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Oh No!  Kids' elbows.

28/1/2016

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People often get confused about which bit of a child's elbow is supposed to have appeared (ossified) and which bits are supposed to be invisible at any given age.  What do you make of this 13 year old's Xray?
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Young and Hip.

28/1/2016

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A teenager presented with pain in his right hip.  It had been present for a couple of weeks after kicking a ball.  There was a reduction in hip flexion to about 90 degrees, although an otherwise reasonable ROM.  He was tender over the antero-lateral hip.  He had an X-ray to exclude Slipped Upper Femoral Epiphysis (SUFE).  What do you think?
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GEMS - WDWLT?

27/1/2016

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What did we learn today?

Audit Presentation: Adult pain management in the ED

Click here to access the poster.

Areas of good practice:
  1. majority of patients in SEVERE pain received their initial pain assessment within 20 minutes
  2. majority of patients arriving in ED with pain had a documented pain score / group
Areas for improvement
  1. all patients should have a pain assessment within 20 minutes of arrival to the ED
  2. administration of correct analgesia for pain assessment
  3. Reduction in the use of Oramorph
  • we are using a lot of Oramorph - why?
    • difficult managing severe pain in minors (IV medication neccesetate trolley and a dgree of monitoring; it is not always practical / possible to move a patient to majors for this reason due to overcrowding)
    • can we look at other options?
      • PR diclofenac
      • IM morphine
      • INTRANASAL opioids?  ...watch this space...
Useful links:
RCEM Pain in Adults Best Practice guideline
Oxford analgesia league table

Burns in the ED

Plymouth is a burn facility.

5 criteria to guide referral decisions
  • TBSA - Total Body Surface Area 
  • Depth - The depth of burn injury
  • Site - Anatomical site of the burn injury
  • Mechanism - The etiology of the burn injury 
  • Other Factors / Parameters that may impact on the severity/complexity of burn injury
Minimum threshold for REFERRAL to a burn centre (via Plastics Team)
  • All burns ≥2% TBSA in children or ≥3% in adults
  • All full thickness burns
  • All circumferential burns
  • Any burn not healed in 2 weeks
  • Any burn with suspicion of non-accidental injury should be referred to a Burn Unit/Centre for expert assessment within 24 hours
Indications for DISCUSSION with Plastics Team
  • All burns to hands, feet, face, perineum or genitalia
  • Any chemical, electrical or friction burn
  • Any cold injury Any unwell/febrile child with a burn
  • Any concerns regarding burn injuries and co-morbidities that may affect treatment or healing of the burn
Essential documentation
  • Age
  • DOI (date of injury)
  • TOI (time of injury)
  • First aid
  • MOI (mechanism of injury)
  • TBSA
  • Depth
  • Suspicion on NAI
  • Dressings = non-adherent (Mepitel)
  • FU plan
Useful links:
Burns assessment
National burn care referral criteria
Burns and Scalds leaflet for Parents

Knee examination

In the assessment of ACL injuries, the history is often the most important aspect in diagnosis.

In the assessment of patella dislocations, look out for these groups who will present with patellar instability.
1. Trochlear dysplasia
  • "J sign" - refers to lateral patellar deviation during terminal knee extension
  • video
2. Patella alta 
  • Insall-Salvati ratio
3. lateralisation of the tibial tuberosity
  • ​Q angle

Other interesting eponymous knee injuries
  • Segond fracture : very frequently (~75% of cases) associated with disruption of the anterior cruciate ligament.
  • Pellegrini-steida lesion (avulsion injury of the medial collateral ligament at the medial femoral condyle)
  • o'donohues unhappy triad (ACL, MCL, medial meniscal tear)

Hand anatomy

Boutonniere Deformity
Jersey Finger
Guyon tunnel syndrome

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It's a real pain in the neck, Doc.

12/1/2016

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Again it’s a Sunday afternoon in minors and its busy…
You see a 40+ old male with a ‘sore throat.’  It's Winter and he's the third such you've seen.  He tells you that he’s had a mild sore throat for the past 2-3 days which is getting worse.  He finds it very uncomfortable to extend his neck and feels like his throat is closing over.  Its also become increasingly difficult to swallow.  He thinks it should be getting better by now.  He wonders if he might have strained his neck at work a few days before.  You confirm the absence of cough and recent viral illness but he does describe a subjective fever (despite being afebrile at triage with no recent antipyretic treatment).
On examination he is sitting with an upright posture and holds his head/neck rather stiffly due to pain.  He has a soft "hot potato" voice but no stridor.  His pharynx is completely unremarkable but palpation of the anterior neck produces pain.  He has a borderline tachycardia.

What are your differentials?  What are you going to do?

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David Bowie eyes..

12/1/2016

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As we mourn the passing of the Space oddity, here's an eye one for all you ED heroes. It’s a Sunday afternoon in minors and the triage nurse comes to tell you she’s just triaged a young man with ‘different colour eyes.’  He was playing Futsal (a kind of football in fashion at the moment) with all the young dudes when the ball ricocheted off an opponent’s knee and hit him in the face.  Its a bit sore and he’s really worried as he ‘can’t see anything,’ out of his left eye.  He doesn’t wear glasses or contact lenses and his formal visual acuity is recorded at right eye 6/5 and left eye light/dark but no detail. You take a closer look with a pen torch and discover the apparently brown left eye is actually red.  What is the diagnosis? And how many Bowie songs are listed in this post?

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