High Yield 1 Flashcards

Question

Risk factors for heat stroke

Answer 1

Young or old Dehydration Increased body fat % Overmotivation Heat exhaustion on prev day / cumulative heat load Heat + humidity Poor acclimatization Inappropriate clothing Equipment (pads, helmets) Sickle trait Supplements/ drugs - cocaine, amphetamine, ephedra, BB, diuretics, CCB, TCAs, antihistamines Concurrent illness - viral illness, cardiac dz

Answer 2

Dehydration Electrolyte abnormality CV disease Exercise associated collapse CNS lesion Thyroid abnormality Infection

Answer 3

Fast cooling ASAP Ice tub, move to cool environment, remove excess clothing, apply ice bags to neck, axilla + groin Supine position w/ legs elevated Replace fluids + electrolytes - PO or IV Monitor rectal temp every few mins - remove from ice bath when temp is 38.9 Observe athletes for an hour after temp returns to normal If unstable or if still symptomatic after 1 hr of cooling, transfer to hospital

Answer 4

End organ failure Death Szs CV collapse ARDS Liver failure Kidney failure Rhabdomyolysis DIC

Answer 5

Pre + post exercise hydration, increase electrolyte intake (mainly sodium) Acclimatise (takes 10-14 days) Appropriate clothing Graduated training Manage heat exhaustion on preceding days effectively Provide shade, ice water, misting fans Modify time, intesnity + exposure during hot/ humid weather Gear up in stages Manage “tough” culture (i.e. player pride, tough coaches) Optimise sleep, no alcohol Cold tubs before and after exercise

Answer 6

Stroke 7 days rest or until asymptomatic + labs returned to normal FU 1 wk Begin gradually increasing training in cool environment over 2 week period Gradually increase heat acclimatization Return to comp 2-4 wks after 2 wks asymptomatic training + acclimatization

Answer 7

Exhaustion - 24-48hrs can return to activity, gradually increase intensity + volume

Answer 8

Superficial - partial or complete freeze of skin Deep - involvement of skin + underlying tissue

Answer 9

Cold temp, wind chill, prolonged exposure, high altitude Wet clothing Immersion in water Fatigue Low body fat Alcohol use Extremes of age Underlying medical conditions - sickle anemia, peripheral vascular disease, diabetes, szs, hypothyroidism

Answer 10

Cold temp, wind chill, prolonged exposure, high altitude Wet clothing Immersion in water Prior cold injury Petroleum or oil lubricants Constrictive clothing or shoes Smoking Vasospastic disorders (Raynauds)

Answer 11

Skin that is erythematous, swollen or waxy, white, yellow, blue/ purple Blisters Numbness +/- pain

Answer 12

Shivering, confusion, amnesia, dysarthria, ataxia

Answer 13

Loss of deep tendon reflexes Loss of shivering Muscle rigidity Cardiac arrhythmias Dilated pupils Reduced LOC Hypotension Reduced RR Tachycardia initially then bradycardia

Answer 14

Core body temp Esophageal has greatest accuracy but only to be used when pt airway is secure If not secure, use epitympanic Oral temp inadequate for diagnosis Rectal temp not advised until in warm environment to reduce further cold exposure

Answer 15

Neurovascular status Pliability of tissue - soft tissue = more likely superficial frostbite, hard tissue = more likely deep

Answer 16

MRI or technetium 99 bone scan for frostbite severity + prognosis ECG to assess for arrhythmias (AFib, VF, prolonged PR, QRS + QT intervals, J waves) Lytes, VBG

Answer 17

frostnip, trench foot, chilblains, raynauds

Answer 18

metabolic abnormalities, alcohol ingestion, head injury

Answer 19

Avoid thawing until no further risk of refreezing Immerse affected part in 37-39 degrees Remove wet clothing Rehydration w/ warmed fluids Avoid rubbing skin Monitor + treat concurrent hypothermia In ED Debride white blisters, apply topical aloe vera Blood blisters - apply topical aloe vera Consider tetanus prophylaxis NSAIDs unless CI Intra-arterial plasminogen activator (alteplase) within 6-24hrs of rewarming may decrease amputation rate IV iloprost administered up to 48hrs after rewarming may decrease amputation rate

Answer 20

Remove wet clothing Blankers, dry clothing, move to warm environment Heating pad, hot water bottle to torso - monitor BP d/t risk of hypotension from rapid rewarming Hot drinks In ED Continuous cardiac monitoring Active internal + external rewarming Monitor electrolytes Severe cases in young, otherwise healthy pts may need cardiopulmonary bypass

Answer 21

Event planning based on temperature Proper clothing inc hats, mittens, multiple layers Avoid alcohol Recognise signs + sx of hypothermia + get to shelter

Answer 22

Cardiac arrhythmias Electrolyte + acid-base disorders DIC

Answer 23

Amputation Premature closure of epiphysis in young athletes Autonomic dysfunction of affected extremity Permanent cold sensitivity + susceptibility to cold injury

Answer 24

Male age Young age Low income Unattended children Alcohol or drug use Limited swimming ability Trauma Risky behaviour Shallow water blackout (intentional hyperventilation) Exacerbation of existing conditions (szs, cardiac dz, syncope) Hypothermia Panic/ anxiety

Answer 25

Respiratory (can occur up to 8 hrs after drowning) Increased RR, wheezing, cough, SOB Bronchospasm Neuro (d/t cerebral edema + raised ICP - can be up to 24hrs after injury) Confusion, myoclonic jerks, szs

