About Retinal Detachments

Which of the following statements is TRUE regarding acute traumatic retinal detachments?

• (A) Most detachments can be visualized on standard fundoscopy
• (B) Eighty percent of detachments occur within 24 h of the traumatic event
• (C) Most detachments originate in the inferotemporal quadrant
• (D) Visual outcome depends on the extent of involvement of the optic disc
• (E) Sudden onset of pain is a prominent feature

The answer is C. 

The typical retinal detachment is heralded by painless flashes of light, floaters, and a shade across the visual field. Interestingly, most detachments follow a latent period, up to 8 months posttrauma in 50 percent of cases.

Detachments begin as small tears in the ora serrata (called dialysis), most frequently affecting the inferotemporal quadrant, followed by the superonasal quadrant. Because most detachments are very peripherally situated on the retina, standard fundoscopy is typically inadequate for visualization. Although a number of techniques have been developed to correct the detachment, visual outcome remains largely determined by the degree of macular involvement.

Papillary muscle Rupture

Rupture of a papillary muscle is usually associated with an infarction of which area of myocardium?

• (A) Inferior
• (B) Inferior–posterior
• (C) Lateral
• (D) Anterior
• (E) Anteroseptal

The answer is B.

Papillary muscle rupture is usually associated with an inferior–posterior infarction and involves the posterior papillary muscle. Outcome depends on whether the entire muscle body or only the head is ruptured. Rupture of an entire muscle body is associated with a high mortality rate (up to 50 percent within 24 h).

Diagnosis of papillary muscle dysfunction or rupture may be made on echocardiography or by measuring large V waves in the pulmonary artery wedge pressure with a Swan-Ganz catheter.

Papillary Muscle Infarct with Rupture: Gross, an excellent example of ruptured papillary muscle.

About Opioids In a multi-trauma patient with a head injury

 In a multi-trauma patient with a head injury, opioids ;

• a)can be used to treat severe pain
• b)cannot be given to a ventilated patient
• c)can be given intramuscularly (IM) in the general ward
• d)will cause a change to ICP in a ventilated patient whose blood pressure remains constant
• e)will require the use of supplemental oxygen

 T F F F T

A multi-trauma patient with a head injury is likely to be in severe pain. Pain can increase ICP, therefore it is not only humane to treat the patient it is intracranially beneficial. However if opioids can be avoided by the use of nerve blocks this should be done. If not suitable, then small intravenous doses of an opioid can be used with the patient’s neurological status closely monitored in an intensive care or high dependency environment.

In patients who are being ventilated, it is quite safe to use opioids. Provided blood pressure does not fall, there is no change in ICP. If BP falls, autoregulation induces cerebral arterial vasodilatation, which, in a decompensated state, will raise ICP. A patient who is breathing spontaneously, may also have a fall in arterial saturation. This would exacerbate the effects of a rising CO.
Supplemental O2 should be given whenever possible to reduce the risk of hypoxia, known to occur when a patient is under the effect of an opioid falls asleep.

Acute Upper Airway Obstruction (Epiglottitis Vs Croup)

Most children who present to the hospital with acute upper airway obstruction have croup (acute laryngo- tracheobronchitis) or epiglottitis. Other differential diagnoses include bacterial tracheitis, foreign body inhalation and angioneurotic oedema.

You have to assess severity by examination of

• constitutional state (toxicity, fever, pulse rate)
  
• stridor
  
• drooling
  
• cough
  
• speech
  
• tachypnoea
  
• tracheal tug on inspiration
  
• intercostal and subcostal indrawing on inspiration
  
• asynchrony of chest and abdominal wall movement
  
• cyanosis in air

Guidelines For The Diagnosis Of Croup And Epiglottitis:

Note: Each of these clinical signs in isolation is a poor discriminator however, considered together, they usually allow the correct diagnosis to be made.

Important Notes

1. All children with stridor must be reviewed by the paediatric admitting officer before discharge home or admission to the ward.
2. If the child is cyanosed he is likely to die very quickly -notify paediatric ICU immediately. The aim is to transfer severely obstructed children to ICU before intubation becomes imperative, as it is preferable to intubate them in ICU.
3. as a child becomes physically exhausted the stridor, indrawing and air entry may decrease.

Raccoon eyes ,a sign for basal skull fracture

Raccoon Eyes. Ecchymosis in the periorbital area, resulting from bleeding from a fracture site in the anterior portion of the skull base. This finding may also be caused by facial fractures.

Raccoon eyes is also known in the UK as panda eyes or periorbital ecchymosis that is a sign of basal skull fracture or a craniotomy that ruptured the meninges.And not due to facial soft-tissue trauma.
It is from bilateral subconjunctival hemorrhage, and occurs when damage at the time of fracture tears the meninges and causes the venous sinuses to bleed into the arachnoid villi and the cranial sinuses.It developes 2-3 days after a closed head injury that results in a basilar skull fracture.

