EM Flashcards
1
Q
Indications for definitive airway (4)
A
- Failure to maintain patent airway - obstruction, burn, angioedema, penetrating trauma, foreign body, epiglottitis, severe maxillofacial trauma
- Loss of protective reflexes - inadequate gag, lack of spontaneous swallowing, inability to handle secretions, GCS<8 (not dt rapidly reversible cause)
- Failure of adequate oxygenation/ventilation - hypoxemia unresponsive to supplemental O2, hypercapnia (may be dt ↓ resp drive, sedatives), or peripheral process (GBS, MG)
- Anticipated clinical deterioration - status epilepticus, multiple traumas +/- head injury, overdose (e.g. TCA), tiring asthmatic
2
Q
6 P’s of rapid sequence intubation (RSI)
A
Preparation Preoxygenation - 3 min 100% NRB or 6 vital capacity breaths Pretreatment Paralysis + Induction Placement of tube Postintubation management
3
Q
Medications (and doses) for RSI pretreatment (3)
A
Lidocaine - given with ↑ intracranial or intraocular pressure and bronchospasm; 1.5mg/kg IV
Fentanyl - mitigates tachycardic response to intubation in dissection, CAD/ 3 µg/kg IV
Atropine - consider for symptomatic bradycardia, doesn’t consistently prevent reflex bradycardia in peds; 0.02mg/kg IV
4
Q
Induction medication for RSI: Etomidate
- Benefit
- Side effect
- Dose
A
Etomidate - Imidazole derivative
- Benefit: ↓ ICP, hemodynamically neutral
- SE: Brief myoclonus, ↓ cortisol
- Dose: 0.3mg/kg IV
5
Q
Induction medication for RSI: Ketamine
- Benefit
- Side effect
- Dose
A
Ketamine - PCP derivative
- Benefit: Bronchodilator, dissociative amnesia, short-acting, preserves respiratory drive (awake intubation) safe in head injuries
- SE: ↑ secretions, ↑ HR, emergence phenomenon
- Dose: 1-2 mg/kg IV
6
Q
Induction medication for RSI: Midazolam
- Benefit
- Side effect
- Dose
A
Midazolam - benzodiazepine
- Benefit: ↓ ICP, anticonvulsant effects
- Side effect: Negative inotropy → ↓ BP
- Dose: 0.1-0.2 mg/kg IV
7
Q
Induction medication for RSI: Propofol
- Benefit
- Side effect
- Dose
A
Propofol - GABA agonist
- Benefit: ↓ ICP, ↓ airway resistance, short onset and duration of action
- Side effect: Negative inotropy, vasodilation → ↓ BP, apnea
- Dose: 1.5-3mg/kg IV
8
Q
Paralytic agent for RSI: Succinylcholine
- Time to onset
- Duration
- Complications
- Dose
A
Succinylcholine - Depolarizing agent
- Time to onset: 45-60s
- Duration: 5-9min
- Complications: HyperK, fasiculations, trismus, ↑ ICP/IOP, malignant hyperthermia, prolonged action if ↓ pseudocholinesterase activity
- Dose: 1.5mg/kg IV
9
Q
Paralytic agent for RSI: Vecuronium
- Time to onset
- Duration
- Complications
- Dose
A
Vecuronium - nondepolarizing agent
- Time to onset: 2-4min
- Duration: 40-60min
- Complications: prolonged action in obese/elderly/hepatorenal dysfunction
- Dose: 0.1mg/kg IV
10
Q
Paralytic agent for RSI: Rocuronium
- Time to onset
- Duration
- Complications
- Dose
A
Rocuronium - nondepolarizing agent
- Time to onset: 1-3min
- Duration: 30-45min
- Complications: tachycardia
- Dose: 1mg/kg IV
11
Q
Risks for hyperkalemia?
What paralytic agent do you avoid?
A
- NM disease (ALS, muscular dystrophy, myasthenia gravis)
- Skeletal muscle denervation (stroke, spinal cord injury), major burn, prolonged abdominal sepsis >5d
- Multiple trauma: from 3d to 6mo
- H/o malignant hyperthermia
** AVOID SUCCINYLCHOLINE
12
Q
Salter type I
Growth disturbance?