Answer 26

ABCs C spine precautions O2 15L via NRB Foil blanket (consider removing wet clothing if possible) Transfer to ED NG tube for stomach decompression Monitor for electrolyte abnormalities Suspected hypoxic brain injury - hyperventilation, head elevation, diuretics + muscle relaxants Monitor for min 8 hrs for pts with resp sx following drowning Can be d/c when normal vitals, normal mentation, improving or resolved resp sx, normal lung sounds, normal CXR

Answer 27

CV Arrhythmia (tachycardia, bradycardia, AFib, PEA, asystole) Cardiac ischemia (d/t takotsubo cardiomyopathy, coronary artery spasm, hypothermia, hypoxia) Hypothermia Hypovolemia d/t cold diuresis (vasoconstriction to direct blood to core organs, central volume receptors sense fluid overload, decreased ADH, increase urine production) Atypical PNA Metabolic acidosis (hypoxia + hypoperfusion) Rhabdomyolysis Acute tubular necrosis DIC

Answer 28

Parental supervision Swimming lessons Pool fencing Lifeguards Restricted swimming areas w/ proper signage

Answer 29

2 unprovoked szs that occur >24hrs apart

Answer 30

One continuous sz lasting >5 mins or 2 or more szs where there is no full return to consciousness

Answer 31

Change in muscle tone Convulsions Decreased LOC Staring spells Bladder or bowel incontinence Postictal confusion Todd paralysis Collateral hx Prev seizures + head injuries

Answer 32

Temp Assess for focal neurological deficits (if present, think trauma or tumor) Meningismus signs Papilledema (think raised ICP) Tongue biting Injuries that could have occurred during seizures

Answer 33

Alcohol w/d AV malformation Hypoglycemia Hyponatremia Fever Hepatic failure Substance use or w/d Intracranial swelling Brain tumor Posttraumatic sz Stroke Syncope Uremia

Answer 34

General Support ABCs If in setting of trauma, stabilize C spine Protect pt from injury Keep pt in lateral recovery position Transfer to ED if no known sz disorder Meds Check blood sugar Intra-buccal, nasal or IM benzo (midaz 10mg) If no success, repeat 5 mins later Longterm: If no reversible cause found, start regular med Levetiracetam, phenytoin, valproic acid May need monitoring

Answer 35

First time unprovoked sz Initiation of anti-convulsant For outpt EEG

Answer 36

Should be based on probability of sz occurring, sz type, usual timing of sx occurrance, SE of anticonvulsant meds

Answer 37

Exercise may decrease sz frequency Sufficient + regular sleep Limiting alcohol intake Exercise at high altitudes can cause hypoxia + induce szs

Answer 38

Prev hx of anaphylaxis Time between exposure + sx Sx: Allergic type mediated by IgE Acute onset (mins - hours) Skin or mucosal tissue involvement: lip, throat, tongue swelling, hives, itching, flushing AND: Resp compromise (SOB, wheezing, stridor, hypoxia) CV (hypotension, syncope, incontinence) GI (abdo pain, vomiting) May have hx of less severe reaction previously on exposure Exercise induced anaphylaxis Occurs in response to physical exertion Cold urticaria Reproducible, rapid onset of erythema, pruritus, edema after exposure to cold

Answer 39

Prev allergic reaction to same allergen Coexisting atopic dz, particularly poorly controlled asthma Older age at first reaction to food allergy

Answer 40

Bronchospasm, layngeal edema Hypotension, arrhythmias Urticaria, angioedema

Answer 41

PE MI Airway obstruction Asthma Tension pneumothorax Vasovagal collapse Septic shock Hereditary angioedema Pheochromocytoma Carcinoid syndrome

Answer 42

Support ABCs Remove trigger Epi 1 in 1000 (usual concentration for IM dosing in anaphylaxis) 0.5mg in adult or 0.3mg in child Repeat every 5 mins if sx continue for 3-4 doses 1 in 10,000 is the concentration usually used for IV dosing, i.e. in ACLS WADA requires emergency TUE afterwards if using epinephrine Place pt supine and elevate legs Ventolin if bronchospasm present

Answer 43

Continuous cardiac monitoring + vitals until stable May need aggressive volume resuscitation IV fluids +/- vasopressors for hypotension In volume refractory hypotension, may need continious IV epi Antihistamines for cutaneous sx Diphenhydramine 50mg IV for adults or 1-2mg/kg slow IV pump for kids Steroids may decrease chance of having a biphasic reaction Methylprednisone for severe reactions 125mg IV for adults 1-2mg/kg IV for kids (max dose 80mg) Prednisone for mild reactions 60mg PO adults 4-8mg/kg IV kids

Answer 44

DIC Szs Death

Answer 45

Avoidance of allergen Immunotherapy

Answer 46

Food most common causative agent in kids Meds most common causative agent in adults Other causes: venom, latex, vaccines

Answer 47

Assess blood loss Weakness, numbness, tingling NSAIDs, ASA, antiplatelets, blood thinners Tetanus Determine potential for FB

Answer 48

Nerve + motor function Pulses distal to laceration Cap refill

Answer 49

ABCs Examine Explore for FB Remove devitalized tissue Assess injury to underlying structures Irrigation Clean w/ soap + water Remove FB Irrigate w/ clean tap water Debride wound edges Closure Close all wounds except puncture wounds that can’t be irrigated Local anesthetic Close w/ surgical tape, staples, glue or sutures Dressing Non stick dressing until staples or sutures are removed Meds Tetanus Vaccine needed if: last tetanus shot >5 yrs ago in dirty wound or >10 yrs in clean wound or not received full tetanus primary 5 dose series Abx for open #, exposed tendon, exposed joint

Answer 50

Timing, frequency, severity Quantify amount of blood loss Trauma? Bleeding conditions Use of intranasal cocaine Meds - ASA, anticoagulants, intranasal steroids

