Lower Extremity Injuries (2024)

December 17, 2024January 10, 2025 ~ iEM Education Project Team ~ Leave a comment

by Nisreen Al Maghraby, Nasser AlJoaib, and Faisal AlGhamdi

You Have A New Patient!

A 27-year-old man was involved in a high-speed motor vehicle collision. He underwent a prolonged extraction process and presents with apparent lower limb injuries. The patient reports severe pain in his right knee and leg. Analgesic medication has been administered, and he was exposed for a comprehensive evaluation while warm blankets were prepared to prevent hypothermia. (To be continued)

Introduction

The lower limb (LL) is an essential part of the human body that plays a crucial role in both mobility and stability. It consists of various anatomical structures, each contributing significantly. These include bones, joints, ligaments, and soft tissue, which are organized in harmony to support the body’s weight and facilitate movement [1].

The bones of the lower limb include the femur, tibia, fibula, patella, and several small bones in the feet. The joints include the hip joint, formed by the articulation of the hip bone and femur; the knee joint, which consists of the femur and tibia; the ankle joint, formed by the talus, fibula, and tibia; and the smaller joints of the feet [2]. The ligaments of the LL provide stability to the joints and include the medial and lateral collateral ligaments, anterior and posterior cruciate ligaments, and the ligaments of the feet. The vascular structures that supply blood to the lower limb include the femoral artery and vein, popliteal artery and vein, and tibial artery and vein [2]. The soft tissues of the lower limb include muscles that generate movement, tendons that connect muscles to bones, and fascia, which is a sheet of connective tissue that covers the muscles.

A logical approach to evaluating these structures is essential to avoid misdiagnosis. This involves looking beyond simple fractures, which are often apparent upon inspection, to identify other injuries that may impair function or pose a limb-threatening risk.

The traditional structured approach begins with a history, followed by a physical examination, laboratory investigations and/or radiological imaging if relevant to the context. A differential diagnosis is then formulated, and only after that is a management plan established. It is crucial to note that this longitudinal approach is typically not applicable in emergency situations. In emergencies, a more horizontal approach is employed, where actions occur simultaneously, including repeated cycles of evaluation, identification, and intervention to address a predefined emergent or urgent differential diagnosis.

A clear understanding of potential diagnoses, informed by initial findings, is vital for effective clinical decision-making. Based on the structures of the LL discussed, the emergent/urgent traumatic differential diagnosis includes the following:

Fractures (closed vs. open)
Dislocations
High-grade ligamentous injuries
Soft tissue injuries (degloving vs. open)
Compartment syndrome
Vascular injuries

Approach

When evaluating patients with lower limb injuries in the emergency department (ED), a comprehensive history and physical examination are essential for accurate diagnosis and management. The initial assessment should include a thorough patient history, covering the mechanism of injury, any associated pain, alterations in sensation, reduced range of motion of the affected joint, swelling, or stiffness. A review of the patient’s medical history, medications, and functional and occupational background should also be obtained. Additionally, eliciting information on any previous dislocations and/or fractures is important, as a history of repeated dislocations may indicate ligamentous laxity and an unstable joint. Such instability could lead to failed reduction attempts, potentially requiring surgical intervention. A comprehensive understanding of the mechanism of injury—specifically differentiating between syncopal and non-syncopal trauma (previously referred to as mechanical or non-mechanical)—is crucial for selecting appropriate investigations and minimizing the risk of additional injury.

The physical examination of the lower limb (LL) is part of the secondary survey. Lower limb injuries can be dramatic, but unless there is an active bleed requiring immediate pressure application, the LL examination should be conducted after the ABCDE evaluation has been completed [3]. The LL examination begins with an observation of the patient’s gait and use of walking aids, which can provide valuable information about the severity of the injury. Visual inspection of the limb for deformities, swelling, or bruising is crucial. Regardless of whether abnormalities are observed, the physician should systematically palpate the entire limb to identify areas of tenderness or crepitus, which may indicate underlying fractures or dislocations. Active (patient-attempted) range of motion of the joint should also be tested, along with assessing the patient’s ability to bear weight on the affected limb.

In addition to a comprehensive physical examination, specific tests can be performed to evaluate particular injuries. For example, the talar tilt test assesses lateral ankle ligament stability, and the Thompson’s test evaluates for Achilles tendon rupture. These tests can help the physician narrow down the differential diagnosis and determine the need for further investigations.

It is also important to assess the neurovascular status of the affected limb. During the neuroexamination of the LL, attention should be given to both motor and sensory components. Motor function is typically assessed by observing muscle strength and tone, checking reflexes, and evaluating for any abnormal movements or gait abnormalities. Sensation is assessed by testing for the ability to feel light touch, pinprick, and temperature changes in different areas of the leg and foot. Dermatome distribution, which extends from L1 to S2 (Figure 1), should also be evaluated by testing sensitivity to light touch or pinprick in specific skin areas innervated by different spinal nerves. By evaluating motor function, sensation, and dermatome distribution in the LL, healthcare providers can gain critical insights into potential neurological issues requiring further investigation.

Examination is incomplete without the use of point-of-care ultrasound. One modality that can aid diagnosis at the bedside is Doppler ultrasound, which is used to evaluate hip trauma and detect potential vascular injuries such as arterial dissection or aneurysm, which may result from dislocations or fractures. Additionally, Doppler ultrasound can help diagnose deep vein thrombosis (DVT), a common complication in patients with fractures [4]. By detecting changes in blood flow and identifying potential vascular injuries, Doppler ultrasound provides valuable diagnostic information for healthcare providers in the management of trauma.

Investigation

Laboratory investigations have limited value in diagnosing lower limb injuries and are typically used for follow-up or preparation for operative interventions. For example, monitoring a patient’s renal function through laboratory investigations may be necessary in cases of compartment syndrome resulting from crush injuries. Conversely, radiological investigations, particularly X-rays, are critical in diagnosing lower limb injuries. X-rays provide valuable images of the bones and joints, aiding physicians in identifying fractures, dislocations, and other bony injuries. They can also help exclude conditions such as infections or tumors that may mimic traumatic injuries.

Other radiological investigations, such as formal ultrasound, CT scans, and MRI, may be utilized to further evaluate specific types of injuries or to assess soft tissue structures, such as muscle or tendon tears.

It is essential to understand the clinical examination findings and the gold-standard radiological imaging for each anatomical structure of the lower limb. This specificity helps avoid redundancy and reduces the length of ED stays.

