A 4-year-old girl was brought in by her parents with sudden onset coughing and choking. She was given back thrusts and some blood came out. A provisional diagnosis of foreign body aspiration was made. Foreign body aspiration is a common cause of these symptoms, especially in young children who may inhale food. Imaging was ordered to investigate further. A 50-year-old woman fell in a restroom and landed on her right shoulder. She was brought in with her arm in a sling. X-rays at the urgent care clinic showed a fracture dislocation of the shoulder, which commonly involves fractures of the greater tuberosity with anterior dislocation. Reduction is typically done under sedation

1. VANAGARAM CPs
April/May 2023
Dr. Aiswarya

2. • 4 year old girl brought by parents with C/O coughing- sudden onset
Given back thrusts for; Choking – few drops of blood came with saliva
• Provisional diagnosis?
• Investigation?

4. Foreign Body Aspiration
• Food is the most common foreign body aspirated – most common 1-
2y incidence
• Usual history – sudden onset of coughing/retching/choking
• Partial obstruction above or at the vocal cords – inspiratory stridor
causing a change in voice/cough/dyspnea
• Partial obstruction of lower airway – In addition – cause
pneumothorax, pneumomediastinum, surgical emphysema

5. High risk foreign body ingestion
• Button batteries lodged in the oesophagus need immediate removal, however once they
enter the stomach, they are less concerning
• Large objects (>6 cm long and/or >2 cm wide) may become entrapped at the pylorus
• Superabsorbent polymers may also cause impaction
• magnet + a metal object or >1 magnet ingestion can cause serious and potentially life-
threatening complications
• lead based objects that fail to transit through the stomach may cause acute systemic lead
absorption
• multi-component objects may break apart and progress separately in the gastrointestinal
tract (eg toys with lights, motors and batteries) and may require removal

8. • 50/F slip and fall in restroom at office, landed on right shoulder .
• Gone to OSH, took an xray, brought in with arm sling .

10. • Name of Classification?
• Reduction technique?
• Analgesia of choice before reduction and dose?

11. Fracture dislocation of shoulder
• Most involve fractures of the greater tuberosity associated with
anterior dislocation of the shoulder.
• Reduce under sedation
• External rotation – With patient reclined at 45 deg, externally rotate
the shoulder gently to 90 deg. If dislocation still not reduced –
forward flex the shoulder
• Modified Kochers method FL-ER-AD-IR
• Modified Milch

12. External rotation maneuver

18. • 41/M no comorbities
• c/o palpitations since 6 hours
• No chest pain, SOB , giddiness

19. • HR- 140 -150/min
• Bp- 110/70
• Sp02- 97% RA
• GCS- 15/15
• No ongoing pain, chest is clear

21. • Inj. Adenosine 6 mg – 12mg
• Didn’t revert
• Inj . Amiodarone 150 mg bolus given - started on infusion

25. Atrial flutter with variable block
• Atrial flutter is typically a regular, narrow complex tachycardia with
2:1 or even higher levels of AV block. In some patients the AV block is
variable; this may be either idiopathic or in the context of complete
heart block
• Irregular rhythm
• Saw-toothed baseline 'flutter' waves at ~300bpm
• Variable atrioventricular block (inconsistent number of flutter waves
between QRS complexes)

27. • Recommended shock in joules for Atrial flutter?
• Why do we do synchronised cardioversion?

29. AHA Journal - -
• The recommended initial energy for cardioversion of atrial
fibrillation is 100 to 200 J MDS.
• Atrial flutter and paroxysmal supraventricular tachycardia
(PSVT) generally require less energy. An initial energy of 50 to
100 J MDS is often sufficient, with stepwise increases in energy
if initial shocks fail.
• Transthoracic cardioversion of atrial fibrillation with a low-
energy (120-J), rectilinear, first-pulse biphasic waveform was
superior to 200 J MDS in a recent controlled trial.

30. • Delivered energy should be synchronized with the QRS complex to
reduce the possibility of inducing VF, which can occur when a shock
“hits” the relative refractory portion of the cardiac cycle.
• Synchronization to prevent this complication is recommended for
hemodynamically stable wide-complex tachycardia requiring
cardioversion, supraventricular tachycardia, atrial fibrillation, and
atrial flutter.

31. ALS guidelines, UK
• For atrial flutter and paroxysmal supraventricular tachycardia:
Give an initial shock of 70 - 120 J.
Give subsequent shocks using stepwise increases in energy.
• For ventricular tachycardia with a pulse:
Use energy levels of 120-150 J for the initial shock.
Consider stepwise increases if the first shock fails to achieve sinus
rhythm.

32. • 13 year old fell while playing football
• Landed on his left knee, unable to weight bear

36. • Tuberosity avulsion fracture
• Patella – high riding
• Quadriceps tendon injury
• Complication?
• Injured structure?

37. Tibial tubercle avulsion fractures
• Tibial tubercle avulsion fractures are an uncommon cause of knee
pain in jumping adolescent athletes.
• Tibial tubercle fractures are a fairly uncommon pediatric fracture and
account for under 1% of epiphyseal injuries. Of all proximal tibial
fractures, approximately 3% are tibial tubercle avulsion fractures.