Treatment?
A
Fracture extends through epiphyseal plate → displacement of epiphysis (may appear merely as widening of the radiolucent area representing growth plate)
Usually no growth disturbance
Tx: Closed reduction and immobilization
13
Q
Fracture extends through epiphyseal plate → displacement of epiphysis (may appear merely as widening of the radiolucent area representing growth plate)
Usually no growth disturbance
Tx: Closed reduction and immobilization
A
Salter type I
14
Q
Salter type II
Growth disturbance?
Treatment?
A
Fracture extends through epiphyseal plate, resulting in displacement of epiphysis + a triangular segment of metaphysis is fractured (Thurston Holland sign)
3/4 of all epiphyseal fractures
Usually no growth disturbance
Tx: Closed reduction and immobilization
15
Q
Fracture extends through epiphyseal plate, resulting in displacement of epiphysis + a triangular segment of metaphysis is fractured (Thurston Holland sign)
3/4 of all epiphyseal fractures
Usually no growth disturbance
Tx: Closed reduction and immobilization
A
Salter type II
16
Q
Salter type III
Growth disturbance?
Treatment?
A
Fracture line runs from the joint surface through epiphyseal plate and epiphysis
Involves germinal layer, therefore growth disruption is common
Tx: ORIF
17
Q
Fracture line runs from the joint surface through epiphyseal plate and epiphysis
Involves germinal layer, therefore growth disruption is common
Tx: ORIF
A
Salter type III
18
Q
Salter type IV
Growth disturbance?
Treatment?
A
Fracture line runs from joint surface through epiphyseal plate and epiphysis but also passes through adjacent metaphysis
Involves germinal layer, therefore growth disruption is common
Tx: ORIF
19
Q
Fracture line runs from joint surface through epiphyseal plate and epiphysis but also passes through adjacent metaphysis
Involves germinal layer, therefore growth disruption is common
Tx: ORIF
A
Salter type IV
20
Q
Salter type V
Growth disturbance?
A
Crush injury of the epiphysis. May be difficult to determine by radiographic examination. Suggested by mechanism of injury and pain over epiphysis. Diagnosis can be established by MRI if hemorrhage or hematoma is DI’d within the growth plate immediately after injury. Also reported is loss of MRI signal from the cartilage. Rarely diagnosed acutely.
Growth arrest is the rule, manifested by shortening or angulation.
21
Q
Crush injury of the epiphysis. May be difficult to determine by radiographic examination. Suggested by mechanism of injury and pain over epiphysis. Diagnosis can be established by MRI if hemorrhage or hematoma is DI’d within the growth plate immediately after injury. Also reported is loss of MRI signal from the cartilage. Rarely diagnosed acutely.
Growth arrest is the rule, manifested by shortening or angulation.
A
Salter type IV
22
Q
Classification of open fractures: Grade I Grade II Grade III Grade IIIA Grade IIIB Grade IIC
A
Classification of open fractures:
Grade I - wound <1cm long, punctured from below
Grade II - wound 5cm long, no contamination/crush, no excessive soft tissue loss/flaps/avulsion
Grade III - lg laceration + contamination/crush, frequently includes a segmental fracture
Grade IIIA - involves extensive soft tissue stripping of bone
Grade IIIB - periosteal stripping has occured
Grade IIC - major vascular injury present
23
Q
Antibiotics for open fractures?
A
First gen cephalosporin (Cefazolin)
Add aminoglycosides if grade II or III
24
Q
Amount of blood loss with radius/unla fracture?
A
150-250mL
25
Amount of blood loss with humerus fracture?
250mL
26
Amount of blood loss with Tib/fib fracture?
500mL
27
Amount of blood loss with femur fracture?
1000mL
28
Amount of blood loss with pelvis fracture?
1500-3000mL
29
Neurapraxia
Contusion of a nerve, disruption of the ability to transmit nerve pulses
Paralysis, if present, is transient, and sensory loss is slight. Normal function usually returns to a neurapraxic nerve in weeks to months.
30
Axonotmesis
Crush injury to a nerve, injury to the nerve within the sheath.
Schwann tubes remain in continuity, spontaneous healing is possible but slow
31
Neurotmesis
Severing of a nerve, usually requiring surgical repair.
