v_chicky Posted June 28, 2006 Share Posted June 28, 2006 marlene - nope, not too easy, we appreciate the questions. what did it used to be? in fetal developement and why was it there? was the ductus arteriosus which serves as a shunt for the fetus to bypass the pulmonary ciruculation while in utero. fetus gets O2 from mom via umbilical vessels, so doesn't need to send blood to the lungs for oxygenation. blood then goes from RV to pulmonary artery and most is then shunted into the aorta without going to the lungs. at birth, the ductus closes and normal adult circulation ensues. maybe one of the ladies who did peds cardio rotations could tell us more about the presentation and treatment of kids who have a patent ductus arteriosus... Quote Link to comment Share on other sites More sharing options...
ajnelson Posted June 28, 2006 Share Posted June 28, 2006 Ok - this is buried pretty deep in my brain, but a kiddo with a PDA has a continuous, loud 'machinery type' murmur - heard best at LUSB. Bounding pulses. If a large defect, may see cardiomegaly (CXR) or RV and LV hypertrophy (EKG). PDA's are pretty common in Down's pts. A PDA can result in increased blood flow to the lungs, therefore the child would present with signs of poor feeding, poor growth and failure to thrive. But, most often, the pt is asymptomatic. Tx is dependent on age and severity of sx: a symptomatic neonate can be given indomethacin (PGE inhibitor) to help promote PDA closure. Most close spontaneously within the first year, but if still patent, can be closed by ligation of insertion of a spring like device into the ductus arteriosis by cardiac catheterization (which then effectively closes the PDA). Quote Link to comment Share on other sites More sharing options...
maryfran123 Posted June 28, 2006 Share Posted June 28, 2006 Here is a made up case of for an injury we see commonly: 77 yo male falls down 4 steps striking this forehead/face upon on the stairwell landing approx. 4 hours prior to being found on the floor by his wife when she came home from bridge club. She immediately called 911. Brought to ED by EMS Presents c/o neck pain and bilateral arm weakness. He also is c/o "shooting" sharp pain across both shoulders radiating to his elbows. No other c/o. No incontinence. Rest of history is non-contributory. ABC's intact. VS normal Pertinent (+): Neuro exam: GCS 15, Motor 2/5 BUE proximal muscles, 0/5 distal muscle groups. Motor exam 3/5 BLE all muscle groups Sensory exam: decreased light touch and pinprick C6-T1 distribution. Pain is hyperesthetic to light touch along C5. (+) loss of proprioception LUE only, loss of temperature C7-T1 dermatomes sacral sensation is intact. Sensory exam for pain,position, light touch and vibration WNL for BLE. Rest of PE--unremarkable Xrays: 3 view Cspine--no obvious fx; lots of DJD with multiple spurs. No subluxation What is the DX, what is the common mechanism for this injury(eg: axial load, flexion, hyperextension, etc) what is treatment plan for this diagnosis? Quote Link to comment Share on other sites More sharing options...
JenGintheED Posted June 28, 2006 Share Posted June 28, 2006 Maryfran, it sounds like central cord syndrome. ABCs are always the first priority. Would intubate given the C5 sxs? NPO. High-dose steroids are no longer recommended, but I think they are often given anyways. Otherwise not sure about tx. Quote Link to comment Share on other sites More sharing options...
maryfran123 Posted June 28, 2006 Share Posted June 28, 2006 Maryfran, it sounds like central cord syndrome. ABCs are always the first priority. Would intubate given the C5 sxs? NPO. High-dose steroids are no longer recommended, but I think they are often given anyways. Otherwise not sure about tx. LA-- Bingo on your dx. Regarding intubation, probably not. It's been 4 hours since his injury by the time you see him and ABC's/VS are stable. Remember he has some muscle strength in the C5-7 distribution so it is very unlikely he'd develop oxygenation/ventilation issues at this level. If you wanted to be sure, what bedside test could you have respiratory therapist do every few hours to be sure? Would you want any additional studies besides the 3 view Cspine? hint: it could influence your treatment plan. Other than NPO, anything else, for example-would you like to consult anyone, what about other precautions? Not every trauma center has gotten rid of the high dose steroid protocol. We are pretty selective in who gets steroids and who doesn't. Let say for the sake of arguement, we decide to gve this guy steroids. How much and for what duration? Quote Link to comment Share on other sites More sharing options...