Clinical & Radiological gold standard for (Bone, Ligament, vascular injuries)

For bone fractures, clinical findings typically include bone tenderness, which can indicate an underlying fracture. The gold standard imaging modality for diagnosing bone fractures is Computed Tomography (CT). CT scans provide highly detailed images of the bone, allowing for precise identification of fracture types and locations [5].

For ligamentous injuries, the clinical examination often focuses on evaluating the active range of motion of the affected joint. A restricted or abnormal range of motion may signal ligament damage. Magnetic Resonance Imaging (MRI) is the gold standard imaging modality for ligamentous injuries. MRI offers excellent visualization of soft tissues, including ligaments, making it ideal for detecting ligament tears or instability [6].

In cases of vascular injury, abnormal perfusion beyond the area of suspicion is a critical clinical finding. This can be assessed through indicators such as pulse, ankle-brachial index (ABI), capillary refill, and temperature changes. Angiography serves as the gold standard imaging modality for vascular injuries [7]. This technique allows for detailed imaging of blood vessels, enabling the identification of arterial dissections, aneurysms, or other vascular abnormalities that may arise from trauma.

Management

In all trauma victims, as previously highlighted, the primary survey—assessing airway patency, breathing, circulation, and disability—takes priority. History-taking and physical examination conducted during the primary and secondary surveys are essential for identifying potential injuries and ruling out others.

The outcome of the initial evaluation should be the determination of the patient’s stability and the need for prompt treatment in the operating room or by interventional radiologists. A hemodynamically unstable patient with a positive focused abdominal ultrasonography (FAST) is presumed to have a significant pelvic and/or intra-abdominal injury and must be urgently transferred for damage control, either surgically or via interventional radiology [8].

Pain management is also crucial for the patient’s comfort and well-being. The standard approach involves a multimodal strategy, incorporating the use of ice, splinting, and medication. Ice can be applied to the affected area to reduce inflammation and swelling, while splinting immobilizes the limb, reduces pain, and prevents further injuries. For medications, a stepwise approach is recommended. A combination of acetaminophen, NSAIDs, and opioids may be used to provide prompt pain relief. Using multiple medications with different mechanisms of action has a synergistic effect, improving pain management while minimizing the risks associated with escalating the dose of a single medication.

Stepwise Approach

The stepwise approach to pain management is designed to address pain severity progressively, ensuring effective relief while minimizing risks. The first step involves the use of acetaminophen (APAP) administered either orally (PO) or intravenously (IV), with or without the addition of adjuvant therapies [9]. This step is typically suitable for patients experiencing mild to moderate pain.

If pain persists or escalates, the second step introduces non-steroidal anti-inflammatory drugs (NSAIDs), also administered either orally or intravenously, along with optional adjuvant therapies [10]. NSAIDs are particularly effective for managing inflammatory pain and can be combined with the first step for enhanced relief.

For patients whose pain remains uncontrolled after the first two steps, the third step involves the use of opioids [11]. This method targets more severe pain that has not responded adequately to non-opioid medications.

In cases of severe, unrelieved pain, the fourth step recommends administering opioids on an as-needed basis, every 30 minutes. This ensures rapid and effective pain control while allowing for adjustments based on the patient’s response.

Early combination of drugs may be required patients presented with severe pain.

This structured approach ensures a systematic escalation of treatment tailored to the patient’s pain level, combining medications with different mechanisms of action to maximize effectiveness and minimize side effects.

Specific Injuries

Hip

Introduction and Epidemiology

Hip injuries are a common presentation to Emergency Departments (ED) worldwide, significantly contributing to patient morbidity and healthcare costs. The epidemiology of hip injuries varies geographically, but they predominantly affect older adults, with a higher incidence in females. The most common types of hip injuries encountered in the ED include fractures, dislocations, and contusions [12]. Among these, hip fractures represent a major public health challenge due to their high associated morbidity and mortality rates [12].

Risk factors for hip injuries include osteoporosis, falls, and high-impact trauma, which are particularly relevant in populations at increased risk, such as the elderly and individuals with pre-existing bone health conditions [12].

History and Physical Examination

When taking a history from a patient with hip trauma, it is important to pay attention to the mechanism of injury. For example, a patient presenting with a dislocation following a motor vehicle collision (MVC) is most likely to have a posterior dislocation (90%) rather than an anterior dislocation [13]. Any associated symptoms, particularly neurological ones, should also be clarified. Patients with a posterior hip dislocation after an MVC may report numbness along the posterior aspect of the limb, which could indicate sciatic nerve injury.

A thorough physical examination, including a neurovascular evaluation as well as an assessment of range of motion and strength, is essential to obtain diagnostic information. The examination should begin with visual inspection of the affected area to identify signs of deformity, swelling, or discoloration, which can provide clues about the nature and severity of the injury. For instance, a patient with a posterior hip dislocation will typically present with the limb adducted and internally rotated, whereas an anterior dislocation will result in the limb being abducted and externally rotated.

Palpation of the affected area to assess for tenderness, warmth, or crepitus (a crackling sensation or sound) can help localize the injury and determine the extent of soft tissue damage. Additionally, specific special tests may be required to evaluate particular hip injuries.

Specific special tests are often required to evaluate suspected hip injuries, depending on the clinical presentation. For hip flexion contractures, the Thomas test is commonly utilized to assess limited hip extension caused by tightness or shortening of the hip flexor muscles [14].

To evaluate hip abductor muscle weakness, the Trendelenburg test is performed. This test identifies weakness in the gluteus medius and minimus muscles by observing the stability of the pelvis during a single-leg stance.

In cases of suspected arthritis or labral tears of the hip, the FABER test (Flexion, Abduction, External Rotation) is employed. This test helps to assess pain or limitations associated with intra-articular pathology or issues involving the sacroiliac joint.

Investigations

To prevent complications such as post-traumatic osteoarthritis, fracture non-union, and avascular necrosis of the femoral head, prompt and accurate diagnosis of hip injuries is essential [15]. Radiographs are the initial imaging modality of choice for evaluating traumatized patients. They are considered the most important diagnostic tool as they are widely accessible and can be performed on-site. On plain film, most fractures of the pelvis and hip joint, as well as avulsion injuries and dislocations, can be identified. However, acetabular, pelvic ring, and sacral fractures are often challenging to detect with plain radiographs alone and typically require CT imaging for accurate diagnosis.

