Opp 2 Miller- Er

Front 1

MOst visits to ER

Back 1

South

Front 2

most ppl visit ER what time and why?

Back 2

after PCP closed

Front 3

Most commonly diagnosed conditions at ER:

Back 3

Injury and poisoning
Number of injury-related visits: 42.4 million

Front 4

Percent of visits resulting in hospital admission

Back 4

13%

Front 5

Median time spent in emergency department:

Back 5

2.6 hours

Front 6

Percent of visits with patient seen in fewer than 15 minutes

Back 6

22%

Front 7

Percent requiring immediate treatment

Back 7

16%

Front 8

Percent seen again for same symptoms within 72 Hours resulting in different Dx

Back 8

3.6%

Front 9

Principle reason for visit ER by Symptom:

Back 9

1. Stomach and abdominal pain, cramps and spasms:

2. Chest pain and related symptoms

3. Fever

4. Headache

5. Back symptoms

6. Dyspnea

7. Cough

Front 10

ED Presentations with pain as a symptom

Back 10

Presenting with pain: 59%
Acute complaints related to musculoskeletal pain
Leg symptoms: 1,645,000
Back (upper and lower)symptoms
Chest pain
Abdominal Pain:(includes cramps and spasms as well)
Fever
Headache
Diffuse: 2,512,000
Ear ache 1,677,000
Trauma
MVA: 1,714,000
Face, hands, neck, head: 1,586,000
Lacerations, other: 1,870,000
Accident other: 1,737,000

Front 11

ED presentations by Diagnosis

Back 11

1. Nervous system
2. Circulatory system
3. Respiratory system
4. GI system
5. GU system
6. Skin
7. Musculoskeletal

Front 12

Do don't use OMM due to

Back 12

no time

Front 13

ED Presentations with pain

Back 13

1. Referred pain related to underlying visceral disorder (viscero-somatic)
2. Referred pain from other somatic dysfunction (somato-somatic)
3. Compensation for somatic dysfunction resulting in pain at remote location

Front 14

Referred pain: viscerosomatic

Back 14

Gallbladder
Tip of R scapula
Cardiac ds
Jaw
Inner L UE
Midepigastrium
Important diagnostically and therapeutically

Diaphragm, Pericardium and Heart, Heart, Digestive tract, Liver and Gall Bladder, Kidney and Ureter, Pelvic Organs

Front 15

ED presentations which respond well to OMT

Back 15

Headache
Viral URI
Otitis
Sinusitis
Trauma:
Whiplash injury
Ankle sprain
Chest pain
Pneumonia
Pyelonephritis
Arthritis (gout)
Back pain

Front 16

OMT for Urgent and Emergent Medical Illness

Back 16

COPD or asthma exacerbation
Pneumonia
Cellulitis?????
Upper respiratory infection (URI)
Sinusitis
costochondritis

Front 17

Pneumonia

Back 17

Treat to enhance movement of fluid and air through lungs
Rib treatment: rib raising, muscle energy
Thoracic spine treatment: BLT, muscle energy
Thoracic inlet and outlet
Lymphatic treatment to enhance immune function
Pedal pumps, thoracic pump, diaphragm doming

Front 18

Cellulitis

Back 18

Body must deliver nutrients and oxygen to area and remove waste products to adequately clear infection
Treat to enhance lymphatic flow and remove edema
Allows improved perfusion of infected tissue
Do it after start of appropriate antibiotic and makse it works before start OPP

Treatment to improve drainage of involved area
Always treat thoracic inlet to allow increased lymphatic return centrally
For improved LE drainage, treat pelvis and lumbar spine
To improve UE drainage, treat thorax and shoulder girdles

Front 19

HA

Back 19

Evaluate for emergent causes
Intracranial hemorrhage
Tumor
Head CT if new onset or different from typical HA they’ve had
LP indicated if suspicious for IC bleed even with negative CT head
Migraine due to sudden vascular dilation or contraction
Tension HA
Usually tension in neck and suboccipital muscles
Trigger points often present to these areas with recurrent tension HA


TX
Suboccipital tension release
Cervical soft tissue techniques
Release of trigger points with pressure or injection

Front 20

Low Back Pain

Back 20

95% disk herniation occurs at L4-L5 or L5-S1 levels
L5-S1
Radiation of pain over anterior compartment mimics shin splints
Radiation of pain to calf mimics thrombophlebitis
Pain over peroneal nerve at fibular head or tibial nerve (S1) in tarsal tunnel

Front 21

Low Back Pain: Evaluation

Back 21

Evaluate spine and posture of patient
More comfortable seated or standing?
Increased lordosis?
Possible spondylosis
stress fracture of pars interarticularis, unilateral belt line tenderness in teenager with repetitive extension
Position of pelvis
Knees, ankles, feet
Footwear