andersenpa Posted June 28, 2006 Share Posted June 28, 2006 jumping in here...... -you can do a NIF for diphragmatic assessment -MRI the cord? Quote Link to comment Share on other sites More sharing options...
maryfran123 Posted June 28, 2006 Share Posted June 28, 2006 andersen, NIF is a good idea, however, we typically use vital capacity testing. Below T4, vital capacity is NL. Above Between C5-T4, a decreasing in vital capacity may be an early sign that the pt requires intubation. SCI from C1-C4 are typically intubated. MRI cspine--good test. Wow do expect to see and what intervention will likely be required?? Any takers on the mechanism for this injury and what about the steroids--dose/duration? Quote Link to comment Share on other sites More sharing options...
v_chicky Posted June 29, 2006 Share Posted June 29, 2006 Methylprednisolone 30mg/kg IV bolus over 15 minutes then 5.4 mg/kg/hr over the next 23 hours. MOI... hmm, I saw a guy with this, but he was in an MVC unrestrained and we weren't quite sure of how the accident happened. He was found with his head tucked under his seat, so I'll guess hyperflexion. Quote Link to comment Share on other sites More sharing options...
maryfran123 Posted June 29, 2006 Share Posted June 29, 2006 Methylprednisolone 30mg/kg IV bolus over 15 minutes then 5.4 mg/kg/hr over the next 23 hours. MOI... hmm, I saw a guy with this, but he was in an MVC unrestrained and we weren't quite sure of how the accident happened. He was found with his head tucked under his seat, so I'll guess hyperflexion. V-- Actually, the mechanism of injury is hyperextension. Pt's that get central cord typically have spinal stenosis w/ increase signal in the spinal cord on MRI. Many require decompressive surgery at a later date. Regarding the steroids, your dosing is correct, however, in my scenario the pt presented 4 hours after injury. For pt's that present 0-3hrs after injury, they receive steroids for a total of 24hrs. For those that present 3+hours-8hrs after injury, they get 48hrs of steroids. After 8hrs, no steroids. Also, don't forget the H2 blocker or PPI while the pt is on the protocol BTW, as an aside, there is no role for steroids in penetrating trauma. I anticipate in the next few years, steroids for SCI will no longer be the standard of care. Good job everyone!! Quote Link to comment Share on other sites More sharing options...
maryfran123 Posted June 29, 2006 Share Posted June 29, 2006 Ok, lets do a new question that almost everyone will see that works in FP, Emed, Urgent Care, Occupation Health, Trauma. How different grades of concussion and give a brief description of each grade. How does the grade of concussion affect DC instructions/activity restrictions? Quote Link to comment Share on other sites More sharing options...
Guest jennie783 Posted June 30, 2006 Share Posted June 30, 2006 grade 1: no loss of consciousness, transient confusion, and other symptoms (headache, dizziness, etc) that resolve within 15 minutes grade 2: no loss of consciousness, transient confusion, and other symptoms that require more than 15 minutes to resolve grade 3: loss of consciousness for any period. grade 1 can be treated with rest and observation alone and the pt can return to normal activity levels once he/she feels asymptomatic (provided neuro exam is normal) grade 2 should be observed for the entire day to make sure symptoms clear. if symptoms worsen or fail to improve the pt should follow up with a neurologist. He or she should also discontinue and sports activities until a week after being symptom free. grade 3 pt should be hospitalized if CT/MRI shows any abnormalities or if symptoms fail to improve. pt should be closely watched upon discharge for any neurological changes. sports should be avoided for 1 wk following loc of less than 1 min and 2 wks following loc > 1 min. pt should follow up with neuro all of these pts should be frequently checked once discharged to make sure they are easily rousable and should go to the emergency room if the pt experiences vomiting, dizziness, unsteady gait or any other unsual changes. Quote Link to comment Share on other sites More sharing options...