Note :Somtimes Raccoon eyes are accompanied by Battle's sign (HERE)

The name of Raccoon eyes is due to dark purple discoloration forming around the eyes, giving an appearance similar to that of a raccoon or panda.

Preferred method for chest compressions in neonatal resuscitations

In the most of neonatal resuscitations, if adequate ventilation is achieved, no need for chest compressions . However, in certain cases of advanced asphyxia and myocardial depression or severe pulmonary dysfunction in which adequate ventilation cannot be readily achieved, chest compressions are necessary to support the circulation during more extensive resuscitation.

Thus, the indication for chest compressions in the newly born differs significantly from that in older children and adults. The mechanics of the thoracic cage and the physical forces of the circulation of blood also differ, especially in preterm infants. The predominance of pulmonary dysfunction, necessitates a relatively lower ratio of compressions to ventilations. The 3:1 ratio of compressions to ventilations is performed with 90 compressions and 30 interposed breaths per minute (or one cycle of 4 events every 2 seconds).

The preferred method for chest compressions is the two-thumb-encircling-hands method , which provides firm support for the back and generates higher systemic arterial pressure and better coronary perfusion pressure than the two-finger method.

STOP Sepsis Bundle

STOP Sepsis(Strategy to Timely Obviate the Progression of Sepsis) Bundle

CLICK on image for better view

How to appreciate Traumatic exophthalmos

Traumatic exophthalmos develops as a retrobulbar hematoma that pushes the eyeball globe outward. Patient presents with periorbital edema, ecchymosis, a marked decrease in visual acuity, and an afferent pupillary defect in the involved eye.
Sometimes the exophthalmos may be obscured by periorbital edema, In this time it can be better appreciated from a superior view. Visual acuity may be affected by the direct trauma to the eye (retinal detachment, hyphema, globe rupture), compression of the retinal artery, or neuropraxia of the optic nerve. The term "Orbital compartment syndrome" occurs when intraorbital pressure exceeds central retinal artery pressure and ocular ischemia ensues. Causes are many with retrobulbar hematoma being the most common.

CT is the best modality to determine both the presence and extent of a retrobulbar hematoma and associated facial or orbital fractures. Consultation of ENT and ophthalmology is indicated on an urgent basis. An emergent lateral canthotomy decompresses the orbit and can be performed in the emergency department and may be sight-saving.

Traumatic Exophthalmos. Blunt trauma resulting in periorbital edema and ecchymosis, which obscures the exophthalmos in this patient. The exophthalmos is not obvious in the AP view and can therefore be initially unappreciated. The Figure below shows the same patient viewed in the coronal plane from over the forehead.

Traumatic Exophthalmos. Superior view, demonstrating the right-sided exophthalmos.

Pneumocephalus

X-ray showing nasal and orbital fractures and pneumocephalus

Pneumocephalus is the presence of air in the cranial vault. It is usually associated with neurosurgery, barotrauma, basilar skull fractures, sinus fractures, nasopharyngeal tumor invasion and meningitis.Headache and altered consciousness are the most common symptoms.
Tension pneumocephalus can occur and is a neurosurgical emergency.Plain X-rays can diagnose pneumocephalus, but CT scan is the diagnostic modality of choice.A classical CT sign of tension pneumocephalus is the “Mount Fuji sign”: the massive accumulation of air that separates and compresses both frontal lobes and mimics the profile of the large volcano in Japan.

Large right pneumocephalus compressing right frontal lobe and widening interhemispheric space. There are also air bubbles in basal cisterns and cerebellar fissures bilaterally

Most cases of pneumocephalus resolve spontaneously, and conservative management should be provided. Nonoperative management involves oxygen therapy, keeping the head of the bed elevated, prophylactic antimicrobial therapy (especially in post-traumatic cases), analgesia, frequent neurologic checks and repeated CT scans.

Procedures to open obstructed airway

#The tongue is the single most common cause of an airway obstruction. In most cases, the airway can be cleared by simply using the head-tilt/chin-lift technique. This action pulls the tongue away from the air passage in the throat ,See this video:

Head tilt chin lift Technique

#The head-tilt/chin-lift is an important procedure in opening the airway; however, use extreme care because excess force in performing this maneuver may cause further spinal injury. In a casualty with a suspected neck injury or severe head trauma, the safest approach to opening the airway is the jaw-thrust technique because in most cases it can be accomplished without extending the neck.See it:

Jaw Thrust Technique

Assessment of Head injuries in children

Perform a primary survey and ensure that the child’s airway, cervical spine, breathing and circulation are secure.

Rapidly assess the child’s mental state using the AVPU scale. Use firm supraorbital pressure as the painful stimulus.

* A Alert
* V Responds to voice
* P Responds to pain
----> Purposefully
----> Non-purposefully :

•  Withdrawal/flexor response
•  Extensor response

* U Unresponsive
Assess pupil size, equality and reactivity and look for other focal neurological signs.

