Trauma Vascular Access– Dr Idara Ndon

  • Shorter catheters have less resistance (highest flow rate are going to be large bore peripheral IVs)
  • Ensure that you are not placing lines in AV fistulas
  • In pediatric patients can use the saphenous veins in the LE
  • Instances where there is blood return but unable to advance catheter
    • Try retracting the needle and re-advancing the catheter or pulling the catheter back and flushing it in
  • In unstable trauma patients access needs to be a priority
    • Based on results of EAST study IO is faster to be placed and more reliable
  • Resources

Health Care of People Experiencing Homelessness– Dr Avik Chaterjee

  • Various resources provided by BHCHP
    • BHCHP is able to store and administer medications for patients
    • BMH- site for medical respite where patients can go if they have a condition that may be exacerbated by living on the street
      • Able to coordinate IV antibiotics, detox, wound care, end of life care
    • SHS is now able to do suboxone in the shelter
  • Experience of homeless patients in the ED
    • Concerned about admission, treatment in the ED, stigma related to being homeless, distrust of patients from providers, withdrawal while in the ED
    • Cannot often present to the ED due to concerns for losing their beds at the shelter
    • Medications at shelters are often times stolen
  • Information regarding shelters
    • SHS opens for beds at noon, variable times for when beds fill, once you are there you often cannot leave
    • Pine St Shelter opens for beds later in the evening (around 7p), has stricter rules, and requires patients to change into scrubs to stay
    • Both BHCHP and Pine St have medication holding and administration programs
  • Resources
    • SHS primary care office is open for referrals
      • 857-654-1605 (number for PCP referrals/intake)
      • Open Mon-Fri from 8a-5p
      • BHCHP on call provider: 781-221-6565

Sick Burns– Dr Ian Mauricio

  • Thermal burns
    • Have high suspicion for impending respiratory compromise in burn patients
      • Stridor, swelling, oral/nasal burns
      • Low threshold to visualize with fiber optics
    • Be aware of circumferential burns especially on the chest (will have poor ventilation)
      • Check distal pulses and cap refill in all extremities
    • Fluid resuscitation: Parkland and Brook formulas (2-4cc*kg*TBSA)
      • TBSA includes deep partial and full thickness burns
      • Rule of 9s for adults (varies for pediatrics)
      • Patient’s palm is approximately 1% TBSA
    • Additional considerations: cyanide and carbon monoxide poisoning, hypothermia
    • Burn categorization: superficial, partial, full thickness
      • Superficial- redness of the skin
      • Partial- partial or deep (involving the epidermis vs deeper dermal)
      • Full- penetration into the dermis, decreased pain over the burn site
    • No longer a role for prophylactic antibiotics but do need TDAP
    • Be aggressive about pain control
    • Dressing- non stick gauze dressing (xeroform) with bacitracin
  • Chemical burns
    • High proportion of patients who need surgical management
    • These are patients who need to be decontaminated
      • Be cautious regarding dry substances and how they react with water
    • Cement- reacts with water causing burns
    • Phenol- found in soaps, sprays, ointments
      • Need to be decontaminated with PEG, oils
      • Reacts with water with severe systemic effects
    • White phosphorus- dry powder that can ignite with dry dressings
      • Irrigate with water/saline
    • Hydrofluoric acid- severe burns with Ca binding
      • Can have ECG changes (PR and QT prolongation)
      • Treat with IV calcium in additional to topical
        • End point is lack of pain
  • Ocular exposures/burns
    • pH strips before and after irrigation with morgan lens
    • Alkaline burns are often times more caustic/concerning
  • Electrical burns
    • Need to evaluate for entry and exit wounds
    • Higher incidence of rhabdo in electric burns

TRIAD– Dr Sabrina Sanchez

  • Instituting a shared decision making pathway for patients with acute appendicitis
  • Rolling out a decision support tool with a video that details the various treatment options for the patients
  • BIG CASH PRIZE
  • Resources