32
Common nerve injury with distal radius fracture?
Median nerve
33
Common nerve injury with elbow injury?
Median or ulnar nerve
34
Common nerve injury with shoulder dislocation?
Axillary
35
Common nerve injury with sacral fracture
Cauda equina
36
Common nerve injury with acetabulum fracture?
Sciatic
37
Common nerve injury with hip dislocation?
Femoral
38
Common nerve injury with femoral shaft fracture?
Peroneal
39
Common nerve injury with knee dislocation?
Tibial or Peroneal
40
Common nerve injury with lateral tibial plateau fracture?
Peroneal
41
O'Riain wrinkle test
Tests for sympathetic nerve function -- soaking normally innervated digits in warm saline for 20min → wrinkling of digital pulps through a mechanism that is not understood.
Presence of wrinkling probably indicates that nerves are intact.
42
Complex regional pain syndrome type 1
Pain syndrome that develops after an initiating noxious event, extends beyond the distribution of a single peripheral nerve, disproportionate to the inciting event.
Most often distal end of affected extremity, with distal-to-proximal gradient.
Associated with edema, changes in blood flow to the skin, abnormal sudomotor activity, allodynia (pain from non-noxious stimuli), hyperpathia (pain persisting or increasing after mild pressure), or hyperalgesia
43
Complex regional pain syndrome type 2
Pain syndrome that develops after an initiating noxious event, extends beyond the distribution of a single peripheral nerve, disproportionate to the inciting event.
Most often distal end of affected extremity, with distal-to-proximal gradient.
Associated with edema, changes in blood flow to the skin, abnormal sudomotor activity, allodynia (pain from non-noxious stimuli), hyperpathia (pain persisting or increasing after mild pressure), or hyperalgesia
+ demonstrable peripheral nerve injury
44
Long bone fx → restlessness, confusion, AMS, thrombocytopenia, petechial rash, respiratory distress, hypoxia
+/- fever, tachycardia, jaundice, retinal changes, renal involvement
Fat embolism syndrome.
Symptoms appear 1-2 days after acute injury or after intramedullary nailing
Fat is seen in the urine in 50% of pts w/in 3d of the injury
Incidence 0.5-2% of isolated long-bone fractures, 5-10% of pts with multiple fractures.
Supportive management, usually ICU. No specific therapy has shown benefit.
Mortality 20%, most pts recover without severe sequelae
45
Treatment for complex regional pain syndrome?
Multidisciplinary - PT and psychological counseling
Definitive tx - sympathetic blockade, usually with regional anesthesia and occasionally by surgical sympathectomy
Oral meds - bisphosphonates, calcitonin, indomethacin, corticosteroids, tricyclics, gabapentin, acupuncture, spinal cord stimulation, regional nerve blocks, and other meds have variable success.
Vitamin C was shown to ↓ incidence after wrist fracture in 1 study
46
Most common areas for fracture blisters?
What should you be worried about?
Ankle, elbow, foot, knee (in that order)
All contain fewer hair follicles and sweat glands to anchor together the epidermal-dermal junction
** believed to occur in the setting of ↑ underlying tissue pressure and may be harbinger of compartment syndrome
47
Vertical fracture of the neck of the talus with subtalar dislocation and backward displacement of the body.
Mechanism: forced dorsiflexion
Avaitor's fracture
1st described in flyers during WWI. Arises from forced dorsiflexioin of the foot in flying accidents and traffic accidents after a head-on collision
48
Oblique intra-articular fracture of the dorsal rim of the distal radius with displacement of the carpus along with the fracture fragment.
Mechanism: high-velocity impact across the articular surface of the radiocarpal joint, with the wrist in dorsiflexion at the moment of impact.
Dorsal Barton's fracture
49
Wedge-shaped articular fragment sheared off the volar surface of the radius (volar rim fracture), displaced volarly along the carpus.
Mechanism: high-velocity impact across articular surface of radiocarpal joint, with wrist in volar flexion at moment of impact.
Volar Barton's fracture
aka reverse Barton's fracture - much rarer than dorsal barton's fracture
50
Oblique fracture through base of 1st metacarpal with dislocation of radial portion of the articular surface.