Answer 51

Sit in upright position, leaning forward Blow nose to remove clots + FB Examine If no source identified, refer to ENT In trauma: Assess for deformity Palpate bony structures Evaluate EOM + stability of teeth Evaluate for concussion Apply LA + vasoconstrictior (Afrin - lido w/ epi + oxymetazoline) Pinch nose against septum continuously for 15 mins Cold compress

Answer 52

If not stopping - may need cautery LA first Silver nitrate x10s Do not cauterize both sides of septum in same session to reduce risk of septal perforation If still not stopping, consider packing Nasal tampon, lubricated Leave in place for 1-5 days If >24hrs, give abx to prevent toxic shock syndrome If posterior bleed, refer to ENT +/- balloon insertion

Answer 53

Septal hematomas, abscesses, pressure necrosis, sinusitis

Answer 54

Refrain from heavy lifting, blowing or picking nose No alcohol Nasal saline rinses FU w/ PCP to investigate underlying cause If recurrent epistaxis, should have XR + nasal endoscopy to r/o neoplastic lesion

Answer 55

Temporal skull # causing bleeding of middle meningeal artery is most common

Answer 56

MVA, falls, assaults

Answer 57

Lucid interval - altered consciousness then improvement then deterioration

Answer 58

Neuro exam - serial GCS Examine skull for #

Answer 59

Once C spine cleared, elevate head of bed to 30 degrees Maintain systolic BP >100 Main temp between 36-38 Consider sz prophylaxis w/ phenytoin If signs of increased ICP, consider mannitol or hypertonic saline Refer to neurosurg If above measures not working, could consider drilling burr holes

Answer 60

State you would use a SCAT card to ask about symptoms Get collateral from parent or coach Mechanism of injury Protective equipment (helmet, mouth guard, neck guard) LOC? If yes how long, Amnesia? Szs? Current symptoms? Improving or worsening? Aggravating factors Sensory sx Physical symptoms (HA, dizzy, n/v, gait unsteadiness, slow to respond, slurred speech, HA with exertion, seeing stars, visual disturbance, ringing in ears) Cognitive symptoms (confusion, amnesia, disorientation, poor concentration, memory disturbance, feeling dinged or dazed, sleep/ wake issues) Emotional symptoms (depression, moodiness, irritable, personality or behavioral change) Past Hx of Concussion (#, dates, length of recovery, sx, LOC, ER, MD, CT/MRI, time off sports) Work/ school functioning

Answer 61

C spine exam BESS 3 tests lasting 20s each Feet together Single leg stance on non dominant foot Heel toe tandem stance with non dominant behind SCAT 6

Answer 62

CT head if concern of structural damage X-ray if concern of associated injuries (facial #, C-spine)

Answer 63

Subdural hematoma Epidural hematoma Intraparenchymal hemorrhage Second impact syndrome (cerebral edema + raised ICP following 2nd impact to head after prev unhealed concussion) Trauma induced migraine C spine injury

Answer 64

Immediate No return to play on same day or if symptomatic Monitor for deterioration (focal neuro deficit, declining mental status or LOC, uncontrolled vomiting) Advice Avoid noisy areas with excessive stimulation, avoid bright lights (sunglasses) Tylenol for HA but avoid NSAIDs Avoid alcohol & drugs Healthy nutrition, regular sleep pattern Continue to participate in team functions & activities to maintain a connection to the team, avoid isolation Rest 24-48 hrs Adjunctive therapy Consider PT/massage for the neck + vestibular sx Osteopath for craniosacral treatment Psychologist especially if prolonged symptoms and struggling with depression, grief, sense of loss, anxiety Regular Follow-up

Answer 65

Simple concussion resolves within 10 days with appropriate post concussion rehab 80% get better in 7-10 days

Answer 66

C-spine tenderness, ↑HA, ↓LOC, ↑tiredness or confusion, lateralizing weakness, Sz, persisting vomiting

Answer 67

>3 concussions increases risk of injuries, mental illness, slowed + prolonged recovery, SU + early Alzheimers Complex has longer lasting symptoms >10days or recurrence of symptoms with exertion Post concussion syndrome

Answer 68

Continued concussion sx after 3 mo Occurs in up to 30% of injuries

Answer 69

Stage 1 - complete mental + physical rest, no school Once sx free x24 hrs, move to stage 2 Stage 2 - return to school w/ academic accommodations Limit tech use No tests, PE, band or chorus Avoid heavy backpacks Rest at home Once sx free x24 hrs, move to stage 3 Stage 3 - increase workload gradually, full time school if possible, light aerobic activity Once sx free x24 hrs, move to stage 4 Stage 4 - resume normal school activities

Answer 70

Stage 1 - complete mental + physical rest, no school Once sx free x24 hrs, move to stage 2 Stage 2 - light aerobic exercise (walking, swimming, cycling) HR <70% - 15 mins Once sx free x24 hrs, move to stage 3 Stage 3 - sport specific exercise Simple drills, no impact activity HR <80% - 45 mins Once sx free x24 hrs, move to stage 4 Stage 4 - no contact training Complex drills, resistance training HR <90% - 60 mins Once sx free x24 hrs, move to stage 5 Stage 5 - full contact practice Once sx free x24 hrs, back to full practice + play

Answer 71

2 types: primary exercise headache (PEH) + “weight lifters headache” (form of primary cough headache) Primary exercise headache = lasts longer, results from more sustained intense exercise, not associated w/ valsalvas Weight lifters headache = short lasting, results from Valsalva

Answer 72

Screen time: Computer use, TV, video games Aggravated by dehydration, heat, fatigue, extreme exercise R/O RF: confusion, disorientation, szs, numbness or focal weakness, amnesia, speech impairment, visual changes, N/V Personal + family hx of migraines, bleeding disorders or blood clots

