How does body fluid shift based on the composition in the administration of IV fluids? The IV bag is originally isotonic, but the body can readily metabolize different components of the fluid to shift the flow of osmotic water movement!
A 3-year-old girl presented to the emergency department after she had ingested a metal pendant. She had not vomited and had no pain in her chest. A physical examination was unremarkable. A radiograph of the chest confirmed a heart-shaped foreign body in the proximal thoracic esophagus. Ingestions of foreign bodies are most commonly reported in children 1 to 3 years of age. Ingested items that warrant immediate endoscopic removal from the esophagus include sharp objects, button batteries, and foreign bodies that have been present for longer than 24 hours. Asymptomatic children who have ingested items that do not have potentially dangerous features may be observed without intervention to allow the foreign body to pass spontaneously. In this patient, the position of the foreign body appeared to be unchanged on repeat radiographs of the chest. The patient was taken to the operating room to undergo rigid endoscopy, and a gold heart-shaped pendant was removed (inset). Reinspection of the esophagus showed minor abrasions of the esophageal mucosa. After the procedure, the patient recovered well and was discharged home.
Hypovolemic shock = not enough blood volume to maintain blood pressure Cardiogenic shock = heart is too weak to maintain cardiac output; often occurs after a heart attack, heart can’t pump strongly enough Obstructive shock = a blockage somewhere prevents blood from circulating Distributive shock = blood vessels leak or dilate too much to maintain blood pressure; systemic shock, all vessels are dilated
Examples
Hypovolaemic shock: dehydration (prolonged poor water intake, diabetic polyuria both mellitus and insipidus, burns); haemorrhage (trauma, clotting factor deficiencies, ruptures/perforations of organs and vessels)
Cardiogenic shock: poor cardiac output (congestive heart failure, arrhythmias, valvular diseases, ventricular outflow tract stenosis,
ischaemic heart disease, myocardial contusions), neurogenic causes (hypofunction of cardioexcitatory centre/hyperfunction of cardioinhibitory centre of medulla)
Obstructive shock: thromboemboli, coarctation of the aorta, cardiac tamponade, pneumothorax
Distributive shock: neurogenic shock (hypofunction of the vasomotor centre in the medulla), anaphylaxis (histamine induced systemic vasodilation w/ increased vascular permeability leading to widespread oedema)
Septic shock: histaminergic effects like anaphylactic shock + reduced cardiac contractility like cardiogenic shock + thrombotic thrombocytopoenia/DIC leading to haemorrhagic shock
Although posterior hip dislocation is an uncommon injury, the consequences of delayed recognition or treatment can be dire. The majority are caused by head-on car crashes, and 90% of these are posterior dislocations. The femoral head is forced across the back wall of the acetabulum, either by the knee striking the dash, or by forces moving up the leg when the knee is locked. This occurs most commonly on the right side when the driver is standing on the brake pedal, desperately trying to stop.
On exam, the patient presents with the hip flexed, internally rotated and somewhat adducted. Range of motion is limited, and increasing resistance is felt when you try to move it out of position. An AP pelvic X-ray will show the femoral head out of the socket, but it may take a lateral or Judet view to tell if it is posterior vs anterior.
These injuries need to be reduced as soon as possible to decrease the chance of avascular necrosis of the femoral head. Procedural sedation is required for all reductions, since it makes the patient much more comfortable and reduces muscle tone. The ED cart needs to be able to handle both the patient’s weight and your own. I also recommend a spotter on each side of the cart.
Standing on the cart near the patient’s feet, begin to apply traction to the femur and slowly flex the hip to about 90 degrees. Then gently adduct the thigh to help jump the femoral head over the acetabular rim. You will feel a satisfying clunk as the head drops into place. Straighten the leg and keep it adducted. If you are unsuccessful after two tries, there is probably a bony fragment keeping the head out of the socket. See an instructional video on this tomorrow.
Regardless of success, consult your orthopedic surgeon for further instructions. And be sure to thoroughly evaluate the rest of the patient. It takes a lot of energy to cause this injury, and it is flowing through the rest of the patient, breaking other things as well.