Usually produced by direct force applied to the end of the metacarpal. Dorsal capsular structures disrupted by the dislocation. Marked tenderness along medial base of thumb.
Bennett's fracture
51
Fracture-dislocation of the ankle resulting in the fibula being entrapped behind the tibia.
Rare, produced by a severe external rotation force applied to the force. PE reveals foot severely externally rotated in relation to the tibia
Bosworth fracture
52
Fracture of the neck of the 4th or 5th metacarpal.
Results from striking a clenched fist into an unyielding object, usually during an altercation, or against a wall, out of frustration/anger.
Boxer's fracture
53
Vertebral fracture, usually lumbar, involving posterior spinous process, pedicles, and vertebral body.
Caused by simultaneous flexion and distraction forces on the spinal column, usually associated with use of lap seat belts.
Anterior column fails in tension along with the middle and posterior columns.
May be misdiagnosed as a compression fracture.
Chance's fracture
54
Solitary intra-articular fracture of radial styloid.
Occurs from tension forces sustained during ulnar deviation and supination of the wrist.
Chauffeur's fracture aka Hutchinson's fracture
Name derives from occurrence in chauffeurs who suffered violent, direct blows to the radius incurred while turning the crank on a car, only to have it snap back.
55
Fracture of the tip of the spinous process of the 6th or 7th cervical vertebra
Clay shoveler's fracture.
1st named for Australian clay shovelers who sustained a fx of the spinous process by traction as they lifted heavy loads of clay
56
Fracture of the distal radius with dorsal displacement and volar angulation, +/- ulnar styloid fracture.
Common mechanism?
Colles'
Most common wrist fracture in adults, esp in elderly.
Mechanism: FOOSH
aka silver fork deformity, which accurately describes the gross appearance in the lateral view
57
Trimalleolar fracture
Cotton's fracture
Fx of lateral malleolus, fx of posterior malleolus, and either fx of medial malleolus or disruption of deltoid ligament with visible widening of the ankle mortise on XR
58
Fx of posterior rim of the acetabulum
Dashboard fx
Named for mechanism - seated passenger striking the knee on a dashboard, driving head of femur into the acetabulum
59
Fracture-dislocation of the ankle
Dupuytren's fracture.
Results from external rotation of the ankle resulting in either deltoid ligament rupture or medial malleolus fracture, diastasis of the inferior tibiofibular joint, and indirect fracture of the fibular shaft
60
Fracture of the radial head with dislocation of distal radioulnar joint
Results from longitudinal (axial) compression of the forearm
Essex-Lopresti fracture
61
Fracture of the shaft of the radius with dislocation of the distal radioulnar joint.
Ligaments of the inferior radioulnar joint are ruptured and head of the ulna displaced from ulnar notch of the radius.
Mechanism?
Galeazzi's fracture.
Results from FOOSH, with wrist in extension and forearm forcibly pronated.
Inherently unstable with tendency to redisplace after reduction.
62
Fracture-dislocation of atlas and axis, specifically of pars interarticularis of C2 and disruption of C2-3 junction. Separation occurs between 2nd and 3rd vertebral bodies from anterior to posterior side.
Mechanism?
Hangman's fracture.
Results from extreme hyperextension during abrupt deceleration. Most common cause is forehead striking the windshield of a car duing a collision.
63
Incomplete, angulated fracture of long bones
Greenstick fracture
64
Incomplete fracture characterized by buckling/wrinkling of the cortex.
Appears as a bump at the base/end of long bones
Torus fracture
65
Fracture of the proximal ulna associated with forward dislocation of the head of the radius
Hume's fracture.
Essentially high Monteggia's injury
66
Burst fracture of ring of C1, or atlas.
Mechanism?
Jefferson's fracture.
Axial loading results in shattering of the ring of the atlas. Decompressive type of injury. Associated with disruption of transverse ligament; an unstable injury
67
Maxillary fracture
Le Fort fracture (types I, II, and III)
68
Avulsion fracture of the anterior cortex of the lateral malleolus.
Le Fort-Wagstaffe fracture.
Rare pull-off injury of the fibular attachment of the anterior tibiofibular ligament
69
Fracture located around the tarsometatarsal joint, usually associated with dislocation of this joint.