Answer 73

PEH Brought on by exercise Bilateral, throbbing, can turn into migraine if pt is susceptible Lasts from 5min-24hrs Cough headache Induced by exercises like lifting, bending over Often occipital/ neck region Lasts only minutes Sharp or stabbing

Answer 74

Neuro exam Head & Neck Exam inc fundoscopy Evaluate for meningismus SCAT Card if concern of concussion

Answer 75

CT head if any focal neuro signs or concern for lesion or stroke MRI head if thinking weight lifters HA Ottawa SAH Rule for HA New, severe, atraumatic HA reaching maximum intensity within 1 hr should be evaluated w/ CT + LP if CT normal and high suspicion remains

Answer 76

Migraine Concussion External compression HA (eg. Swimming goggles, mask squeeze) SAH High altitude HA Cervicogenic HA Tension HA Tumor TMJ (especially with diving) Cervical artery dissection Viral illness AVM

Answer 77

Avoid provoking activity NSAIDs for treatment or prevention Indomethacin or ergotamine can be used prior to activity or propranolol for prevention long term Diary of symptoms & triggers Consider PT/massage for the neck Healthy nutrition, regular sleep pattern Avoid caffeine & Etoh Avoid exercising in extreme temperatures (hot and cold) Sudden severe HA w/ exercise - go to ED

Answer 78

High altitude Hot weather Dehydration Extreme exercise Alcohol and caffeine consumption

Answer 79

50% of pts w/ PEH have personal or fam hx of migraine 50% of pts with cough headache have a space occupying lesion of posterior fossa (usually Chiari type 1 malformation)

Answer 80

Unilateral headache with neck, shoulder and arm pain Starting in neck and spreading to head Triggered by neck movement Associated with nausea, vomiting, dizziness, blurred vision, photophobia

Answer 81

Reduced C spine range of motion Symptoms on palpation of head or neck Anaesthetic blockade abolish pain

Answer 82

MOI - penetrating trauma (velocity, type of material, size) Diplopia, blurred vision, photophobia Flashing lights, floaters Pain C spine pain, LOC, HA Prev facial/ nasal # Facial protection Glasses/ contacts Prior vision issues Tetanus status

Answer 83

Remove contacts CN exam inc visual acuity, EOM + sensation to skin Impaired downward gaze - inferior rectus or oblique muscle entrapment Pupil exam inc light response Examine head, scalp, face, orbital area Palpate orbital rim External eye structures - conjunctiva, cornea (blood, swelling, FB) Use fluorescein + cobalt blue light - abrasions will appear green IOP with Tono-Pen Fundoscopy - defer if vision significantly abnormal (as ophtho will do) Red reflex Slit lamp Assess cornea, anterior chamber, iris, lens If unavailable, use pen light to look for hyphema, laceration + shrunken appearing globe Evert upper eyelid

Answer 84

Subconjunctival hemorrhage (reddened, painless) Conjunctival laceration (pain, redness) Corneal abrasion (pain + FB sensation) Corneal laceration (severe pain, sensitivity to light, blurred vision, vision threatening) Globe rupture (vision loss, pain, eye deformity, vision threatening) Hyphema (blurred vision, light sensitivity, vision threatening) Retinal detachment (floaters, flashes, dark curtain, vision threatening) Orbital rim # (impaired upward gaze)

Answer 85

No RTP Systemic analgesics (no NSAIDs) Consider patching for comfort Elevate head at least 30 degrees at all times, pt should not lie flat Cold packs x48 hrs Nasal decongestants, avoid blowing nose or valsalva movements Refer to ophtho Tetanus shot if abrasions

Answer 86

Treat w/ chloramphenicol 0.5% ointment q2hrs x2 days then q4H x3 days + padding of eye Topical cyclopegics for photophobia (2% homadropine)

Answer 87

Noncontact sport - 2 wks Contact sport - 4-6 wks

Answer 88

Severe eye pain, persistent blurred or double vision, persistent photophobia suspected penetrating injury, embedded foreign body, hyphema, marked impaired visual activity, loss of parts of visual field

Answer 89

If they involve lid margins or lacrimal duct or if suspicion of penetrating injury

Answer 90

Can be associated w/ intracranial bleed or orbital roof #

Answer 91

Blood accumulating in anterior chamber from ruptured iris vessels. Can be microscopic and only visualised on slit lamp. Can be associated w/ increase in IOP. Optic atrophy + secondary hemorrhage can occur. Treatment is relative rest, eye patch.

Answer 92

Can be from direct blow to eye or back of head, or from straining. Central retinal damage causes blurred vision. Sx can include sudden increase in flashes or floaters. Refer to optho

Answer 93

Tenderness of orbital margin, reduced upward eye movement, double vision, nose bleed, reduced sensation in cheek

Answer 94

Assess for eyelid laceration Topical anesthetic (tetracaine) if no globe perforation suspected Irrigate eye, if superficial FB can use cotton tipped applicator to try and remove If deep or penetrating; place hard shield over eye + refer to ophtho

Answer 95

Check for concussion Epistaxis Prev facial/ nasal #

Answer 96

Nasal deformity Nasal obstruction Periorbital swelling + ecchymosis Palpate nasal bones for deformity + crepitus Palpate all bony structures of face inc teeth Ring test (collect fluid from nose onto filter paper - if a clear ring of CSF diffuses out beyond central area of blood = CSF leak) Visualise anterior septum w/ nasal speculum or otoscope Probe w/ finger or cotton tip, feeling for swelling, fluctuance, widening of septum Blood clots adjacent to septum should be evacuated Hematomas are soft and compressible Ensure absence of CSF leak Hematoma appears as a bluish red bulge from septum to nasal vestibule or as asymmetric mucosal fold Control bleeding w/ direct pressure + topical decongestants or cautery in order to adequately visualise septum Septal hematomas do not shrink w/ decongestants