Anteroposterior (AP) radiographs of the pelvis are used to evaluate the location of the femoral head in relation to the acetabulum and to compare findings with the contralateral hip. For patients with known or suspected hip fractures, specific hip radiographs consisting of an AP view and a cross-table lateral image of the affected hip joint are recommended. In cases of hip dislocation, a three-view pelvic radiographic examination may be advised to allow for a more thorough evaluation of the acetabular walls and columns.

In situations where plain film radiographs yield negative results but clinical suspicion remains high, advanced imaging modalities such as CT may be necessary for a more definitive evaluation [16].

Emergency Management of Hip Injuries

Any pelvic fractures or unstable dislocations, whether suspected or confirmed, require prompt orthopedic consultation. Pelvic and acetabular fractures should raise suspicion for possible internal injuries [8]; therefore, a cross-match of blood should be requested even if the patient is hemodynamically stable. The patient must be immobilized, two large-bore antecubital IV lines should be inserted, appropriate analgesics administered, and oral intake restricted to nil by mouth (NPO). In unstable patients, it is crucial to stabilize the pelvis by wrapping it with a sheet or applying a pelvic binder to control bleeding through a tamponade effect.

For open pelvic fractures, treatment with broad-spectrum intravenous (IV) antibiotics is essential, along with tetanus prophylaxis if indicated. Empiric antibiotic treatment should be initiated as early as possible, ideally within the first hour, with cefuroxime as the recommended antibiotic of choice [17]. Patients who are unvaccinated against tetanus or have not completed a primary series of tetanus vaccinations should receive tetanus immunoglobulin (TIG) at a dose of 250 IU administered intramuscularly.

In cases of hip dislocations, other injuries often take precedence; therefore, all life-threatening injuries must first be ruled out. A neurovascular examination should be performed, and abnormal findings should prompt urgent management of the dislocation. Reduction should be performed under proper procedural sedation analgesia (PSA) administered by a dedicated physician using appropriately dosed sedatives, analgesics (e.g., ketamine), and muscle relaxants (e.g., propofol). Reduction requires one person to apply traction and one or two individuals to provide counter-traction, excluding the physician responsible for managing the PSA. No more than three attempts at closed reduction in the ED setting are recommended, as multiple attempts increase the risk of avascular necrosis (AVN). If reduction fails, an emergent CT scan may be required to identify any impediments to successful reduction.

Disposition

Hip fractures and traumatic dislocations generally require admission under the care of the orthopedic team for consideration of either conservative or surgical interventions. If a hip dislocation cannot be successfully reduced in the ED, urgent surgical reduction in the operating room is typically required.

The decision for surgical intervention in fractures depends on factors such as the patient’s age, overall health status, and the severity and location of the fracture.

Urgent orthopedic consultation is necessary in cases of hip trauma under the following circumstances:

An unstable hip joint (e.g., dislocation recurring after reduction)
Displaced fractures
Pelvic fractures
Fractures associated with neurovascular injury

Knee

Introduction and Epidemiology

Knee injuries necessitate high-quality care to ensure the best possible outcomes for patients. Due to the painful nature of knee injuries, it is often difficult to evaluate and accurately diagnose these conditions. The knee is the most frequently injured body part [18]. Certain knee injuries carry a high risk of morbidity and may require surgical intervention as well as extensive rehabilitation. Therefore, it is essential to optimize emergency care to effectively manage these injuries and minimize long-term complications.

History and Physical Examination

Examination of the knee should be performed on both knees for comparison and reference. The assessment includes inspection of the knees for any asymmetry, wounds, swelling, patellar displacement, or visible deformities. Additionally, palpation should be conducted to evaluate joint line or point tenderness, temperature, and the presence of effusion.

Special tests for each suspected injury includes following;

For suspected anterior cruciate ligament (ACL) injuries, the Lachman’s test is the primary diagnostic test. It is often supplemented by the pivotal shift test, which helps assess the integrity of the ACL and determine any abnormal movement of the knee [19].

In cases of suspected middle cruciate ligament or lateral cruciate ligament injuries, the varus/valgus stress tests are performed. These tests evaluate the stability of the knee ligaments by applying lateral or medial forces to the joint [20].

For patients with suspected meniscal injuries, several specialized tests can be used to confirm the diagnosis. These include the Thessaly test, the McMurray test, and Ege’s test, which assess for pain, clicking, or locking during knee movements. Additionally, Apley’s test can be performed, particularly when combined with joint line tenderness, to further evaluate meniscal damage [21].

In cases of patella dislocation, specific tests such as the patella tilt test, the apprehension test, and the patella glide test are utilized. These tests assess the position, mobility, and stability of the patella to identify any dislocation or misalignment [22].

Investigations

An important criterion to consider is the Ottawa Knee Rule, which has been validated in multiple studies to help identify patients at low risk for clinically significant knee injuries, thereby avoiding unnecessary imaging [23].

The Ottawa Knee Rule provides clear criteria to determine when an X-ray is indicated for patients with knee injuries. Patients who meet any of these criteria are classified as high risk and should undergo imaging. Conversely, patients who do not meet any of the criteria can be safely discharged without imaging [24]. Criteria;

Age greater than 55 years.
Isolated patellar tenderness without other bony tenderness.
Inability to flex the knee to a 90° angle.
Tenderness at the head of the fibula.
Inability to bear weight, defined as taking four steps both immediately after the injury and in the emergency department.

The use of the Ottawa Knee Rule and other clinical decision rules helps reduce unnecessary imaging and associated costs while ensuring that patients with clinically significant injuries receive appropriate diagnostic testing.

The initial imaging study for acute knee trauma is typically a radiograph, which is effective in detecting fractures, dislocations, and other bony abnormalities [23]. For complex fractures, computed tomography (CT) scans can provide valuable information, particularly when planning for surgical interventions. CT imaging is also utilized for vascular assessment, often as part of a lower limb run-off during the Pan-CT trauma protocol when lower limb injuries are suspected [25]. However, CT scans are performed only after stabilization of polytrauma patients.

Additional imaging studies, such as magnetic resonance imaging (MRI), are rarely used in the emergency setting. MRI may, however, be indicated for evaluating soft tissue injuries, including ligament and meniscal tears, when more detailed assessment is required [25].

Emergency Management of Knee Injuries

In addition to the standard management provided in cases of lower limb (LL) trauma, aspiration of joint fluid may be indicated in knee trauma with significant joint effusion. Aspiration can help relieve pain and improve joint mobility. Furthermore, antibiotics should be administered in cases of significant open wounds, guided by the Gustilo-Anderson Classification [26].

