Test Your Knowledge: Managing Dislocations of the Hip, Knee, and Ankle in the ED January 9, 2020

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Dislocation of the major joints of the lower extremities–hip, knee, and ankle–can occur due to motor-vehicle crashes, falls, and sports injuries. These are painful presentations in the trauma ED that must be managed quickly to avoid morbidity, disability, and even possible amputation.

Test Your Knowledge

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The correct answer: B.

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Points from Managing Dislocations of the Hip, Knee, and Ankle in the Emergency Department (Trauma CME):

  • 90% of hip dislocations are posterior; 10% percent are anterior.
  • Typically, an AP pelvic radiograph is adequate to diagnose a hip dislocation. Judet views are help­ful in diagnosing associated fractures.
  • Traumatic dislocations of the native hip should be reduced within 6 hours to reduce the risk of avascular necrosis and posttraumatic arthritis.
  • The Allis, Bigelow, Captain Morgan, Rocket Launcher, and East Baltimore Lift techniques can all be used to reduce a hip dislocation. None have proven to be superior to the others; the choice can be made according to provider capability and preference.
  • All hip reduction methods can be used on both native and prosthetic hips.
  • Consider an ultrasound-guided fascia iliaca com­partment block to augment and reduce proce­dural sedation and analgesia.
  • All hip fracture dislocations should be deferred to orthopedic surgery.
  • After reduction of a native hip dislocations, a CT scan should be obtained. The patient will need to be admitted to the hospital.
  • Many knee dislocations spontaneously reduce. Maintain a low threshold of suspicion for this injury, as missing a knee dislocation could have catastrophic consequences.
  • In any knee dislocation with a pulse deficit, perform immediate reduction without imaging. Delays longer than 8 hours have a higher inci­dence of amputation.
  • After reduction of the dislocated knee, patients should be admitted for serial vascular examina­tions or vascular imaging should be obtained. Compartment syndrome is a delayed complica­tion of knee dislocations.
  • Ankle dislocations require immediate recognition and prompt reduction, as they can be associated with significant neurovascular, skin, and soft-tissue complications.
  • Subtalar dislocations are rare, but appear similar to ankle dislocations. Attempting to reduce a subtalar dislocation before imaging may lead to worsening of the dislocation.
  • Emergent orthopedic consultation and post-reduction CT are necessary after reduction of a dislocated ankle.

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Right for the Season: Clinical Flowchart for Management of Burns in the Emergency Department November 7, 2019

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Holidays are busy times for everyone, including emergency departments. Maybe it’s the rushing around during preparation or too many people in the kitchen, but inevitably someone gets hurt and burns are among the top injuries seen in the ED during the Thanksgiving holidays.

Thermal burn injuries are a significant cause of morbidity and mortality worldwide. In addition to treatment of the burns, emergency clinicians must assess for inhalation injury, exposure to toxic gases, and related traumatic injuries.

Priorities for emergency resuscitation include stabilization of airway and breathing, intravenous fluid administration, pain control, and local wound care. Special populations, including children and pregnant women, require additional treatment considerations. Referral to specialized burn care for select patients is necessary to improve long-term outcomes.

This pathway outlines evidence-based treatment strategies for treating thermal burn injuries in the ED.

Clinical Pathway for Management of Burns in the Emergency Department

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Right for Halloween: Clinical Algorithm for Pediatric Patients with Multiple Injuries October 10, 2019

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When children with multiple serious injuries present to the ED, how do you ensure that you identify and address all of their injuries?

Management of the child with multiple traumatic injuries can be challenging, and important injuries may not be readily recognized. Early recognition of serious injuries, initiation of appropriate diagnostic studies, and rapid stabilization of injuries are key to decreasing morbidity and mortality in the multiply injured pediatric trauma patient. The differential diagnosis for these patients is wide, and treatment is targeted to the specific injuries.

This clinical flowchart provides a systematic approach to the management of pediatric patients with multiple traumatic injuries. Download now.

