Question Of The Day #72

question of the day

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

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). 

*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.

 

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

Cite this article as: Joseph Ciano, USA, "Question Of The Day #72," in International Emergency Medicine Education Project, January 14, 2022, https://iem-student.org/2022/01/14/question-of-the-day-72/, date accessed: January 17, 2022

Question Of The Day #71

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

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

Cite this article as: Joseph Ciano, USA, "Question Of The Day #71," in International Emergency Medicine Education Project, January 7, 2022, https://iem-student.org/2022/01/07/question-of-the-day-71/, date accessed: January 17, 2022

Question Of The Day #70

question of the day
712 - deep fore arm laceration
Which of the following is the most appropriate next step in management for this patient’s condition?  

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

Cite this article as: Joseph Ciano, USA, "Question Of The Day #70," in International Emergency Medicine Education Project, December 31, 2021, https://iem-student.org/2021/12/31/question-of-the-day-70/, date accessed: January 17, 2022

Question Of The Day #69

question of the day
Neck injury with fish
Which of the following is the most appropriate next step in management for this patient’s condition?  

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

Cite this article as: Joseph Ciano, USA, "Question Of The Day #69," in International Emergency Medicine Education Project, December 24, 2021, https://iem-student.org/2021/12/24/question-of-the-day-69/, date accessed: January 17, 2022

Question Of The Day #68

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

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

Cite this article as: Joseph Ciano, USA, "Question Of The Day #68," in International Emergency Medicine Education Project, December 17, 2021, https://iem-student.org/2021/12/17/question-of-the-day-68/, date accessed: January 17, 2022

Question Of The Day #67

question of the day
SS Video 2  Large Pericardial Effusion

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

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

Cite this article as: Joseph Ciano, USA, "Question Of The Day #67," in International Emergency Medicine Education Project, December 10, 2021, https://iem-student.org/2021/12/10/question-of-the-day-67/, date accessed: January 17, 2022

Question Of The Day #66

question of the day
40.1 - Pneumothorax 1

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

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

Cite this article as: Joseph Ciano, USA, "Question Of The Day #66," in International Emergency Medicine Education Project, December 3, 2021, https://iem-student.org/2021/12/03/question-of-the-day-66/, date accessed: January 17, 2022

Question Of The Day #65

question of the day
Longitudinal Orientation

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

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

undifferentiated trauma patient
undifferentiated trauma patient

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #65," in International Emergency Medicine Education Project, November 26, 2021, https://iem-student.org/2021/11/26/question-of-the-day-65/, date accessed: January 17, 2022

Question Of The Day #64

question of the day
Left Upper Quadrant

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

This patient arrives in the Emergency Department after an assault and has pallor (paleness), hypotension, and tachycardia 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 free fluid between the left kidney and spleen in combination with hypotension and tachycardia.  This patient is in hemorrhagic shock until proven otherwise and needs prompt operative management.  See labelling of the FAST exam image below.

us image showing bleeding
us image showing bleeding

 

A CT scan of the chest, abdomen, and pelvis (Choice A) and a CT scan of the head (Choice C) may be helpful in the evaluation of this patient, but this patient is hemodynamically unstable.  Radiographic tests that require the patient to leave the Emergency Department should be avoided if the patient is unstable.  The specific location or cause of the hemodynamic instability can be diagnosed in the operating theater where there are opportunities to control the intraperitoneal bleeding (i.e., splenectomy, vessel ligation or cautery, etc.).  Bedside diagnostic peritoneal lavage (Choice D) is not indicated in penetrating abdominal trauma when there is a negative FAST exam and CT scanning is available.  This patient sustained blunt abdominal trauma, so a DPL is less informative.  The best next step for this patient is exploratory laparotomy (Choice B) in the operating theater.  Hemodynamically unstable patients with a positive FAST exam should always go to the operating theater for further diagnosis and treatment.  See the algorithm below for further detail.

 

undifferentiated trauma patient
undifferentiated trauma patient

 

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #64," in International Emergency Medicine Education Project, November 19, 2021, https://iem-student.org/2021/11/19/question-of-the-day-64/, date accessed: January 17, 2022

Question Of The Day #63

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

This patient presents to the Emergency Department after a high-speed motor vehicle accident in the setting of alcohol intoxication.  On examination, he is intoxicated with a GCS of 14 (normal GCS is 15).  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 is intoxicated but is awake with a patent airway. Endotracheal intubation (Choice C) is not indicated.  Neurosurgical consultation (Choice D) is also not indicated at this stage as there is no concrete information to indicate a surgical emergency.  CT imaging may demonstrate a cervical spine fracture or intracerebral bleeding, but these results are not provided by the question stem.  A CT scan of the head without contrast (Choice B) is a reasonable test for this patient given his significant mechanism of injury and intoxication on exam.  However, both a CT scan of the head and cervical spine (Choice A) should be ordered due to the patient’s intoxication creating an unreliable physical exam.  Alcohol intoxication or drug use can alter a patient’s ability to sense pain and provide accurate information.  The presence of intoxication should always raise awareness for possible occult injuries. 