Gustilo-Anderson Classification

Type I Injuries

Description:
- Clean wound, ≤ 1 cm in size with minimal soft tissue damage.
- Low-energy mechanism, minimal fracture comminution, no periosteal stripping.
- Local skin coverage with no neurovascular injury.
Antibiotic of Choice:
- 1st generation cephalosporin (e.g., cefazolin).

Type II Injuries

Description:
- Moderate contamination with wound size between 1–10 cm and moderate soft tissue damage.
- Moderate energy mechanism, moderate fracture comminution with no periosteal stripping.
- Local skin coverage with no neurovascular injury.
Antibiotic of Choice:
- 1st generation cephalosporin (e.g., cefazolin).

Type IIIA Injuries

Description:
- Extensive contamination with wound size usually > 10 cm and extensive soft tissue damage.
- High-energy mechanism with severe fracture comminution and periosteal stripping.
- Local skin coverage with no neurovascular injury.
Antibiotic of Choice:
- 1st generation cephalosporin for gram-positive coverage.
- Aminoglycoside (e.g., gentamicin) for gram-negative coverage.

Type IIIB Injuries

Description:
- Extensive contamination with wound size usually > 10 cm and extensive soft tissue damage.
- High-energy mechanism with severe fracture comminution and periosteal stripping.
- Skin requires free tissue flap or rotational flap coverage with no neurovascular injury.
Antibiotic of Choice:
- 1st generation cephalosporin for gram-positive coverage.
- Aminoglycoside (e.g., gentamicin) for gram-negative coverage.

Type IIIC Injuries

Description:
- Extensive contamination with wound size usually > 10 cm and extensive soft tissue damage.
- High-energy mechanism with severe fracture comminution and periosteal stripping.
- Typically requires flap coverage.
- Exposed fracture with arterial damage that requires repair.
Antibiotic of Choice:
- 1st generation cephalosporin for gram-positive coverage.
- Aminoglycoside (e.g., gentamicin) for gram-negative coverage.

Special Considerations

Penicillin should be added if there is a concern for anaerobic organisms (e.g., farm injuries).
Fluoroquinolones (e.g., ciprofloxacin) are recommended for fresh water or saltwater wounds (alternatives for patients allergic to cephalosporins or clindamycin).
Doxycycline and 3rd or 4th generation cephalosporins (e.g., ceftazidime) are used for saltwater wounds.

When considering surgical management for knee trauma, the timing and type of intervention depend on the specific injury and patient factors such as age and activity level. For example, anterior cruciate ligament (ACL) reconstruction may be recommended for younger, active patients with significant ACL tears. In contrast, older or less active patients may be managed conservatively with physical therapy and activity modification.

Ultimately, the goal of emergency management of knee trauma is to accurately diagnose and treat injuries in a timely manner, while minimizing long-term complications and maximizing functional outcomes for the patient [23].

Disposition

Situations where consultation may be necessary for knee trauma in the ED include:

Significant ligamentous injury, such as an anterior cruciate ligament (ACL) tear.
Patellar or quadriceps tendon rupture.
Significant intra-articular injury or meniscal tear that may require an MRI or further evaluation.
Displaced or comminuted fractures.
Fracture dislocations.
Significant knee effusion.

In the above situations, admission is typically required. Conversely, discharge can be safely considered for patients with mild or stable knee injuries that can be managed conservatively or through outpatient follow-up after receiving adequate pain management. Patients who can safely ambulate on their own or with the assistance of crutches or other assistive devices, have been cleared for weight-bearing, and can perform activities of daily living without significant difficulty may be discharged. Additionally, discharge is appropriate for patients with good social support and an adequate home environment to manage their injury and ensure follow-up care [23,25].

It is important to emphasize that each case is unique, and decisions regarding admission or discharge should be individualized based on the patient’s specific circumstances and clinical presentation.

Ankle

Introduction and Epidemiology

Ankle injuries are a frequent presentation in the ED and can result from various causes, including sports activities, falls, or accidents.

History and Physical Examination

In addition to the standard questions asked during history-taking, identifying aggravating and alleviating factors can help guide the diagnosis. For example, pain associated with weight-bearing may suggest a degenerative cause, while pain relieved by applying ice could indicate local inflammation, such as plantar fasciitis. Additionally, any associated abnormal sounds, such as popping or clicking, should be noted, although it is important to clarify that the presence of such sounds does not necessarily indicate a fracture [27].

The patient’s footwear at the time of injury and their activity level should also be documented, as these factors can contribute to the severity and mechanism of the injury. Specifics, such as the palpation of the entire limb, should be systematically performed to identify areas of tenderness. For example, severe proximal fibular tenderness in a patient should raise the suspicion of a Maisonneuve fracture [28].

Further special tests relevant to ankle injuries are as follows.

For suspected injuries involving the anterior talo-fibular ligament (ATFL), the Anterior Drawer Test is performed. This test assesses the stability of the ATFL, which is commonly injured in ankle sprains [29].

In cases of suspected injury to the calcaneo-fibular ligament, the Talar Tilt Test is utilized. This test evaluates the integrity of the ligament by assessing excessive talar tilt, which may indicate ligamentous laxity or injury [30].

For suspected deltoid ligament injuries, the Eversion Stress Test is performed. This test assesses medial ankle stability by applying eversion stress to detect any laxity or pain suggestive of deltoid ligament damage [31].

Finally, for syndesmotic injuries, the External Rotation Stress Test is used. This test helps identify injuries to the syndesmosis (the ligamentous connection between the tibia and fibula) by applying external rotation to the ankle and observing for pain or instability [32].

Investigations

As with other joint injuries previously discussed, a plain radiograph is the appropriate initial imaging modality for ankle injuries. The Ottawa Ankle Rules provide guidelines for selecting patients who require imaging [33].

Ottawa Ankle Rule

An ankle radiographic series is required if the patient presents with pain in the malleolar area and meets any of the following criteria:

Bone tenderness at the posterior edge of the distal 6 cm or the tip of the lateral malleolus.
Bone tenderness at the posterior edge of the distal 6 cm or the tip of the medial malleolus.
Inability to bear weight for at least 4 steps, both immediately after the injury and at the time of evaluation.

Ottawa Foot Rule

A foot radiographic series is required if the patient experiences pain in the midfoot region and meets any of the following criteria:

Bone tenderness at the navicular bone.
Bone tenderness at the base of the fifth metatarsal.
Inability to bear weight for at least 4 steps, both immediately after the injury and at the time of evaluation.

