SpecDis- ER

Airway- are they talking, blood, edema, vomitus, foreign body, local injury

Breathing- respiratory rate, work of breathing, patterns, listen for breath sounds, check pulse ox

Circulation/C-spine- mental status, color, peripheral pulses, HR, rhythm, BP

Disability- neuro exam, Glasgow coma scale

Expose- visualize for injury or other associated exam findings

Describe the general approach to the emergent patient.

False

True or false: a patient may leave AMA if they are intoxicated

foreign body airway obstruction of upper airway, non-intact upper airway (laryngectomy), severe facial trauma that obscures landmarks for intubation (require surgical airway)

Contraindications to intubation?

<8

What Glasgow Coma Scale necessitates advanced airway placement?

airway with cuff inflated below the level of the vocal cords

What is a secured airway?

treatment of hypoxia, can maintain airway and patent nasal passages

does not ↑ ventilation so cannot be used for hypercarbic respiratory failure

Indications for high flow nasal canula?

respiratory acidosis, dyspnea, increased O2 demands, hypoxic respiratory failure

Indications for CPAP/BiPAP?

unconscious patient with impaired airway protective reflexes (no gag reflex)

apneic patient who cannot be ventilated with positioning alone

Indications for OPA?

unconscious patient with impaired airway protective reflexes

apneic patient who cannot be ventilated with positioning alone

conscious patient with anatomic airway obstruction or impaired airway protective reflexes

Indications for NPA?

head injury, stroke, dead (RIP)

Causes of apnea?

gradual ↑ and ↓ in respirations with periods of apnea

Causes- increasing intracranial pressure, brain stem injury

What is Cheyne Stokes breathing? Causes?

rapid, deep respirations (gasps) with short pauses in between sets

Causes- spinal meningitis, many CNS causes, head injury

What is Biot's breathing? Causes?

tachypnea and hyperpnea

Causes- renal failure, metabolic acidosis, diabetic ketoacidosis

What are Kussmaul's respirations? Causes?

prolonged inspiratory phase with shortened expiratory phase

Cause- lesion in brain stem

What is apneustic breathing? Causes?

1. zone of coagulation: tissue is irreversibly destroyed within thrombosis of blood vessels

2. zone of stasis: stagnation of microcirculation, can progressively become more hypoxemic and ischemic if resuscitation is not adequate

3. zone of hyperemia: ↑ blood flow, minimal damage to the cells and spontaneous recovery is likely

What are the 3 zones of burn wounds?

involves only the epidermis

skin is red, painful and tender without blister formation

usually heals in about 7 days without scarring, require only symptomatic treatment

What is a superficial burn?

involves epidermis and superficial dermis

often caused by hot water scalding

skin is blistered, red and moist, capillary refill intact

exceedingly painful to touch

usually heals in 14-21 days, minimal scarring, full return of function.

What is a superficial partial thickness burn?

extends into deep dermis, damages hair follicles and sebaceous glands

usually caused by hot liquids, steam or flames

absent capillary refill and absent pain sensation

healing takes 3 weeks-2 months, scarring is common

may need surgical debridement and skin grafting

What is a deep partial thickness burn?

involves entire thickness of skin

typically caused by flame, hot oil, steam, or contact with hot objects

skin is charred, pale, painless, and leathery

do not heal spontaneously, need surgical repair and skin grafting, significant scarring

What is a full thickness burn?

extend through the skin to subcutaneous fat, muscle, and even bone

can be life-threatening

amputation or extensive reconstruction sometimes required

What is a fourth degree burn?

face- 9%

front of torso- 18%

back of torso- 18%

each arm- 9%

pubic region- 1%

each leg- 18%

Lund-Brown used more often and more accurate

How does the rule of nines estimate the percentage of body surface area involved in burns?

partial thickness burns >10% of BSA (>5% if young/old)

burns that involve the face, hands, feet, genitalia, perineum

any electrical or chemical burns

burns w/ associated smoke inhalation injuries

burns in patients with pre-existing medical conditions that could complicate management