Clinical Pathway for the Management of a Pediatric Patient With Multiple Traumatic Injuries

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Concussion Aftercare Guidelines for the ED October 10, 2019

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One important aspect of concussion management for the emergency clinician is the provision of adequate aftercare instructions at the time of discharge from the ED. This requires a paradigm shift for the emergency clinician, as discharging a head-injured patient was primarily focused on providing precautions for potential deterioration.

Patients with severe symptoms may be concerned about their ability to recover and the long-term implications, due to heightened media attention on concussion. An understanding of the expected course of recovery can be very helpful to the patient and family, providing reassurance that the majority of patients with concussion will recover fully.

Instructions for aftercare may include a period of rest, but should allow for limited, progressive cognitive and physical activity as tolerated by the patient and as symptoms improve. Emergency clinicians should not create disability by recommending strict rest. Several studies have found no benefit in the prescription of strict rest when compared to the resumption of moderate cognitive or physical activity. Brown et al demonstrated improved recovery in children who were provided with moderate cognitive rest compared to no cognitive rest, but there was no additional benefit with extremes of cognitive rest. It has also been shown that patients who resumed moderate levels of cognitive or physical activity recovered better than those with strict rest or resumption of high levels of activity.

While strict rest may inhibit recovery, the discussion with the patient must be balanced by maintaining a healthy respect for the vulnerability of the concussed brain. Rodent studies have clearly demonstrated that there is a window of vulnerability after a concussion, during which even a mild repeat injury significantly increases the risk of a complicated recovery. MRI spectroscopy studies in humans have demonstrated neurometabolic changes that persist beyond apparent clinical resolution of the concussion, but the clinical implications of these findings are not yet clear. Patients should be counseled on the risks of re-injury and should not return to sport or high-risk physical activities, such as bike riding, until cleared from the concussion during a follow-up medical visit.

When providing aftercare instructions, the emergency clinician should advise patients and caregivers that return to school is appropriate once severe symptoms have improved. Return to school typically can take place within 48 to 72 hours after the injury. Academic adjustments may be needed to support recovery in the school environment. The primary care clinician or concussion specialist is more suited than the emergency clinician to work with the patient’s school on specific plans for return to school. It is not necessary to keep students out of school until they are symptom free, as doing so increases the risk for development of social isolation, stress from missed school work, and/or school avoidance behaviors.

Sleep disturbance is almost universal in concussion and can be a significant source of disability and delayed recovery. The emergency clinician should counsel patients on sleep hygiene to help prevent a disturbed sleep cycle, as patients may spend more time than normal sleeping during the early course of recovery. Approximately 1 to 2 weeks after the injury, increased sleep often gives way to day-night reversal, difficulty falling asleep, and difficulty staying asleep.

Patients should be advised to eliminate napping within a few days after the injury and should be counseled that proper sleep hygiene techniques should be implemented within a week of the injury. The burden of electronic device use by patients should not be underestimated, as this can contribute to sleep disturbance even without concussion. Constant audible alerts and emission of blue light from electronic devices can contribute to sleep disturbance. Proper sleep hygiene techniques are outlined in Table 7.

Table 7. Proper Sleep Hygiene Techniques

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Brain Teaser: Signs of pneumothorax when seen on thoracic ultrasound September 13, 2019

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The pediatric patient is arguably more suited for emergency ultrasound than the adult patient. Children generally have a smaller body habitus than adults and, therefore, less tissue for the ultrasound beams to penetrate. This often leads to clearer images of the different organ systems, which should yield better diagnostic accuracy.

Test your knowledge and see how much you know on pediatric ultrasound!

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The correct answer: D.

Review this Pediatric Emergency Medicine Practice issue to get up-to-date on POCUS in the ED.

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Test Your Knowledge: Concussion in the ED September 10, 2019

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An increasing number of patients with concussive injuries are presenting to the ED, due to a combination of factors, including media attention to sport-related concussion, early dedication to competitive sport, and improved screening and diagnostic tools for concussion.

