A True Orthopedic and Vascular Emergency

Case: A 76-year-old male presents after falling down a long flight of stairs. On exam the patient has multiple obvious external injuries, including a grossly deformed right shoulder with a large overlying hematoma. His chest x-ray and shoulder x-ray demonstrate a superiorly and laterally displaced right scapula, as well as a comminuted right scapular fracture and clavicle fracture. On further CT imaging, the patient has subtle widening of the scapulothoracic articulation.

OneQuestion: What potentially devastating injury should be considered in this patient?

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Overly Traumatic: A Teenager Elbowed in the Stomach

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Overly Traumatic: A Teenager Elbowed in the Stomach

Case: 

A 17 yo healthy M presents with abdominal pain and a syncopal episode several hours after getting elbowed in the stomach at a soccer game.

PMH: Intermittent asthma

ROS: Sore throat, cough and fatigue x 1 week.

Physical Exam:

VS: T 98.3 °F | HR 90 | BP 129/60 | RR 16 | SpO2 100%

Pale but comfortable and alert. Abdomen diffusely tender, guarding in the upper quadrants. Exam otherwise unremarkable.

FAST exam: 

RUQ: Free fluid in Morrison’s pouch & at the tip of the liver

LUQ: Free fluid in splenorenal recess & bowel floating in free fluid

Transverse Bladder: Large amount of fluid & clotted blood anterior to the bladder

Click ahead to reveal diagnosis

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US articles: PTX in trauma, FAST for Thoracotomy, Pedi Hip Effusions

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Brown Ultrasound Tape Review:  10/15/15

Article 1: FAST Exam to Predict Survivors of ED Thoracotomy

Inabi, et al. FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy. Annals of Surgery 262(3):512-518, 2015.

Fresh off the trauma surgical press last month, this study examined the utility of FAST exam (specifically parasternal and subxiphoid cardiac views) to predict positive outcomes (survival to discharge or organ donation) of ED resuscitative thoracotomy (RT).

This was a prospective cohort study at LA County/USC Medical Center. In 3.5 years, 187 patients arrived in traumatic arrest and underwent FAST and RT (that’s 4-5 thoracotomies a month – WOW!). They documented +/- pericardial fluid and +/-  cardiac motion. PGY2-4 EM residents performed the FAST exams after some formal training, and they were supervised by “faculty” – not clear if those were surgeons or EM attendings.

About ½ patients lost vitals at the scene and another ¼ both en route and in the ED. Overall survival – 6 patients (3.2%). Overall organ donation – 3 patients (1.6%). Cardiac motion on FAST was 100% sensitive for the identification of survivors and organ donors (and 73.7% specific).  While the tables and discussion include a lot on the presence or absence of pericardial fluid, this did not impact the sensitivity or specificity of FAST. If cardiac motion was absent, the likelihood of survival was 0.

Bottom line: Given that RT is such a high risk, low survival procedure, cardiac FAST can be used (with excellent sensitivity) to identify traumatic arrest patients with better odds of survival or organ donation from ED thoracotomy. No cardiac motion means pretty much no chance of survival or organ donation.


 

Article 2: Handheld E-FAST for Pneumothorax

Kirkpatrick, et al. Hand-Held Thoracic Sonography for Detecting Post-Traumatic Pneumothoraces: The Extended Focused Assessment With Sonography for Trauma (EFAST). Journal of Trauma 57:288-295, 2004.

This was another trauma surgery study out of Vancouver Hospital and Health Sciences Centre interested in the test characteristics of hand-held US to look for PTX in trauma patients. They compared EFAST examinations for PTX to:

(1) CXR results

(2) a “composite standard” of clinical information, which included some combination of CXR, CT if it happened, clinical course, and need for chest tubes/needle decompression

(3) CT alone (the gold standard for patients who had a CT).

This was a retrospective chart review on trauma patients (note – those who were in “physiologic extremis” with suspected PTX were excluded). All EFASTs were done by the attending trauma surgeon using a linear transducer. They looked for lung sliding or comet tail artifacts or color power Doppler evidence of pleural sliding in at least 3 rib spaces. PTX was diagnosed if neither sliding nor comet tail artifacts were seen.

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Crack the Chest

Part of our recurring ’52 Articles’ series exploring landmark articles in Emergency Medicine, inspired by the ALiEM blog’s index project, 

Main Points:

  1. Over 23 years 950 patients underwent post injury thoracotomy at Denver Health Medical Center and overall survival was noted to be 4.4 percent with 3.9 percent surviving functionally intact.
  1. Using various assumptions for cost analysis the authors concluded that “the benefit-charge ratio was strongly in favor of performing EDT [emergency department thoracotomy] at 5.6:1, it was 1.8:1 if adjusted for the cost of maintaining all neurologically injured survivors throughout their lifetime.”