38. • Injury may be caused by quadriceps contraction during knee
extension such as initiating a jump.
• Damage can also take place during landing when the quadriceps
contracts and the knee flexes to absorb the impact of landing.
• The patellar ligament inserts on the secondary ossification center,
which places the tibial tubercle at risk for an avulsion injury.
• Most dreaded complication – compartment syndrome due to injury
to anterior tibial artery.

39. Watson & Ogden classification
•Type I - fracture through the secondary
ossification center
•Type II - fracture extends to an area
between secondary and primary ossification
centers
•Type III - fracture crosses through the
secondary and primary ossification centers
•Type IV - fracture through the proximal
tibial physis
•Type V - extensor mechanism avulsion

41. Classification

42. CT findings
• Fracture of upper end of left tibia with involvement of both epiphysis
and metaphysis
• Superior displacement of patella
• Hemarthrosis of knee joint

43. 66/M had a skid and fall from 2 wheeler in his farm on 3 months prior
No H/o LOC, vomiting , ENT bleed, seizures.
Now presented with H/o altered speech for 1 week and headache .
K/C/O HTN, CAD on dual antiplatelets

44. • GCS- E3 V4 M6 B/L PERL 1.5mm
• HR- 40 – 50 /min fluctuating
• BP- 160/90
• RR- 12 /min
• Spo2- 99 % RA
• CBG- 102

48. CT FINDINGS
• Isodense subacute subdural hemorrhage along left cerebral convexity
with max thickness of 2.3 cm.
• Small hyperdense areas within subdural h’ge – hyperacute
component.
• Mass effect with effacement of underlying cortical sulci
• Midline shift of 7.7 mm

49. ACUTE SDH
• Acute SDH is a rapidly clotting blood collection below the inner layer
of the dura but external to the brain and arachnoid membrane.
• Two further stages—subacute and chronic—may develop with
untreated acute SDH. Generally, the subacute phase begins 3-7 days
after acute injury (surgical literature favors 3 days; radiologic
literature favors 7days.) The chronic phase begins about 2-3 weeks
after acute injury.

50. • Traumatic acute SDH is associated with high mortality despite
intensive treatment.
• In a study of patients with traumatic acute SDH, a midline shift
exceeding the thickness of the hematoma by 3 mm or more at initial
computed tomography (CT) predicted mortality in all cases.

51. ED management in Acute SDH
• Intubation and imaging
• Optimizing venous outflow and reducing ICP
• Hyperventilation to a target partial pressure of carbon dioxide (pCO2)
of 30 mm Hg can reduce intracranial pressure (ICP) in the short term,
although a pCO2 level less than 25 mm Hg is strongly discouraged.
Intravenous mannitol (0.25 g/kg) may be used to decrease ICP.

52. Trephination
• Burr holes are a temporizing option when rapid demise is associated
with severe head trauma, especially if a herniation syndrome is
clinically evident.
• Generally, because the lesion represents clotted blood, the burr hole
is not curative, and emergent craniotomy is necessary.
• However, burr holes can guide surgical therapy when head CT imaging
is unavailable.

54. MI complicating an ICH
• Seen mostly in SAH – Mechanism unclear ? Secondary to massive
catecholamine release
• The acute myocardial infarction would prompt the cardiologist to
perform emergency percutaneous coronary intervention and
administer antithrombotic drugs.
• The unprotected aneurysm would make the neurologist reluctant to
administrate these antithrombotic agents, given the risk of
rebleeding.
• Routine treatment of a subarachnoid haemorrhage consists of coiling
or clipping of the aneurysm within 72 hours.

55. • Ideally, treatment of an unprotected aneurysm with concomitant
myocardial infarction would consist of immediate coiling or clipping of
the aneurysm followed by percutaneous coronary intervention.
• Antithrombotic drugs can only be safely installed after coiling or
clipping.
• When the aneurysm cannot be coiled immediately, coronary
intervention can be considered as initial treatment despite the use of
antithrombotic drugs.

56. • 45/M accidental skid and fall from two wheeler
• No signs of head injury
• Local examination – Right ankle swelling and ROM painful

59. Bimalleolar fracture
• Involve medial and lateral malleoli and the posterior malleolus
(posterior part of distal tibia); The ankle mortice joint allows very little
rotation or angulation – Twisting or angulation causes fracture.
• In severe cases – disruption of distal talofibular syndesmosis
• Displaced bimalleolar fracture – unstable; needs ORIF; Adequate
sedation to allow talar shift;
• Immobilize in BKPOP cast.

60. 37/M fall from broken ladder at home
Landed on R elbow and R hip
No H/s/o of head injury
Came to walking to ER

63. • Comminuted fracture of right ulna and fracture of right radius with
gross displacement of head of radius.
• Name of eponymous fracture with fracture of radial head in
combination with a wrist fracture?

64. Essex Lopresti fracture dislocation

65. Radial head fracture
• Flexion/Extension limited.
• Check for elbow effusion
• Collar and cuff
• Displaced and comminuted fracture – surgical fixation

67. Cortical breach in Right greater trochanter.

68. THANK YOU.