A healthy level of paranoia avoids missed injuries

Paranoia

So what can you do to avoid this potential problem? Here are some tips:

  • Admit that it can really happen to you.
  • Adopt a firm definition of “delayed diagnosis.”
  • Implement a tertiary survey process. This is a complete physical re-examination followed by a review of all diagnostic studies (lab and radiology) that have been performed.
  • Be paranoid. I hate the phrase, “maintain a high index of suspicion” because it’s meaningless. It’s like those stupid “start seeing motorcycles” bumper stickers. You can’t see what you can’t see. But you can be suspicious all the time, constantly looking for the inevitable clinical surprises of trauma care.

Radiological evidence of child abuse (in the ED)

There are many radiographic findings suggestive of NAT, but highly specific findings include:

  • Rib fractures (especially posterior)
  • Metaphyseal lesions – “bucket handle” or “corner” fractures
  • Scapular fractures
  • Spinous process fractures
  • Sternal fractures

ACLS Revision: Hyperkalaemia

Learning Points:

  1. When a patient is bradycardic, especially if irregular, one must always think of hyperK and one must get a 12-lead ECG.
  2. One must recognize this pattern as hyperK
  3. Calcium’s effect is almost miraculous
  4. Slow atrial fibrillation implies an sick AV node, or one affected by electrolytes, ischemia, or medications/drugs.  Otherwise, the ventricular response should be fast.

Necrotizing Fasciitis

Necrotizing Fasciitis

KEY POINTS

  • Necrotizing fasciitis may be misdiagnosed as cellulitis due to the benign appearance of cutaneous findings early in the clinical course.
  • Clues to the diagnosis of necrotizing fasciitis are vital sign abnormalities, swelling, and severe pain out of proportion to cutaneous findings.
  • If you are suspicious for necrotizing fasciitis, have a low threshold to start broad-spectrum antibiotics and consult Surgery without delaying for advanced imaging, even if clinical score and plain films are unremarkable.