Hip Dislocations POD

This POD was inspired by a case that Dr. Zerzan had in the Peds ED. An 8 year old with a traumatic injury presented with hip pain and was found to have an isolated posterior hip dislocation…

Hip dislocations!

Posterior hip dislocations (PHDs) are far more common than anterior hip dislocations

(90% - 10%). This holds true in pediatrics as well in adults.

In a posterior dislocation, the patient presents with the extremity internally rotated and shortened.

In anterior dislocations, patients typically present with extremity flexed, abducted, and externally rotated.

We will focus on

posterior dislocations.

Classic presentation is with an axial load such as a knee hitting the dashboard in an MVC or other high energy mechanisms.

Important point: in adults and children >10yo, PHDs require a high energy mechanism and will often have several associated injuries.

However in children <10yo, PHDs can be seen in lower energy mechanisms such as routine sports injuries which is why you may actually see an isolated hip dislocation in a child. There are also fewer associated acetabular fractures in pediatric PHDs than adult PHDs.

Any child PhD knows…

..that PHDs are true emergencies!

You need to

get it reduced ASAP (within 6 hours)

to prevent complications of femoral head osteonecrosis and sciatic nerve injury. Other complications include post-traumatic arthritis, and in pediatrics, physeal injury. Incidence of recurrent dislocation is higher in pediatrics than in adults!

Reduction techniques:

The Allis Maneuver:

The Captain Morgan:

Video here: 

https://www.youtube.com/watch?time_continue=82&v=lQMWaFX-MeQ

Propofol is preferred agent for procedural sedation given its muscle relaxant properties if it is going to be reduced in the ED, but pediatric cases are often reduced in the OR to ensure optimal muscle relaxation and to have more options available.

It is essential to have optimal muscle relaxation in pediatrics as the growth plates can be damaged during reduction.

Open reduction should be considered if fracture-dislocation or unsuccessful closed reduction attempt.

All patients should get at least a CT to evaluate for femoral head fractures, intra-articular loose bodies/incarcerated fragments, acetabular fractures.

Children should get an MRI to evaluate for ligamentous injury as well.

If closed reduction is successful, disposition is protected weight-bearing 4-6 weeks, ortho follow up.

Cordis Placement POD

Today’s Pearl of the Day is onCordis Placement! This topic is geared more toward our interns and second-years who have less experience in big trauma (have not yet rotated at Shock).

The

cordis is the preferred central line in trauma

, unstable GI bleeds, ruptured AAAs, or any other situation in which the necessity for rapid transfusion of blood products is anticipated. It is a short, wide, single-lumen central venous catheter that is perfect for rapid large-volume infusions.

The kit looks like this.

(The kit in the picture above also has a sterile sleeve for transvenous pacer placement, but that plays no role in cordis placement for resuscitation).

Here it is with all the components taken out, in order of use.

Note that when you first open the kit, the dilator sits BACKWARDS in the cordis catheter.

So the first step in setting up for this line is to take the dilator out of the front end of the cordis and place it in the back end of the cordis so it looks like this.

Flush the line (unless you need to draw blood off of it immediately) and lock it so it doesn’t bleed everywhere.

The rest of cordis placement is fairly straightforward.

Cordis placement: wire in, dilator-cordis in, wire and dilator out (while cordis catheter stays in).

Contrast that with

triple lumen catheter placement: wire in, dilator in, dilator out, triple lumen catheter in, wire out (while triple lumen catheter stays in).

For a more detailed explanation of cordis placement, READ ON!

By this point the patient has already been prepped/draped/anesthetized (if time permits).

The next step is to 

get your wire into the vessel

. To achieve this you can either use the wire-through-needle technique or wire-through-catheter technique. For a review of the wire through catheter technique, please see Dr. Strayer’s video on this topic: 

https://vimeo.com/133254469

I will focus on the wire through needle technique in this guide.. Note that this kit has a special

blue syringe: the introducer syringe.

 It has a hole in the back of the plunger that allows you to advance the needle directly through the syringe and out the needle. Using this feature allows you to skip the step of taking the syringe off the needle which can lead to the needle slipping out of the vessel.

If using ultrasound, note depth of vessel, position in center of ultrasound screen, visualize vessel, and advance needle tip directly into the center of the vessel (see my PIV POD email/Maimo Blog post 

http://mmcedrco.w02.wh-2.com/EMBlog/2018/08/23/

 for description of this technique).

If using landmarks (this guide will focus on the femoral vein site), place a thumb on the pubic symphysis and index finger on ASIS. The line between them is the inguinal ligament. Half-way between them is the femoral artery and 1cm more medial is the femoral vein. 