maryfran123 Posted June 30, 2006 Share Posted June 30, 2006 grade 1: no loss of consciousness, transient confusion, and other symptoms (headache, dizziness, etc) that resolve within 15 minutes grade 2: no loss of consciousness, transient confusion, and other symptoms that require more than 15 minutes to resolve grade 3: loss of consciousness for any period. grade 1 can be treated with rest and observation alone and the pt can return to normal activity levels once he/she feels asymptomatic (provided neuro exam is normal) grade 2 should be observed for the entire day to make sure symptoms clear. if symptoms worsen or fail to improve the pt should follow up with a neurologist. He or she should also discontinue and sports activities until a week after being symptom free. grade 3 pt should be hospitalized if CT/MRI shows any abnormalities or if symptoms fail to improve. pt should be closely watched upon discharge for any neurological changes. sports should be avoided for 1 wk following loc of less than 1 min and 2 wks following loc > 1 min. pt should follow up with neuro all of these pts should be frequently checked once discharged to make sure they are easily rousable and should go to the emergency room if the pt experiences vomiting, dizziness, unsteady gait or any other unsual changes. Jennie--Great job!! We have many ER 1st and 2nd year residents that don't know this!!! I'm not sure I agree that all pt's with post concussive syndrome(PCS) need to be seen by a neurologist but that is MY personal bias. Actually, we(trauma) follow all of our own PCS pt's and only refer out those who have sxs that last longer than 6wks. At our facility, for just post concussive HA they may get referred to neurologist, however, our PMR docs have a much greater interest in following these pts. So, that is where they are sent. Also, we tend to use 2 wks restricted activity for any Grade 3 concussion. Truth is, it is very rare you get an accurate duration or LOC and we err on being safe. grade 3 pt should be hospitalized if CT/MRI shows any abnormalities or if symptoms fail to improve. pt should be closely Also just to clarify, for a dx of concussion, any grade, to be made the CT head must be normal. Therefore, if they have a (+) finding on CT scan, it is no longer called a concussion. Grade 3 concussions can be dc'd home with a reliable person if asymptomatic. However, we admit many of our for neurochecks. We never get MRI for concussions. Can anyone tell me what some common post concussive sxs are, typical duration of PCS and possible treatment options. As long as we are discussing traumatic brain injury: what is the GCS, how is it scored, of the 3 parts of the GCS scoring what score is the most sensitive prognostically for recovery from TBI. What GCS levels constitute mild, moderate and severe TBI? Quote Link to comment Share on other sites More sharing options...
Guest pac4hire Posted June 30, 2006 Share Posted June 30, 2006 since i have a t sheet in front of me with the GCS on it it is unfair for me to answer, however sx of PCS transient memory loss, confusion, visual scotoma to name a few. symptoms can last upwards of a year. I personally cannot remember a good 6 month period following a high speed mva with LOC. ( i thought i was DE Jr) Quote Link to comment Share on other sites More sharing options...
ajnelson Posted June 30, 2006 Share Posted June 30, 2006 Maryfran - I had actually learned 5 separate categories for concussion. Grade 1 and 2 are exactly what jennie said, grade 3 was LOC <5 mins, grade 4 LOC 5-10 mins, and grade 5 LOC >10 mins. Otherwise treatment and follow-up were pretty much the same on grade 3-5. Is this why any LOC was just grouped into group 3? Quote Link to comment Share on other sites More sharing options...
maryfran123 Posted June 30, 2006 Share Posted June 30, 2006 AJ-- I'm not familiar with a class 1-5. The major societies of Trauma, AAN(neurology), Neurosurgery and the CDC use grades 1-3. Sean, good initial list of PCS sxs. Anyone know any others? thanks for not cheating on the GCS sean:D :p BTW, how is the GCS scored differently in Peds? Actually, we tell pt's that sustain sequlae of traumatic brain injury that it can take a year to recover. However, a majority of pts will have their PCS resolve in the first 2 wks and up to 95% within 6wks. It helps reassure pts ALOT to know that their sxs will likely get better on their own in this time frame. Anyone else with answers to the other parts of the question? You're doing great!!! Quote Link to comment Share on other sites More sharing options...
JenGintheED Posted June 30, 2006 Share Posted June 30, 2006 I don't know why, but I love the GCS. It's a scale to measure level of consciousness after head trauma, although in EMS we would use it for any pt with ALOC. Actually, the score is the sum of three scales: best eye response 4 = spontaneous eye opening 3 = opens to verbal stimuli 2 = opens to painful stimuli 1 = no eye opening best verbal response 5 = normal speech 4 = confused but appropriate speech 3 = inappropriate speech 2 = sounds, not words 1 = no sounds best motor response 6 = normal purposeful movement 5 = localizes to pain 4 = withdraws from pain 3 = abnormal flexion (decorticate posturing) 2 - abnl extension (decerebrate posturing) 1 = no movement best score is 15, worst is 3. unless score is 15 or 3, it should be reported broken down and not as a sum.... not "GCS=8" but "GCS: E4 V1 M3" GCS of 13-15 is associated with a possible mild TBI 9-12 moderate TBI 8 or less severe TBI The peds scale is the same except for verbal... best verbal response 5 = infant babbles or coos as normal 4 = irritable infant cries a lot 3 = cries to pain 2 = moans to pain 1 = no sounds Sean, I guess I'm in good company. I don't remember most of my senior year of high schoolafter being ejected from a car. :p Quote Link to comment Share on other sites More sharing options...