Background:

Emergency department thoracotomy remains a hotly debated procedure within the scope of emergency medicine.  Not only is it a resource intense process that potentially places providers at increased risk for blood borne infections, but it is also one whose utility has been questioned given the limited success rate of meaningful patient outcomes. The authors of this study reviewed a cohort of consecutive trauma patients presenting to a level I hospital in Denver, CO in hopes of clarifying not only the costs as well as the utility of the procedure. The authors in this study reported “neurologically intact survival at time of discharge” as one of the study outcomes; however, it does not appear that any patients had post-hospitalization follow up to evaluate for any future changes. Continue reading

Morning Report: Management of Pulmonary Contusions

Case #1: Middle-aged patient on Coumadin rollover MVC:

PulmContusion1

Case #2: Young patient jump off bridge:

PulmContusion2

Pulmonary contusions were first described during WWI, when the battlefield dead were noted to be without signs of trauma but postmortem exams revealed lung hemorrhage. Pulmonary contusions are caused by direct bruising of the lung parenchyma followed by alveolar edema and hemorrhage. It is most commonly seen after MVC’s with rapid deceleration, high velocity missile wounds, and blast injuries. If sufficient hemorrhage to the lung has occurred, the injury will be apparent on CXR. The treatment is supportive. Here were a few points I learned from these two cases:

  • There are no pathognomonic features for pulmonary contusion on CXR. The same increased density of tissue and alveolar consolidation can occur with pneumonia, aspiration, or pulmonary infarction. It is the context of trauma that defines the appearance as contusion.
  • The natural history of pulmonary contusions is that it tends to worsen over the first 24-48 hours before it improves over the next 7 days. Therefore, keep a close eye on these folks in the trauma bay, especially when the pulmonary contusion is already visible on your initial CXR. Respiratory distress and hypoxia are indications for intubation.

The first patient died, and the second patient was discharged after a prolonged course in the TICU on ECMO.

 

References:

Broder, J. (2011). Chapter 6: Imaging Chest Trauma. Diagnostic Imaging for the Emergency Physician. 
Simon, B, et al. (2012). Management of Pulmonary Contusions and Flail Chest EAST Guidelines.

Canadian Cervical Spine Rules: Moving North a Better Option, Eh?

Main Points:

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1. The final Canadian C-spine Rule comprises three questions:

A.) Is there a high-risk factor that mandates radiography such as: age≥65, dangerous mechanism, or paresthesias in extremities?

B.) Is there any low-risk factor that allows safe assessment of range of motion such as: simple rear end MVC, sitting position in ED, ambulatory at any time since injury, delayed onset of neck pain, or absence of midline C-spine tenderness?

C.) Is the patient able to actively rotate neck 45° to the left and right?

 

  1. The Canadian C-Spine Rule was tested on a convenience sample of 8,924 alert and stable trauma patients in 10 Canadian emergency departments with 151 cases of clinically significant C-spine injury and proved to have a sensitivity of 100% (95% CI: 98-100%) and a specificity of 42.5% (95% CI: 40-44%).

 

Background:

Less than three percent of trauma series yield a positive result.

According to the data compiled by the researchers in the Canadian CT Head and C-Spine Study the use of C-spine radiography is quite variable among emergency physician providers based on local culture and the overall cost of C-spine radiography is in the multi-millions. Their research demonstrated that less than three percent of trauma series yield a positive result. Continue reading

NEXUS Review: Clear That Collar Doc!

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This is the first in a blog series that will explore landmark articles in Emergency Medicine. 

Main Points:

  1. Patients meeting the following five simple clinical criteria are safe to clear without cervical spine imaging following blunt trauma:
    • No focal neurologic deficit
    • Normal alertness
    • No intoxication
    • No midline posterior bony cervical spine tenderness, and
    • No painful distracting injury
  1. The sensitivity and specificity of the NEXUS criteria for detecting low probability injury and avoiding unnecessary imaging was 99 and 12.9 percent respectively, with a negative predictive value of 99.8 percent for the detection of clinically significant injuries.

Level of evidence: 1 (Prospective cohort trial)

Based on the ACEP grading scheme for diagnostic questions the NEXUS trial receives a class of evidence rating of 1.

Background:

Blunt trauma is a frequent cause of emergency department visits. However, the overall prevalence of cervical spine injury is generally only between 2-4% (2.4% in the NEXUS cohort). The goal of the NEXUS group was to create a simple clinical tool with which to risk stratify patients following blunt trauma, thereby reducing unnecessary cervical spine imaging and subsequently improving patient care through cost-reduction and a decrement in the downstream oncogenic risk secondary to radiation exposure. Continue reading