Answer 97

Reduction If nose grossly displaced consider immediate reduction Most cases require referral to specialist within 3-7d for reduction (open or closed) May not need reduction of non displaced Defer surgical tx until cessation of “high risk” activities

Answer 98

If hematoma present, needs needle aspiration or sharp I+D following by suction of clot Place drain/ wick if abscess suspected Bilateral anterior nasal packing to prevent recurrence x2-4 days Systemic abx w/ clindamycin or amox-clav

Answer 99

Persistent rhinorrhea should raise suspicion for cribriform damage + CSF leak CT + ENT referral urgently

Answer 100

Hematoma (usually from an inferior blow) Hematoma can lead to pressure necrosis or abscess Cartilage destruction, collapse of nasal dorsum or saddle nose deformity can occur

Answer 101

Sx: epistaxis, nasal deformity/ swelling, ecchymosis, pain, difficulty breathing through one/ both nostrils Can occur up to 14 days after trauma Close FU needed w/ ENT Children should be followed for 1 yr for cartilagenous changes RTP once nasal packing removed

Answer 102

Hematoma between skin and perichondrium - can become fibrotic within 2 wks. Use ice + compression and aspirate hematoma

Answer 103

No contact 1-2 wks RTP w/ nasal protective device for another 4 wks following initial trauma Extended to 6 wks if surgery needed 10-12 wks for combat sports

Answer 104

Pain Temperature sensitivity Color changes Inability to chew Force + velocity of injury Past dental hx

Answer 105

1 = enamel fracture only Chipped tooth feels rough, may go unnoticed 2 = enamel + dentin # Exposure of yellow dentin Pain w/ exposure of dentin to air, touch, cold 3 = enamel, dentin + pulp Dental emergency (within 3 hrs) Exposure of red-pink pulp 4 = root # Dental emergency (within 3 hrs)

Answer 106

Head + neck exam Palpate mandible, zygoma, TMJ, mastoid Check jaw movement Chin laceration - think C spine! Intraoral exam - teeth, tongue, gums, buccal mucosa

Answer 107

XRs Maxillary or mandibular teeth injury = 2x periapical views at different angles, lateral anterior view If SOB, hemoptysis or missing tooth = CXR Mandibular or condylar # = panoramic XR Negative XRs may be repeated 1-2 days later Post reduction views also needed

Answer 108

Analgesia - 1ml lidocaine into buccal mucosa over injured tooth; avoid oral meds initially d/t risk of swallowing blood + fragments of teeth Locate all teeth or tooth fragments, handle only by crown Irrigate with sterile saline or milk Replant tooth ASAP unless pt obtunded (firmly reinsert tooth into socket then get pt to bite gently on gauze to set tooth in) Transport immediately to dental office or ED w/ on call dentist Place nonimplantable teeth or fragments in milk, sterile saline solution (can last up to 6 hrs) Forceful blow: Luxated tooth should be repositioned to the original site using firm finger pressure/bite on sterile gauze and splinted with aluminum foil prior to dental referral - should be splinted for 2-4wks Enamel chip fractures are not painful and require non-urgent dental referral - fragment may be reattached with bonding or resin 5-10 days of abx (penicillin or clindamycin) in case of exposed pulp or avulsion Tetanus Soft/ liquid diet for a timeP

Answer 109

Properly fitted custom made mouth guard, consider bimaxillary guard which covers upper + lower teeth but make breathing + speech difficult Face masks in hockey + football Rinse mouth guard w/ antiseptic mouth wash Regular dental check ups

Answer 110

Primary Survey C spine - pain at rest? Tenderness? Airway - ask pt’s name, MOI (is airway patent?) Breathing - check BP, HR, RR, sats, temp, glucose Circulation - HR, CRT Secondary survey Head + neck - GCS, PEARL, EOM, TM, movement + sensation x4 limbs, strength (flex/ ex wrists + ankles), palpate skull + facial bones Chest: inspection, auscultation, palpation, hematoma Abdomen: inspection, auscultation, palpation Palpate every bone Roll and palpate C-L spine and check rectal tone Pelvic stability Check helmet

Answer 111

Stabilise C spine Remove helmet - 1 person holding C spine ant-posteriorly, one person removes helmet + then places rolled up towel or block under head Realign head into neutral position - if causing any pain, muscle spasm or neuro signs, immobilise head in position found. Hold manual inline stabilization Realign spinal column into neutral position Stabilize on RSB Once on board, convert to external stabilisation with head blocks

Answer 112

AP (vertebral bodies + intervertebral spaces) Lateral (zygapophyseal joints, soft tissue structures, spinous processes) Odontoid (C1 + C2) Oblique (intervertebral foramina) Swimmer’s view (C7-T1 junction)

Answer 113

Measure neck height from jaw line to trap using flat hand

Answer 114

C5 - axillary

Answer 115

C5 - musculocutaneous

Answer 116

C7 - radial

Answer 117

C6-7 - radial

Answer 118

C6-7 - median

Answer 119

C8 - median

Answer 120

C7 - radial (posterior interosseous)

Answer 121

T1 - ulnar

Answer 122

L2-3 - femoral

Answer 123

L3-4 - femoral

Answer 124

L4 deep peroneal

Answer 125

L5 inferior gluteal

Answer 126

S1 - sciatic

Answer 127

S1 - tibial

Answer 128

Paralysis in hands, arms, trunk, legs May be unable to breathe, cough or control bladder or bowels Ability to speak can be impaired Requires 24/7 care

