able to sit unsupported (unless not already able to)
What is chronic pain?
- pain that lasts for >3 months
- pain that persists beyond a reasonable time of healing
- pain that persists 1 month beyond the usual course of acute disease

p. 291

- serves no obvious function
Four basic types:
1. pain persisting beyond the NML healing time for dz
2. pain related to degenerative dz or persistent Neuro conditions
3. CA related pain
4. pain that emerges or persists w/o an idenfiable cause
What is acute pain?
An essential biological signal to warn the individual to stop a potentially injurious activity, or seek medical attention

p. 291
Signs/Sxs chronic pain, what is the following:

Symmetric numbness and burning/stabbing pain in the lower extremities; allodynia may occur

Sensory loss in the lower extremities
Diabetic Neuropathy

p. 291
Signs/Sxs chronic pain, what is the following:

Variable, aching, cramping, burning and squeezing, or tearing sensation

May have peri-incisional sensory loss
Phantom Limb Pain

p. 291
Signs/Sxs chronic pain, what is the following:

Paroxysmal, short bursts or sharp, electric-like pain in the nerve distribution

Tearing or red eye may be present
Trigeminal Neuralgia

p. 291
Signs/Sxs chronic pain, what is the following:

Symmetric pain and paresthesias, most prominent in the toes and feet

Sensory loss in areas of greatest pain symptoms
HIV related Neuropathy

p. 291
Signs/Sxs chronic pain, what is the following:

Allodynia; shooting, lancinating pain

Sensory changes in the involved dermatome
PostHerpetic Neuralgia

P. 291
Signs/Sxs chronic pain, what is the following:

Same side as weakness, throbbing, shooting pain; allodynia

Loss of hot and cold differentiation
PostStroke pain

p. 291
Signs/Sxs chronic pain, what is the following:

Constant, intermittent burning or aching, shooting, electric shock-like pain, may follow a dermatome; Leg pain>Back pain

possible muscle atrophy in the area of pain, possible reflex changes
Sciatica

p. 291
Signs/Sxs chronic pain, what is the following:

Burning persistent pain, allodynia, associated with immobilization or disuse

Early: edema, warmth, local sweating
Late: above alternates with cold, pale, cyanosis, eventually atrophic changes
Complex regional pain syndrome type I

p. 291
Signs/Sxs chronic pain, what is the following:

Burning persistent pain, allodynia, associated with peripheral nerve injury

Early: edema, warmth and local sweating
Late: above alternates with cold, pale, cyanosis, eventually atrophic changes
Complex regional pain syndrome type II

p. 291
Signs and Symptoms of non-neuropathic pain syndromes; what is the following:

Constant, dull pain, occasionally shooting pain

Trigger points on scalp, muscle tenderness and and tension
Myofascial HA

P. 291
Signs and Symptoms of non-neuropathic pain syndromes; what is the following:

Constant dull pain

Diffuse scalp tenderness, as well as associated tenderness
Chronic Tension HA

P. 291
Signs and Symptoms of non-neuropathic pain syndromes; what is the following:

initially migraine HA, becomes constant, dull, and associated N/V

Muscle tenderness and tension, NML Neuro examination
Transformed Migraine

p. 291
Signs and Symptoms of non-neuropathic pain syndromes; what is the following:

Constant dull pain, occasionally shooting pain, pain does not typically follow nerve distribution

No trigger points, poor ROM in involved muscle
Chronic Neck Pain

p. 291
Signs and Symptoms of non-neuropathic pain syndromes; what is the following:

Diffuse muscular pain, stiffness, fatigue, sleep disturbances

Diffuse muscle tenderness, >11 trigger points
Fibromyalgia

p. 291
Signs and Symptoms of non-neuropathic pain syndromes; what is the following:

Constant dull pain, occasionally shooting pain, pain that does not follow nerve distribution

No trigger points, poor ROM in involved muscle
Chronic Back Pain

p. 291
Signs and Symptoms of non-neuropathic pain syndromes; what is the following:

Constant dull pain, occasionally shooting pain, pain that does not usuallt follow nerve distribution

Trigger points in area of pain, usually no muscle atrophy, poor ROM in involved muscles
Myofascial back pain syndrome

p. 291
Signs and Symptoms of non-neuropathic pain syndromes; what is the following:

Constant, dull pain, occasionally shooting pain that does not typically follow a nerve distribution.

