Conference was really great this morning! We started with two great guest lectures on hand anatomy and amputations. After that Dallon Jones, MD one of our third years gave an excellent lecture on chest pain dispositions (when to send home and when to admit.) I’m going to start with a brief refresher on hand anatomy.
Dr. Frank Birinyi pointed out a great mnemonic for remembering the bones of the wrist that we all learned in medical school, but i’m posting this one I recently learned from one of our medical students, Trai Shinn: “Steve left the party to take Carol home.”
The other big thing I took from his lecture is the difference between a lunate and perilunate dislocation. Look at the two pictures below:
The key to differentiating which dislocation your patient has is to note the location of the lunate. Look at the picture on the right. The lunate is sitting normally in line with the radius. This is a perilunate dislocation because as Dr. Birinyi pointed out “the peri is dislocated.” In the picture on the left, the lunate is not in line with the radius (some say the tea-cup is tipped over.) In this case, the patient has a lunate dislocation.
Dr. Michael Ruff from our hand service talked about catastrophic injuries of the upper extremity. He made some great points! Let me summarize:
1. Six hours is usually the maximum time to replant a limb. This is because of the amount of muscle the limb has. For fingers, your window increases because of less muscle.
2. If you see a patient with a nearly complete amputation, resist the urge to cut that last piece of skin off. This sometimes contains very important veins that are very important to replantation.
3. At the scene, cover amputation with gauze and saline; immobilize and hold direct pressure if needed. Transport in a ziplock bag placed in an ice water slurry.
4. Keep all parts of the amputation even if you don’t think they are salvageable. The surgeons have some creative ways to use these “extras.”
5. Give one baby aspirin to these patients if EMS hasn’t already done so.
6. Good candidates for replantation: thumb, multi digits, distal forearm, humeral level, anything in a child, transmetacarpal amps, wrist level amps
7. Poor candidates for replantation: multi-level amps, index finger (unless a really good reason to replant), crush injuries, patients with atherosclerosis, prolonged warm time after amp, patients with certain psychological issues (self mutilators), significant additional injuries and systemic illness (sepsis)
Chest Pain Dispositions
Dallon did a great job with this talk! This is a huge topic and we could talk for hours on the subject, but here are some take home points:
1. STEMI patients need Plavix and the elevator (to the cath lab)
2. 82% of patients discharged from observation units receive the diagnosis of “unspecified chest pain.”
3. Acute Coronary Syndrome (ACS) is the highest dollar amount paid out in malpractice claims.
4. Risk factors in ED patients with chest pain are poor predictors for ACS. They are NOT predictive in female patients.
5. A “delta troponin” (usually 2 hours) will essentially rule out an MI, but NOT unstable angina. You need a provocative test for that (exercise stress or stress echo.) If you decide to get a “delta troponin” you must see the number stay the same or go down. A negative delta troponin DOES NOT mean 2 troponins in the normal range.
6. Learn about coronary artery remodeling. This link will get you started. The key point here is that the remodeling takes place outward giving the artery a sometimes normal appearance on coronary cath. This scares me A LOT!!!