For patients meeting the Ottawa ankle criteria, a three-view radiography series is recommended. This series consists of:

Anteroposterior (AP) view – useful for evaluating soft tissue swelling, which may indicate subtle fractures, as well as visualizing oblique fibula fractures and avulsion fractures of the fibula and tibia.
Lateral view – important for detecting chip or avulsion fractures of the tibia.
Mortise view – obtained with the foot internally rotated 15 to 20 degrees, which is essential for assessing the location of the talus and the integrity of the syndesmosis.

In patients who do not meet the Ottawa criteria, radiographs should still be performed if there is a neurovascular deficit, concern for a Lisfranc injury, trauma to the metatarsophalangeal joint, polytrauma, delayed presentation, or re-presentation [35].

Additional imaging modalities are generally not required in the Emergency Department (ED). However, ultrasonography (US) or magnetic resonance imaging (MRI) may be requested by orthopedics when there is suspicion of an acute Achilles tendon rupture. A clinical examination combined with a positive Thompson test is usually sufficient to confirm this diagnosis. In contrast, suspected Lisfranc injuries require immediate CT imaging for accurate evaluation [34].

Emergency Management of Ankle Injuries

Certain severe ankle sprains require physiotherapy rehabilitation in addition to the previously mentioned treatment regimen. Fractures of the ankle and foot require urgent orthopedic assessment. The choice between conservative or surgical therapy depends on the fracture’s location, articular involvement, soft tissue involvement, and stability. If there is evidence of neurovascular compromise during evaluation, immediate reduction in the ED is necessary. Regardless of the type, all fractures require immobilization using casts or braces [34].

A Maisonneuve fracture is characterized by a combination of a proximal fibular fracture with a medial ankle fracture or ligamentous injury [28]. Management requires immobilization with complete removal of weight-bearing and an urgent orthopedic consultation. A misaligned mortise requires urgent open reduction, while an intact mortise with no displacement can be managed conservatively with casting and close orthopedic follow-up.

Disposition

The disposition of patients presenting with ankle injuries to the ED can vary depending on the severity of the injury. In cases of fractures and dislocations, orthopedic consultation is recommended, and admission is highly likely. The majority of fractures require surgical intervention and therefore necessitate admission. Additionally, patients with significant swelling, pain, or limited mobility may require further evaluation and treatment either in the ED or in an outpatient clinic setting [34].

General considerations for admission of ankle injuries include:

Unstable fractures or dislocations.
Complex injuries or those requiring advanced imaging.
Severe pain that is not well-controlled with medications.
Neurovascular compromise, such as in cases of compartment syndrome.
Open fractures or significant degloving injuries requiring surgical management or extensive wound care.
Deep vein thrombosis (DVT) or pulmonary embolism (PE) as a complication of late presentation of an ankle injury.

If the decision is made for outpatient follow-up, discharge should include proper safety netting, adequate pain medications, and detailed discharge instructions. These instructions should outline expectations for recovery and highlight red flags that would warrant the patient’s return to the ED [34].

Special Tests

Specialized tests are an integral part of physical examinations for patients presenting with hip, knee, or ankle pain, as they allow for a targeted evaluation of specific aspects of joint function and help identify the underlying cause of pain or dysfunction.

For the hip, the Thomas test is used to identify hip flexion contractures, the Trendelenburg test examines hip abductor muscle weakness, and the FABER test (Flexion, Abduction, External Rotation) assesses for potential hip pathology, such as arthritis or labral tears.

For the knee, the Lachman test is performed to analyze the integrity of the anterior cruciate ligament (ACL), the McMurray test evaluates for meniscal injuries, and the patellar apprehension test assesses for patellar instability.

For the ankle, the anterior drawer test evaluates the anterior talofibular ligament, the talar tilt test is used to assess the lateral ligament complex, and the squeeze test helps identify syndesmotic damage.

When these specialized tests are conducted in conjunction with a thorough medical history, detailed physical examination, and imaging studies, they provide critical information to aid in the accurate diagnosis and effective management of joint pain and dysfunction.

Open Wound Injuries

Open wound injuries of the lower limb can range from minor abrasions to severe lacerations. The approach to managing these injuries involves assessing the extent of the wound, controlling bleeding, and providing comprehensive wound care, which includes adequate irrigation, debridement, and the application of wet-to-dry dressings. Antibiotic therapy may be necessary to prevent or treat infections, with the selection of antibiotics guided by the Gustilo-Anderson classification (see above sections) [26]. Pain management and tetanus prophylaxis should also be administered if the patient has not received a tetanus booster within the past 10 years. If there is uncertainty regarding tetanus immunization, the patient has a 72-hour window to confirm with their primary care provider. If follow-up is difficult or uncertain, tetanus prophylaxis should be provided in the ED.

Irrigation is a critical component of wound care, especially in emergency settings. It involves flushing the wound with pressurized fluid to remove debris, bacteria, and other contaminants, thereby decreasing the risk of infection and promoting healing. Various irrigation solutions, such as sterile saline or water, can be used, and the fluid pressure can be adjusted depending on the nature and severity of the wound.

Following wound irrigation, it is essential to apply an appropriate dressing to support healing and prevent infection. Dressings can be made from various materials, including gauze, foam, and hydrocolloid, and should be selected based on the wound’s characteristics. Dressings should be changed frequently, typically every other day, depending on the severity of the wound and the level of drainage. Proper wound care, including effective irrigation and dressing, is essential for achieving the best possible outcomes for patients with open lower limb injuries.

Soft Tissue Hemorrhage

A degloving soft tissue hemorrhage is a serious injury that can occur in the lower limbs, where the skin and underlying soft tissues are stripped away from the underlying structures such as muscle and bone. These injuries often result from crushing injuries or motor vehicle collisions (MVC) and can lead to significant blood loss and tissue damage [36]. A high level of clinical suspicion is required, and a formal ultrasound (US) can be used to confirm the diagnosis.

Surgical intervention may be necessary to drain the collection, repair the damage, and reconstruct the soft tissue, as well as to address any underlying bone or joint injuries. The primary goals of treatment are to prevent complications such as infection, tissue necrosis, or limb loss, and to promote healing and recovery [36].

Patients with this type of injury often require comprehensive rehabilitation, including physical therapy to restore function and psychological support to address the mental and emotional impact of the injury.

