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Trauma Awareness Month Is Almost Here – Test Your Knowledge with Genitourinary Trauma Question April 18, 2019

Posted by Andy Jagoda, MD in : Brain Tease , add a comment

A patient suffering blunt abdominal trauma complains of suprapubic pain and has gross hematuria. Initial CT of the abdomen and pelvis with IV contrast is normal. Do yo know the answer?

For trauma patients in the ED, life- and limb-threatening injuries take priority, but renal and genitourinary injury can have long-term consequences for patients, including chronic kidney disease, erectile dysfunction, incontinence, and other serious problems.


Did you get it right? Click here to find out!

The correct answer: A.

Check out the issue on Emergency Management of Renal and Genitourinary Trauma: Best Practices Update to brush up on the subject.Plus earn CME for this topic by purchasing this issue. 

Do you need to do anything regarding the missing fragment? — ED Management of Dental Trauma in Pediatric Patients April 11, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

Case Recap:
Your first patient of the day is a 2-year-old girl who tripped and fell while walking, hitting her mouth on the concrete sidewalk. On your examination, her left central incisor tooth appears to be fractured, with a yellow dot visible inside the tooth. The tooth is nontender and nonmobile. The parents don’t have the other part of the tooth and think it fell onto the street. You start to consider: How do you determine what kind of fracture this is and how serious it is? How does management differ between primary teeth versus permanent teeth, and how can you tell if this is a primary tooth or a permanent tooth? Do you need to do anything regarding the missing fragment?

Case Conclusion:
After seeing the 2-year-old girl with the chipped tooth, you realized that, given her age, this was likely primary dentition, which you confirmed with the parents. You could also tell on examination that the upper right central incisor was more of a milky-white color with a smooth edge, which is also consistent with primary dentition. You decided that the management priorities were to prevent further harm to the developing permanent dentition and to confirm that the tooth fragment was truly lost. You were unable to detect any retained foreign bodies on your physical examination, but you decided to obtain radiographic images to confirm. On facial radiography, there appeared to be a small foreign body inside her right upper lip. You repeated your physical examination and were able to extract the small tooth fragment. The girl’s left central incisor appeared to be an uncomplicated crown fracture. The girl was able to drink without difficulty. You did not have dental panoramic radiography available at your institution, so you instructed the parents to follow up with the girl’s dentist for assessment of her permanent dentition. You recommended a soft diet and to clean the tooth with chlorhexidine until the patient was able to see the dentist.

Did you get it right?

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Should you give antivenom again? — ED Management of North American Snake Envenomations April 11, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 2comments

Case Recap:
A 26-year-old man arrives to the ED via private vehicle with his arm in a makeshift sling. He reports that his pet rattlesnake bit him on his right index finger about 45 minutes ago. His hand and wrist are swollen. He reports that he has no past medical history besides his 3 previous visits for snakebites. He reports having a “reaction” to the snakebite antidote during his last visit. You wonder whether the patient is immune . . . or should you give antivenom again?

Case Conclusion:
The 26-year-old man with 3 prior rattlesnake bites was at risk for significant morbidity related to this fourth snakebite, including impaired use of his dominant hand. Additionally, his initial lab values showed a developing coagulopathy. You decided to administer 6 vials of antivenom, but you ordered pretreatment with IV corticosteroids and antihistamines. You moved the patient to your resuscitation area for administration of antivenom and admitted him to the ICU for continued monitoring; fortunately, there were no side effects with the initial dose of antivenom.

Did you get it right?

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A 68-year-old man with past medical history of atrial fibrillation on warfarin presents to the ED after motor vehicle crash — Brain Teaser. Do you know the answer? March 23, 2019

Posted by Andy Jagoda, MD in : Brain Tease , add a comment

Test your knowledge and see how much you know about treating and managing blunt cardiac injury in the ED.


Did you get it right? Click here to find out!

The correct answer: C.

Earn CME for this topic by purchasing this issue. 