Forearm Trauma– Dr Gervase Spurlin

  • Radius and the ulna form a ring so a fracture to one bone will often cause a fracture in the other
  • Neurovascular assessment
    • Rock, paper, scissors hand movements will capture all nervous structures
    • Have patients make the “OK” sign as well
  • Normal elbow XR– anterior fat pad can be normal, radial shaft should intersect the capitellum
  • Elbow dislocations- often associated with concomitant fractures, high risk for NV injury
    • Reduction- need to pull distally while applying downward force to allow the ulna to clear the capitellum
    • Splinting- long arm posterior splint
    • Consult in ED for associated fractures, NV compromise, open injuries
  • Coronoid fracture- rarely in isolation, typically associated with dislocation
    • Needs urgent 24 hour eval due to role in stability of the elbow
  • Olecranon fracture- often time required surgical repair due to involvement of tricep tendon
  • Radial head/neck fracture- often difficult to identify, look for fat pad signs
    • Sling with early ROM, often times no need for surgical management
  • Isolated ulnar shaft- often times in the setting of assault
    • Ortho consult for unstable fractures
  • Isolated radial shaft fracture- displacement needs orthopedic evaluation
    • Sling vs posterior long arm splint
  • Combined ulnar and radial fractures- high mechanism injuries at high risk for compartment syndrome
    • Orthopedic consultation for closed reduction
  • Colles fracture- distal radial fracture with angulation and impaction
    • Pay attention to angulation and shortening
    • Closed reduction with sugar tong splint
  • Smith fracture- distal radius with volar angulation
    • Similar treatment as Colles
  • Barton fracture- involvement of the articular surface but does not involve entire radius
    • Pay attention to amount of displacement and involvement of articular surface
  • Radial styloid fracture- intra articular fracture
    • Pay attention to displacement due to high need for ORIF
  • Ulnar styloid fracture- often times have associated radial and ligamentous injuries
    • Similar treatment to radial styloid fracture
  • Radioulnar joint dislocation
    • Often times best seen on lateral film with displacement
    • Reduce with supination or pronation at the bedside
  • Monteggia- ulnar fracture with a radial dislocation
    • More common in children requiring ORIF
  • Galeazzi- radial fracture with ulnar dislocation
    • More common in children requiring ORIF
  • Essex-Lopresti- radial head fracture with distal radioulnar joint dislocation
    • Often times missed requiring surgical management
  • Other considerations- due to forearm compartments at high risk for NV compromise
  • Resources

Safe Stimulant Use– Dr Alexandra Van Besien

  • Stimulants engage the adrenergic aspects of the ANS leading to tachycardia, hyperthermia, delirium, hypertension, agitation
    • At risk for renal dysfunction secondary to dehydration and rhabdo
    • Severe complications can lead to CV complications like ACS, dissection, arrhythmias in addition to seizures and noncardiogenic pulmonary edema
  • Be aware that the term “crack” refers to base cocaine but is rooted in racist policies instituted by prior administrations levying heavier penalties on people using base cocaine and not strictly the powdered form
  • All stimulants have multiple forms of administration
  • Both cocaine and methamphetamines stimulate large releases of dopamine
    • Methamphetamine can have severe withdrawal secondary to severe depletion of dopamine stores
  • More common for patients to participate in frequent redosing of stimulants than with opiates
  • Crashing/withdrawal
    • Will appear similar to opiate intoxication without obvious evidence of an opiate toxidrome
    • Acutely patients experience hypersomnolence, depression, anxiety
    • Subacutely people experience difficulty with sleep, worsening cravings
    • Chronically people can start to have changes in cognitive function
  • Harm reduction methods
    • Asking people about how they are using (smoking vs injecting)
    • REMEMBER there are clean supplies in the ortho closet for various needs
      • Have a low threshold to ask people about transitioning to smoking versus injecting
  • Resources
    • START clinic
      • Intensive behavior based methodology for patients with substance use
      • Can be placed as an ambulatory referral but NEED PHONE NUMBER