Perform a secondary survey looking specifically at:

* Neck and cervical spine – deformity, tenderness, muscle spasm
* Head – scalp bruising, lacerations, swelling, tenderness, bruising behind the ear (Battles sign)
* Eyes – pupil size, equality and reactivity, fundoscopy
* Ears – blood behind the ear drum, CSF leak
* Nose – deformity, swelling, bleeding, CSF leak
* Mouth –dental trauma, soft tissue injuries
* Facial fractures
* Motor function – examine limbs for presence of reflexes and any lateralising weakness
* Perform a formal Glasgow Coma Score
* Consider the possibility of non-accidental injury during secondary survey especially in infants with head injury.
* Other injuries

Photos for Battle's sign

Battle's sign, also called mastoid ecchymosis : consists of bruising over the mastoid process (just behind the auricle), as a result of extravasation of blood along the path of the posterior auricular artery.

It is an indication of fracture of the base of the posterior portion of the skull, and may suggest underlying brain trauma.

Brain herniation Sites

Brain herniation refers to displacement of a portion of the brain from its normal position through openings in the inelastic dura secondary to focal or diffuse intracranial pressure. Recognition of the CT signs of brain herniation on the emergent head CT is critical to proper patient management. The types of brain herniations are schematically illustrated...":a) " Subfalcial (cingulate) herniation ; b) uncal herniation ; c) downward (central, transtentorial) herniation ; d) external herniation ; e) tonsillar herniation.Types a, b, & e are usually caused by focal, ipsilateral space occupying lesions, ie., tumor or axial or extra-axial hemorrhage."

"Schematic representation of various herniation pathways (1) subfalcine, (2) uncal (Transtentorial), (3) cerebellar, and (4) transcalvarium)

Pinna Contusion and Hematoma

Blunt external ear trauma may cause a contusion or hematoma of the pinna which, if untreated, may result in cartilage necrosis and chronic scarring or further cartilage formation and permanent deformity or "cauliflower ear." Open injuries include lacerations (with and without cartilage exposure) and avulsions.

Pinna Contusion. Contusion without hematoma is present. Reevaluation in 24 hours is recommended to ensure a drainable hematoma has not formed.

Pinna Hematoma. A hematoma has developed, characterized by swelling, discoloration, ecchymosis, and fluctuance. Immediate incision and drainage or aspiration is indicated, followed by an ear compression dressing.

BLUNT ABDOMINAL TRAUMA(Surgery algorithm)

The Confusion Assessment Model (CAM)

CLICK for enlarment

Button battery in ear; How dangerous is it ?

Young children commonly place foreign bodies in the ear canal and nose. If a vegetable foreign body is present, do not use ear drops because they will cause the foreign body to swell.

One of the most dangerous foreign bodies is a button battery. This type of foreign body should be removed immediately. Prior to removal, the use of ear drops of any kind is absolutely contraindicated.

The electrical charge of the battery will produce electrolysis of any electrolyte-rich fluid. This produces hydroxides which will cause a severe alkaline burn. The picture above shows a severe burn of the external auditory canal which resulted in the exposure of bone over 180 degrees of the ear canal's circumference. The battery was in the child's ear for approximately three days and the picture was taken one month after the battery was removed. Healing is slow and damage to the eardrum, facial nerve, and inner ear can occur. Luckily in this patient the injury was confined to the ear canal.

Appearance of lye strictures in X-ray

-What is the most likely diagnosis in the patient shown below?

a. Esophageal varices
b. Esophageal carcinoma
c. Reflux esophagitis
d. Lye stricture
e. Fibrovascular polyp


THE RIGHT ANSEWR : .d

There is very long segment of smoothly narrowed esophagus from just below the level of the clavicles to the EG junction. This appearance is characteristic of a stricture caused by the ingestion of a caustic material such as lye. Lye, which became component of some drain cleaners in the late ?60s, is so highly toxic that only a few drops can cause this full-thickness liquefaction necrosis of the esophagus. The acute ulcerative phase is invariably followed in several weeks by this fibrotic stage. There is a significantly higher incidence of carcinoma of the esophagus in patients with lye strictures than in the normal population.

Ultrasound use in trauma - the fast exam

instructional video describing ultrasound use in trauma - the fast exam

Ileocecal Intussusception

A 45-year-old man with no notable medical or surgical history presented with a 24-hour history of intense pain in the right side of the abdomen with associated nausea and vomiting. He reported having had similar but much less severe episodes during the previous 6 months. Results of initial laboratory tests were unrevealing.
Physical examination showed moderate abdominal distention. Computed tomographic scans of his abdomen revealed an ileocecal intussusception (Panel A, arrow) with a pathologic mass, 2.5 cm in diameter, at the apex, also known as the lead point (Panel B, arrow). Diagnostic laparoscopy was performed, and the diagnosis of intussusception was confirmed.

Laparoscopically assisted ileocecal resection with primary anastomosis was performed. Gross inspection of the specimen showed a pedunculated lipoma within the terminal ileum. The patient had a rapid recovery, with complete resolution of his symptoms.