Clinical Pathway for Management of Emergency Department Patients With Suspected Blunt Cardiac Injury March 16, 2019

Posted by Andy Jagoda, MD in : Feature Update , 1 comment so far

Blunt cardiac injury describes a range of cardiac injury patterns resulting from blunt force trauma to the chest. Due to the multitude of potential anatomical injuries blunt force trauma can cause, the clinical manifestations may range from simple ectopic beats to fulminant cardiac failure and death. Because there is no definitive, gold-standard diagnostic test for cardiac injury, the emergency clinician must utilize an enhanced index of suspicion in the clinical setting combined with an evidence-based diagnostic testing approach in order to arrive at the diagnosis. This review focuses on the clinical cues, diagnostic testing, and clinical manifestations of blunt cardiac injury as well as best-practice management strategies.

This clinical pathway will help you improve care in the management of patients with suspected blunt cardiac injury. Download now 

Clinical Pathway for Management of Emergency Department Patients With Suspected Blunt Cardiac Injury

Quiet morning shift. What do you do? March 8, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 3comments

You are working a quiet morning shift when a patient is brought in after a motor vehicle crash. The patient is hypotensive, and the FAST exam reveals a pericardial effusion. You know that time is of the essence, so you rapidly assess the options and wonder whether a needle pericardiocentesis is the best option…

Case Conclusion:
The patient was triaged directly to the resuscitation unit and the trauma surgery service was immediately available at bedside. Further review of the FAST exam revealed right ventricular collapse, and the initial blood pressure of 80/40 mm Hg was consistent with pericardial tamponade. Two large-bore peripheral IVs were placed, and an ECG revealed sinus tachycardia. A bedside pericardiocentesis was performed under ultrasound guidance and 25 mL of blood was aspirated. Repeat blood pressure was 100/60 mm Hg. Chest and pelvic x-rays were within normal limits. The patient was then emergently transported to the operating room for further management. A thoracotomy was performed and noted a 2.5-mm rupture of the right anterior ventricular wall. The defect was repaired, and the patient had an uneventful recovery.

Would you have done it different? Tell us how you would have handled this case.

24-year-old subdued with taser — Brain Teaser. Do you know the answer? November 24, 2018

Posted by Andy Jagoda, MD in : Brain Tease , 1 comment so far

Test your knowledge and see how much you know about treating and managing electrical injuries in the ED.


 

Did you get it right? Click here to find out!

The correct answer: C.

Earn CME for this topic by purchasing this issue. 

 

10 Risk Management Pitfalls for Electrical Injuries in the Emergency Department November 17, 2018

Posted by Andy Jagoda, MD in : Feature Update , add a comment

Human tissues have varying resistance characteristics and susceptibility to damage, so injuries may be thermal, electrical, and/or mechanical, potentially causing burns, thrombosis, tetany, falls, and blast injury. Here are 10 risk management pitfalls to avoid and 4 time- and cost-effective strategies for when you’re managing eletrical Injuries.

10 Risk Management Pitfalls for Electrical Injuries in the Emergency Department

1. “I sent the patient with a low-voltage minor electrical burn home and told her she was fine (she was!). She came back to the ED 2 weeks later and is angry because she developed dizziness and paresthesia in her fingers.”

Electrical injuries have a high incidence of delayed neurological sequelae,41 with studies noting between 25% and 80% of patients reporting neurological complaints after electric shock.39,40 It is important to give specific, detailed discharge instructions, including return precautions for numbness, dizziness, weakness, and mental status changes.

2. “I admitted an electrician with upper extremity and facial burns and airway management who was injured working on a high-voltage line. The orthopedic surgeon called and is angry because he has an open foot fracture. The ED was busy; I can’t take every single patient’s boots off.”

High-voltage injuries have a high incidence of orthopedic injuries, and electrical current at entrance and exit sites can be sufficient to cause open injuries. Remember to completely undress patients so you do not miss injuries on your primary and secondary survey.

3. “The man was found lying in the grass, unconscious. His CT scan and labs were normal. He seemed confused on re-evaluation, so I admitted him for altered mental status, which I thought was probably drug-related. The next day I got a call from the hospitalist; apparently the ENT said he has extensive inner and middle ear damage and is now deaf.”