Emergency clinicians play an important role in diagnosing concussion, initiating treatment, and providing concussion education to patients and their caregivers to optimize recovery.

Can you get it right?

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The correct answer: D.

Check out the issue on Concussion in the Emergency Department: A Review of Current Guidelines to brush up on the subject. Plus earn CME for this topic by purchasing this issue.

Ultrasound Assessment for Skull Fractures August 15, 2019

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The use of ultrasound at the point of care by emergency clinicians, as well as by other specialists, has become increasingly common over the last 25 years. Emergency POCUS can be used as a diagnostic test and also to visualize anatomy for procedural guidance. It allows the emergency clinician to rapidly rule in or rule out disease processes and guide ongoing investigation and management of patients in the ED.

Pediatric emergency ultrasound has been slower to progress than adult emergency ultrasound. However, the use of emergency ultrasound for pediatric patients has recently begun to formalize.

The pediatric patient is arguably more suited for emergency ultrasound than the adult patient. Children generally have a smaller body habitus than adults and, therefore, less tissue for the ultrasound beams to penetrate. This often leads to clearer images of the different organ systems, which should yield better diagnostic accuracy.

Ultrasound can be used in the evaluation of children with blunt head trauma to assess for skull fractures. (See Figure Below) The presence of a skull fracture increases the risk of traumatic intracranial hemorrhage 4- to 6-fold.

While the absence of a skull fracture does not rule out the presence of intracranial injury, assessment for skull fracture has been used to risk stratify.

Skull Fracture on Ultrasound

Patients with blunt head trauma. In a meta-analysis published in 2000, skull x-rays had a sensitivity of 38% and a specificity of 95% when interpreted by radiologists. Given this poor sensitivity, skull x-rays have been falling out of favor for assessment of skull fracture. However, there has been a renewed interest in skull ultrasound as perhaps a better tool to assess for skull fracture and to risk stratify patients with blunt head trauma.

Skull ultrasound is performed with a high-frequency linear array probe. The probe should be placed on the area of the skull with maximal tenderness, hematoma, or other sign of possible fracture. It should be scanned in 2 planes, looking for disruptions in the cortex. Sutures can be differentiated from fractures by following the cortical break to a fontanelle and by scanning the contralateral side for comparison. Additionally, the cortical break in a fracture will appear ragged, with sharp margins, while a suture will have a smooth appearance.

Several prospective studies have evaluated bedside ultrasound for skull fractures in children. Rabiner et al pooled data from previous trials along with their own data. They reported a sensitivity of 94% and specificity of 96% for ultrasound detection of skull fractures. Parri et al performed another study not captured in the Rabiner et al study, and showed a sensitivity of 100% and a specificity of 95%, with 1 false-positive result. A limitation of these studies was that the ultrasounds were performed on patients for whom a CT scan was planned. Therefore, the study population was already determined to be at higher risk for injury as compared to the entire spectrum of head trauma patients presenting to the ED. Nonetheless, it can be concluded that the diagnostic accuracy of skull ultrasound is superior to that of skull x-ray.

Future Applications
The current trend in the evaluation and risk stratification of pediatric head trauma is the incorporation of clinical decision rules, with the PECARN pediatric head injury prediction rule being the most sensitive and most commonly used in the United States.56 An area of future research is the incorporation of skull ultrasound in conjunction with a clinical decision rule to better risk stratify patients and possibly further decrease the number of CT scans being performed.

To read more about the PECARN Pediatric Head Injury Prediction Rule, go to: www.ebmedicine.net/PECARN-head-rule

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May is Trauma Awareness Month! May 16, 2019

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Clinical Pathway For Management In The Emergency Department Of Pediatric Patients With Suspected Cervical Spinal Cord Injury

Spinal injuries from blunt trauma are uncommon in pediatric patients, representing only about 1.5% of all blunt trauma patients. However, the potentially fatal consequences of spinal injuries make them of great concern to emergency clinicians.