Answer 129

Can raise arms + bend elbows Paralysis of wrists, hands, trunk, legs Can speak + use diaphragm Breathing weakened Needs assistance w/ ADLs but can move in power wheelchair

Answer 130

Nerves affect wrist extension Paralysis in hands, trunk, legs Able to bend wrists back Can speak + use diaphragm Breathing weakened Can move in and out of bed + wheelchair w/ assistive equipment May be able to drive adaptive vehicle Little voluntary control of bowel or bladder

Answer 131

Nerves control elbow extension and some finger extension Most can straighten arm and have normal movement of shoulders Can do most ADLs solo May be able to drive Little voluntary control of bowel or bladder

Answer 132

Nerves control some hand movement Should be able to grasp + release objects Can do most ADLs solo May be able to drive Little voluntary control of bowel or bladder

Answer 133

Nerves affect muscles, upper chest, mid back + abdo muscles Arm + hand function normal Injuries affect trunk + legs Likely use manual wheelchair Can stand in standing frame, may be able to walk w/ braces

Answer 134

Nerves affect muscles of trunk Normal upper body movement Fair to good control + balance of trunk in seated position Should be able to cough Little voluntary control of bowel or bladder Can stand in standing frame, may be able to walk w/ braces

Answer 135

Loss of function in hips + legs Little voluntary control of bowel or bladder May need wheelchair or braces

Answer 136

Loss of function in hips + legs Little voluntary control of bowel or bladder Most can walk

Answer 137

Spinal “shock” = transient areflexia, flaccid paralysis, anesthesia - resolves with time Neurogenic shock = hypotension, bradycardia

Answer 138

Complete cord injury Reduced sensation + power at next caudal level to injury and absent sensation + power in levels below Acute - areflexia, flaccid muscle tone, priapism in males, urinary retention + bladder distension Incomplete spinal cord injury Various degrees of motor + sensory function, sensory function usually more preserved Level of injury determined by finding lowest segment of cord with power >3 bilaterally, with intact sensation + power (5/5) above this level Central cord syndrome Occurs after trauma in setting of pre-existing cervical spondylosis Greater motor impairment in upper compared with lower extremities, bladder dysfunction, variable sensory loss below level of injury Anterior cord syndrome Lesions that affect anterior ⅔ of spinal cord and spare dorsal column Bilateral paralysis/ weakness below level of lesion, bilateral loss of pain + temp sensation below level of injury but intact touch, vibration + proprioception below level of injury Brown-Sequard syndrome Hemisection to ½ of spinal cord resulting in paralysis and loss of proprioception on ipsilateral side as injury and loss of pain and temp sensation on contralateral side of lesion

Answer 139

High risk factor present? Age >65, extremity paraesthesias or dangerous mechanism (fall from >3ft, axial load injury, high speed MVC, bike collision, motorized recreational vehicle) if yes - needs imaging If no: Low risk factor present? Sitting position in the ED, ambulatory at any time, delayed (not immediate onset) neck pain, no midline tenderness. Simple rearend motor vehicle collision (MVC) If not - needs imaging. If yes - able to actively rotate neck 45 degrees left + right? If yes - C spine cleared If not - needs imaging

Answer 140

GCS <15 Age <16 Unstable vitals Known vertebral dz Acute paralysis Pregnant Prev C spine surgery

Answer 141

Short term rest Cryotherapy within 36-48hrs can be helpful Protection against flexion with an orthosis for 4-6 wks RTP once # is healed and pt has full painless ROM and no neuro deficits

Answer 142

Avulsion type injuries from contraction of trapezius, rhomboid minor, serratus posterior MOI = forced flexion of neck (football, weight lifters)

Answer 143

Visceral injuries, commonly to spleen + liver

Answer 144

Direct trauma

Answer 145

L4 = acetabular # L5 = pelvic ring injuries

Answer 146

Abdo CT d/t risk of visceral, abdo + other ortho injuries

Answer 147

Physical Inspection (wasting? asymmetry? cervical lordosis?) Palpation (prominent vertebrae = C7, occipital region, trapezius, levator scapulae) ROM - flexion (Add extra pressure), extension, then flexion + extension w/ rotation, lateral rotation, side flexion (pain = brachial plexus injury) Spurlings test (radicular pain) - look to side of pain, move neck into extension + then apply axial load Neurological assessment Sensation to lateral deltoid (C5), thumb (C6), middle finger (C7), little finger (C8), medial elbow (T1) power - deltoid (C5), biceps (C5), wrist extension (C6), triceps (C7), claw grip (C8), fingers splayed (T1) Reflexes - biceps jerk (C5), brachioradialis (C6), triceps (C7)

Answer 148

Commonly presents in young adulthood, males>females Chronic, progressive Pain, morning stiffness >30mins in SI + lumbar region that improves w/ exercise but persists at rest Peripheral arthritis (shoulder, knee, hands, wrist, feet) Enthesopathy (iliac crest, ischial tuberosity, greater trochanter, patella, calcaneus/Achilles, tibial tubercle, vertebral bodies) Iritis Pulmonary involvement Constitutional sx like weight loss, fever, malaise, night sweats, night pain, n/v

Answer 149

Spinal exam Peripheral joint exam + major entheses (calcaneus, patella, tibial tubercle) Eye exam Skin exam (signs of psoriasis) Decreased cervical motion (tested w/ occiput to wall test) Increased thoracic kyphosis Decreased chest expansion Decreased lumbar motion (Schober test <5cm)

Answer 150

XR SI joint + lumbar spine MRI to evaluate early inflammatory changes before structural changes are seen on XR HLA-B27 - 90-95% of patients with AS have HLA-B27 CRP or ESR Rheumatologic work-up (RF, ANA, dsDNA, complement, ESR) - these will be negative

