Author: Joseph Ciano, USA

Joey Ciano, DO, MPH is an Emergency Medicine Physician from New York, USA. He completed his Emergency Medicine Residency in Brooklyn, NY and a Fellowship in Global Emergency Medicine in the Northwell-LIJ Health System. He is interested in building the educational infrastructure of EM in countries where EM is not yet recognized as a field and in countries that are in the early stages of this process. He has partnered with international NGOs in EM educational projects and works as a visiting EM faculty member in West Bengal, India. He is excited to collaborate with the other authors of the iEM Education Project to contribute to world of FOAM-ed.

Question Of The Day #76

February 11, 2022February 12, 2022 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management?

Explanation

This patient arrives to the Emergency department 10 hours after ingesting 11grams of paracetamol (APAP). She has mild symptoms of nausea and upper abdominal discomfort and has normal vital signs.

Paracetamol, also known as acetaminophen or APAP, is a commonly used pain medication safe for use in childhood, pregnancy, and breastfeeding. Paracetamol is an ingredient present in many over the counter pain, headache, and cold medications. Toxic paracetamol doses are acute ingestions over 150mg/kg, or about 10grams in adults. Toxic paracetamol doses for children are 150mg/kg. Multiple ingestions of paracetamol over 24 or 48 hours can also cause toxicity. Ingestions of 10grams over 24hours or 6 grams/day over 48hours can also cause toxicity in adults. Symptoms of acute poisoning can be absent or mild in the first 24 hours as seen in this patient. After 24 hours, AST, ALT, bilirubin, and INR levels begin to increase, and over 72 hours post-ingestion, hepatic failure ensues. 5 days after an acute ingestion is when multi-organ failure occurs or hepatotoxicity resolves (less common). Toxicity of APAP is thought to be caused by a toxic metabolite produced during APAP breakdown in the liver known. This toxin is known as NAPQI.

APAP overdose can be fatal without treatment with the antidote commonly known as NAC, or N-acetylcysteine. NAC is a free radical scavenger and prevents the damage caused by NAPQI. If serum APAP testing is available, APAP levels drawn 4 hours after the time of an acute ingestion are used to determine if NAC is warranted. APAP levels over 150mcg/mL at 4hours are the threshold for starting NAC. This is based on use of the Rumack-Mathew Nomogram for APAP (see below).

Hendrickson RG, McKeown NJ. Acetaminophen. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. eds. Goldfrank’s Toxicologic Emergencies, 11e. McGraw Hill; 2019.

Since this patient’s acute ingestion is above the known 10gram toxic dose, it is reasonable to start N-acetylcysteine therapy (Choice B) without first knowing the exact serum APAP level. PO Activated charcoal (Choice A) can be used after oral ingestions to help bind some toxic substances and prevent their absorption through the GI system. The majority of APAP is absorbed 2-4 hours after ingestion, so charcoal would not be helpful in this case where the ingestion was 10 hours ago. Liver transplantation (Choice C) may ultimately be required for this patient depending on the liver function tests and how the patient responds over the coming days. However, the best next step is NAC treatment to prevent liver failure and death. IV Sodium bicarbonate (Choice D) is used in salicylate and tricyclic antidepressant overdose, but it has no role in APAP overdose. The best next step is IV N-Acetylcysteine (Choice B).

References

Abdrabbo, M. (2018). TOXCard: Acetaminophen toxicity and management. EM Docs. http://www.emdocs.net/toxcard-acetaminophen-toxicity-and-management/
Hendrickson RG. Acetaminophen. In: Goldfrank’s Toxicologic Emergencies 9^th edition. Nelson LS, et al (Eds). New York, NY, McGraw-Hill 2011.

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Question Of The Day #75

February 4, 2022March 20, 2022 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause of this patient’s condition?

Explanation

This patient presents to the Emergency Department with altered mental status after ingestion of an unknown agent as part of a suicide attempt. Her exam demonstrates hypertension, tachycardia, elevated temperature, disorientation, dilated pupils, and dry and hot skin. Altered mental status has a broad differential diagnosis, including intracranial bleeding, stroke, post-ictal state, hypoglycemia, electrolyte abnormalities, other metabolic causes, infectious etiologies, toxicological causes, and many other conditions. This patient’s history and exam support the presence of a toxidrome. See the chart below for a review of the most common toxidromes (toxic syndromes).