Clinical goals in the emergency department are to identify all injuries using selective imaging and to minimize further harm from spinal cord injury. Achieving these goals requires an understanding of the age-related physiologic differences that affect patterns of injury and radiologic interpretation in children, as well as an appreciation of high-risk clinical clues and mechanisms.

Clinical Pathway For Management In The Emergency Department Of Pediatric Patients With Suspected Cervical Spinal Cord Injury

This clinical pathway will help you improve care in the management of pediatric patients with suspected cervical Spinal cord injury. Click here to download yours today. 

It is Stroke Awareness Month! May 16, 2019

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10 Risk Management Pitfalls For Cervical Artery Dissections

Cervical artery dissections involve the carotid or vertebral arteries. Although the overall incidence is low, they remain a common cause of stroke in children, young adults, and trauma patients. Symptoms such as headache, neck pain, and dizziness are commonly seen in the emergency department, but may not be apparent in the obtunded trauma patient. A missed diagnosis of cervical artery dissection can result in devastating neurological sequelae, so emergency clinicians must act quickly to recognize this event and begin treatment as soon as possible while neurological consultation is obtained.

Use these risk management pitfalls to avoid unwanted outcomes when performing cervical artery dissections. Download now.

1. “This patient has a left temporal headache that radiates into his left ear. His examination is benign, except his pupil is smaller on that side. I did a noncontrast CT head and it’s negative. The headache is probably just due to a hard game of basketball yesterday. I’m going to give him some IV ketorolac and send him out.”

Dissections can occur spontaneously or as a result of minor trauma, even from a basketball game. Failure to consider the diagnosis will result in a missed diagnosis. Headaches in carotid artery dissections can be nonspecific, but are mostly located in the frontal or temporal regions; the radiation to the ear is also characteristic. His examination is also concerning for a partial Horner syndrome. Both of those are suspicious for carotid artery dissection and warrant further vascular imaging.

2. “She has a history of migraines, and she says that this one is different from what she usually feels, but it definitely sounds like a migraine because it is unilateral, pulsatile, and she had a visual aura. I’m going to give her the usual migraine cocktail and see how she does.”

Not suspecting cervical arterial dissection in the beginning of the evaluation results in a significant delay to diagnosis. It can be many hours by the time she has a couple of migraine cocktails before you realize her headache isn’t better and you need to rethink your plan. Due to the risk of early stroke in these patients, a delay in diagnosis could lead to long-term neurological sequelae. Headaches in carotid dissections can be unilateral, pulsatile, and with an aura. Any time a patient with a history of migraines states that the symptoms are not typical, take note.

3. “A 35-year-old woman was attacked by her boyfriend. He hit her on the right side of the neck near her jaw, causing her head to snap around to the left. Her neurological examination is completely normal. She is in a great deal of pain, but it seems to be related to the soft-tissue injury from the hit, because her noncontrast CT head and c-spine are negative. I’m going to treat her pain and see how she feels.”

Pain due to the trauma could mask specific signs or symptoms of dissection. In these patients, relying on the history to identify high-risk factors is important. Due to the location of the blow, it may have caused a hyperextension and rotation of her head in addition to direct trauma, which could have caused a dissection. Patients with risk factors should have advanced vascular imaging (CTA or MRA).

4. “I couldn’t do a neurological examination because she was in too much pain. I’ll treat her headache and then try again later.”

Although it seems kind to give patients a little time to obtain comfort before performing an examination, a prompt neurological examination is absolutely necessary in order to determine any findings that need to be addressed immediately, such as an acute stroke.

5. “A 12-year-old boy fell off of his bike after running into a parked car, and then he had a seizure. The noncontrast CT head and c-spine were normal. He is still in some pain, but I don’t see anything abnormal on his neuro examination, so I’m going to clear his c-spine.”

Pediatric patients with dissection have different symptoms from adults; seizure has been shown to be a presenting symptom in 12.5% of cases. The seizure, along with the mechanism, should prompt vascular imaging to assess for a cervical artery dissection before the cervical collar is removed.