Of note, intoxication and altered mental status are indications to perform a CT scan of the cervical spine based on a well-validated decision-making tool known as the NEXUS criteria (National Emergency X-Radiography Utilization Study).  Other criteria on the NEXUS tool that support CT cervical spine imaging are midline spinal tenderness, the presence of a focal neurologic deficit, or the presence of a distracting injury (i.e., femur fracture). The Canadian C-Spine Rule and Canadian CT Head Rule are other validated decision-making tools to help a clinician decide on whether or not to order CT head or cervical spine imaging. Correct Answer: A

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #63," in International Emergency Medicine Education Project, November 12, 2021, https://iem-student.org/2021/11/12/question-of-the-day-63/, date accessed: January 17, 2022

Question Of The Day #62

627.15 - Figure 15 - lentiform epidural hematoma in the right hemisphere

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

This patient presents to the Emergency Department after a high-speed motor vehicle accident.  On examination, he is tachycardic, mildly tachypneic, and has an altered mental status (somnolent).  The first step in evaluating this 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.  A noncontrast CT scan of the head is a reasonable test for this patient given his significant mechanism of injury and altered mental status on exam.  The CT scan shows a hyperdense (white) biconvex area on the right side of the brain.  This white area indicates the presence of fresh blood on the CT scan.  Keep in mind that CT scans are read as if you are looking up from the patient’s feet to their head.  This means left-right directionality is reversed.  See image below.

A hyperdense area with a sickled or crescent-shaped appearance would indicate an acute subdural hemorrhage (Choice A).  This is caused by tearing of the cerebral bridging veins.  Hyperdense areas throughout the brain tissue itself would indicate an intraparenchymal hemorrhage (Choice B).  Hyperdense areas around the sulci of the brain and a starfish appearance would indicate a subarachnoid hemorrhage (Choice D). Subarachnoid bleeding is caused by rupturing of a brain aneurysm or an arteriovenous (AV) malformation.  Subarachnoid bleeding can also be associated with trauma. 

This patient’s CT image shows an epidural hemorrhage (Choice C), indicated by the biconvex lens shaped area of blood.  This is caused by tearing of the middle meningeal artery.  Treatment of all types of intracranial bleeding involves general supportive care, airway management (i.e., endotracheal intubation for GCS < 8), elevating the head of the bed to 30 degrees to lower intracranial pressure (ICP), managing pain and sedation (lowers ICP), blood pressure maintenance (goal SBP <140mmHg), reversal of coagulopathy, neurosurgical evaluation for possible operative intervention, and providing ICP lowering treatments (mannitol or hypertonic 3% NaCl) when concerned about elevated ICP or brain herniation.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #62," in International Emergency Medicine Education Project, November 5, 2021, https://iem-student.org/2021/11/05/question-of-the-day-62/, date accessed: January 17, 2022

Question Of The Day #61

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

This patient arrives to the hospital after penetrating trauma to the right chest.  His initial examination reveals hypotension, tachycardia, tachypnea, and a low oxygen saturation.

All medical and trauma patients that arrive to the Emergency Department, especially those who are ill-appearing or with abnormal vital signs, should undergo the “ABCs”.  This is also known as the primary survey.  The primary survey aims to create a step-wise initial approach to patients where all life-threatening conditions are identified and treated early in the encounter with the patient.  The primary survey should be conducted prior to taking a full history.  In trauma patients, the primary survey is extended to include the “ABCDEFs”.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam.  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition. 

Airway assessment involves checking for airway patency (clear voice, stridor, blood or vomitus in mouth, etc.) and applying cervical spine immobilization if needed.  Endotracheal intubation or a surgical airway may need to be placed during this step.  Breathing assessment involves auscultation of the lungs, checking the oxygen saturation, and providing supplemental oxygen to the patient if needed.  Abnormalities in the breathing exam (absent unilateral lung sounds, tracheal deviation, etc.) may prompt the placement of a chest tube or needle decompression.  It is during the breathing step that a pneumothorax, tension pneumothorax, or hemothorax is identified and treated.  Circulation assessment involves checking the heart rate and blood pressure, palpating all peripheral pulses, establishing IV access, and administering IV fluids or blood products.  It is during the circulation step that hemorrhage and shock is identified and controlled (pressure dressing applied to bleeding extremity wound, tourniquet applied to slow bleeding at amputated limb, etc.).  Disability assessment involves checking the patient’s neurologic status.  This involves calculating a GCS (Glasgow Coma Score), measuring the patient’s glucose level, and performing a focused neurologic exam.  Exposure involves removing all the patient’s clothes which may be obstructing view of other injuries.  This step involves rolling the patient to the lateral decubitus position to check the back and perineal areas for trauma.  The last step of the primary survey in trauma is the FAST exam (Focused Assessment with Sonography in Trauma).  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 question stem provides information regarding the airway of the patient, which is stated to be patent.  The next step in the “ABCDEFs” should be evaluation of the ‘Breathing’.  Administration of packed red blood cells (Choice A) is considered part of the “Circulation” assessment.  Removing the patient’s clothes to evaluate for occult injuries (Choice C) is important, but the “Breathing” assessment should be performed prior to the patient’s “Exposure” step.  Performing a FAST exam (Choice D) is also an important part of the primary survey, but it should be performed after the “Breathing” step is completed.  Auscultation of both lungs (Choice B) is the best next step, as this is part of the “Breathing” step after the “Airway” assessment.  During this step, the patient should be given supplemental oxygen and evaluated for abnormal or absent unilateral lung sounds.  This is important as this patient is at risk for a large pneumothorax, tension pneumothorax, or hemothorax after his penetrating trauma.   

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #61," in International Emergency Medicine Education Project, October 29, 2021, https://iem-student.org/2021/10/29/question-of-the-day-61/, date accessed: January 17, 2022