Front 22

MRI indicated with Low back pain:

Back 22

for evidence of neurological impairment
Weakness, numbness
Incontinence
Decreased rectal tone
(Saddle sensory symptoms)
Or immunosuppression

Front 23

Referred pain: musculoskeletal

Back 23

Psoas, Iliacus, Quadratus
Low back
Ipsilateral groin
Contralateral piriformis area
Piriformis m. spasm
Ipsilateral buttock and post thigh
Can recruit hip flexors and extensors

Front 24

Low Back Pain: Common SD

Back 24

Psoas and Quadratus spasm very common cause
Paraspinal + other mm spasm
Evaluate anterior abdominal wall
Sacral lesion
Easy to treat and very frequently effective for acute or chronic pain

Front 25

Low Back Pain: abdominal wall

Back 25

Trigger points over rectus abdominis refer pain to low back area
Relaxed, stretched abdominal wall present with anterior pelvic tilt and increased lordosis creates

Front 26

Low Back Pain: sacral lesions

Back 26

1. Flexed sacrum
Mechanism: arching backward, throwing, catching self from falling backward
More comfortable standing than seated
2. Extended sacrum
Mechanism: standing and lifting heavy object with low back rounded forward (lumbar flexion)
Difficult to stand upright
May be more comfortable sitting
3. SI joint pain
Refers pain to inguinal region and anterolateral thigh as well as lower abdominal quadrants
Pain may simulate acute appendicitis or ovarian cyst
May be bilateral or alter sides
Long periods of sitting will exacerbate pain

Front 27

Sciatica/Piriformis Syndrome

Back 27

Spasm of piriformis can compress sciatic n.
Also generates pain in distribution over buttocks radiating to post thigh

Front 28

Acute Low Back Pain TX and levels for TX

Back 28

Improve movement: (level 2)
Unload the muscles involved with FPR, CTS
Analgesics short duration (Acetaminophen, non-narcotic only)
Return to regular routine as soon as possible (No bed rest, no targeted exercises) (not leveled)
In Large study patients advised to get back to their routines as actively as possible had significantly fewer sick days than either other group at both 3 and 12 weeks, losing 4.7 days from work as compared to 7.2 days for exercise group and 9.2 days for bed rest group
Good advice (level 2)
Muscle relaxants in those who are anxious only (unleveled)
Avoid intramuscular corticosteroid injections (level 2)
Avoid NSAIDS more than 2 days (level 2)
Heat short term may be beneficial (level 2). Ice=insufficient evidence
Avoid HVLA (level 1)

Front 29

Prediction rule: (level ?)

Back 29

Acute Low Back Pain
Level 2

patients most likely to benefit from spinal manipulation meet at least 4 of 5 criteria
symptom duration < 16 days
no symptoms distal to knee
score < 19 on fear-avoidance measure
at least 1 hypomobile lumbar segment
at least 1 hip with > 35 degrees of internal rotation

osteopathic manipulative therapy (OMT) appears effective based on limited evidence

Front 30

Ankle Injury

Back 30

Forced Inversion sprain most common
40% develop chronic problems
Edema is directly related to decreased ROM
Initial manipulation very effective to speed healing and decrease pain

Front 31

Ankle Injury Classifications
III:

Back 31

complete tear and loss of integrity of a ligament

Severe swelling (more than 4 cm about the fibula)Severe ecchymosisLoss of function and motion (i.e., patient is unable to bear weight or ambulate)Mechanical instability (moderate to severe positivity of clinical stress examination)

Front 32

Ankle Injury Classifications
I:

Back 32

I: partial tear of a ligament

Mild tenderness and swellingSlight or no functional loss (i.e., patient is able to bear weight and ambulate with minimal pain)
No mechanical instability (negative clinical stress examination)

Front 33

Ankle Injury Classifications
II:

Back 33

II: incomplete tear of a ligament, with moderate functional impairment


Moderate Pain and swelling
Mild to moderate ecchymosisTenderness over involved structuresSome loss of motion and function (i.e., patient has pain with weight-bearing and ambulation)Mild to moderate instability (mild unilateral positivity of clinical stress examination)

Front 34

Ankle Injury Classifications
Mild tenderness and swellingSlight or no functional loss (i.e., patient is able to bear weight and ambulate with minimal pain)
No mechanical instability (negative clinical stress examination)

Back 34

Ankle Injury Classifications

I: partial tear of a ligament

Front 35

Ankle Injury Classifications
Moderate Pain and swelling
Mild to moderate ecchymosisTenderness over involved structuresSome loss of motion and function (i.e., patient has pain with weight-bearing and ambulation)Mild to moderate instability (mild unilateral positivity of clinical stress examination)