Compartment Syndrome

Compartment syndrome in the lower limb occurs when there is an increase in pressure within a closed space, such as a muscle compartment. This increased pressure can reduce blood flow to the affected area, potentially leading to tissue damage, muscle necrosis, or nerve damage if left untreated. Common causes of compartment syndrome include traumatic injuries, such as fractures or crush injuries, and surgical procedures.

Symptoms typically include severe pain, swelling, numbness, and loss of sensation or movement. A hallmark sign of compartment syndrome is pain out of proportion to the injury. Diagnosis is confirmed by measuring compartment pressure. Pressures above 20 mmHg are suggestive of compartment syndrome, although the delta pressure (diastolic pressure minus compartment pressure) of less than 30 mmHg is considered a more reliable predictor than absolute pressure alone [37].

Treatment typically involves immediate surgical intervention, known as fasciotomy, to relieve the pressure and restore blood flow. Fasciotomy involves making an incision in the fascia surrounding the affected compartment to decompress it. Without prompt and proper treatment, compartment syndrome can lead to permanent muscle or nerve damage, limb loss, or even life-threatening complications.

Vascular Injuries

Popliteal vasculature injuries can occur due to knee dislocations, which are often the result of high-energy trauma. The popliteal vasculature includes the popliteal artery and vein, which supply blood to and drain blood from the lower leg and foot. Symptoms of popliteal vasculature injuries include pain, swelling, numbness, or a cold sensation in the lower leg or foot. Treatment typically involves surgical intervention to repair or reconstruct the damaged vessel [38].

Other examples of vascular injuries include damage to the femoral artery and vein, which typically occurs during high-energy trauma, such as motor vehicle collisions (MVC) or falls from a height. The posterior tibial artery and vein are often damaged by fractures of the tibia, while the anterior tibial artery and vein can be injured by lacerations or crush injuries. Additionally, the peroneal artery and vein are prone to injury in cases of fractures of the fibula or penetrating trauma.

Prompt recognition and treatment of these injuries are critical to prevent complications and improve outcomes. An ankle-brachial index (ABI) is usually measured if vascular injuries are suspected. The ABI is calculated by dividing the systolic blood pressure of the upper extremity by the systolic blood pressure of the affected limb. In healthy individuals, the ABI is normally 1 or higher. An ABI of less than 1 in healthy individuals or less than 0.9 in patients with comorbidities should raise suspicion for vascular injuries [39].

Long Bone Fractures

Fractures of the lower extremities are treated in the emergency room with timely assessment, immobilization of the injured leg, and administration of pain medication. Open fractures of the femur, tibia, fibula, ankle, and foot require prompt surgical intervention to prevent infection. In open femur fractures, wound irrigation and debridement are performed to reduce the risk of infection, followed by surgical fracture stabilization. Closed femur and tibia/fibula fractures are managed with immobilization, imaging investigations, and referral to an orthopedic surgeon. Similarly, closed ankle and foot fractures are often treated conservatively with immobilization and pain management [40,41].

Imaging plays a critical role in determining the severity of a fracture and guiding the most effective treatment approach. A multidisciplinary approach to management typically involves pain management, wound care, and fracture stabilization, with the specific strategy determined by the type of fracture.

The Thomas splint is a commonly used traction splint for stabilizing fractures of the lower extremities, particularly femur fractures. Invented by British surgeon Hugh Owen Thomas in the late 19th century, the splint consists of two cushioned metal rods joined by a traction device. The Thomas splint provides effective limb stabilization, pain control, and prevention of further injury in emergency settings, making it an essential tool [42].

One of the primary advantages of the Thomas splint is its ability to provide adequate stability while permitting traction application. Its ease of application further underscores its value in emergency situations. However, while the Thomas splint is a useful tool in emergency medicine, it is not a definitive treatment option, and individualized treatment regimens must be developed for each patient.

Dislocations Of The Hip, Ankle, And Knee

These injuries require early assessment and treatment in the Emergency Department (ED). Initial management includes prompt evaluation, reduction, immobilization, and pain management. Proper positioning for traction and countertraction is critical to achieving a successful reduction.

For hip dislocations, the patient is positioned supine with the affected hip flexed, adducted, and internally rotated for reduction [13]. In ankle dislocations, the treatment involves stabilizing the foot, applying distal traction, and using proximal countertraction. For knee dislocations, the knee is flexed, and longitudinal traction is applied to achieve reduction.

A neurovascular examination is essential in the evaluation of these injuries, especially in cases of complicated dislocations, to identify any neurovascular injury or compromise. Early diagnosis and treatment are critical to preventing the development of long-term consequences.

Patients with repeated dislocations are referred to an orthopedic surgeon for definitive treatment, which may involve surgical intervention.

Revisiting Our Patient

The patient responded poorly to appropriate analgesia and required opioids for adequate pain control. Pain out of proportion to the injury was noted and taken into consideration. On examination, the patient presented with an obvious effusion of the right knee, multiple superficial abrasions on both legs, and bony tenderness of the right leg. The right knee was found to be unstable on examination for ligamentous injuries.

An X-ray confirmed a mid-shaft tibia/fibula fracture. A CT angiography of the right leg was requested as the ankle-brachial index (ABI) was less than 1, which revealed a partial popliteal artery injury. Due to the pain out of proportion to the clinical findings, an orthopedic consultation was requested to measure compartment pressures. Elevated compartment pressures were identified, secondary to the crush injury.

The patient underwent a fasciotomy in the Emergency Department and was subsequently admitted for open reduction and internal fixation (ORIF) of the tibia/fibula fracture. He was discharged a few days later in a relatively stable condition and continued follow-up care with the orthopedic and vascular clinics as an outpatient.

Authors

Nisreen Al Maghraby

Dr. Nisreen Maghraby, a double-board-certified North American graduate, holds two master’s degrees from McGill University: a Master’s in Educational Psychology and the International Master’s for Health Leadership. She currently serves as an Assistant Professor and Consultant in Emergency Medicine, Trauma, and Disaster Management at IAU in Dammam, KSA. Dr. Maghraby is the Founder and Director of the Simulation and Clinical Skills Center and serves as the Competency-by-Design Lead for postgraduate programs. She also chairs the Emergency Medicine Saudi Board Exam Committees at the SCFHS and is a Senior Educator Advisory Board Member for the ATLS program at the American College of Surgeons. Her academic and research interests include trauma, healthcare facilities disaster preparedness, medical education and simulation, and faculty development.