Trigger points in areas of pain, usually no muscle atrophy, poor ROM of the involved muscles
Myofascial neck pain

p. 291
Patients should be asked about drugs, alcohol and hx of rehab intervention. Prior addiction to alcohol and/or drugs is a relative contraindication to what treatment for chronic pain?
Opioid tx

p. 292
What are some objective findings of acute pain?
- tachycardia
- hypertension
- diaphoresis
- muscle spasms on stimulation

p. 292
What is the difference between trigger points of pain and simple focal tenderness?
Trigger points, focal points of muscle tenderness and tension, that when stimulated with pressure provoke a referred pain, MC along the involved muscle

Simple focal tenderness: palpation w/o referred pain

p. 292
How is myofascial HA different from regular tension HA?
Myofascial HA posses some trigger points.
Additionally, has constant squeezing scalp discomfort, with occasional shooting pain. N/V and neck pain and tenderness

p. 292`
A HA that began as a classic form, treated inappropriately with opioids; once episodic is now constant. What is it?
Transformed migraine

p. 292
What requires 11 or 18 tender points as well as sxs present for > 3 months (do I really have to say more?)
Fibromyalgia

p. 292
What neuropathic pain is often triggered by chewing, brushing teeth, speaking, or soemthing touching the face. It is paroxysmal "bursts" of electric shock pain...
Trigeminal neuralgia...

p. 293
You suspect that a patient has CRPS (complex regional pain syndrome); you also think you may have caught it early in the dx...what tx may reduce on going sxs?
Steroids

p. 293
If associated with a fixation device, such as with ortho cases, it may need to be removed for comfort.
What are the 4 criteria for Complex Regional Pain Syndrome?
1. presence of initiating noxious event or cause of immobilization
2. continued pain: allodynia, hyperesthesia- disproportinate to the inciting event
3. evidence at some time of edema, changes in skin, blood flow, abnormal sweating in region of pain
4. exclusion of other diagnosis to explain sxs or dysfunction

p. 293
What are some classic reasons someone may have adverse effects with opioids? (10)
1. unexpected results in toxicology screening
2. Frequent requests for dose increase
3. Concurrent use of non-prescribed psychoactive substances
4. Failure to adhere to dose schedule
5. Failure to adhere to concurrently recommended treatments
6. Frequently reported loss of prescriptions
7. Frequent visits to the ED for opioid therapy
8. Missed f/u visits
9. Prescriptions obtained from a secondary provider
10. Tampering with prescriptions.

p. 294
What is an important/realistic goal to discuss with the patient regarding pain relief with their "chronic pain condition"?
Complete pain relief is unrealistic as a goal

p. 294
When providing NSAIDs for pain mgt, what is a way to relief GI side effects?
Add a proton pump inhibitor...infact the combo may actually be as effective and cheeper than going with COX-2 which has cardiac risks associated with it

p. 294
What two drugs are commonly given for generalized HA's in the ER?
Compazine 10 mg IV as well as Diphenydramine

- for the HA and the dystonic rxn

p. 294
What medication is supposed to be good for transformed migraines as well as for chronic migraines...beginning at 25 mg PO HS, not to exceed 100 mg?
Elavil (Amitriptyline)

p. 294
What is the most consistently effective therapy for chronic neuropathic pain?
TCA's

p. 295
However, Spinal cord injury, phantom limb pain, HIV and CRPS are definitely not going to benefit from this.
Spinal Cord injury: Lyrica
Phantom Limb pain: Neurontin
HIV: Lamictal; then Neurotin, Lyrica, etc.
CRPS: Steroids, then calcitonin and the/or IV mgt, such as bisphosphonates- admit to ortho
T/F: Steroids are helpful in the treatment of sciatica, when given in 24 hrs.
False, steroids when given early may provide temporizing relief for 24 hrs, but by and large are of no acute or chronic benefit.

p. 295
What is the most resistent form of neuropathic pain to pharmacotherpay?
Complex regional pain syndrome

p. 295
Chronic pain is MC in the elderly, affecting >70% of patients. What are the two MC reasons for this?
1. OA

