SpecDis- ER - GPardi

Describe the general approach to the emergent patient.

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

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

False

Contraindications to intubation?

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

What Glasgow Coma Scale necessitates advanced airway placement?

<8

What is a secured airway?

airway with cuff inflated below the level of the vocal cords

Indications for high flow nasal canula?

treatment of hypoxia, can maintain airway and patent nasal passages

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

Indications for CPAP/BiPAP?

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

Indications for OPA?

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

apneic patient who cannot be ventilated with positioning alone

Indications for NPA?

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

Causes of apnea?

head injury, stroke, dead (RIP)

What is Cheyne Stokes breathing? Causes?

gradual ↑ and ↓ in respirations with periods of apnea

Causes- increasing intracranial pressure, brain stem injury

What is Biot's breathing? Causes?

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

Causes- spinal meningitis, many CNS causes, head injury

What are Kussmaul's respirations? Causes?

tachypnea and hyperpnea

Causes- renal failure, metabolic acidosis, diabetic ketoacidosis

What is apneustic breathing? Causes?

prolonged inspiratory phase with shortened expiratory phase

Cause- lesion in brain stem

What are the 3 zones of burn wounds?

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 is a superficial burn?

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 partial thickness 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 deep 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 full 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 fourth degree burn?

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

can be life-threatening

amputation or extensive reconstruction sometimes required

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

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

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

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

Management for minor burns?

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

Management for moderate and severe 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

Which types of burns have a higher risk of infection?

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

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

True

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

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

Why are lactated ringers the preferred fluid for burn victims?

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

What are signs of a smoke inhalation injury?

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

intubate as needed, otherwise high-flow O2

How does cooling help with burn healing?

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

Which burn patients are escharotomy indicated in?

burn patients with vascular compromise

Which types of burns are the most painful?

superficial partial thickness burns

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

True

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

lacerations over the metacarpophalangeal joints

Describe appropriate skin preparation for wound closure

topical, local, or regional anesthesia

debridement of tissue if necessary

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

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

False

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

False but can facilitate wound evaluation and closure

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

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

What are the 3 mechanisms of wound closure?

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

Which type of wound closure has the lowest infection rates?

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

Which type of wound closure has the lowest dehiscence rates?

sutures - also have greatest tensile strength

What types of wounds require prophylactic antibiotics?

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

Signs and symptoms of bee stings? Treatment?

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

What are some potential organ system effects from bee stings?

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

Signs and symptoms of ant bites? Treatment?

S/sx: edema, erythema, induration, urticaria

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

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?

Black widow spider bite

Tx: self-limiting, cool compresses, 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?

Brown recluse spider bite

Tx: self-limiting, antibiotics if infected

Signs and symptoms of snake bite? Treatment?

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

Managment for marine trauma?

do not suture lacerations or puncture wounds!

antibiotic coverage, tetanus coverage, culture wounds

Typical reaction to a coral cut? Treatment?

stinging pain, erythema, swelling, pruritus

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

Signs and symptoms of a stingray injury? 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 an octopus bite? Treatment?

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

Tx: wrap limb with occlusive dressing, mechanical ventilation

Signs of elevated intracranial pressure?

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

What symptoms are concerning for underlying brain injury?

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

What can pupil changes indicate?

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

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

CT of the head and cervical spine

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?

Ruptured globe

Dx with CT scan of orbits

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

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

Alkali- common in cleaning agents and in building materials

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

Management for chemical ocular injuries?

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

perform eye exam after irrigation, erythromycin ointment

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?

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

Is imaging needed for suspected nasal fractures?

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

Signs and symptoms of nasal fracture? Tx?

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

Management of a nasal septal hematoma?

I&D urgently to avoid ischemic necrosis of nasal septum

can develop into abscesses and cause infections elsewhere in body

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

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

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

Orbital fracture

Tx: Augmentin, repair within 1-2 weeks

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

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

True

Management for frontal bone fractures?

operative repair and oral antibiotics

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?

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

What are Le Fort fractures?

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

Presentation of Le Fort fractures? Management?

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

Imaging for suspected mandible fracture?

Panorex

Components of the Glasgow Coma Scale?

eye opening, verbal response, motor resposne

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

Adults- New Orleans, Canadian head CT rule

do not apply to patients taking anticoagulants or antiplatelet agents

Children- PECARN algorithm

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?

Basilar skull fracture

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?

Epidural hematoma

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?

Subdural hematoma

*antiplatelet and anticoagulation therapy ↑ risk*

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

Subarachnoid hemorrhage

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

Signs and symptoms of diffuse axonal injury?

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 postconcussive syndrome?

≥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

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

vascular injuries

Workup for neck trauma?

no zone-targeted diagnostic workup, multi display CT angiography

Identify major structures in the 3 neck zones

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

Management for laryngotracheal injuries?

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

Why is the cervical spine most vulnerable to injury?

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

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

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

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

primary- mechanical forces

secondary- vascular and chemical injury

evaluate w/ CT of C spine

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?

Anterior cord syndrome

MC after hyperflexion 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?

Central cord syndrome

MC after hyperextension injuries

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?

Brown-Sequard syndrome

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

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

Cauda equina syndrome

Perform emergency MRI!

What is the NEXUS criteria?

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

Gold standard for C spine imaging?

CT

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

How are odontoid fractures typically caused?

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

How are Jefferson 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

What is a hangman's fracture?

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 clay shoveler'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 burst 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

Signs of traumatic pain?

clear trigger/onset/source, localized

sharp, shooting, well-demarcated

Signs of neuropathic pain?

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

Signs of visceral 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)