Which types of burns should be referred to a burn center?

cool immediately in cool/room temp water, pain management, clean with mild soap and water, apply topical antibiotics

Management for minor burns?

ensure adequate and patent airway- early intubation if s/sx of compromise

IV fluids (any burn patient w/ >15% BSA can be hypovolemic)- use Parkland formula (4mL x %BSA x kg)

Foley to assess hydration status, topical antibiotics

Management for moderate and severe burns?

non-superficial due to ↓ neutrophil activity, impaired T lymphocyte activity and cytokine imbalance

Which types of burns have a higher risk of infection?

True

True or false: due to catecholamine response associated with a burn injury, a heart rate of 100-120 bpm is considerd within normal limits for adults

in patients with partial thickness burns of >20% of body surface area

When should you insert an NG tube in a burn victim?

lactate may buffer metabolic acidosis in the early post-burn phase

Why are lactated ringers the preferred fluid for burn victims?

carbonaceous sputum, singed facial or nasal hairs, facial burns, oropharyngeal edema, voice changes

intubate as needed, otherwise high-flow O2

What are signs of a smoke inhalation injury?

creates local vasoconstriction, stabilizes mast cells and reduces histamine release, kinin formation, and thromboxane B2 production

How does cooling help with burn healing?

burn patients with vascular compromise

Which burn patients are escharotomy indicated in?

superficial partial thickness burns

Which types of burns are the most painful?

True

True or false: repositioning a wounded joint or extremity in the position assumed during injury can better reconstruct the mechanism of injury and identify injured structures

lacerations over the metacarpophalangeal joints

What types of wounds should be treated as "fight bites?"

topical, local, or regional anesthesia

debridement of tissue if necessary

if wound is heavily contaminated- high pressure irrigation with soap and water

Describe appropriate skin preparation for wound closure

False

True or false: full sterile technique reduces wound infection rates after laceration repair in the ED setting

False but can facilitate wound evaluation and closure

True or false: hair removal is necessary before wound repair to reduce incidence of infection

point tenderness, ↑ pain w/ motion, sensation of foreign body by patient, plain X-ray may also be helpful at identifying radiopaque foreign bodies

What signs and symptoms are suggestive of foreign bodies in wounds?

primary closure- wound immediately closed by approximating edges

secondary closure- wound left open and allowed to close on its own (well suited for highly contaminated or infected wounds)

delayed (tertiary) closure- wound is initially cleansed then packed with moist sterile gauze, dressing is removed after 4-5 days, wound edges can be closed if no infection

What are the 3 mechanisms of wound closure?

adhesive tapes but frequently fall off, lower tensile strength, highest rate of dehiscence

Which type of wound closure has the lowest infection rates?

sutures - also have greatest tensile strength

Which type of wound closure has the lowest dehiscence rates?

human bites, cat bites, deep dog bite puncture wounds, bite wounds to the hand, open fractures and wounds w/ exposed joints or tendon

Tx: augmentin for mammalian bites, 1st gen cephalosporin for open fractures or joints

What types of wounds require prophylactic antibiotics?

S/sx: localized itching, pain, erythema, swelling- can last up to several days and will spontaneously resolve

Tx: remove stinger, wash wound, cold compresses, NSAIDs, may be associated with lymphangitic streaks

Signs and symptoms of bee stings? Treatment?

renal and hepatic failure, DIC, rhabdomyolysis

delayed reaction may appear 5-14 days after a sting and consist of serum sickness-like signs- fever, malaise, HA, urticaria, lymphadenopathy, polyarthritis

What are some potential organ system effects from bee stings?

S/sx: edema, erythema, induration, urticaria

Tx: local wound care, treat for anaphylaxis, wear socks or cotton tights

Signs and symptoms of ant bites? Treatment?