Answer 151

Mechanical LBP Myofascial LBP SI joint dysfunction Degenerative disc dz Herniated nucleus pulposus Spondylolysis Discitis Scoliosis Multiple myeloma, bony mets, facet joint arthropathy Fibromyalgia, osteomyelitis, discitis, osteoporosis w/ compression # Vertebral #, lumbar sprain/ strain, visceral organ dz (AAA, pyelo, kidney stones, PID)

Answer 152

AS Reactive arthritis Arthritis w/ IBD Arthritis w/ psoriasis Unspecified spondylitis

Answer 153

Ankylosing spondylitis is present if bilateral sacroiliitis is associated with any single criterion: Low back pain and stiffness for more than 3 months Pain and stiffness in the thoracic region Limited motion in the lumbar region Limited chest expansion History of evidence of iritis or its sequela

Answer 154

Patient should be encouraged to return to their normal activities of daily living as soon as symptoms permit Activity modification & education on proper lifting techniques Lifelong regular physical activity & exercises, healthy body weight, pool exercises to avoid stiffness & pain Breathing exercises for lung capacity Medications NSAIDS - try 2 before moving on. Monitor for GI SE, kidney and hepatic failure TNFi (infliximab, adalimumab) - try 2 before moving on to DMARD. Increased risk of infection - screen for HIV, TB and hepatitis, no live vaccines during treatment DMARDs (sulfasalazine, pamidronate) Interleukin 17a inhibitor (secukinumab) Corticosteroid injections Physiotherapy, core program, postural exercises Massage Refer to Rheumatologist Refer to Ophthalmologist if sx of iritis (anterior uveitis in 20% of patients with temporal association with peripheral arthritis) Surgery

Answer 155

Chronic LBP, buttocks, legs, worsening over time Burning, cramping Standing or walking upright increases sx Unable to walk for long periods but can bike for much longer Relieved by sitting down/ leaning forward/ walking uphill Radiating pain into groin/ testes R/o cauda equina

Answer 156

Spinal exam Broad based gait Abnormal Romberg’s Flexion relieves pain, extension worsens Femoral nerve stretch might be positive if stenosis is at L3/4 Straight leg raise usually negative Examine vascular lower limbs

Answer 157

Vascular claudication Space occupying lesion Scoliosis Disc dz/ herniation Spondylitic dz Multiple myeloma Bony mets Arthritis Fibromyalgia Osteomyelitis Discitis Pyelonephritis Compression # Paget’s dz Lumbar sprain/ strain

Answer 158

NSAIDs Lumbar support Epidural steroid injection Acupuncture Multilevel decompressive laminectomies PT - Core strengthening, good posture and flexibility can slow progression

Answer 159

Neurogenic - worse w/ standing, can walk variable distances, improved w/ change of position, improves after ~10 mins Vascular - can walk a set distance, improves w/ stopping, improves after ~2 mins

Answer 160

Athletes with cervical stenosis are at increased risk of quadriplegia and should not do contact or collision sports - need to be referred to spinal specialist

Answer 161

Stress # of pars interarticularis Cause: repeated hyperextension +/- rotation (gymnastics, cricket, volleyball, tennis, throwing sports) Most common cause of back pain in athletes Commonly L5 and L4 Males > females

Answer 162

Usually asymptomatic, found incidentally Insidious LBP Pain with running + jumping, no pain sitting Pain w/ landing from dismount Pain worse w/ bending and lateral flexion

Answer 163

Spinal exam Tender to palpate Pain with extension Ipsilateral back pain when pt stands on one leg and hyperextends back May feel step off when palpating spinous processes if significant listhesis is present

Answer 164

XR Bone scan +/- CT (SPECT) - can show if lesion is improving or worsening but high radiation dose MRI - good for assessing pars defects + nerve root compression, needed if ?cauda equina but unable to determine if lesion is improving or worsening

Answer 165

Cessation of sports x3mo for symptomatic young pts Bracing (controversial - could be used if initial rest fails) Positive XR but negative bone scan means lesion is chronic and does not need bracing Boston brace Surgery Indicated if rest + brace x6mo has not worked or for cases w nerve compression Direct repair of bilateral pars defects or posterolateral fusion Restricted lumbar extension +/- rotation Core + lumbar strengthening when pain free

Answer 166

Spinal stenosis Tumor Scoliosis Disc dz/ herniation Spondylytic dz Vertebral # Osteoid osteoma or other malignancy Reactive arthritis AS Vertebral osteomyelitis Lumbar sprains + strains Pyelonephritis

Answer 167

Spondylolisthesis

Answer 168

Slippage of one vertebra on another (usually L5 on S1) Associated w/ bilateral pars defects (usually familial predisposition) Usually L5 on S1 Rarely from athletic overuse injuries May be secondary to breakdown of bilateral pars defects, congenital, due to degenerative disease or trauma

Answer 169

Insidious onset LBP, can be intermittent Can have radicular symptoms

Answer 170

AP + lateral XR Standing may worsen apparent slippage Bone scan w/ SPECT

Answer 171

Low grade slips = rest x3mo +/- modified Boston brace (3-6mo) Grade 3 or higher - refer to surgeon for consideration High grade slippage >50% or high slip angle >55 degrees or slip progression may warrant surgery Nerve compression warrants surgery Decompressive laminectomy w/ fusion rest + core strengthening Hamstring stretches Core strengthening Water therapy Pelvic tilt exercises No high speed or contact sports (grade 3 + 4) RTP if pain free >3mo w/ extension after bracing

Answer 172

Family history Sports with extreme spinal motion, especially repetitive hyper extension Growth spurts An atomic variations like spina bifida, scoliosis, increased lumbar lordosis

