Emergency Trauma Care: Current Topics & Controversies Volume IV

Accreditation

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation

EB Medicine designates this enduring material for a maximum of 16 AMA PRA Category 1 Credits^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Objectives

Upon completion of this article, you should be able to:

1. Utilize chest x-ray, CT, and eFAST as indicated to assess for traumatic pneumothorax and determine appropriate management of pneumothorax, including needle decompression, tube thoracostomy, pigtail catheter, or observation.
2. Select the appropriate methods and materials for wound closure and identify wounds that are at high risk for complications.
3. Describe the utility of various clinical findings and imaging studies for rib fracture diagnosis and utilize evolving treatment algorithms for rib fractures in both inpatients and outpatients.
4. Utilize a diagnostic approach to the patient with possible spinal cord injury (SCI) and outline a management pathway while also identifying patients who are at risk for acute decompensation from respiratory and/or hemodynamic complications.

Table of Contents

Traumatic Pneumothorax: Updates in Diagnosis and Management in the Emergency Department (Trauma CME)

1. About This Issue
2. Abstract
3. Case Presentation
4. Introduction
5. Anatomy and Pathophysiology
6. Emergency Department Evaluation
   1. Primary Survey
   2. Secondary Survey
7. Diagnostic Studies
   1. Chest X-Ray
   2. Ultrasonography
   3. Computed Tomography
8. Emergency Department Management
   1. Needle Decompression
   2. Chest Tube Insertion
   3. Observation
9. Controversies and Cutting Edge
   1. Positive-Pressure Ventilation
   2. Observation Versus Thoracostomy
   3. Chest Tube Sizing
10. Strategies for Management of Traumatic Pneumothorax
11. Summary
12. Case Conclusions
13. Clinical Pathway for Detection and Management of Pneumothorax in the Emergency Department
14. Tables and Figures
15. References

Emergency Department Management of Cervical Spine Injuries (Trauma CME)

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Epidemiology and Pathophysiology
   1. Epidemiology
   2. Anatomy
   3. Pathophysiology
7. Differential Diagnosis
   1. Spinal Fracture
   2. Nontraumatic Spinal Compression
   3. Visceral Injuries
   4. Vascular Injury
   5. Muscle Spasm
8. Prehospital Care
   1. Recognition
   2. Immobilization
      1. Summary Recommendations
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. Airway
      2. Breathing
      3. Circulation
      4. Disability
      5. Exposure
   3. Secondary Survey
   4. Neurological Assessment
10. Diagnostic Studies
    1. Decision Rules in Imaging
    2. Plain Films
    3. Computed Tomography
    4. Magnetic Resonance Imaging
    5. Assessing Ligamentous Stability
    6. Assessing for Vascular Injury
11. Treatment
    1. Supportive Care
       1. Airway Management
       2. Blood Pressure Augmentation
    2. Medical Therapy
    3. Surgical Therapy
       1. Closed Reduction
       2. Decompression
12. Special Populations
    1. Pediatric Patients
       1. Atlantoaxial Rotatory Fixation
       2. SCIWORA
13. Controversies and Cutting Edge
    1. Stem Cell Treatment
14. Disposition
15. Summary
16. Time- and Cost-Effective Strategies
17. Risk Management Pitfalls for Spinal Cord Injury in the Emergency Department
18. Case Conclusions
19. Clinical Pathway for Emergency Department Management of Blunt Cervical Trauma in Adult Patients
20. Tables, Figures and Appendix
    1. Table 1. Incomplete Spinal Cord Injuries
    2. Table 2. Unstable Spinal Fractures
    3. Table 3. Stable Spinal Fractures
    4. Table 4. Differential Diagnosis of Spinal Injury
    5. Table 5. Guidelines for Prehospital Spinal Immobilization
    6. Table 6. Immediate Life Threats in Spinal Cord Injury
    7. Table 7. The NEXUS Low-Risk Criteria for Cervical Spine Imaging
    8. Table 8. Comparison of NEXUS Criteria and Canadian C-Spine Rule
    9. Table 9. Modified Denver Screening Criteria for Blunt Cerebrovascular Injury
    10. Table 10. Summary of Key Updates in Management of Spinal Injuries
    11. Figure 1. Causes and Demographics of Spinal Cord Injury in the United States
    12. Figure 2. The Denis 3-Column Model of Spinal Stability
    13. Figure 3. Spinal Cord Anatomy and Function
    14. Figure 4. The Canadian C-Spine Rule
    15. Figure 5. Thoracolumbar Imaging Clinical Decision Tool
    16. Figure 6. Atlantoaxial Rotatory Fixation
    17. Appendix. The American Spinal Injury Association Spinal Assessment Worksheet
21. References