Black widow spider bite

Tx: self-limiting, cool compresses, antibiotics if infected

A patient presents with painful target lesion with a blanched center and surrounding erythema on her hand that she reports started as an erythematous macule. She reports this lesion developed a few hours after she felt a pinprick sensation at the site. She is also experiencing cramp-like spasms in her trunk, back, and abdomen, as well as a headache. She is hypertensive and tachycardic. Dx? Tx?

Brown recluse spider bite

Tx: self-limiting, antibiotics if infected

A woman presents with a lesion with erythema, blanching, and ecchymosis. She reports it began as a mildly swollen erythematous lesion, turned into a hemorrhagic blister, and now looks red, white, and blue. She can't recall if she was bit by anything because she never felt a painful bite. Dx? Tx?

S/sx: localized pain, progressive edema from bite site, N/V, weakness, oral numbness, tingling of mouth, dizziness, muscle fasciculation, tachypnea, tachycardia, hypotension, AMS, angioedema

Tx: Sawyer Extractor suction, immobilize extremity, constriction bands, antivenom, make sure sufficient dosing and evaluate local effects, systemic effects, hematologic abnormalities

Signs and symptoms of snake bite? Treatment?

do not suture lacerations or puncture wounds!

antibiotic coverage, tetanus coverage, culture wounds

Managment for marine trauma?

stinging pain, erythema, swelling, pruritus

Tx: self-limiting over 3-6 weeks, clean, irrigate, antibiotics

Typical reaction to a coral cut? Treatment?

local pain that may radiate and last for many hours, significant bleeding

Tx: submerge in hot water for 10-30 min, topical lidocaine, irrigate wound, control bleeding

Signs and symptoms of a stingray injury? Treatment?

tetrodotoxin, small painless puncture marks, vomiting, progressive flaccid paralysis, respiratory failure

Tx: wrap limb with occlusive dressing, mechanical ventilation

Signs and symptoms of an octopus bite? Treatment?

Cushing reflex- hypertension, bradycardia, irregular respirations (depends on where increased pressure is)

Signs of elevated intracranial pressure?

focal neurologic deficit, seizures, emesis or depressed level of consciousness

What symptoms are concerning for underlying brain injury?

single fixed and dilated pupil- intracranial bleed

bilateral fixed and dilated pupils- ↑ ICP w/ poor brain perfusion, bilateral uncal herniation, drug effect, severe hypoxia

bilateral pinpoint pupils- opiate exposure or central pontine lesion

What can pupil changes indicate?

CT of the head and cervical spine

How should you assess a patient with head blunt-force or penetrating trauma?

Ruptured globe

Dx with CT scan of orbits

Tx: cover the eye w/ metal shield, consult opthalmology immediately, elevate HOB, broad-spectrum IV antibiotics

A patient was hitting the gritty when all of a sudden he hit it way too hard and smacked down face-first on the concrete. He is now complaining of eye pain but no decrease in his visual acuity. Physical exam reveals severe subconjunctival hemorrhage, conjunctival edema, a "deflated" looking anterior chamber, teardrop pupil in the affected eye, and a positive seidel test. Dx? Tx?

Alkali- common in cleaning agents and in building materials

tend to be more serious because they cause liquefaction necrosis and deep penetration into tissue

Which types of chemical ocular injuries are more common- alkali or acid?

irrigation until pH is <7.4, normal saline or other isotonic solution by Morgan lens

perform eye exam after irrigation, erythromycin ointment

Management for chemical ocular injuries?

Tympanic membrane perforation

Tx: most heal spontaneously, do not allow water to enter canal, refer to otolaryngologist w/in 24 hours if perforation is in posterosuperior quadrant or secondary to penetrating wound

Patient presents with an acute onset of pain and hearing loss after a few days of having an ear infection. They report they noticed some bloody otorrhea. Dx? Tx?

no- clinical diagnosis, only need CT if there is concern for intracranial injury or other facial fractures

Is imaging needed for suspected nasal fractures?