*Treatment of all toxic ingestions should include general supportive care and management of the airway, breathing, and circulation of the patient. Examples include administration of supplemental oxygen in hypoxia, IV fluids in hypotension, cooling measures in hyperthermia, etc.
**Flumazenil is the antidote for benzodiazepine overdose, but it is rarely used clinically as it can trigger benzodiazepine-refractory seizures.

Paracetamol (Choice A) is often accompanied with little to no symptoms in the first 24hours. Later in the ingestion timeline, liver failure and its associated sequalae can occur if no antidote is given. The symptoms exhibited by the patient do not correlate with APAP overdose. Dextroamphetamine (Choice B) is a sympathomimetic agent that could be responsible for many of the patient’s symptoms, like elevated heart rate, hypertension, agitation, and dilated pupils. However, dextroamphetamine should cause diaphoretic skin, not the dry skin that the patient has. Ethanol (Choice C) may be a co-ingested agent in this scenario that could lead to agitation and confusion, but ethanol alone should not cause fever. Diphenhydramine (Choice D) is an antihistamine agent, but it also has anticholinergic properties, especially when taken in excess. This patient has all the signs of an anticholinergic toxidrome. The presence or absence of dry skin can help differentiate a sympathomimetic toxidrome from an anticholinergic toxidrome. Diphenhydramine (Choice D) is the most likely agent responsible for this patient’s symptoms. Correct Answer: D

References

Kitchen, L. (2015). The Approach to the Poisoned Patient. EMDocs. http://www.emdocs.net/the-approach-to-the-poisoned-patient/
Srisuma, S. (2015). Physostigmine for management of anticholinergic toxidrome. EM Docs. http://www.emdocs.net/physostigmine-for-management-of-anticholinergic-toxidrome/

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Question Of The Day #74

January 28, 2022December 27, 2021 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

Explanation

This patient presents to the Emergency Department with altered mental status, difficulty breathing, vomiting, and hypersalivation after an unknown ingestion. His exam shows an ill patient with constricted pupils (miosis), wet skin (diaphoresis), bradycardia, and tachypnea. Altered mental status has a broad differential diagnosis, including intracranial bleeding, stroke, post-ictal state, hypoglycemia, electrolyte abnormalities, other metabolic causes, infectious etiologies, toxicological causes, and many other conditions. This patient’s constellation of signs and symptoms support the presence of a cholinergic toxidrome due to organophosphate poisoning. See the chart below for a review of the most common toxidromes (toxic syndromes).

Cholinergic toxidromes can be caused by organophosphate or carbamate pesticides, as well as nerve gas agents (i.e., sarin gas). These agents cause poisoning by increasing the amount of acetylcholine at the neuromuscular junction, causing stimulation at muscarinic and nicotinic acetylcholine receptors. This causes a dramatic increase in bodily secretions with increased respiratory secretions and airway compromise as the most common cause of death in this population. The cholinergic toxidrome can be remembered with the mnemonic “DUMBBELLS” (diarrhea/diaphoresis, urination, miosis, bradycardia, bronchorrhea, emesis, lacrimation, low BP, salivation).

The first step in treating any patient who has the potential cause to harm or expose staff members to the poisoning agent is patient decontamination (Choice C). This patient should be undressed and adequately decontaminated by staff members who are wearing personal protective equipment (PPE). Once the patient is decontaminated, the airway should be established with endotracheal tube placement (Choice A) and IV atropine (Choice B) should be given to reverse the toxidrome. Atropine can be started at 2-4mg IV and repeated every 5-10 minutes until respiratory secretions are cleared. Pralidoxime (Choice D) should also be given as soon as possible to prevent irreversible changes (“aging”) to the acetylcholinesterase at the neuromuscular junction. This timeframe varies from minutes to hours after exposure, depending on the agent. All choices provided in this question are important actions to take, but patient decontamination (Choice C) is the most important initial next step. Correct Answer: C

References

Kitchen, L. (2015). The Approach to the Poisoned Patient. EMDocs. http://www.emdocs.net/the-approach-to-the-poisoned-patient/
Sahi, N. (2018). TOXCard: Nerve agents. EM Docs. http://www.emdocs.net/toxcard-nerve-agents/

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Question Of The Day #73

January 21, 2022December 27, 2021 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause of this patient’s condition?