Lisfranc's fracture.
70
Fracture of the proximal 1/3 of the fibula associated with rupture of the deltoid ligament or fracture of the medial malleolus and disruption of the syndesmosis.
Maisonneuve fracture.
Results from external rotation of the ankle with transmission of forces through syndesmosis; proximally the force is relieved by fracture of the fibula.
71
Fracture of the ilium near the SI joint, with displacement of the symphysis, or a dislocation of the SI joint with fracture of both ipsilateral pubic rami
Malgaigne's fracture. Unstable.
72
Fatigue, or stress fracture of the metatarsal due to repetitive use trauma
March fracture
73
Fracture of the junction of the proximal and middle 1/3 of the ulna associated with anterior dislocation of the radial head.
Mechanism?
Monteggia's fracture.
Usually caused by FOOSH with forced pronation of the forearm, or by direct blow on the posterior aspect of the ulna.
74
Fracture of either radius, ulna, or both.
Nighstick fracture
75
Closed fracture of the radius at the middle third-distal third junciton, without associated ulnar fracture.
Piedmont fracture
76
Bimalleolar fracture, or fracture of distal fibula, 4-7cm above the lateral malleous
Pott's fracture
77
Intra-articular fracture at base of metacarpal, frequently Y or T shaped, or may be severely comminuted.
Produced by axial loading with metacarpal in partial flexion.
Rolando's fracture
worse prognosis than a bennett's fracture
78
Epiphyseal fracture occuring in children or adolescents
Salter-harris fracture
79
Extra-articular fracture of the distal radius with volar displacement of the distal fragment. Usually results from fall with force to the back of the hand.
Smith's fracture.
Reverse of Colles' fracture and more uncommon. Sometimes referred to as "garden spade" deformity.
80
Avulsion of the ulnar corner of the base of the proximal phalanx of the thumb.
Bony equivalent of rupture of the ulnar collateral ligament, or "gamekeepers thumb"
Stener fracture
81
Wedge-shaped fracture of the anteroinferior portion of the vertebral body, displaced anteriorly.
Teardrop fracture.
Commonly involves ligamentous injury and may produce neurologic injury.
82
Triangular metaphyseal fragment that accompanies the epiphysis in Salter-Harris type II fractures.
Thurston Holland's fragment
83
Isolated avulsion fracture of the anterolateral aspect of the distal tibial epiphysis.
Occurs in older adolescents (12-15yo) after medial parts of the epiphyseal plates close, but before the lateral part closes. External rotation force places stress on anterior talofibular ligament.
Tillaux fracture
84
What nerve (and nerve roots)?
Extends wrist and MCP joints
Abducts and extends thumb
How does it enter the hand?
Radial nerve (C6-C8)
Passes through supinator muscle, enters dorsal wrist between radial styloid and Lister's tubercle
** Radial nerve is PURELY SENSORY in the hand... motor functions are for extrinsic hand muscles only, no intrinsic muscles
85
What nerve (and nerve roots)?
Innervates abductor/flexor/opponens digiti minimi, interossei, lumbricals to 4th and 5th fingers, adductor pollicis in the hand.
Innervates flexor carpi ulnaris and ulnar 1/2 of flexor digitorum profundus.
How does it enter the hand?
Ulnar nerve (C7, C8, T1)
Passes through flexor carpi ulnaris muscle in forearm. Lies ulnar to artery and superficial to the flexor retinaculum. Enters hand at the wrist through the ulnar tunnel (Guyon's canal)
86
What nerve (and nerve roots) is injured?
Wrist drop, fingers are held in flexion at MCP joints and thumb is adducted
Proximal radial nerve (C6-C8)
87
What nerve (and nerve roots) is injured?
Inability to pinch a piece of paper tightly between thumb and index finger.
Ulnar nerve (C7-T1)
88
What nerve (and nerve roots) is injured?
Clawing of the ring and little fingers; hypertextended at MCP joints by extensor digitorum communis (radial nerve) and flexted at IP joints by FDP (intact proximal ulnar neve) + atrophy of interossei and hypothenar muscles.
Duchenne's sign
Distal ulnar damage (C7-T1)
89
What nerve?
