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Ultrasound Guided Lp

Ultrasound guided LP

 

Equipment needed:

-       high-frequency (small parts linear probe) for patients with normal weight

-       low-frequency 2-4 MHZ probe (abdominal curvilinear probe) for obese patients

-       transducer gel

-       skin marking pen

-       LP tray

 

Positioning: left lateral decubitus or seated position

 

Technique:

1-   Identify spinous process which signifies the midline of the spine. Probe must be in transverse position, probe marker to clinician’s left side, at level of iliac crest. Spinous process looks like cresent shape hyperechoic structure with posterior acoustic shadowing.

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2

 

2-   Mark the midline with a skin marking pen at the center of the probe. Drag the probe superiorly (head) and inferiorly (feet) and again mark the midline of the spine.

3-   Rotate the transducer to the sagittal (longitudinal) plane, with probe marker pointed at patient’s head. The probe should be parallel with patients spine and in between spinous processes previously marked.  The spinous processes again appear as hyperechoic cresent shapes.

 

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4. Mark the space between the two spinous processes which is the interspinous space, on left and right side of probe.

5. The point of intersection represent the middle of the interspace and most ideal place for LP needle insertion.

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6. Proceed with LP as you usually would. Instruct patient not to move as this may obscure landmarks and skin markings.

 

Reference: http://emedicine.medscape.com/article/1458641-overview#showall   Written by our very own Sinai EM attending’s Suzie Bentley and Danny Duque!

 

https://www.youtube.com/watch?v=ndnZxAcNjdg

Chlamydia Conjunctivitis in Newborn

10d male p/w R eye tearing and discharge x1 day. Today purulent. Born FT via NSVD, uncomplicated pregnancy and delivery. No fever. No vomiting, diarrhea. No URI. Taking good PO.  On exam, AFVSS, R eye diffuse soft tissue swelling, crusting to lashes, conjunctiva injected with purulent discharge:

Conjunctivitis

 

Chlamydia Conjunctivitis in Newborn

Transmission – from mothers genital flora during vaginal delivery

Incubation period- 5 to 14 days after delivery

Presentation – mild watery discharge that progresses to mucopurulent discharge, swelling of eyelid, thickened conjunctiva (chemosis), pseudomembrane may form on conjunctiva, conjunctiva may become friable and bleed.

Complications- Granulation tissue, corneal and conjunctival scarring may occur if left untreated

Diagnosis – culture is gold standard. Consider testing all newborns less than 1 month age with conjunctivitis.

Treatment- AAP and CDC recommend oral erythromyicin 50 mg/kg/day PO in 4 divided doses for 14 days

Prevention- prenatal maternal screening

 

Our case, underwent full sepsis work up, WBC 20.7, normal diff,  normal CXR, LP, urine, blood cultures. Did well after antibiotic treatment.

 

References:

Kimberly Kahne, MD- Thank you to our PEM fellow for the case!

Uptodate- Chlamydia trachomatis infections in the newborn

 

Inferior Shoulder Dislocations

55 yo F presents with shoulder pain after fall from bicycle:

Infshoulder

Also known as “luxatio erecta”  - to place upward

 

Inferior shoulder Dislocation

Infshould2

 

 

Mechanism of injury: fall and sudden grasp of object above head resulting in hyperabduction

Presentation: Patients hold arm above head and is unable to adduct, looks like a person raising their hand to ask a question

Exam: Can palpate humeral head along lateral chest wall, forearm is pronated, unable to adduct, elbow usually flexed above head. Check distal radial pulse and axillary nerve  pin prick sensation at shoulder.

Assoc injuries: Axillary artery, brachial plexus – most often axially nerve. Neurovascular deficits usually resolve with prompt reduction. Also associated with rotator cuff tears and greater tuberosity fractures.

Imaging: Reveals humeral head beneath glenoid

Reduction: Closed reduction often successful with traction-countertraction and slow gentle adduction of affected arm. Open surgical reduction is required when humeral head in a tear of the inferior capsule, also known as “buttonhole deformity”

 

Infshould3

 

 

References:

Simon and Sherman, Emergency Orthopedics 6th Ed, pgs 353-54

http://www.uptodate.com/contents/shoulder-dislocation-and-reduction

Rosh Review

Happy Match Day!

Congrats to all that have matched today!

 

Interestingly enough, did you know that Lloyd Shapley and Alvin Roth won the Nobel Prize in Economic Sciences in 2012 for their research over many decades about stable matching, which is used in the NRMP’s Match algorithm?

 

Check it out: http://www.nobelprize.org/nobel_prizes/economic-sciences/laureates/2012/popular-economicsciences2012.pdf

Eye Trauma & Bradycardia

A 3yo M comes into your ED around midnight after a fall off a stool onto his face. He has been vomiting, is bradycardic in triage to the 50s so is brought into your pediatric RESUS bay. Mom states that his eyes “look weird”. On exam, pt is scared but awake and alert, with full EOMI of the L eye, unable to look superiorly or medially with the R eye. PERRL. Mild erythema and tenderness over R inferior orbit. Vision grossly intact to fingers and colors in both eyes. No photophobia. Rest of PE is normal. HR on monitor varies from 80s to the 40s.

CT scan of the head shows no bleed. Orbital cuts show a R inferior orbital fracture suspicious for muscle entrapment. Admitted to PICU for hemodynamic monitoring and continuous neuro checks, and OR in the am. EKG shows sinus bradycardia.

Why is he intermittently bradycardic?

Continue reading “Eye Trauma & Bradycardia” »


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