Explanation

This patient presents to the Emergency Department with a depressed mental status and normal sized pupils after an unknown toxic ingestion. Many different agents can act as Central Nervous System depressants and cause this clinical presentation. Some examples include ethanol, toxic alcohols (methanol, ethylene glycol, isopropyl alcohol), benzodiazepines, barbiturates, opioids, and muscle relaxants.

Of the choices listed, Heroin (Choice A) and Alprazolam (Choice B) are the most likely. Heroin is an opioid, and Alprazolam is a benzodiazepine (a sedative-hypnotic agent). The clinical presentation caused by overdoses of opioids versus sedative-hypnotic agents overlaps in many areas, but the pupillary exam can help the most in differentiating the type of ingestion. Opioids will can constricted, pinpoint pupils, while benzodiazepines should not cause change in pupillary size. See the chart below for a review of the most common toxidromes (toxic syndromes).

Cocaine (Choice C) is a sympathomimetic with a CNS excitatory effect, not a CNS depressant effect as in this patient. A large ingestion of paracetamol (Choice D) is often accompanied with little to no symptoms in the first 24hours. Later in the ingestion timeline, liver failure and its associated sequalae can occur if no antidote is given. Correct Answer: B

References

Kitchen, L. (2015). The Approach to the Poisoned Patient. EMDocs. http://www.emdocs.net/the-approach-to-the-poisoned-patient/

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Question Of The Day #72

January 14, 2022December 27, 2021 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause of this patient’s condition?

Explanation

This patient presents to the Emergency Department with severe agitation and altered mental status. His exam demonstrates hypertension, tachycardia, elevated temperature, restlessness, dilated pupils, and wet diaphoretic skin. Altered mental status has a broad differential diagnosis, including intracranial bleeding, stroke, post-ictal state, hypoglycemia, electrolyte abnormalities, other metabolic causes, infectious etiologies, toxicological causes, and many other conditions. This patient’s history and exam support the presence of a toxidrome. See the chart below for a review of the most common toxidromes (toxic syndromes).

This patient has a sympathomimetic toxidrome (Choice C), which can be caused from cocaine, MDMA (ecstasy), methamphetamine, and other drugs. The anticholinergic toxidrome (Choice A) has many overlapping features with the sympathomimetic toxidrome, such as elevated blood pressure and heart rate, elevated temperature, agitation, and dilated pupils. One feature that can be used to differentiate these toxidromes is the skin exam. Sympathomimetic agents commonly cause wet diaphoretic skin, while anticholinergic agents cause dry skin. The cholinergic toxidrome (Choice B) presents with increased secretions (wet skin, diarrhea, vomiting, hypersalivation, bronchorrhea, etc.). One cause of this toxidrome is exposure to organophosphates. This patient is diaphoretic, but otherwise does not possess the other features of the cholinergic toxidrome. The opioid toxidrome (Choice D) would present with somnolence, as opposed to the CNS excitation seen in this patient. Correct Answer: C

References

Christy, G. (2019). EM@3AM: Overdose. EMDocs. http://www.emdocs.net/em3am-overdose/

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Question Of The Day #71

January 7, 2022December 27, 2021 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

Explanation

This patient arrives to the Emergency Department with lethargy, decreased respiratory rate, hypoxemia, pinpoint pupils, and a normal glucose level. The initial evaluation and treatment of this patient should be focused on management of the patient’s airway, breathing, and circulation (ABCs, also known as the ‘primary survey’). The airway should be repositioned to minimize obstructions to breathing, such as the tongue. Vomitus in the airway can also be removed manually or via suction to prevent obstruction of the airway or aspiration. Next, supplemental oxygen should be provided to treat the patient’s hypoxemia.

Altered mental status has a broad differential diagnosis, including intracranial bleeding, stroke, post-ictal state, hypoglycemia, electrolyte abnormalities, other metabolic causes, infectious etiologies, toxicological causes, and many other conditions. This patient’s history and exam support the presence of an opioid toxidrome. See the chart below for a review of the most common toxidromes (toxic syndromes).

toxidromes — *Treatment of all toxic ingestions should include general supportive care and management of the airway, breathing, and circulation of the patient. Examples include administration of supplemental oxygen in hypoxia, IV fluids in hypotension, cooling measures in hyperthermia, etc.
**Flumazenil is the antidote for benzodiazepine overdose, but it is rarely used clinically as it can trigger benzodiazepine-refractory seizures.