maryfran123 Posted June 30, 2006 Share Posted June 30, 2006 Great job on the GCS, including the Peds verbal. LA--actually, we do say "GCS 11" or whatever it is and then do the breakdown but that is just us. Remember to use the pt's BEST response is all 3 categories, not the most consistent response. A pt that is intubated highest score is usually "11T" --T standing for tube/intubated and infers that you are unable to assess verbal. Motor score on the GCS is typical the portion used for prognosis after TBI. The higher the motor score on presentation the more likely it is the pt will have a good outcome. Anyone want to try and make a list of post concussive sxs? Quote Link to comment Share on other sites More sharing options...
JenGintheED Posted June 30, 2006 Share Posted June 30, 2006 Not to hijack the thread but since you're pimping us on trauma... does anyone use the revised trauma score anymore? That was what we used in my first EMS job but I haven't seen it used anywhere since. Quote Link to comment Share on other sites More sharing options...
maryfran123 Posted June 30, 2006 Share Posted June 30, 2006 We use the RTS as part of our trauma registry and PI process It is not part of our initial evaluation. Quote Link to comment Share on other sites More sharing options...
ajnelson Posted June 30, 2006 Share Posted June 30, 2006 Post concussive symptoms that I can think of off the top of my head: nausea, vomiting, memory loss, HA, dizziness, tinnitis, anxiety, depression, insomnia and irritablility. I do remember that if there are any motor sx, it is a more severe head injury. Quote Link to comment Share on other sites More sharing options...
maryfran123 Posted July 1, 2006 Share Posted July 1, 2006 Post concussive symptoms that I can think of off the top of my head: nausea, vomiting, memory loss, HA, dizziness, tinnitis, anxiety, depression, insomnia and irritablility. I do remember that if there are any motor sx, it is a more severe head injury. __________________ Aj-- Good list!! Lets expand it to include: anosmia(loss of sense of smell), vertigo, congitive deficits including short term memory loss, decreased attention span, word finding difficulty, anger/rage, difficulty processing new information, easy mental and/or physical fatigue, decreased libido, apathy, new difficulty completing work or school assignments, easy distractability, sensitivity to light/noise, feelings of being in a "fog", impaired balance/coordination, any sleep disturbance, and numbness/paresthesias not in a specific dermatome. This is essentially the list I run with our concussion/TBI patients when we see them in clinic. It is also a good idea to talk to a spouse/partner/family member/parent because with changes in personality, pts can have a lack of insight regarding these sxs. Quote Link to comment Share on other sites More sharing options...
JenGintheED Posted July 1, 2006 Share Posted July 1, 2006 QAD from open-er.com: Q: Although a Type I Salter-Harris fractureproduces a separation through the physis the risk for any growth disturbances is low. Why? Quote Link to comment Share on other sites More sharing options...
merseur Posted July 1, 2006 Share Posted July 1, 2006 OMG, Im having a brain fart. My brain is mooosh from studying. Anyway, I think its because SH1 is limited to the physis and does not involve the epiphysis and metaphysis. The injury dont interfere with bone growth. Quote Link to comment Share on other sites More sharing options...
Guest jennie783 Posted July 2, 2006 Share Posted July 2, 2006 QAD from open-er.com: because it is a separation of the joint the sh1 doesn't actually involve any cracks in the epiphysis or metaphysis it doesn't actually cause a disturbance in the growth plate where the cells are active. Quote Link to comment Share on other sites More sharing options...
ajnelson Posted July 2, 2006 Share Posted July 2, 2006 Since I got a different question of the day yesterday, I thought I'd share mine as well: In what 2 circumstances may naloxone (Narcan) not be effective? Quote Link to comment Share on other sites More sharing options...
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