Back 35

Ankle Injury Classifications

II: incomplete tear of a ligament, with moderate functional impairment

Front 36

Ankle Injury Classifications
Severe swelling (more than 4 cm about the fibula)Severe ecchymosisLoss of function and motion (i.e., patient is unable to bear weight or ambulate)Mechanical instability (moderate to severe positivity of clinical stress examination)

Back 36

Ankle Injury Classifications
III: complete tear and loss of integrity of a ligament

Front 37

Grading of sprains
type 1

Back 37

The grade I sprain is characterized by stretching of the anterior talofibular and calcaneofibular ligaments

Front 38

Grading of sprains
type 2

Back 38

Grading of sprains. (A) The grade I sprain is characterized by stretching of the anterior talofibular and calcaneofibular ligaments. (B) In the grade II sprain, the anterior talofibular ligament tears partially, and the calcaneofibular ligament stretches. (C) The grade III sprain is characterized by rupture of the anterior talofibular and calcaneofibular ligaments, with partial tearing of the posterior talofibular and tibiofibular ligaments.

Front 39

Grading of sprains
type 3

Back 39

The grade III sprain is characterized by rupture of the anterior talofibular and calcaneofibular ligaments, with partial tearing of the posterior talofibular and tibiofibular ligaments

Front 40

lateral ligament of ankle in ankle injury

Back 40

anterior talofibular ligament > calcaneofibular ligament > posterior talofibular ligament)

Front 41

syndesmosis in ankle injury

Back 41

(anterior tibiofibular ligament, posterior tibiofibular ligament, transverse tibiofibular ligament, interosseous ligament, interosseus membrane) may be injured by forced external rotation of foot or during internal rotation of tibia on planted foot, commonly seen in contact sports and skiing; in series of 96 ankle sprains at West Point military academy, 17% were syndesmosis sprains

Front 42

may avulse base of foot metatarsal during ankle injury

Back 42

(bony attachment of peroneus brevis, treat with cast or high lace boots for 2-6 weeks then physical therapy)

Front 43

History of Present Illness (HPI):
ankle injury

Back 43

most often results from acute injury via forced inversion mechanism

if foot was in plantar flexion at time of injury, higher risk of damage to anterior talofibular ligament and likelihood of subsequent disability
inability to bear weight after injury is suggestive of possible fracture and x-rays are indicated
hearing "pop" may indicate full ligament or tendon rupture
history of previous sprain increases risk of reinjury

Front 44

significant tenderness or swelling over medial aspect of ankle (deltoid ligament) or anterior aspect of ankle -

Back 44

severe injury, refer to orthopedist
point tenderness of ankle

Front 45

severe injury at what location, refer to orthopedist
point tenderness of ankle

Back 45

significant tenderness or swelling over medial aspect of ankle (deltoid ligament) or anterior aspect of ankle -

Front 46

what ankle injury suggests sprain

Back 46

inflammation at midfoot ligaments suggests sprain

Front 47

midfoot ligaments inlammmation at akle suggests

Back 47

sprain

Front 48

point tenderness of malleoli, distal fibula, calcaneus or base of fifth metatarsal suggests

Back 48

fracture

Front 49

What inlfammation suggests ankle fracture?

Back 49

point tenderness of malleoli, distal fibula, calcaneus or base of fifth metatarsal suggests fracture
soft tissue swelling

Front 50

localized in first-degree sprains
more generalized in higher-degree injuries
often egg-shaped swelling near anterior talofibular ligament
ecchymosis signifies at least some ligamentous tearing (at least second-degree)

Back 50

soft tissue swelling

Front 51

soft tissue swelling
at ankle

Back 51

localized in first-degree sprains
more generalized in higher-degree injuries
often egg-shaped swelling near anterior talofibular ligament
ecchymosis signifies at least some ligamentous tearing (at least second-degree)

Front 52

Ottawa Ankle Rules

Back 52

100% sensitive for 74 malleolar fractures and 19 midfoot fractures in series of 2,342 adults with decreased use in ankle radiography, waiting times and costs without patient dissatisfaction

Front 53

RICE when w ankle injury? Level?

Back 53

first 48 hours
level 2

Front 54

Early Mobilization
what level?

Back 54

2

Front 55

NSAIDS w ankle injury?
level?

Back 55

less than 7 days (level 1 evidence

Front 56

Eisenhart study for ankle injury

Back 56

osteopathic manipulative therapy (OMT) may improve range of motion (level 2 [mid-level] evidence)