Nasser AlJoaib

Dr. Nasser AlJoaib is a PGY-1 General Surgery resident at King Fahd Hospital in Al-Khobar, Saudi Arabia, and an incoming Vascular Surgery resident at the University of Toronto. His academic interests include trauma, vascular disease, and vascular trauma. Dr. AlJoaib has an extensive research portfolio, with publications in high-impact journals and presentations at international conferences.

Faisal AlGhamdi

Faisal AlGhamdi is an Emergency Medicine resident at King Fahad University Hospital in AlKhobar, Saudi Arabia, with a strong interest in research, trauma, and critical care. He has authored several papers in Emergency Medicine published in reputable journals and has participated in both national and international conferences, receiving recognition for his work. Faisal's interest in Emergency Medicine developed during his medical education, where he gained hands-on experience in the field. After completing rotations at various Emergency Departments, he chose to pursue his residency training at King Fahad University Hospital. He plans to further specialize through a fellowship in critical care. In addition to his clinical work, Faisal is actively involved in research and educational activities. His contributions include participation in toxicology competitions and presenting at conferences. Faisal aims to continue advancing his knowledge and skills in Emergency Medicine and critical care, contributing to the field through both clinical practice and research.

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Reviewed and Edited By

Jonathan Liow

Jonathan conducts healthcare research in the Emergency Department at Tan Tock Seng Hospital. A graduate of the University at Buffalo with a BA in Psychology and Communication, he initially worked on breast cancer research studies at GIS A*STAR. His research interests focus on integrating AI into healthcare and adopting a multifaceted approach to patient care. In his free time, Jonathan enjoys photography, astronomy, and exploring nature as he seeks to understand our place in the universe. He is also passionate about sports, particularly badminton and football.

James Kwan

James Kwan is the Vice Chair of the Finance Committee for IFEM and a Senior Consultant in the Department of Emergency Medicine at Tan Tock Seng Hospital in Singapore. He holds academic appointments at the Lee Kong Chian School of Medicine, Nanyang Technological University, and the Yong Loo Lin School of Medicine, National University of Singapore. Before relocating to Singapore in 2016, James served as the Academic Head of Emergency Medicine and Lead in Assessment at Western Sydney University's School of Medicine in Australia. Passionate about medical education, he has spearheaded curriculum development for undergraduate and postgraduate programs at both national and international levels. His educational interests focus on assessment and entrustable professional activities, while his clinical expertise includes disaster medicine and trauma management.

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Procedural Sedation and Analgesia (2024)

December 11, 2024December 11, 2024 ~ iEM Education Project Team ~ Leave a comment

by Nik Hisamuddin Nik Ab Rahman

Introduction

Sedation for painful procedures involves the administration of drugs by any route or technique that results in a reduction of awareness and pain levels. The main aim of procedural sedation analgesia (PSA) is to reduce discomfort while maintaining the effective performance of the procedure. Effective PSA induces a reduced level of consciousness while enabling the patient to independently sustain oxygenation and manage their airway [1, 2].

The use of sedation involves certain risks, including:

Impairment of the patient’s protective reflexes, which can result in airway obstruction or aspiration.
Suppression of respiratory and cardiovascular functions, which may lead to complications such as hypoxia, hypotension, bradycardia, or even cardiac arrest.

The effects of sedative medications can vary, with the possibility of over-sedation or airway obstruction at any point. Ensuring patient cooperation and maintaining verbal communication are critical objectives for procedural sedation. These guidelines are designed to assist non-anaesthesiologists in safely administering sedation and analgesia to adult patients, whether in an operating room or other settings, to minimize risks and enhance patient safety [3].

When sedation is managed by non-anaesthesiologists, it is essential to limit the sedation level to minimal or moderate. The ideal goal is to achieve a moderate level of consciousness, allowing the patient to independently maintain their airway and cardiovascular stability. Deep sedation should be avoided unless an emergency physician skilled in airway management or an anaesthesiologist is present throughout the procedure (Figure 1).

Goals of PSA include:

Ensuring patient safety before, during, and after PSA.
Minimizing pain and anxiety associated with the procedure.
Reducing the patient’s movement during the procedure.
Maximizing the likelihood of procedural success and facilitating the patient’s return to their pre-sedation state as quickly as possible.

Indications

Alleviate pain and/or anxiety commonly associated with therapeutic or diagnostic procedures.
Enhance the success of procedures by promoting patient relaxation and minimizing movement, thereby improving the precision and efficiency of the intervention.

Therapeutic or diagnostic interventions include, but are not limited to, synchronized cardioversion for the management of arrhythmias, closed reduction of dislocations or fractures, incision and drainage of abscesses, primary closure of lacerations, thoracostomy tube placement for pleural effusions or pneumothorax, extraction of foreign bodies, vascular access establishment for intravenous or intra-arterial administration, and cannulation for hemodynamic monitoring or intervention.

Contraindications

Absolute Contraindications

The urgent need for immediate treatment (e.g., hemodynamic instability) that cannot be delayed for sedation.
Hypersensitivity to the administered drug or its delivery vehicle.
Specific to nitrous oxide: Conditions such as pneumothorax, pneumomediastinum, bowel obstruction, or the presence of an intraocular gas bubble (e.g., following vitreoretinal surgery), where nitrous oxide can expand into air-filled spaces.

Allergy to eggs or soy is no longer considered a contraindication to propofol, as the allergenic components in eggs or soy differ from the moieties used in propofol formulations.

Relative Contraindications

Severe cardiopulmonary disease, which increases the risk of decompensation due to respiratory depression.
Obstructive sleep apnea.
Obesity or anatomical features (e.g., micrognathia, macroglossia, short neck, or congenital anomalies) suggestive of potential difficulties with intubation.
Chronic liver or kidney disease, which may impair drug metabolism and lead to prolonged sedation.
Patients older than 60 years of age, who face an increased risk of decompensation; PSA drug doses should often be reduced.
Acute alcohol or sedative drug intoxication, which heightens the risk of respiratory complications; PSA drug doses should be decreased accordingly.
Chronic alcohol or substance use disorder, which may necessitate an increased PSA drug dosage.
Pre-procedural intake of food or drink; institution-specific protocols regarding fasting prior to PSA should be reviewed.

When any of these relative contraindications are present, consult an anesthesiologist or consider the use of drugs that do not depress respiration (e.g., ketamine) [4, 5].

Although some guidelines recommend postponing elective procedural sedation for several hours after ingestion of clear liquids and for eight hours after ingestion of solids, there is no definitive evidence to support the efficacy or necessity of such measures.