If you can’t remember which side the vein is on, remember “

venous is toward the penis

”. The

puncture site should be 1-2cm distal to the inguinal ligament

.

 If the artery is palpable, enter 1cm medial to it. If it isn’t easily palpable, enter just above the webspace between your thumb and index finger as they are positioned on pubic symphysis and ASIS respectively.

Always aspirate the plunger while you advance.

Once you get flash, keep needle/syringe perfectly still in non-dominant hand braced on patient. Check once more that blood can be aspirated, then reach for wire with your dominant hand;

advance wire through syringe

(assuming you’re using the blue introducer syringe). It should advance smoothly. If it doesn’t, take out the wire, check that blood is still easily aspirated, reposition or drop your angle as needed and try to advance wire again.

Wire is now in place.

Needle/syringe are removed

over the wire. Make a 

skin-nick with the scalpel

in the direction of the wire.

Advance the dilator-cordis-unit over the wire

, stabilizing the wire from behind the dilator-cordis with your non-dominant hand and advancing the dilator-cordis with your dominant hand.

Advance sequentially with small twisting motions

 always

gripping the cordis close to the skin

, until it is “hubbed” (cannot advance any further). 

Wire comes out, then dilator comes out.

(Or wire and dilator can come out together if you can grab them both comfortably). Flush your line, suture in place, cover with sterile dressing kit, and you’re done.

Image credit:

Brown EM Educational Blog Website

(

http://blogs.brown.edu/emergency-medicine-residency/the-central-line-part-2-technique-procedural-steps/)

Slideshare.net

Google image search

Friday Pearl of the Day: Not Your Ordinary STEMI Notification

We’re going to go though this POD as a case rather than me yelling facts at you. READ ON!

Red phone rings. “We’re bringing in a STEMI. Vitals are HR 155, BP 75/55, RR 35, 90% on NRB. Our prehospital EKG should be in the email system already.” Cath lab fellow is notified.

The patient is brought into resus. Middle aged man, diaphoretic, holding his chest, tachypneic but no accessory muscle use. “Help me doc. I think I’m dying. My chest hurts so bad and I can’t breathe… What’s that? No I don’t take meds or have medical problems but I don’t really see doctors either.”

You listen to his lungs: crackles b/l; ultrasound his lungs: B-lines b/l… seems like acute pulmonary edema but he’s hypotensive so nitro’s out of the question. Furthermore, looks like it could be RV MI. You call for BiPAP (cautiously because that could make him more hypotensive too), which he tolerates and he feels better. A small dose of fentanyl helps with his pain as well.

Meanwhile, cardiology is busy consenting him for cath lab, you put in orders, and labs are being drawn. Another EKG and set of vitals are repeated, essentially the same as prehospital.

Chest X-ray shows up and shoots an image.

Oh damn, this guy really does have pulmonary edema. Why does this guy have acute pulmonary edema? You astutely go back and put the probe on his chest again to look at the heart.

His parasternal window is garbage but his apical window is decent. Below is your apical long (same probe orientation as parasternal long but in the apical position).

...there’s something flapping around on his mitral valve… it’s his papillary muscle! This guy ruptured his papillary muscle!

Papillary muscle rupture

… you have a sudden flashback to studying for USMLE Step 1. A table that you once studied comes to your mind…

Right! It’s one of the

mechanical complications of acute MI

… happens with

RCA infarcts

, can happen

acutely and within 3-5 days

…

acute severe pulmonary edema with flail leaflet on the echo

... bad news…

Your flashback ends and you’re back in the ED ultrasounding this guy. His mitral regurgitation is pretty insane when you put some color on it.

Probably 4+

Suffice it to say, cardiology doesn’t want to take him to the cath lab any more, but at least the fellow documents an official echo to back you up. You change your underwear and

call cardiothoracic surgery

. They’re booking him for the OR immediately to repair his valve.

As an academic exercise, you and the cardiology fellow take a second to listen to his murmur. God forbid you had to diagnose this without ultrasound.

There it is,

holosystolic at the apex

.

He’s still hypotensive though and now he’s getting a little altered. The OR isn’t ready yet.

If he wasn’t hypotensive you could use nitroprusside to reduce his afterload

and improve his forward cardiac output… but since he’s hypotensive, cardiology helps you set up the only

other option: an intra-aortic balloon pump

to support perfusion to his heart and brain until surgery.

Off to the OR he goes. His operative mortality is 50% but it’s his best shot. With medical therapy alone, his mortality would be 75% at 24 hours and 95% at 2 weeks.

Well done, doc. He has a fighting chance now.