In addition to supportive treatments, like airway repositioning and supplemental oxygen, the antidote to opioid overdose should be promptly administered. Naloxone (Choice C) is the antidote to opioid overdose. Naloxone can be administered intravenously, intramuscularly, and intranasally. Naloxone should be started at a dose of 0.04mg and can be administered every 2-3 minutes at incrementally higher doses to a maximum total dose of 10mg. The goal of Naloxone administration is to achieve independent ventilations. Administering a larger initial dose of 0.4mg or 1mg can precipitate acute opioid withdrawal in a chronic opioid user.

IV Lorazepam (Choice A) is a benzodiazepine and would make the patient more sedated. Benzodiazepines are helpful in patients with an active seizure, severe agitation, or anxiety. Anticholinergic overdose (atropine, scopolamine) or sympathomimetic overdose (cocaine, methamphetamines, MDMA) are also responsive to benzodiazepines. IV Atropine (Choice C) is an anticholinergic agent. Atropine would worsen this patient’s borderline hypotension and mild bradycardia. IV Dextrose (Choice D) would be a reasonable medication to give if the glucose was unknown. The question stem provides a normal glucose level. Correct Answer: B

References

Kitchen, L. (2015). The Approach to the Poisoned Patient. EMDocs. http://www.emdocs.net/the-approach-to-the-poisoned-patient/
Santos, C. (2017). Tox Cards: Narcan (naloxone). EMDocs. http://www.emdocs.net/tox-cards-narcan-naloxone/

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Question Of The Day #70

December 31, 2021November 20, 2021 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

Explanation

This patient arrives to the hospital after a suicide attempt with multiple bleeding arm wounds, hypotension, tachycardia, and a depressed mental status. This patient is in hemorrhagic shock.

The first step in evaluating any trauma patient involves the primary survey. The primary survey is also known as the “ABCDEFs” of trauma. This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma). Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition. The primary survey should be conducted prior to taking a full history. After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history.

The airway and breathing status of this patient have been assessed with no acute issues as noted in the question stem. On assessment of the patient’s circulation, he is tachycardic, hypotensive, and has an actively bleeding extremity wound. The first step in managing a bleeding wound is to apply constant direct pressure to the site. Direct pressure to the site for 15 minutes should control bleeding in most cases. If the origin of the bleeding is difficult to identify for direct pressure application, or if direct pressure fails, the next step is to apply a tourniquet (Choice D). If a tourniquet is not available, an easy alternative is to apply a blood pressure cuff proximal to the bleeding wound and inflate the cuff to 250mmHg or until the bleeding stops. This will allow careful examination and repair of the bleeding wound. Topical tranexamic acid (Choice A) and subcutaneous lidocaine with epinephrine injections (Choice B) can work as adjuncts to tourniquet application. Suturing the area will also help tamponade the bleeding site and aid in clot formation after a tourniquet is applied. Checking a serum toxicology screen (Choice C) may be helpful to evaluate for a concurrent overdose, but this is not as important as initial hemorrhage management.

Other steps to hemorrhage control and treatment include establishing large bore IV access, administering IV fluids or blood products as needed, and reversing coagulopathy. Correct Answer: D

References

Bucher, J. (2016). Bleeding hand wounds. EmDocs. http://www.emdocs.net/bleeding-hand-wounds/

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Question Of The Day #69

December 24, 2021December 11, 2021 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

Explanation

The neck is a compact anatomical area with many vital structures, including blood vessels that provide oxygen to the brain, the aerodigestive tracts (trachea and esophagus), nerves, and the apices of the lungs. A penetrating injury to the neck can be catastrophic and requires prompt examination and appropriate management. The neck is divided into 3 anatomical zones, and each zone houses different anatomical structures. Zone 1 is from the clavicle to the cricoid cartilage, Zone 2 is from the cricoid cartilage to the mandible, and Zone 3 is from the angle of the mandible to the base of the skull. See the reference below for pictures and further descriptions of each zone.