Answer 173

Less than 7% for adults and less than 7.5% for adolescents

Answer 174

Blood sugar over 13.9 and ketones in urine Blood sugar over 16.5

Answer 175

Should participate in free, unstructured play to improve motor skill development Youth should be encouraged to participate in a variety of sports Children who participate in more hours of sport per week than their age, or who spend more than 16 hours per week in intense training, should be closely monitored for burnout, overuse injury and overtraining Youth can benefit from strength and conditioning Youth specialising in a single sport should have neuromuscular training to reduce injury risk

Answer 176

Social isolation, dependence, burnout, manipulation, overuse injury, compromised growth and maturation

Answer 177

Less lean body mass Higher body fat composition Wider pelvis, increased inward slant of femur and knee more medial Lower maximum cardiac output and VO2 max Higher cardiac work and index, higher exercising heart rate Lower blood volume and hemoglobin

Answer 178

Pain and discomfort in breasts Urogenital symptoms (particularly in cycling) Urinary incontinence Hypermobility PatelloFemoral pain syndrome ACL injuries Anaemia Menstrual dysfunction and contraception RED-S Pregnancy

Answer 179

Those are transition from female to male are eligible to compete in the male category without restriction Those are transition from male to female are eligible to compete in a female category under the following conditions : Athlete has declared that her gender identity is female, the declaration cannot be changed for minimum four years The total testosterone has been below 10 for at least one year prior to her first competition

Answer 180

Schedule at a time of year and day when environmental conditions will not adversely affect health Discuss criteria at which the medical director should have authority to cancel race based on weather conditions, ie using a wet bulb globe temperature Plan the course so that the finish area is large enough to accommodate finishes, Medical and Emergency vehicles First aid stations along the route 3-5km apart Pre-participation screening and qualification standards Pre-race seminars to educate athletes on training, nutrition, fluids, dangers Past medical history on registration forms

Answer 181

Benzos Anti-convulsants Narcotics First generation antihistamines Antiemetics Tricyclic antidepressants Lithium Fluoroquinolone antibiotics Antiarrhythmics Muscle relaxant Corticosteroids Decongestants

Answer 182

Periosteum is thicker in children and has considerable healing potential Articular cartilage of growing bone is thicker in children and can remodel The junction between the epiphyseal plate and metaphysis in children is vulnerable to disruption Tendon attachment sites (apophyses) are cartilagenous plates that are relatively weak and are predisposed to avulsion injuries Children tend to suffer incomplete fractures (green stick)

Answer 183

Adults: sprain of UCL Children: fracture of proximal phalangeal physis (usually salter-harris type 3)

Answer 184

Adults: Children:

Answer 185

Adults: mallet finger (extensor tendon injury) Children: # of distal phalangeal epiphysis (salter harris type 2 or 3)

Answer 186

Adults: # of metacarpal head Children: # of metacarpal epiphysis (salter harris type 2)

Answer 187

Adults: AC sprain Children: # of middle 1/3 of clavicle epiphysis

Answer 188

Adults: quad or hamstring strain Children: apophyseal avulsion of AIIS or ischial tuberosity

Answer 189

Adults: dislocated shoulder Children: # of proximal humeral epiphysis (salter harris type 1 or 2)

Answer 190

Adults: meniscal or ligament injury Children: # distal femoral or proximal tibial epiphysis, avulsion of tibial spine

Answer 191

Adults: lateral ligament sprain Children: salter harris 1 or 2 # of tibia or fibula

Answer 192

Adults: achilles tendonopathy Children: sever's disease

Answer 193

cast immobilisation x4 wks growth disturbance

Answer 194

sling x3 wks vascular compromise of brachial artery, median nerve damage, malalignment

Answer 195

cast, non wt bearing x4-6 wks growth disturbance up to 18mo later

Answer 196

cast, non wt bearing x4-6 wks premature closure of physis can lead to angulation + leg length discrepancy

Answer 197

anatomical reduction long leg cast x4-6 wks growth discrepancies - must be monitored closely

Answer 198

Migraines Female Children + teens Hx of concussion ADHD, learning disabilities, mood disorders

Answer 199

structural hyperkyphosis of the thoracic or thoracolumbar spine that occurs due to abnormal vertebral growth during adolescence. It is the most common cause of hyperkyphosis in teenagers

Answer 200

Rigid thoracic hyperkyphosis that does not correct with extension (unlike postural kyphosis) Possible compensatory lumbar lordosis. Mid back pain, worse with prolonged standing or activity. Stiffness

Answer 201

Teens Fam hx Males High mechanical stress on the spine (e.g., athletes in rowing, gymnastics, weightlifting)

Answer 202

Kyphosis that does not correct with active extension

Answer 203

Physio Bracing (for significant curves) NSAIDs for pain Surgery if severe

Answer 204

Exertional leg pain Cramping, tightness or fatigue of leg w/ exertion Sx resolve w/ rest As it progresses, can get paresthesias in foot

Answer 205

popliteal artery is compressed due to an abnormal relationship with surrounding muscles, usually the gastrocnemius or popliteus. This can lead to vascular insufficiency, particularly in young athletes.

Answer 206

Young, active people Males Repetitive lower limb motion (runners, cyclists) Congenital/ anatomic variations of muscle Muscular hypertrophy

Answer 207

Palpate popliteal and posterior tibial pulse + dorsalis pedis at rest and with active foot movements. Maneuvers to provoke symptoms: Ankle dorsiflexion + active plantarflexion → loss of pulse. Knee flexion + passive dorsiflexion → reproduction of symptoms. Compare pulses bilaterally (asymmetry may be a clue)

Answer 208

Doppler US CT angio Angiography

Answer 209

Activity modification Physio Surgery for muscle resection if sx persist