Patients found unconscious for no apparent reason in an open area should have lightning strike in the differential. (Lightning can strike even when it is not raining, during an event called a “dry” thunderstorm.) The concussive force of the strike can be sufficient to rupture tympanic membranes and cause inner ear damage.47 A thorough ENT examination is necessary.

4. “A patient was brought in by the police last night. He was ‘minding his own business’ and somehow ended up Tasered. He said it hurt to lift his arm. I x-rayed his humerus and elbow, both negative, with normal pulses and sensation, so I discharged him into police custody. Unfortunately, they brought him back 2 days later… he ended up being diagnosed with a scapular fracture.”

Taser (or other electroshock weapon) injuries are on the rise in the United States, and 1 out of 9 police-related injuries presenting to United States EDs are caused by these devices.76,77 The majority of injuries are minor abrasions, lacerations, and contusions. Forceful muscle contraction can cause fractures, including spinous process fractures and scapular injuries. Cardiac electrical capture with subsequent ventricular fibrillation and asystole is a rare complication.78

5. “I work at the regional burn center. EMS brought in a 45-year-old lineman who touched a high-voltage line. The shock entered his left arm and exited his right leg. I admitted him to burn ICU, gave IV fluids for his open injuries, but I didn’t have time to recheck him. He needed multiple doses of pain medicine. While he was holding in the ED his arm became tight, shiny, and pale…he had a delay in his emergent fasciotomy.”

Burn patients with significant orthopedic injuries are at high risk for compartment syndrome, and electrical burns are at even higher risk because of the full-thickness nature of many of these injuries. Frequent neurovascular checks are a must, especially in the first 12 hours. Your ED should have a protocol for neurovascular checks for these patients, and progressive or uncontrolled pain should prompt further investigation.

6. “The 2-year-old had a small burn on his face after playing with an electrical cord. There was no airway involvement, and I sent him home to follow up with a burn specialist. Then 24 hours later, he came back bleeding profusely from the mouth…that airway was touch-and-go.”

Oral burns in children who chewed on an electrical cord have up to 24% incidence of bleeding from the labial artery. Proper initial management is controversial, but ENT consultation should be obtained, and if the patient goes home, you must give strict discharge instructions and set patient/family expectations for the possibility of bleeding.48,49

7. “This patient was transferred to our burn center for evaluation of his high-voltage burns after he was cleared by the trauma center. We admitted him to the burn floor, where he had a seizure and then became obtunded. It turned out he had a basilar skull fracture. The surgeon asked me if I had looked behind his ears.’”

Initial traumatic injuries may not be apparent in high-voltage exposures, and you should do a thorough traumatic evaluation in these patients. In this case, early recognition of a skull fracture (which may reveal the Battle sign, with bruising behind the ears) could have prompted seizure prophylaxis, neurosurgical consultation, intracranial pressure monitoring, etc.

8. “My patient had a high-voltage burn that had entry at his head and exit from the right arm. He had some minor facial burns and an arm fracture. We admitted him to the floor, but he boarded in the ED for a while. I’m glad he did, because he became progressively more dyspneic and needed emergent intubation. He had a lot of edema; I barely got the tube passed.”

Remember that the extent of burn seen on the skin in high-voltage burns may not give an accurate picture of underlying burn injury. You cannot use traditional burn metrics of soot in the mouth or nares, facial hair singeing, or burns to the lips as risk factors for intubation. Maintain a high index of suspicion for airway involvement and consider fiberoptic laryngoscopy or early intubation in electrical burns involving the face or neck.

9. “We saw a patient who grabbed a low-voltage line with both hands. She said that her left arm hurt, but there was no sign of trauma, x-ray was negative, and her ECG was completely normal. That night she returned, and her arm was cold and pale.”

There is a risk of acute arterial and venous thrombosis in patients injured by electric current. This is hypothesized to be due to both thermal damage and electrical damage to the intima of the vessel. In a patient with unexplained pain in a limb after electrical injury, you must document neurovascular status and serial examinations. If pain persists, further workup is necessary, which may include ultrasound, CT angiography, or formal angiography.

10. “This high-voltage injury patient came to the ED with 10% total body surface area burns. I followed the Parkland formula for fluids, but she stayed hypotensive and, during her hospital course, developed acute renal failure. I thought that formula was solid for taking care of a burn patient.”

