Traumatic Hyphema

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23yM catches a racquetball with his left eye and comes in with pain.
In cases of ocular trauma, shearing of the vessels of the iris or ciliary body can cause blood to pool in the anterior chamber. Patients will have vision loss, pain, photophobia, tearing.
Grade 1 - <1/3rd of chamber
Grade 2 - 1/3rd - 1/2
Grade 3 - > 1/2
Grade 4 - complete filling (surgical)
Image result for traumatic hyphema
First, elevate the head of the bead (prevent plugging of trabecular meshwork -> high IOP). Then, cycloplegics (atropine 1%) will help immobilize the iris and prevent rebleeding. Consult ophtho and possibly admit if Grade 2 or pt has increased IOP. If there is increased IOP, consider topical timolol or acetazolamide. Aspirin and NSAIDs are contraindicated for pain management. Rebleeding 3-5 days later is the most important complication. You discharge this patient with an eye shield and ophtho follow-up, and advise him to wear eye protection when playing racquetball.
Sources
Rosh Review
FOAMEM: Hyphema 
ERCast: Hyphema

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Myxedema Coma

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78yF comes in lethargic, cool to the touch, and in her medication bag you find an empty, expired bottle of levothyroxine.
In myxedema coma, rarely are patients edematous or comatose, so think of this condition as "decompensated hypothyroidism." It typically presents in the elderly and in the winter months. Even with early recognition and treatment, mortality can be 60%. 
It is precipitated by infection/sepsis in a patient with partially or untreated longstanding hypothyroidism. Sedative drugs, stroke, and cold exposure can also precipitate this condition.
Think of 3 major categories of symptoms
1 - Hypothermia 
2 - AMS - Lethargy, seizure
3 - Cardiovascular depression - Bradycardia, hypotension, decreased RR
Labwork can show elevated TSH and low free serum T4, but there is no cutoff level to make the diagnosis. Elevated LDH, respiratory acidosis, hypoglycemia, hyponatremia, and anemia are common.
EKG - bradycardia, low voltage, loss of T waves
Image result for myxedema coma ecg
First, manage the airway (macroglossia, edema), give IVF/pressors. Then, empirically give IV levothyroxine 100-500mcg. Many people also have coexisting adrenal insufficiency and so 100mg of IV hydrocortisone is also indicated, which may correct hypotension. Treat the precipitating factor (often sepsis or medication discontinuation). These patients will also need active and passive rewarming measures in severe hypothermia. Admit to the ICU given the high mortality associated with this condition.
Sources
Rosh Review
NEJM: Myxedema

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Carpal Ligamentous Injuries

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There are four degrees of carpal ligamentous injuries, each with worsening carpal instability. The most common injury mechanism is a fall onto an outstretched hand (FOOSH). Patients present with pain, swelling, and tenderness over the dorsum of the wrist. 25% of perilunate/lunate dislocations are missed on initial presentation.
Scapholunate dissociation (stage I) - Widening of the scapholunate joint by >3mm, called the "David Letterman" sign after the gap between his front teeth. This injury may require orthopedic pinning.
Perilunate dislocation (stage II) - On lateral wrist xray, the capitate will be dislocated and dorsally displaced relative to the lunate. The lunate still articulates to the radius in this dislocation.This requires emergent orthopedic consultation for reduction as this injury can be complicated by median nerve compression and avascular necrosis.
 
Stage III - Perilunate dislocation with dislocation of the triquetrum.
Lunate dislocation (stage IV) - The lunate disarticulates from the radius and rotates in a volar direction relative to it. On a lateral wrist x-ray you will see a "spilled teacup sign". On PA view, crowding of the carpal bones can result in a triangular-appearing lunate aka "piece-of-pie" sign. This will also require immediate reduction and splinting.
Sources
Rosh Review
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