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Podcast 722: Lower Extremity Dislocations

Emergency Medical Minute

Release Date: 10/19/2021

Mental Health Monthly #9: Suicide Assessment in the ED: Using the ICAR2E Tool show art Mental Health Monthly #9: Suicide Assessment in the ED: Using the ICAR2E Tool

Emergency Medical Minute

Dr. Kim Nordstrom discusses a valuable bedside tool for evidence-based assessment in patients that visit the ED and are at risk for suicidality. Dr. Nordstrom is a practicing emergency psychiatrist and associate professor with the University of Colorado. As a developer and user of the tool, Dr. Nordstrom gives us invaluable insight into a new avenue for psychiatric care in emergency medicine.   Educational Pearls:   An app-based tool made in conjunction with ACEP Identifying suicidal risk for each patient, including assessment of clues like bodily injuries Communicating with...

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Podcast 750: Take Home Naloxone show art Podcast 750: Take Home Naloxone

Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: Think about giving take home naloxone kits for anyone on long-term opioids as well as anyone with an opioid use disorder, those in opioid withdrawal, or those who recently overdosed on opioids Also consider for individuals with non-opioid substance use disorders For patients seen in the ED with an opioid overdose the 1-year mortality is about 5% and 1-month mortality is about 1%  Also 50% of accidental pediatric overdose deaths are due to opioids, so ensuring naloxone is present in the household can save lives Prescriptions have a very...

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Podcast 749: PCC for Me? show art Podcast 749: PCC for Me?

Emergency Medical Minute

Contributor: Nick Tsipis, MD Educational Pearls: Prothrombin complex concentrate (Kcentra)  and Vitamin K are used to reverse life-threatening bleeds in patients on warfarin (Coumadin) Factors II, VII, IX, and X are included in four-factor PCC PCC/Kcentra dosing is 500-2000 units based on INR and patient weight PROPER3 RCT was a non-inferiority trial done to evaluate standardized dosing of PCC/Kcentra versus variable dosing based on INR and weight Looked at end-points to assess hemostasis, but ultimately this trial did not show non-inferiority of standardized dosing compared to variable...

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Podcast 748: Botulism show art Podcast 748: Botulism

Emergency Medical Minute

Contributor: Nick Hatch, MD Educational Pearls: Botulism requires a prompt clinical diagnosis as lab results can take about 5 days to return Whale blubber, honey, home fermented foods, homemade wine (especially the wine made in prison), and improperly stored canned food can all contain the toxin The botulinum toxin is create by a Clostridium botulinum that is prevalent on our food and in the soil, but the toxin is readily degraded with heat and light Blocks release of acetylcholine at the neuromuscular junction preventing release of neurotransmitter and therefore the propagation of an...

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Podcast 747: Food Impaction show art Podcast 747: Food Impaction

Emergency Medical Minute

Contributor: Ricky Dhaliwal, MD Educational Pearls: Esophageal food impaction can be managed in the ED prior to calling GI for endoscopy Coca-cola, glucagon, benzodiazepines, calcium channel blockers, and dissolved nitroglycerin are all options to try For pediatric patients, weighted bougies can be used under sedation to attempt retrieval of the food bolus  Always evaluate airway status, especially if the patient cannot maintain secretions References Long B, Koyfman A, Gottlieb M. Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review. J...

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Podcast 746: Elderly Head Trauma on Anticoagulation show art Podcast 746: Elderly Head Trauma on Anticoagulation

Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: Biggest study to date examined new protocol for repeat head CT in anticoagulated elderly patients with head trauma and an initial negative head CT 0.5%-6% of patients in this category will get a delayed ICH and this can occur up to a week out from initial injury 18% of the study group had an ICH on initial head CT, but the rest who had negative head CT initially received a repeat head CT at 6 hours 0.9% had a bleed identified on repeat head CT 6 hours after initial imaging, but of this group no one had an intervention for this bleed...

