<Severe right hip pain after running ! >

A senior high school student suffered a sudden right hip pain while running.

Right hip ROM was marked limited with severe pain. Palpable of the right hip also revealed a severe tender area.

Here was his pelvic radiography

Avulsion fracture of the Anterior Superior Iliac Spine (ASIS)  was identified.

Tendons are much more stronger than muscles for any cross-sectional area. When a sudden strain is applied to a muscle-tendon-bone unit, the muscle will rupture, or the tendon will avulse at its insertion, together with a fragment of bone to which it is attached.

The most common avulsion fractures of the pelvis and its related muslce attachement are  (Figure)
1. ASIS                    -- Sartorius muscle
2. AIIS                     -- Rectus femoris muscle
3. Ischial tuberosity -- Hamstring muscles
4. Lesser tuberosity -- iliopsoas muslce

 

References:
1. Fernbarch, Wilkonson RH. Avulsion injuries of the pelvis and proximal femur. Am J Roentgenol 1981; 137:581-4
2. M Naude, Lindeque, Rensburg. Avulsion fractures of the pelvis. Sports Medicine. June 2003.

A middle-aged man presented with profound shock and chest pain. Systolic blood pressure 50~70 mmHg. Here is the 12-lead ECG. 

 

 

 

 

1. What is the ECG findings ?

 

Here is his right side ECG :

2. What is the culprit vessel ?
3. How to explain his profound shock ?



A 23 y/o young man fall by direct impact on left shoulder. Here is his radiographys.

1. What is the injury ?

     Acromioclavicular joint seperation.

2. What is the mechanism for this type of injury ?

    Fall with direct impact on the superior aspect of acromion.

3. What type of injury in this patient ?

    Type V.

4. What is the treatment goal for an EP ?

    Type I~II is conservative.

    Type III optional/controversial

    Type IV~VI is surgical intervention.

Classification of AC joint seperation:

     Type I appear normal

     Type II 0~50% displacement at the AC joint but no increase in the coracoclavicular interval

     Type III clavicle displaced superiorly 50% to 100% when compared to normal side.

     Type IV distal clavicle displaced posteriorly into or through the trapezius

     Type V  displaced > 100~300%

     Type VI distal clavicel displace inferiorly

Here were the post-op view of this patient



Biphasic stridor and plethora

A 73 y/o female presented with dyspnea and malaise. Underlying disease of cervical cancer and metastasis to lung/mediastinum/head were found last month. She was scheduled to receive palliative radiotheray next weeek. On inspection, there were facial and bilateral upper limbs flushing, dilated and engorged anterior chest vein. Biphasic stridor was also noted. Here was her chest radiography

 

 

1. What is the possible differential diagnosis ?
        a. Superior vena cava syndrome
        b. Superior mediastinal syndrome
        c. Vocal cord palsy
        d. Trachea stenosis
        e. Portal-A related DVT
        f. Cardiac tamponade

 

2. What is the common etiologies of SVC syndrome ?
       a. •lung cancer, especially small cell, and lymphoma in approximately 90% of cases.
       b. –fibrosing mediastinitis
       c. thrombosis of indwelling central venous devices. 
       d. •Syphilitic aortic aneurysm and tuberculosis use to be common causes in developed countries.


3. What is the common symptoms of SVC ?
       facial or neck swelling(plethora) (82%),
       arm swelling (68%),
       dyspnea (66%),
       cough (50%),
       dilated chest veins (38%),
       orthopnea is commonly noted.
       Facial swelling and plethora, exacerbated when supine and cyanosis can be dramatic.

 

 

4. What is  Pemberton's sign ?
    Pemberton's sign is the development of facial flushing,[1] distended neck and head superficial veins, inspiratory stridor and elevation of the jugular venous pressure (JVP) upon raising both of the patient's arms above his/her head simultaneously, as high as possible (Pemberton's maneuver).

It is named for Dr. Hugh Pemberton, who characterized it in 1946.

5. How to treat ?

    a. corticosteroids and diuretics provide temporay relief

    b. avoid IV catheters placed at upper limbs

    c. radiation therapy is the treatment of choice

Nodules over scalp and forehead were caused by skull metastasis

 

 

 

" We found a strong association between survival outcomes and increased compression depth but no clear evidence to support or refute the 2010 recommendations of >50 mm. "

不管多努力, 壓胸仍是不够深, 壓胸的時間還是太少, 但至少正在壓的時候速度是够的.
可是, 不管高矮胖瘦都要至少5公分嗎 ?

What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation?   Crit Care Med. 2012 Apr;40(4):1192-8.

Abstract

BACKGROUND:

The 2010 international guidelines for cardiopulmonary resuscitation recently recommended an increase in the minimum compression depth from 38 to 50 mm, although there are limited human data to support this. We sought to study patterns of cardiopulmonary resuscitation compression depth and their associations with patient outcomes in out-of-hospital cardiac arrest cases treated by the 2005 guideline standards.

DESIGN:

Prospective cohort.

SETTING:

Seven U.S. and Canadian urban regions.

PATIENTS:

We studied emergency medical services treated out-of-hospital cardiac arrest patients from the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest for whom electronic cardiopulmonary resuscitation compression depth data were available, from May 2006 to June 2009.

MEASUREMENTS:

We calculated anterior chest wall depression in millimeters and the period of active cardiopulmonary resuscitation (chest compression fraction) for each minute of cardiopulmonary resuscitation. We controlled for covariates including compression rate and calculated adjusted odds ratios for any return of spontaneous circulation, 1-day survival, and hospital discharge.

MAIN RESULTS:

We included 1029 adult patients from seven U.S. and Canadian cities with the following characteristics: Mean age 68 yrs; male 62%; bystander witnessed 40%; bystander cardiopulmonary resuscitation 37%; initial rhythms: Ventricular fibrillation/ventricular tachycardia 24%, pulseless electrical activity 16%, asystole 48%, other nonshockable 12%; outcomes: Return of spontaneous circulation 26%, 1-day survival 18%, discharge 5%. For all patients, median compression rate was 106 per minute, median compression fraction 0.65, and median compression depth 37.3 mm with 52.8% of cases having depth <38 mm and 91.6% having depth <50 mm. We found an inverse association between depth and compression rate ( p < .001). Adjusted odds ratios for all depth measures (mean values, categories, and range) showed strong trends toward better outcomes with increased depth for all three survival measures.

CONCLUSIONS:

We found suboptimal compression depth in half of patients by 2005 guideline standards and almost all by 2010 standards as well as an inverse association between compression depth and rate. We found a strong association between survival outcomes and increased compression depth but no clear evidence to support or refute the 2010 recommendations of >50 mm. Although compression depth is an important component of cardiopulmonary resuscitation and should be measured routinely, the most effective depth is currently unknown.

Left ankle pain after MBA

29 year-old female complaint of left ankle pain after MBA.

Her ankle was shown below

 

Medial ankle showed mild swelling and ecchymosis; Lateral ankle appeared normal

Her ankle x-ray:

Her Foot X-ray:  

What is your diagnosis ?

Left foot pain after MBA

18 year-old man presented after MBA. He ambulatory on scene or at ED. Left mild medial midfoot pain was complaint but without any abrasion or echymosis on dorsal or plantar foot.

Here are his left foot x-ray (AP and oblique view)

1. What clinical decision rule could guide the utility of x-ray ?
     Ottawa Foot Rule

2. What are the radiographic abnormalities ?
     Widening of space between the 1st and 2nd MT base.  Diastasis > 2mm is diagnostic of Lisfranc injury.

3. What is your diagnosis ?
     Lisfranc Injury.

4. What is Lisfranc Joint ?
     The Lisfranc joint, or tarsometatarsal articulation of the foot, is named for Jacques Lisfranc (1790–1847), a field surgeon in Napoleon's army.

5. What is the clinical significant of this injury ?
    Lisfranc joint fracture–dislocations and sprains carry a high risk of chronic secondary disability.

6. What is the different between Lisfranc joint and Lisfranc joint complex ?
   
7. What clinical sign could be found on this kind of injury ?
    Plantar ecchymosis sign
    Palpable tender on medial aspect of midfoot   
    Patient unable to bear weight while standing on tiptoe
    Check for dorsal pedis pulse and distal capillary refilling tie

8. What is the radiographic pitfall when interpretating the film ?
   Weight-bearing radigraphy is necessary to reveal minor injury.
   Compared with the normal side
   "Fleck sign"-small avulsed fragments within the joint space

    Here is the patient unaffected side x-ray:

 

   
 

Urethral Injury

When to suspect  urethral injury

• blood at the urethral meatus
• perineal ecchymosis
• blood in the scrotum
• high riding or nonpalpable prostate
• pelvic fracture
• inability to void

Earler's sign
Detsot's sign

Retrograde urethrogram
Retrograde cystogram

ATLS Primary Survey

Primary Survey

1. Airway Maintenance with Cervical Spine Protection

• "Airway Obstruction"
• Airway Manipulation
• check for FB and related fractures
• repeated assessment
• cervical spine immobilization-manual in line stabilization (MILS)

  
Comparison of cervical spine stabilization

2. Breathing and ventilation

• "Tension Pneumothorax"
  "Massive Hemothorax"
  "Open Pneumothorax"
  "Fail Chest with Pulmonary Contusion"
• Needle decompression, tube thoracostomy

3. Circulation with hemorrhage control

• Cardiac Tamponade
• blood volume and cardiac output-level of consciousness, skin color, pulse
• bleeding- SCALPeR
• Two large-caliber IV catheters, rate of infusion related to the internal diameter of the catheter and inversely by its length (not by the size of the vein)

  "Are 2 smaller intravenous catheters as good as 1 larger intravenous catheter?"

• IV solutions warmed or storage in 37~40 degree Celcius; high-flow fluid warmer for crystalloid fluids to 39 degree Celcius but blood product should not be warmed in a microwave oven.

4. Disability (Neurologic evaluation)

• Level of consciousness
• pupillary size and reaction
• lateralizing signs
• spinal cord injury level
• cerebral oxygenation/perfusion VS direct cerebral injury

5. Exposure/environment control