Pearl of the Day - Understanding EKG Patterns.

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Understanding EKG Patterns

Imagine that you receive a transfer from an outside facility of a patient with SVT that turned out to be a perf'd appy, or you're asked to present an M&M of a patient with rapid a.fib due to an underlying process. We start to realize the important EP skill of EKG pattern recognition. When paired with a detailed history and physical exam (and maybe some good POCUS), we can make the proper diagnosis.
Check out these two cases on Dr. Smith's EKG blog for more pearls and pitfalls in the management of abnormal EKGs.
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Pearl of the day - Nebulized Analgesia

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To paraphrase Dr. Sergey Motov: when IV access is unattainable or undesirable, nebulized, intranasal and transmucosal administration of analgesics should be considered for acute pain management in the ED. The best evidence is from a systematic review of nebulized fentanyl (see citation).

The doses (off-label use) are: 4mcg/kg for an adult titrated up to three doses. Peds: 2-4mcg/kg. For morphine: 0.2mg/kg peds, 10mg or 20mg adults fixed-dose.

We can use the breath-actuated nebulizer (pic) to ensure patient-controlled dosing. It is located in the pyxis or from pharmacy. If you still don’t know how to use it, ask!

Manufacturer video: https://www.youtube.com/watch?v=7Xk-tYhhEdU

See this article for more information:

Thompson JP, Thompson DF. Nebulized Fentanyl in Acute Pain: A Systematic Review. Annals of Pharmacotherapy 2016, Vol 50(10): 882-891.

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Rapid Board-Style Review of Orthopedic Injuries to the Foot/Ankle

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SALTER HARRIS I -> S-slipped -> non-op

II -> A-Above physis (through metaphysis) -> non-op

III -> L-Lower than physis (through epiphysis) -> unstable

IV ->T-Throuh physis (all 3 involved) ->limb-length discrepancy->Op

V ->R-ERasure of growth plate (crush) -> Op

ANKLE/FOOT injuries.

▪Achilles tendon rupture – weekend warriors, cipro use, -> + Thompson test – no plantar flexion w/ calf compression -> splint in equine position, ortho eval.

▪Ottawa ankle rules – pain at posterior edge of either malleoli, inability to bear weight immediately/in ED. Navicular TTP, TTP at base of 5th metatarsal

▪Weber ankle fractures -> unstable fractures are types B/C at or below the ankle joint -> OR

▪Trimalleolar fx -> OR

▪Maisonneuve fx – Eversion injury -> proximal fibula fx + medial malleolus fx + disruption of syndesmosis

▪Plafond or pilon fx – comminuted distal tibia -> look for associated injuries

▪Calcaneus fx – most common tarsal bone fx <20 degrees Bohler’s angle -> look for associated injuries such as vertebrae

▪Talus bone is most susceptible foot bone to AVN (also scaphoid, odontoid, femoral head)

▪ATFL (ligament) – Inversion injury (most common ankle sprain).

▪ (left pic) Jones fx -> 5th metatarsal shaft fx -> NWB -> Op

▪(right pic) Pseudojones fx -> 5th metatarsal avulsion fx -> hard sole shoe -> most non-op

▪Tarsal tunnel syndrome -> posterior tibial N neuropathy -> weak flexors, pain on sole of foot.

▪Morton’s neuroma -> pain between 2nd/3rd toes usually

▪Plantar fasciitis -> worst in morning, better after use. Tx: rest/NSAIDs

▪Lisfranc fx -> Joint between base of 1st, 2nd metatarsals and cuneiform disrupted. Most require OR.

▪Plantar puncture wounds -> staph/strep most common. Pseudomonas concern if punctured through shoe. Abx controversial

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