S/sx: periorbital ecchymosis, profuse epistaxis, nasal bone mobility

Tx: most do not require immediate intervention and can be managed by ENT w/in 6-10 days

Signs and symptoms of nasal fracture? Tx?

I&D urgently to avoid ischemic necrosis of nasal septum

can develop into abscesses and cause infections elsewhere in body

Management of a nasal septal hematoma?

blow-out: involves only the orbit without causing an orbital ridge or rim fracture, force transmitted results in fracture of weaker inferior or medial orbital walls

impure: lateral, inferior and superior orbital ridge fractures typically occur with other facial features, often associated with other injuries of facial bones

Difference between an orbital blow-out fracture and an impure orbital fracture?

Orbital fracture

Tx: Augmentin, repair within 1-2 weeks

emergent ophthalmology consult if ↓ visual acuity, poor EOM, and ↑ IOP

A patient suffers trauma to the face and presents with enophthalmos, infraorbital anesthesia, diplopia on upward gaze. Dx? Tx?

True

True or false: otorrhea and/or rhinorrhea in the setting of frontal bone fracture is CSF leak until proven otherwise

operative repair and oral antibiotics

Management for frontal bone fractures?

Zygoma fracture

Tx: pain meds and DC home if isolated temporal arch fracture

IV antibiotics and operative repair if zygomaticomaxillary fracture or any loss of vision

A patient was punched in the face and now presents with zygomatic arch tenderness, flattening of the malar eminence, infraorbital anesthesia and trismus. There is crepitus and the patient has diplopia. Dx? Tx?

separation of the hard palate from the upper maxilla due to a transverse fracture running through the maxilla and pterygoid plates at a level just above the floor of the nose

What are Le Fort fractures?

often presents dramatically with significant hemorrhage, early swelling, bilateral orbital ecchymosis and CSF fluid leaks

Management: airway protection, oral and nasal packing, IV antibiotics, surgical repair

Presentation of Le Fort fractures? Management?

Panorex

Imaging for suspected mandible fracture?

eye opening, verbal response, motor resposne

Components of the Glasgow Coma Scale?

Adults- New Orleans, Canadian head CT rule

do not apply to patients taking anticoagulants or antiplatelet agents

Children- PECARN algorithm

Which algorithms are used to determine if a head CT is needed in adults and children?

Basilar skull fracture

A patient presents after a MVC with otorrhea and rhinorrhea, vertigo, decreased hearing, and facial nerve palsy. A few hours later, he now has mastoid and periorbital ecchymosis. Dx?

Epidural hematoma

A boy was playing in his baseball game when he was accidentally hit on the side of his head with a bat. He had a brief loss of consciousness, but now he is awake and complains of a headache, nausea, and has some focal neurological deficits. Dx?

Subdural hematoma

*antiplatelet and anticoagulation therapy ↑ risk*

An elderly woman fell at home and hit her head 2 days ago and now presents with a headache, confusion, nausea, and feeling more drowsy. Her husband reports these symptoms have been worsening since her fall. Dx?

Subarachnoid hemorrhage

CT performed 6-8 hours after injury are sensitive for detecting traumatic SAH

A patient presents post-MVA with the "worst headache of her life," photophobia, stiff neck, severe nausea and vomiting. Dx?

common TBI- disruption of axonal fibers in white matter/brainstem

mild: coma for 6-24hrs, usually recover without long-term sequela

moderate: coma for >24 hours, wake up w/ long-term cognitive deficits

severe: prolonged coma, persistent vegetative state

Signs and symptoms of diffuse axonal injury?

≥3 months- HA, dizziness, ↓ concentration, memory problems, sleep disturbances, irritability, fatigue, visual disturbances, judgment problems, depression, anxiety

≥3 concussions pose risk for long-term sequelae, including chronic traumatic encephalopathy

Signs and symptoms of postconcussive syndrome?

vascular injuries

What are the most common cervical injury and leading cause of death from penetrating neck trauma?

no zone-targeted diagnostic workup, multi display CT angiography

Workup for neck trauma?