6. “I really thought that patient with the headache, anterolateral neck pain, and partial Horner syndrome had a carotid dissection, but the CTA was read as negative, so I guess I was wrong. I’ll just treat her pain and send her home.”

CTA is an excellent screening tool, but it is not 100% sensitive and can miss small intimal flaps, intramural hematomas, or a slight fusiform dilatation of the vessel. In patients for whom there is a high suspicion of dissection and a negative or equivocal CTA or MRA, further imaging with MRI or digital subtraction angiography is indicated.

7. “The CTA showed a dissection, so I gave him an aspirin and called neurology. However, he now says he doesn’t want to wait and wants to go home. His neuro examination is normal, so I was thinking of sending him out on aspirin.”

Sending the patient home in the acute setting without consultation is not a good idea. Due to high risk of stroke in the first 24 hours and the high incidence of progression of lower-grade dissections, these patients warrant close monitoring and early follow-up imaging to determine the need for escalation of care.

8. “The intubated trauma patient had his noncontrast CT head and c-spine and the radiologist just called and said there is a temporal bone fracture through the carotid canal. I’m going to pass it along and let the trauma service finish the workup after he gets to the intensive care unit.”

This will lead to a significant delay in diagnosis, which could be devastating for the patient. Due to its sensitivity and availability in the ED, a CTA should be performed prior to the patient being transported upstairs, so treatment can be started immediately.

9. “The CTA showed a vertebral artery dissection on that patient from the roller coaster ride, so I consulted the neurology service for admission. Her neuro examination is normal, so I’m going to wait to treat her and see what they recommend.”

An antithrombotic agent for stroke prevention needs to be started on this patient and can be started in the ED to avoid treatment delays. Studies in this population have not shown superiority of one over the other, so the choice of aspirin or heparin depends on patient factors. For uncomplicated dissections, antiplatelet agents are sufficient, and heparin is preferred in patients with an acute thrombus or high risk for thromboembolic events if no contraindications exist.

10. “The patient is a 42-year-old man presenting with an acute onset of right-sided hemiplegia and global aphasia that started 1 hour ago while at the grocery store. His CT head was negative for hemorrhage, but the CTA showed a dissection in his left carotid artery with about 50% vessel occlusion. Unfortunately, that excludes him from treatment with rtPA due to the risk of hemorrhage or intramural hematoma expansion.”

Data have shown rtPA to be as safe in patients with cervical dissections as with patients with strokes due to other causes. Therefore, this patient should be treated with rtPA as soon as possible if there are no contraindications. Endovascular treatment should also be considered if there are contraindications to IV rtPA or if he does not improve after treatment.

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It is Trauma Awareness Month! Can you solve the trauma case below? May 10, 2019

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

Case Recap:
You are then asked to see a 15-year-old adolescent boy who has come in with a tooth avulsion. He was at basketball practice when another player accidentally elbowed him in the mouth. He did not lose consciousness and has pain only in his mouth. He was immediately brought to your ED, which is about 15 minutes away from where the accident happened. His coach arrives with the boy’s tooth in a container of milk. On physical examination, the patient has lost his right lateral incisor and a clot remains where his tooth had been. How much time do you have to replace the tooth to have the best success of replantation? What do you need to consider while handling, storing, and cleaning the tooth?

Case Conclusion:
For the 15-year-old boy, you decided to replace the tooth as soon as possible. The patient had no other medical problems. You used Yankauer suction and light irrigation to remove the clot from the socket. You held the tooth by the crown, briefly rinsed it off, and used firm, gentle pressure to reinsert the tooth without any difficulty. You had Coe PakTM paste available at your facility, and you created a temporary splint to secure the tooth. You instructed the mother to follow up with the dentist tomorrow and to provide only a soft diet until then. You told the coach and the boy’s mom that, in the future, they should attempt to reimplant the tooth at the time of the accident and instructed them on the steps involved.

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Click here to review the issue, Emergency Department Management of Dental Trauma: Recommendations for Improved Outcomes in Pediatric Patients (Trauma CME and Pharmacology CME).

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