Forearm: Innervates pronator teres, flexor carpi radialis, flexor digitorum superficialis, radial part of flexor digitorum profundus, flexor pollicis longus, pronatur quadratus.
-- What branch innervates abductor pollicis brevis, opponens pollicis, flexor pollicis?
** What branch innervates lumbricals to 2nd and 3rd fingers?
How does it enter the hand?
Median nerve
Enters hand through carpal tunnel with the extrinsic flexor tendons of the digits.
-- Recurrent median nerve
** Common digital branches
90
What nerve is injured and where?
Weakness/absence of flexion of the index finger distal/middle phalanx, thumb flexion, thumb abduction/opposition.
"Apelike" appearance of hand with atrophied thenar eminence
Median nerve in the upper forearm/elbow
91
Loss of sensation to volar tip of 5th digit
Ulnar nerve damage
92
Loss of sensation to volar tip of 2nd digit
Median nerve damage
93
Loss of sensation to dorsal 1st webspace
Radial nerve damage
94
What nerve?
Finger abduction and adduction
Ulnar nerve
95
What nerve?
Wrist extension
Finger extension
Supination
"Thumbs up"
Radial nerve
96
What nerve?
```
Flexion of digits I, II, and III
Thumb opposition
Pincer function
Pronation
"A-OK"
```
Median nerve
97
Prophylaxis for open hand fracture??
Cephalosporin
*** If highly contaminated, treat with PCN + B-lactamase inhibitor AND aminoglycoside
98
Which carpal bones have single vessel supply and are at highest risk for AVN? (3)
Scaphoid
Capitate
Lunate
99
Sequential stages of carpal dislocation (4)
I: scapholunate dissociation
II: perilunate dissociation - dorsal dislocaiton of capitate (+/- scaphoid/radial styloid/capitate fx)
III: triquetrum dislocation +/- volar triquetral fracture
IV: lunate dislocation
100
Tendons affected with de Quervain's disease?
APL and EPB, both within the first dorsal extensor compartment of the wrist.
101
What is in the volar compartment of the forearm?
pronators, hand flexors
Radial, ulnar, anterior interosseus arteries
Median, ulner, superficial radial nerves
102
What is in the dorsal compartment of the forearm?
Extensor muscles of the hand
Posterior interosseus artery and nerve
103
What is in the "mobile wad" compartment of the forearm?
Located in the proximal lateral aspect of the forearm
Brachioradialis
Extensor carpi radialis longus
Extensor carpi radialis brevis
104
Most common elbow fracture in peds
Supracondylar fx
105
Peds supracondylar fx with posterior displacement of the distal fragment.
What type of supracondylar fx?
What is the mechanism?
Extension-type supracondylar fx
Hyperextension injury to elbow incurred from a FOOSH: olecranon is forcefully driven into the olecranon fossa, forces concentrated in supracondylar area → failure of anterior cortex and posterior displacement of distal fragment
95% of supracondylar fractures
106
Peds supracondylar fx with anterior displacement of the distal fragment.
What type of supracondylar fx?
What is the mechanism?
Flexion-type supracondylar fx
Elbow is flexed when it hits the ground, energy transferred from posterior aspect of proximal ulna to distal humerus → supracondylar fx with anterior displacement and failure of the cortex posteriorly
5% of supracondylar fractures (extension more common)
107
Fixed elbow flexion, forearm pronation, wrist flexion, metacarpophalangeal joint extension, interphalangeal flexion
Volkman's ischemic contracture - due to unrecognized ischemic injury (i.e. from supracondylar fx)
108
Ossification centers of the elbow (6)
+ approx year of ossification
```
CRITOE:
Capitellum -- 1y
Radial head -- 3y
Internal (medial) epicondyle -- 5y
Trochlea -- 7y
Olecranon -- 9y
External (lateral) epicondyle -- 11y
```
109
Peds lateral elbow XR:
Capitellum is posterior to line drawn from anterior edge of distal humerus
What injury is suspected?
Extension-type supracondylar fracture
Normal: lines from anterior distal humerus and from middle of proximal radius should both bisect the capitellum
110
Peds elbow:
Annular ligament loosened from head of radius, slipping into radiocapitellar joint and becoming entrapped.