Electrical burns on the skin do not necessarily give a clear picture as to how much tissue was actually damaged by thermal and electrical energy. Isotonic IV fluids sufficient to maintain urine output at 1.0 to 1.5 cc/kg/ hr must be given to these patients. Continue fluid resuscitation until you reach that urine output and urine myoglobin has cleared. Fluid requirements may be much higher than specified by the Parkland formula. CK levels and myoglobinuria should be monitored.

4 Time- and Cost-Effective Strategies

References:

39. Singerman J, Gomez M, Fish JS. Long-term sequelae of low voltage electrical injury. J Burn Care Res. 2008;29(5):773-777. (Retrospective study; 38 patients)
40.* Bailey B, Gaudreault P, Thivierge RL. Neurologic and neuropsychological symptoms during the first year after an electric shock: results of a prospective multicenter study. Am J Emerg Med. 2008;26(4):413-418. (Prospective cohort study; 86 patients)
41. Tondel M, Blomqvist A, Jakobsson K, et al. [Immediate and delayed outcomes after electrical injury. A guide for clinicians]. Lakartidningen. 2016 Dec 1;113. (Descriptive study and review of Swedish national data; 300 patients)
47. Modayil PC, Lloyd GW, Mallik A, et al. Inner ear damage following electric current and lightning injury: a literature review. Eur Arch Otorhinolaryngol. 2014;271(5):855-861. (Meta-analysis; 35 articles)
48. Canady JW, Thompson SA, Bardach J. Oral commissure burns in children. Plast Reconstr Surg. 1996;97(4):738-744. (Descriptive study; 24 patients)
49. Thomas SS. Electrical burns of the mouth: still searching for an answer. Burns. 1996;22(2):137-140. (Review and case report; 5 patients)
76. Cherington M. Lightning injuries. Ann Emerg Med. 25(4):516-519. (Practice guidelines)
77. Pfortmueller CA, Yikun Y, Haberkern M, et al. Injuries, sequelae, and treatment of lightning-induced injuries: 10 years of experience at a Swiss trauma center. Emerg Med Internat. 2012;2012:167698. (Retrospective study; 9 patients)
78. Gluncic I, Roje Z, Gluncic V, et al. Ear injuries caused by lightning: report of 18 cases. J Laryngol Otol. 2001;115(1):4-8. (Case series; 18 patients)

 

How would you prioritize the workup? — Electrical Injuries in the ED Conclusion November 12, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment
Case Recap: 
As you start work, you wonder where your end-of shift colleague is. The question is answered when the curtain for bay 2 is pulled back and you see her intubating a young man. She tells you he arrived by ambulance for “burn care.” He fell 12 feet to the ground after his mop pole touched a power line above the semi-trailer he was cleaning. There are minor burns to his hands and chest wall, but more worrisome is the pink fluid draining from his ears and nose. As you assess the patient, you wonder how best to prioritize the patient’s workup…
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Case Conclusion:
The pink fluid draining from the nose and ears of your patient who fell off the semi-trailer was caused by the patient having sustained a basilar skull fracture from the fall. The burns on his hand and chest most likely represented the entrance and exit of the electrical discharge and the fall possibly due to a transient dysrhythmia. Fortunately, his vital signs were stable and there was no evidence of myocardial damage. Instead, the leaking cerebrospinal fluid was the biggest concern, and you were reminded of the importance of a careful secondary survey in patients with electrical injuries. The patient was admitted to the neurosurgical ICU, remained stable, and had an uneventful recovery.
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Did you get it right?
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How would you prioritize the workup? — Electrical Injuries in the ED November 5, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 5comments
As you start work, you wonder where your end-of shift colleague is. The question is answered when the curtain for bay 2 is pulled back and you see her intubating a young man. She tells you he arrived by ambulance for “burn care.” He fell 12 feet to the ground after his mop pole touched a power line above the semi-trailer he was cleaning. There are minor burns to his hands and chest wall, but more worrisome is the pink fluid draining from his ears and nose. As you assess the patient, you wonder how best to prioritize the patient’s workup…
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Where would you begin?
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Last Modified: 04-22-2019
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