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Podcast 745: Nitrous-Induced B12 Deficiency show art Podcast 745: Nitrous-Induced B12 Deficiency

Emergency Medical Minute

Contributor: Alicia Oberle, MD Educational Pearls: Nitrous oxide (N2O) can cause a vitamin B12 deficiency in patients after regular use N2O is used in procedural sedation but also as a popular recreational drug  N2O binds and inactivate B12 in the body, therefore decreasing usable supply Lack of B12, which is essential for myelinating nerves, can lead to subacute combined degeneration of the spinal cord Presentation may include paresthesias, ataxia, gait changes, or bilateral lower extremity motor weakness B12 can be normal on labs, as the B12 is present but inactivated Treatment is...

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Podcast 744: Glucagon for Beta Blocker Toxicity show art Podcast 744: Glucagon for Beta Blocker Toxicity

Emergency Medical Minute

Educational Pearls: Glucagon can be used to treat hypoglycemia and esophageal foreign body, but it can also be used in beta-blocker toxicity to bypass cardiac beta-blockade The superior option for treating bradycardia due to beta-blocker toxicity is glucagon Glucagon has decreased efficacy in patients with heart failure, so increased doses up to 10 mg might be required in the event of beta-blocker toxicity References Khalid MM, Galuska MA, Hamilton RJ. Beta-Blocker Toxicity. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available...

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Podcast 743: Rust Rings show art Podcast 743: Rust Rings

Emergency Medical Minute

Contributor: Jared Scott, MD Educational Pearls: A rust ring can occur after a metallic foreign body is left in the eye for a prolonged period of time Issues occur when the rust ring is left as it can epithelialize and become a permanent spot in the patient’s vision An eye burr or Alger brush can help to gouge out the rust ring in the emergency setting These tools have a failsafe mechanism to prevent the eye burr from going through layers past the cornea (though this does not work if the foreign body is already through the cornea) Referral to ophthalmology, antibiotic drops, and dilating...

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Podcast 742: Pulse Check During CPR show art Podcast 742: Pulse Check During CPR

Emergency Medical Minute

  Contributor: Aaron Lessen, MD Educational Pearls: Pulse checks are necessary during CPR to check for return of spontaneous circulation (ROSC) Previous studies have shown that assessing ROSC with palpating for pulse are not a very consistent Study compared palpating pulses at carotid/femoral artery versus a newly contrived gold standard for pulse checks The gold standard used was an increase in end tidal CO2 + cardiac activity on ultrasound + perfusing rhythm on ECG Carotid artery palpation was the best location to confirm pulse during pulse check, although femoral artery palpation ...

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More Episodes

Contributor: Donald Stader, MD

Educational Pearls:

  • Hip Dislocation
    • Prolonged dislocations can impair blood supply to femoral head
    • Hip dislocation for >6 hours puts patient at high risk for needing a hip replacement in the next two year
  • Knee Dislocation
    • High mechanism
    • Often looks anatomically normal on knee x-ray
    • Vascular injuries of the popliteal artery can cause significant morbidity with some studies suggesting an 80% amputation rate if not treated within 6 hours
  • Ankle Dislocation
    • Common dislocation and often co-occurs with ankle fractures (bimalleolar/trimalleolar)
    • Pressure on the skin from the displaced joint can cause skin tenting, which can lead to skin necrosis
    • Hematoma blocks work well for ankle reductions as an adjunct to or substitute for procedural sedation

References

Arnold C, Fayos Z, Bruner D, Arnold D. Managing dislocations of the hip, knee, and ankle in the emergency department. Emerg Med Pract. 2017;19(12):1-28.

Dawson-Amoah K, Raszewski J, Duplantier N, Waddell BS. Dislocation of the Hip: A Review of Types, Causes, and Treatment. Ochsner J. 2018;18(3):242-252. doi:10.31486/toj.17.0079

Patterson BM, Agel J, Swiontkowski MF, Mackenzie EJ, Bosse MJ; LEAP Study Group. Knee dislocations with vascular injury: outcomes in the Lower Extremity Assessment Project (LEAP) Study. J Trauma. 2007;63(4):855-858. doi:10.1097/TA.0b013e31806915a7

Ross A, Catanzariti AR, Mendicino RW. The hematoma block: a simple, effective technique for closed reduction of ankle fracture dislocations. J Foot Ankle Surg. 2011;50(4):507-509. doi:10.1053/j.jfas.2011.04.037

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD