Supracondylar Fractures

Pediatric Supracondylar Fractures

Background

• Defined by fracture of distal aspect of humerus above the epicondyles

• Mechanism

  • Direct: blow to the elbow, fall onto flexed elbow

  • Indirect (more common): FOOSH, fall onto hyperextended UE

    1. 95% of these fractures are due to extension injury

• Most common age: 5-8 year olds

  • Also more likely to be dislocated in this age group

• Males>Females

Exam

• Complain of pain/swelling/decreased ROM of elbow

• “S shaped deformity”

  • when fracture is entirely displaced (distal humerus)

• Need to perform neurovascular exam!

  • Median nerve: A-OK sign

    1. Mostly commonly affected

  • Radial nerve: thumbs up sign

  • Ulnar nerve: abduct/adduct fingers (try to remove paper they are holding in between adducted fingers)

• Check for cap refill!

• Evaluate brachial artery

  • Compromise of the artery can lead to permanent volkmans contracture, which is flexion at the wrist

Gartland Classification

• Based on the integrity of the cortex and extent of displacement

• Type 1: minimal to no displacement ; limited XR findings, look for occult signs of fx on xray (ie: fat pad)

• Type 2: posterior hinge aka displaced anterior wall but intact posterior wall; anterior humeral line is anterior to capetellum

• Type 3: complete displacement with no cortices in tact, neither anterior nor posterior wall in tact

• Type 4: periosteal disruption with instability in extension AND flexion

Imaging

• Need AP and lateral films

• Lines

  • Abnormality can indicate occult fracture

  • Radiocapitellar line (yellow): Line through central radius and central capitellum (middle third). Should be evaluated in both views

  • Anterior humeral line (blue): Line in front of the humerus and passes the anterior 1/3 of the capitellum.

• Fat pads

  • Anterior: can be normal; elevation is abnormal

  • Posterior: always pathologic

• These abnormalities without obvious sign of fracture along bones indicative of type 1 SC fx

Dispo:

• Type 1: long arm posterior splint, ortho follow up

• Type 2/3: OR with ortho for reduction (closed vs. open) and pinning

Electrical Storm

Electrical Storm

Background

• three or more episodes of sustained ventricular tachycardia, ventricular fibrillation, or appropriate ICD shocks in a 24 hour period

• frequently, hemodynamic unstable

• believed to mostly be due to catecholamine surge (sympathetic overdrive), but need to consider the causes below:

  • MI

  • Electrolytes

  • Acute HF

  • QT prolongation/shortening

  • Torsades

  • Brugada

  • Thyroid storm

  • Drugs

  • Sepsis

• Presentation is broad

  • May complain of pain from ICD shocks, palpitations, syncope

  • Can present in cardiac arrest

Management

• ABCs

• ACLS guidelines should be followed

  • Pulse (VT)==>cardiovert

  • Pulseless (VT/VF)==>defibrillate

    1. Consider dual defibrillation if VT/VF persists after 5 delivered shocks (see image below)

       1. Coordinate firing of both defibrillators at the same time
          

• Should you place a magnet over ICD if patient has one?

  • Remember, magnets turn of the ability to defibrillate, but don't affect pacing capability

  • If you want the patient to be shocked then do not place a magnet, unless you think you’re dealing with something other than VF/VT and thus it is shocking inappropriately (sinus tach, afib)

    1. Practice variation exists. Some will place the magnet, especially if the pt is stable, to spare pt more anxiety/pain contributing to the storm

• Start them on an anti-arrhythmic

  • Amiodarone 300mgè150mg IV //

  • Procainamide 10 mg/kg IV over 20 min //

  • Lidocane 1-1.5mg/kg IV

• Add a Beta Blocker to suppress the sympathetic tone and increase the dysrhythmia threshold

  • Metoprolol 2.5-5mg IV q2-5min //

  • Propranolol .15mg/kg IV over 10 min followed by standing order//

  • Esmolol 300-500 mcg/kg push followed by drip

• Consider an anxiolytic or sedation

• Brugada

  • Unlike aforementioned, VF in these pts is thought to be due to excessive vagal tone

    1. Isoproterenol drip will increase the sympathetic tone

  • Quinidine has been shown to help

• Torsades

  • Magnesium, replete electrolytes

  • If have episodes of bradycardia then add isoproterenol drip

Dispo

• Admit to CCU if possible

• May need cath lab, ablation, ECMO

LITFL

First10EM

Unstable Bradycardia

Unstable Bradycardia

Background

·       HR less than 60 BPM

·       Not all bradycardia is bad and scary, some presentations are benign and asymptomatic

·       Broad differential, some examples include:

• Cardiac (structural/EP): AV block, STEMI, CHD, CM, Aortic dissection, etc.

• Respiratory: Hypoxia, resp failure

• Infectious: Myocarditis (viral), Lymes dx, etc.

• Metabolic/Endocrine: electrolytes, hypothyroidism/myxedema coma, hypoglycemia, hypothermia, heat exhaustion/stroke

• Tox/iatrogenic: BB, CCB, Dig, Clonidine, Opioids, TCAs, Keppra, Amio, etc.

• Trauma: increased ICP, spinal injury

·       Place pacer/Zoll pads on patient

·       ACLS guidelines for bradycardia exist

Unstable patient

·       ABCs

·       Don’t let the patient D.I.E

• Think drugs, ischemia, electrolytes

·       Place on monitor and obtain access

• If cant get an pIV, then try IO or central line

• *send for labs, VBG/BMP asap. Looking for electrolyte derangements (hyperK) that can change management

·       Place transcutaneous pacer pads so you’re ready to pace at any moment

• Anterior/posterior position best

·       Try atropine

• Doesn’t hurt to try, may work

• .5mg IV, can be repeated q3min to a max dose of 3mg

·  If atropine is not working, high probability it wont, then start transcutaneous pacing while getting chronotropic medication (pressors) ready and then titrating to desired effect

• Place dial on pacer mode

• Set pacer rate >30BPM above pts intrisic rhythm (usually 60-80 BPM)

• Set mAmp on 40, increase by 5mAmp as needed

• Monitor for capture

  • Electric capture: downward pacer spike followed by wide QRS

  • Mechanical capture: palpate pulse and correlate with monitor/pulse ox

• Try to give pt something for pain

• Get ready to place a TVP

·       Pressors

• “For symptomatic bradycardia or unstable bradycardia IV infusion a chronotropic agent (dopamine & epinephrine) is now recommended as an equally effective alternative to external pacing when atropine is ineffective.”

  • Thought: takes time to draw up meds/titrate. start external pacing. Get meds ready and administer, especially if hypotensive.

• Can start either Epinephrine 2-20 micrograms/min or Dopamine 2-20 micrograms/kg/min, titrate accordingly

  • If epi/dopamine don’t work separately, then try them together

    • If bradycardia still not improving, then try isoproterenol 2-10mcg/min

      • Isoproterenol is an analog of epinephrine

·       Additional medications to consider

• Digoxin  

  • Send dig level

  • Consider digibind

• CCB

  • Calcium gluconate, high dose insulin

• BB

  • Glucagon, high dose insuli

• Organophosphates

  • Atropine, pralidxime

·       STEMI?

• Usually inferior wall MI

• Advocate for pt to go to cath lab