The presence of any “hard signs” of aerodigestive or neurovascular injury should prompt emergent operative management. These “hard signs” include airway compromise, expanding or pulsatile hematoma, active and brisk bleeding, hemorrhagic shock, neurological deficit, massive subcutaneous emphysema, and air bubbling through the wound. If the patient is hemodynamically stable and does not have any of these dangerous “hard signs”, it is reasonable to pursue CT angiography of the neck (Choice A) to evaluate for any vascular, aerodigestive, or neurologic injuries. The fish should not be removed (Choice B) in the Emergency department as this may result in uncontrolled bleeding. A more controlled environment, like an operating theater, is a more appropriate setting to remove a penetrating foreign body. The patient in this case has 2 hard signs (bubbling through wound and airway compromise), so he will need operative management (Choice C). However, the patient’s airway compromise is a more emergent and time-sensitive issue that needs to be addressed first with endotracheal intubation (Choice D). Intubation is the next best step in management. Correct Answer: D

References

Swaminathan, A. (2018). Penetrating neck injuries. REBEL-EM. https://rebelem.com/penetrating-neck-injuries/

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Question Of The Day #68

December 17, 2021November 20, 2021 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management?

Explanation

This elderly man presents to the Emergency Department after a mechanical fall down the stairs with left flank pain. He is on anticoagulation. His chest X-ray shows 3 lower rib fractures. The diagnosis of rib fractures is clinical in conjunction with imaging. A history of rib trauma with pleuritic chest pain, tenderness over the ribs, and skin ecchymoses over the chest all support a diagnosis of rib fracture. Chest X-ray is often performed as an initial test, but it should be noted that about 50% of rib fractures are not able to be visualized on chest radiography alone. Bedside ultrasonography and CT scanning are more sensitive in detecting rib fractures than plain radiography. Treatment for rib fractures is mainly supportive and includes pain management and incentive spirometry (or regular deep inspiratory breaths) to prevent the development of atelectasis or pneumonia as complications. Many patients with rib fractures can be discharged home with these supportive measures.

Another important part of rib fracture management is evaluation for the complications or sequalae of rib fractures. This includes pulmonary contusion, pneumonia, atelectasis, flail chest, traumatic pneumothorax or tension pneumothorax, hemothorax, and abdominal viscus injuries. Elderly patients with multiple rib fractures are more likely to have poor outcomes and should be admitted for close observation. Admission to the hospital for pain management (Choice A) may be needed in this case, but it is not the best next step. Placement of a chest tube (Choice C) is not needed in this case as there are no signs of a pneumothorax. Incentive spirometry (Choice D) is important to prevent atelectasis or pneumonia, but it is not the best next step. The presence of multiple lower rib fractures (ribs #9-12) as seen in this case should prompt evaluation for abdominal injuries, such as hepatic or splenic lacerations. Potential abdominal injuries should be of greater concern since this patient is on anticoagulation for his atrial fibrillation. The best next step is a CT scan of the chest, abdomen, and pelvis (Choice B).

References

Ramzy, M, Hamilton, R. (2018). The chest bump: Pulmonary pearls & pitfalls to consider in patients with chest trauma. EmDocs. http://www.emdocs.net/the-chest-bump-pulmonary-pearls-pitfalls-to-consider-in-patients-with-chest-trauma/

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Question Of The Day #67

December 10, 2021November 20, 2021 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause of this patient’s condition?

Explanation

This patient arrives in the Emergency Department after sustaining penetrating chest trauma and is found to be hypotensive, tachycardic, and with a low oxygen saturation on room air. The first step in evaluating any trauma patient involves the primary survey. The primary survey is also known as the “ABCDEFs” of trauma. This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma). Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition. The primary survey should be conducted prior to taking a full history. After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history.

The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries. The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas. The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam. The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid. In the setting of trauma, free fluid is assumed to be blood. The presence of free fluid on a FAST exam is considered a “positive FAST exam”. This patient’s ultrasound shows fluid in the pericardiac sac which in combination with the patient’s hypotension and tachycardia, this supports a diagnosis of cardiac tamponade. See the image below for labelling.