Name of injury?
Mechanism?
Nursemaid's elbow (radial head subluxation)
Axial traction placed on extended and pronated arm.
May also occur when child falls onto outstretched arm, sustains minor direct trauma to the elbow, or simply twists the arm
111
Peds:
Pt refusing to walk and reverting back to crawling
Toddler's fx - oblique distal tibia fx
112
Skeletal injuries concerning for non-accidental trauma (8)
```
Complex skull fractures
Rib fracture
Metaphyseal fracture
Vertebral fracture/subluxation
Midshaft humeral fracture
Scapular fracture
Femoral fracture
```
113
Kocher criteria for pediatric septic arthritis
Fever
Inability to bear weight
ESR >40
WBC >12
3/4 up to 93% of septic arthritis
4/4 99% likelihood
114
Septic arthritis:
Birth-2mo
Most likely organisms? (4)
Treatment?
GBS
S. aureus
GNR
N. gonorrhoeae
Tx: Nafcillin 50mg/kg + Cefotaxime 50-75mg/kg
115
Septic arthritis:
2mo-5y
Most likely organisms? (5)
Treatment?
```
S. aureus
S. pneumo
Strep pyogenes
Kingella kingae
H. flu
```
Tx: Nafcillin 50mg/kg + Ceftriaxone 50mg/kg
Consider Vancomycin 10mg/kg
116
Septic arthritis:
5y-12y
Most likely organisms? (2)
Treatment?
S. aureus
Strep pyogenes
Tx: Nafcillin 50mg/kg + Ceftriaxone 50mg/kg
Consider Vancomycin 10mg/kg
117
Septic arthritis:
12+ yo
Most likely organisms? (2)
Treatment?
S. aureus
N. gonorrhoeae
Tx: Nafcillin 50mg/kg + Ceftriaxone 50mg/kg
Consider Vancomycin 10mg/kg
118
Peds hip XR:
Small femoral head compared to other side, widening of medial joint space, subchondral lucent zone (crescent sign), irregular physeal plate, blurry radiolucent metaphysis
Initial stage of Legg-Calve-Perthes disease
119
Peds synovial fluid analysis:
Character: Clear/yellow
WBCs: <200
PMNs: <10
Normal
120
Peds synovial fluid analysis:
Character: Turbid
WBCs: 250-50K
PMNs: 50-70
↓ complement
Juvenile rheumatoid arthritis
121
Peds synovial fluid analysis:
Character: Cloudy/turbid or clear
WBCs: 100-150K
PMNs: 50-70
↑ complement
Reactive arthritis
122
Peds synovial fluid analysis:
Character: Turbid
WBCs: 500-100K
PMNs: >50
Lyme arthritis
123
Peds synovial fluid analysis:
```
Character: Turbid or white/gray
WBCs: 10K-250K
PMNs: >75
↓ glucose
↑ lactate
```
Septic arthritis
124
Septic arthritis:
Birth-2mo
Most likely organisms? (4)
Treatment?
GBS
S. aureus
GNR
N. gonorrhoeae
Tx: Nafcillin 50mg/kg + Cefotaxime 50-75mg/kg
125
Septic arthritis:
2mo-5y
Most likely organisms? (5)
Treatment?
```
S. aureus
S. pneumo
Strep pyogenes
Kingella kingae
H. flu
```
Tx: Nafcillin 50mg/kg + Ceftriaxone 50mg/kg
Consider Vancomycin 10mg/kg
126
Septic arthritis:
5y-12y
Most likely organisms? (2)
Treatment?
S. aureus
Strep pyogenes
Tx: Nafcillin 50mg/kg + Ceftriaxone 50mg/kg
Consider Vancomycin 10mg/kg
127
Septic arthritis:
12+ yo
Most likely organisms? (2)
Treatment?
S. aureus
N. gonorrhoeae
Tx: Nafcillin 50mg/kg + Ceftriaxone 50mg/kg
Consider Vancomycin 10mg/kg
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Peds hip XR:
Small femoral head compared to other side, widening of medial joint space, subchondral lucent zone (crescent sign), irregular physeal plate, blurry radiolucent metaphysis
Initial stage of Legg-Calve-Perthes disease