I (clavicles to cricoid cartilage): subclavian artery, major vessels of upper mediastinum, apices of lungs, esophagus, trachea, thyroid, thoracic duct

II (cricoid cartillage to angle of mandible): larynx, trachea, esophagus, pharynx, jugular vein, vagus nerve

III (angle of mandible to mastoids): distal jugular vein, salivary and parotid glands, cranial nerves IX to XII

carotid and vertebral in all 3

Identify major structures in the 3 neck zones

evaluate with flexible fiberoptic laryngoscopy to define airway patency and extent of intraluminal injury, CT imaging is critical

Management for laryngotracheal injuries?

it is the most exposed, flexible, and mobile portion of the spinal column

Why is the cervical spine most vulnerable to injury?

hard cervical collars are associated with patient discomfort and pressure sores of the neck

Why is it important to clear the cervical spine as soon as possible?

primary- mechanical forces

secondary- vascular and chemical injury

evaluate w/ CT of C spine

What are the two potential injuries to the spinal cord? How should they be evaluated?

Anterior cord syndrome

MC after hyperflexion injuries

A patient presents after a hyperflexion injury with lower extremity motor deficits and lower extremity pain and temperature deficits. Her lower extremity proprioception, vibration, and light touch are all in tact. Dx?

Central cord syndrome

MC after hyperextension injuries

A 68-year-old woman presents after a hyperextension injury with upper extremity motor deficits and upper extremity pain and temperature deficits. Her upper extremity proprioception, vibration and pressure are all preserved. Dx?

Brown-Sequard syndrome

Causes ipsilateral loss of motor function, proprioception and vibratory sensation + contralateral loss of pain and temperature sensation

A patient was dueling with his friends and suffered a penetrating injury to the R side of his spinal cord at T12. He now presents with R sided loss of motor function, proprioception and vibratory sensation in his lower extremities. He also has L sided loss of pain and temperature sensation in his lower extremities. Dx?

Cauda equina syndrome

Perform emergency MRI!

A patient presents after a MVC with saddle anesthesia, decreased lower extremity reflexes, decreased anal sphincter tone, and bladder dysfunction. Dx?

recommends C-spine imaging in all patients w/ trauma unless meet all following criteria:

no posterior midline C spine tenderness, no evidence of intoxication, normal level of alertness, no focal neurologic deficits, no painful distracting injuries

What is the NEXUS criteria?

CT

X-ray misses injuries and is poor for imaging C1 and C2

Gold standard for C spine imaging?

C2 fracture- low energy falls (fall from standing position) in elderly and high energy traumatic injuries in younger patients

How are odontoid fractures typically caused?

C1 fracture- usually by impact or load on the back of the head- diving into shallow water, impact against the roof of a vehicle, falls

not normally associated with neurological deficit

How are Jefferson fractures typically caused?

when the pars of C2 fractures on both sides, C2 may move out of position relative to C3

causes neck pain but neuro exam usually intact b/c cervical canal is widest at C2 area

What is a hangman's fracture?

avulsion fracture of the lower cervical or upper thoracic spinous processes, can be seen in trauma and sports-related activity, usually responds to rest from painful activity

What is a clay shoveler's fracture?

injury to spine in which the vertebral body is crushed in all directions, typically occurs from severe trauma

more severe than compression fracture b/c spinal cord is liable to be injured, bony fragments can bruise spinal cord causing paralysis or partial neurologic injury, spine becomes much less stable

What is a burst fracture?

clear trigger/onset/source, localized

sharp, shooting, well-demarcated

Signs of traumatic pain?

burning, stabbing, electric shock-like, tingling, numbness, "pins and needles"

Signs of neuropathic pain?

associated with thoracic, abdominal or pelvic organs

diffuse, difficult to localize. dull, aching, deep pain

associated with autonomic nervous system- N/V, sweating, pallor, vital sign abnormalities (tachycardic, hypertensive, tachypneic)

Signs of visceral pain?