Emergency Department Management of Rib Fractures (Trauma CME)

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Chest X-Ray
    2. Computed Tomography
    3. Ultrasound
    4. Laboratory Testing
11. Treatment
    1. Pain Management
       1. Oral, Intravenous, and Topical Pharmacological Treatments
          • Adjuvant Pharmacologic Pain Management Agents
       2. Regional and Neuraxial Analgesia
          • Ultrasound-Guided Regional Anesthesia
       3. Nonpharmacological Treatments
       4. Pain Management Summary
    2. Ventilatory Support
       1. Noninvasive Positive Pressure Ventilation
       2. High-Flow Nasal Cannula
       3. Invasive Mechanical Ventilation
       4. Summary of Ventilatory Support Options
    3. Operative Fixation of Acute Rib Fractures
    4. Treatment of Complications of Rib Fractures
12. Special Populations
13. Controversies and Cutting Edge
14. Disposition
15. Risk Management Pitfalls for Managing Rib Fractures in the Emergency Department
16. Summary
17. Time- and Cost-Effective Strategies
18. Case Conclusions
19. Clinical Pathway for Emergency Department Management of Rib Fractures
20. Tables and Figures
    1. Table 1. American College of Radiology Appropriateness Criteria® for Chest Imaging after Minor Blunt Trauma Confined to the Chest
    2. Table 2. Ventilation Recommendations for Patients With Rib Fractures
    3. Table 3. Battle Score for Mortality Complications in Emergency Department Patients with Rib Fracture
    4. Table 4. RibScore Criteria
    5. Figure 1. Rib Cage Anatomy, Anterior View
    6. Figure 2. Pneumothorax on Chest X-Ray and Computed Tomography
    7. Figure 3. Ultrasound of a Normal Lung Versus an Injured Lung
    8. Figure 4. Kinesiotaping of Rib Fracture
    9. Figure 5. Emergency Department Rib Fracture Management Pathway According to Forced Vital Capacity
21. References

Acute Traumatic Wounds: Evaluation, Cleansing, and Repair in the ED (Trauma CME and Pharmacology CME)

1. About This Issue
2. Abstract
3. Introduction
4. Pathophysiology
   1. Anatomy
   2. Mechanism of Injury
   3. Phases of Wound Healing
      1. Hemostasis and Inflammation
      2. Proliferative Phase
      3. Maturation and Remodeling
5. Differential Diagnosis
6. Prehospital Care
7. Emergency Department Evaluation
   1. History
   2. Physical Examination
8. Diagnostic Studies
   1. Laboratory Studies
   2. Imaging Studies
9. Treatment
   1. Closure Decisions and Time Since Injury
   2. Wound Irrigation
   3. Aseptic Versus Sterile Technique
   4. Anesthesia
      1. Topical Anesthetics
      2. Intradermal Anesthesia
      3. Nerve Blocks
      4. Anesthesia Adjuncts and Procedural Sedation
   5. Sutures
      1. Simple Interrupted Suture
      2. Continuous Running Suture
      3. Running Subcuticular Suture
      4. Mattress Suture
      5. Corner Stitch
   6. Tissue Adhesive
   7. Staples
   8. Hair Apposition
   9. Adhesive Tape
   10. Prophylactic Antibiotics
   11. Post-Repair Wound Care
       1. Sun Exposure
10. Special Circumstances
    1. Specialist Consultation
    2. Facial Lacerations
       1. Eyelid Lacerations
       2. Intraoral Lacerations
       3. Lip Lacerations
       4. Cheek Lacerations
11. Controversies
    1. Absorbable Sutures for Percutaneous Closure
12. Disposition
13. Time- and Cost-Effective Strategies
14. Risk Management Pitfalls in Wound Management
15. Clinical Pathway for Management of Acute Traumatic Wounds in the Emergency Department
16. Tables and Figures
    1. Table 1. Dosing Recommendations for Commonly Used Local Anesthetics
    2. Table 2. Optimal Suture Material for Facial Wounds
    3. Figure 1. Proposed Diagnostic Algorithm to Enhance the Detection of Radiolucent Foreign Objects in the Hand
    4. Figure 2. Digital Block Techniques
    5. Figure 3. Simple Interrupted Suture
    6. Figure 4. Continuous Running Suture
    7. Figure 5. Running Subcuticular Suture
    8. Figure 6. Vertical Mattress Suture
    9. Figure 7. Horizontal Mattress Suture
    10. Figure 8. Corner Stitch
    11. Figure 9. Hair Apposition Technique
    12. Figure 10. Skin Tension Lines
    13. Figure 11. Lip Laceration Repair
    14. Figure 12. Cheek Anatomy
17. References