A 5-year-old male is brought to your office with forearm pain after a fall, and you diagnose a non-angulated buckle fracture of the distal radius and ulna.
Which one of the following treatments has the best functional outcome at 3-4 weeks?
Correct Answer B: Although casting for 3-4 weeks with a short arm cast has been the traditional treatment for buckle fractures of the wrist, functional outcome in the short term is better with a simple removable splint, and management is easier. Long-term outcomes are good with either treatment.
Rigid splinting adds to short-term functional stiffness, and a wet cast or foreign bodies placed between the cast and skin necessitate additional visits. Surgical approaches are contraindicated and would not improve healing or position.
A patient brought into the ED after a gun shot wound to the abdomen. He has a low blood pressure, low central venous pressure (CVP), low pulmonary capillary wedge pressure (PCWP), and prolonged capillary refill.
What is the appropriate initial management?
Correct Answer C: This patient has lost a lot of blood due to this gun shot wound and is in hypovolemic shock. Prolonged capillary refill indicates peripheral vasoconstriction, which in turn increases vascular resistance. He will need immediate fluid replacement with ringers lactate.
Choices A, B and D are appropriate for neurogenic, inflammatory and cardiogenic shock respectively.
This table illustrates the parameters in different types of shock:
A middle-aged woman is admitted unconscious to the Emergency Department following a head injury in a car accident. There is bruising over the upper abdomen. Blood pressure is 80 mm Hg systolic, pulse 120/minute.
What is the most important initial step in the management of this patient?
Correct Answer C: Almost all circulatory shock states require large-volume IV fluid replacement, as does severe intravascular volume depletion (eg, from diarrhea or heat stroke). Intravascular volume deficiency is acutely compensated by vasoconstriction, followed over hours by migration of fluid from the extravascular compartment to the intravascular, maintaining circulating volume at the expense of total body water.
The preferred site for an emergency airway is:
Correct Answer B: Fortunately, emergency tracheotomy is not often necessary, but should one be necessary the best site for the incision is directly above the cricoid cartilage, through the cricothyroid membrane. Strictly speaking, this is not a tracheotomy, because it is actually above the trachea. However, it is below the vocal cords and bypasses any laryngeal obstruction. The thyrohyoid membrane lies well above the vocal cords, making this an impractical site. The area directly below the cricoid cartilage which includes the second, third, and fourth tracheal rings, as well as the thyroid isthmus is the preferred tracheotomy site under controlled circumstances, but excessive bleeding and difficulty finding the trachea may significantly impede the procedure in an emergency.
A 55-year-old man presents to the emergency department with dull, continuous pain in the renal angle. He had a similar attack of this pain a year ago after which he passed a kidney stone. A few years earlier the patient developed incarcerated hernia that resulted in resection of about 2 meters of his small intestine (mostly of the ileum).
Intravenous urography showed a stone of about 0.6 cm at the pelviureteric junction. An analgesic was prescribed and the patient was advised to watch his urine for the stone. Fortunately the stone again passed in urine a few days later. The stone was found to be made of calcium oxalate.
Recurrence of this stone can be prevented by:
Correct Answer D: The proportion of dietary oxalate absorbed has been shown to correlate negatively and linearly with calcium intake. Thus, while about 17% of ingested oxalate is absorbed with dietary calcium of 200 mg/day, only 2.6% was absorbed when dietary calcium was raised to 1200 mg/day. The probable reason for this is that calcium binds to oxalate and makes it insoluble and consequently reduces its absorption.
With intestinal resection and especially when it involves a large segment of the ileum, deficiency of bile salts impairs digestion and absorption of fat. Un-absorbed fat competes with oxalate for binding to calcium. Thus, the higher the amount of un-absorbed fat, the lesser is the amount of calcium available for binding to oxalate and large amounts of it will consequently be absorbed. A diet low in fat (choice D) is then expected to reduce oxalate absorption and calcium oxalate stone formation.
→ High rather than low calcium diet (choice A) would help prevent the condition. With high calcium in diet, there would be a high amount of un-absorbed calcium. This would bind oxalate and minimize its absorption.
→ With high phosphate intake (choice B), amounts of this anion will increase in gut lumen. Like fat, this anion would bind to calcium and leave little for oxalate to bind to. More oxalate will be absorbed in this case.
→ Citrate (choice C) has been shown to reduce stone forming capacity of urine and indeed citrate ingestion should be promoted rather than restricted.
→ Magnesium (choice E), being a cation like calcium would behave similarly. A high rather than low magnesium diet would help prevent absorption of oxalate.
Make sure you know functional changes in patients with intestinal resection.
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