2. Neuralgia

p. 296
There are many risks associated with treating elderly pain: GI bleed with NSAIDs, as well as renal dz, additionally, opioids can cause constipation and sedation. However, opioids, when titrated appropriately can actually have fewer SE's than NSAIDs. As with a all age groups, what is more likely the case with pain control in the elderly?
they are often undermedicated for pain control

p. 296
Local anesthetics are either what two types?
Ester and amides

p. 270
Amides: -caines
Where are esters hydrolized?
in the plasma

- by choliesterase enzyme

p. 270
Where amides metabolized?
hepatic microsomal enzymes

p. 270
What is the onset of action of a local anesthetic a function of?
pKa (the pH at which 50% of the drug will be in its non-ionized form- which is the form that diffuses most rapidly across the lipid membrane)

p. 270
drugs with a lower pKa have a more rapid onset of action
(non-ionized form is the active form)
the pH of local anesthetics is acidic...the addition of sodium bicarb, increase the pH- making it faster...
The addition of bicab can cause precipitation of the anesthetic agent...and accelerating degredation of epinephrine...so when should it be added?
Bicarb should not be added to an anesthetic unless it can be used IMMEDIATELY

p. 270
T/F: injecting anesthesia into the margins of the wound, versus along the intact skin surrounding the wound is one way to reduce pain of infiltration.
True

p. 270
What determines the duration of action of a local anesthesia?
The receptor affinity of the agent.
- bupivicaine, ropivicaine, and levobupivicaine have higher receptor affinity
- lidocaine and prilocaine- have a lower receptor affinity

p. 270-271
The systemic toxicity of local anesthetics occurs with dose related progression in sodium channel blockade in none target tissues. What are the two organs most likely affected?
brain and heart

p. 271
Toxicity can range from subtle neurologic sxs to refractory seizures, and cadiovascular collapse.
What toxic effect can occur with prilocaine and benzocaine?
Methemoglobin

p. 271
If someone says that they are allergic to epi, but you want something to help make the local injection last as well as decrease bleeding. Is there another agent that can be sustituted?
Clonidine- alpha agonist, vasoconstriction

p. 271
0.5 mcg/kg to a max of 150 mcg
What is the risk of >150mcg of clodine for an aid to local anesthesia?
sedation, HoTn and Bradycardia

p. 271
In the setting of wound mgt, there are many factors to consider with regard to the route of routes of local anesthetics?
1. patient factors (age, anticipated pain tolerance, comrobidities)
2. wound factors (location, depth, presence of absence of contamination and/or neurovascular injury)
3. technical factors (time required, clinical experience)

p.271
what are some examples of topical anesthetics:

Used on the Intact Dermis
EMLA, Ametop, liposome encapsulated lidocaine

p.271
what are some examples of topical anesthetics:

On open dermis
LET

p.271
what are some examples of topical anesthetics:

mucosa
ZAP, Hurricaine, and Viscuous licocaine

p. 271
How is digital vascular function assessed?
by noting skin color and temperature and measuring cap refill time and palpation of pulses.

p. 272
Hos is the distal neurologic function assessed?
noting cutaneous (pain and touch) and motor function (active movement and strength)

p. 272
What is NML 2 point discrimination?What is a "common" 2 pt discrimination?
< 6mm, 2 mm

p. 272
What is a significant less cardiotoxic agent: bupivicaine, ropivocaine, and levobupivicaine?
Ropivicaine

p. 272
all however offer longer duration of action
Where may the flexor tendon nerve sheaths not be successful in anesthesia?
Finger tip

p. 273
Why is a generous amount of anesthesia needed in a radial nerve block?
because the distribution of the radial nerve is less predictable

p. 274
What nerve block provides anesthesia to the medial aspect of the ankle?
saphenous

p. 278
Where is the optimal block site for rib blocks?
"rib angle"

p. 281
What impairs ribs 1-6 for nerve blocking purpises?
rhomboid muscles and scapula

p. 281
Regarding rib blocks, what does blocking posterior to the midaxillary line ensure, with regard to analgesia?
blocking the lateral cutaenous and anterior branch of the intercostal nerve.

p. 281
What is recommended to use when performing a femoral nerve block?
peripheral nerve stimulator or u/s guidance.

p. 282
When performing a hematoma block, what must you be cautious in doign with the anesthesia?
1. Not exceeding the recommended amount of anesthesia
2. Not injecting into a contaminated wound
3. Not injecting into an open fracture

p. 283
read BIER block p. 283
that's all!