Cardiac tamponade is considered a type of obstructive shock. As with other types of obstructive shock, such as pulmonary embolism and tension pneumothorax, there is a state of reduced preload and elevated afterload. This causes a reduction in cardiac output (Choice C) which leads to hypotension, tachycardia, and circulatory collapse. High cardiac preload (Choice A), low cardiac afterload (Choice B), and high cardiac output (Choice D) do not occur in cardiac tamponade. Treatment for cardiac tamponade includes IV hydration to increase preload, bedside pericardiocentesis, and ultimately, a surgical cardiac window performed by cardiothoracic surgery. Correct Answer: C

References

Avila, J. (2020). Pericardial tamponade. Core ultrasound. https://www.coreultrasound.com/pericardial-tamponade/
Simon, E. (2017). EM@3AM – Cardiac tamponade. EmDocs. http://www.emdocs.net/em3am-cardiac-tamponade/

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Question Of The Day #66

December 3, 2021November 20, 2021 ~ Joseph Ciano, USA ~ 1 Comment

Which of the following is the most likely diagnosis of this patient’s condition?

Explanation

This man presents to the Emergency Department with pleuritic chest pain, shortness of breath after a penetrating chest injury. He has tachypnea and low oxygen saturation on exam, but he is not hypotensive or tachycardic. The first step in evaluating any trauma patient involves the primary survey. The primary survey is also known as the “ABCDEFs” of trauma. This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma). Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition. The primary survey should be conducted prior to taking a full history. After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history.

This patient should immediately be given supplemental oxygen for his low oxygen saturation. The history of penetrating chest trauma and hypoxemia also should raise concern for a traumatic pneumothorax, and oxygen supplementation is part of the treatment for all pneumothoraces. The patient’s chest X-ray shows a large left sided pneumothorax indicated by the absence of left sided lung markings. There is some left to right deviation of the heart and the primary bronchi. There is no large left sided pleural effusion in the costodiaphragmatic recess to indicate a pneumo-hemothorax. There is also no deviation of the trachea, hypotension, or tachycardia to indicate a tension pneumothorax (Choice B). The patient is hemodynamically stable, so he cannot be in hemorrhagic shock (Choice A) or have cardiac tamponade (Choice C). Although the pneumothorax is large with mild deviation of the heart, the lack of hemodynamic instability supports the diagnosis of a traumatic non-tension pneumothorax (Choice D). The treatment for this would include 100% oxygen supplementation and placement of a chest tube. A CT scan of the chest is more sensitive imaging test than a chest X-ray and should be considered to evaluate for additional injuries (blood vessel injuries, rib fractures, etc.). Correct Answer: D

References

Bartels, B. (2020). EM@3AM: Pneumothorax. EMDocs. http://www.emdocs.net/em3am-pneumothorax/

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Question Of The Day #65

November 26, 2021November 20, 2021 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

Explanation

This patient arrives in the Emergency Department after an assault with penetrating abdominal trauma and is hemodynamically stable on exam. The first step in evaluating any trauma patient involves the primary survey. The primary survey is also known as the “ABCDEFs” of trauma. This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma). Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition. The primary survey should be conducted prior to taking a full history. After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history.

The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries. The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas. The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam. The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid. In the setting of trauma, free fluid is assumed to be blood. The presence of free fluid on a FAST exam is considered a “positive FAST exam”. This patient has no free fluid between the right kidney and liver. There also is no free fluid above the diaphragm to indicate a hemothorax. The question stem notes that all other FAST exam views are nonremarkable. Therefore, this patient has a negative FAST exam. See labelling of the FAST exam image below.

An exploratory laparotomy (Choice A) would be indicated in a patient with penetrating or blunt trauma, a positive FAST exam, and hemodynamic instability. This patient has a negative FAST exam and is hemodynamically stable. Packed red blood cell infusion (Choice B) would be indicated in the setting of hemodynamic instability and trauma, as this is assumed to be hemorrhagic shock. This patient is not tachycardic or hypotensive. A urinalysis to check for hematuria (Choice D) may be a helpful adjunctive investigation to evaluate for renal or bladder injury, but it is not the most crucial next step in management. Performing a CT scan of the abdomen and pelvis (Choice C) is the best next step as the patient is hemodynamically stable with a negative FAST exam and a penetrating abdominal injury. The CT scan will help further evaluate for any internal injuries that may require operative repair. See the algorithm below for further detail on an abdominal trauma work flow. Correct Answer: C

References

Avila, J. (2020). E-FAST exam. Core Ultrasound. https://www.coreultrasound.com/efast/
Gadhok, K, Fairbrother, H. (2015). Abdominal trauma: Is there anything we can be doing better? EmDocs. https://www.emdocs.net/abdominal-trauma-anything-can-better/

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