Equipment and Patient Preparation

Choices of Sedative and Analgesic Agents

Always plan to use the minimum number and dosage of sedative and analgesic agents required to achieve the targeted level of sedation. This approach minimizes the risk of adverse drug effects and reduces the likelihood of complications associated with PSA.

“Never use neuromuscular blocking (NMB) agents for PSA.”

The selection of agents may differ based on local protocols or nationwide regulations. It is essential to consult the relevant institutional or regional guidelines. In cases of uncertainty, seek guidance from qualified emergency physicians or anesthetists [6].

Ketamine (IV or IM)
Ketamine can be administered intravenously (IV) or intramuscularly (IM). For IV administration, the loading dose ranges from 0.5 to 2 mg/kg, while for IM administration, the loading dose ranges from 2 to 4 mg/kg. Maintenance dosing is recommended at 0.1 mg/kg IV every 10 minutes. The typical dose for a 70 kg adult is 35 to 70 mg for IV administration and 140 to 280 mg for IM administration.

Fentanyl (IV)
Fentanyl is administered intravenously. The loading dose ranges from 50 to 100 mcg over a period of one minute. Maintenance dosing is 25 mcg every five minutes as required. For a typical 70 kg adult, the dose is approximately 50 mcg.

Midazolam (IV)
Midazolam is administered intravenously. The loading dose ranges from 1 to 2.5 mg IV given over two minutes. Maintenance dosing involves 1 mg every five minutes as required. For a typical 70 kg adult, the usual dose is 1 to 2.5 mg IV or 5 mg IM.

Etomidate (IV)
Etomidate is given intravenously with a loading dose of 0.1 to 0.2 mg/kg. Maintenance dosing is 0.05 mg/kg every five minutes. For a 70 kg adult, the typical dose is 7 to 15 mg IV.

Propofol (IV)
Propofol is administered intravenously with a loading dose ranging from 0.5 mg/kg (in elderly patients) to 1 mg/kg. Maintenance dosing is 0.1 mg/kg every one to two minutes. For a typical 70 kg adult, the loading dose is 35 to 70 mg, with a maintenance dose of 10 mg.

Ketafol (Ketamine + Propofol) (IV)
Ketafol, a combination of ketamine and propofol, is administered intravenously. The loading dose is 0.5 to 1 mg/kg of ketamine, with maintenance dosing of 10 mg of propofol every two minutes. For a 70 kg adult, the ketamine loading dose ranges from 35 to 70 mg IV, and the propofol maintenance dose is 10 mg every two minutes.

Ketamine is considered safe for use in children undergoing procedural sedation and analgesia in the emergency department (ED). Propofol is safe for procedural sedation and analgesia in both children and adults in the ED (LEVEL A).
Etomidate is safe for procedural sedation and analgesia in adults in the ED. Additionally, a combination of propofol and ketamine is safe for procedural sedation and analgesia in both children and adults (LEVEL B) [7].
Ketamine is safe for procedural sedation and analgesia in adults in the ED. Alfentanil is also safe for procedural sedation and analgesia in adults in the ED. Furthermore, etomidate is safe for use in children undergoing procedural sedation and analgesia in the ED (LEVEL C) [8, 9].

Facilities & Equipment

The procedure must be conducted in a facility that is sufficiently spacious and adequately equipped to handle potential cardiopulmonary emergencies. The required resources include:

A room of adequate size to accommodate resuscitation efforts, if necessary.
Adequate lighting for performing procedures safely.
An operating table, trolley, or chair that can be tilted head-down (preferable but not mandatory).
A suction apparatus meeting operating room standards.
A reliable oxygen supply and suitable devices for administering oxygen to a spontaneously breathing patient.
Equipment for lung inflation with oxygen (e.g., a self-inflating bag and mask) and access to a range of advanced airway management tools, including masks, oropharyngeal airways, endotracheal tubes, laryngoscopes, and laryngeal mask airways.
A resuscitation trolley equipped with appropriate drugs and equipment for cardiopulmonary resuscitation.
A pulse oximeter for monitoring oxygen saturation.
A sphygmomanometer or another device for blood pressure monitoring.
Ready access to an electrocardiogram (ECG) machine and a defibrillator.
A reliable means of summoning emergency assistance.

Patient Preparation

Patient preparation is a critical step in ensuring the safety and effectiveness of procedural sedation and analgesia (PSA) in the emergency department. Proper preparation minimizes the risks of complications, enhances patient comfort, and facilitates procedural efficiency [10-12].

A comprehensive pre-procedural assessment is essential to evaluate the patient’s medical history, allergies, and current medications, including over-the-counter drugs, herbal supplements, and recreational substances. Identifying contraindications to sedation, such as a history of adverse reactions to sedatives or anesthetics, is crucial. Patients should be provided with detailed fasting instructions tailored to the type of sedation and their medical condition. Typically, fasting guidelines recommend 6–8 hours for solid food and 2–4 hours for clear liquids to reduce the risk of aspiration. However, many emergency department patients

Informed consent is a cornerstone of patient preparation. Patients or their guardians should receive clear explanations about the procedure, its risks, benefits, and potential alternatives, and written consent should be obtained. It is equally important to address any anxiety or stress by offering reassurance and allowing patients to express concerns. Effective communication and education about what to expect during and after PSA help alleviate anxiety and improve the overall experience. Additionally, patients should be instructed to remove jewelry, dentures, or other loose objects before the procedure and wear comfortable, loose-fitting clothing.

On the day of the procedure, patients must have a responsible adult accompany them to the emergency department and arrange transportation home post-procedure. Intravenous (IV) access should be secured for administering sedatives, analgesics, and potential fluid resuscitation. Continuous monitoring of baseline vital signs, including oxygen saturation, heart rate, and blood pressure, must be ensured throughout the procedure to detect and address any adverse events promptly.

Post-procedure care involves monitoring the patient until they have fully recovered from sedation. Before discharge, patients should be provided with detailed written instructions on post-procedural care, including medication guidance, activity restrictions, and follow-up appointments. A contact number for the emergency department or healthcare provider should also be provided in case of concerns or complications after discharge.

Adhering to these recommendations, including thorough preparation, education, and monitoring protocols, ensures patient safety and comfort, reduces the likelihood of complications, and optimizes the success of PSA in the emergency department

Procedure Steps

General Clinical Management and Documentation

Written documentation of procedural sedation must be completed by the responsible physician or surgeon, covering all phases of the procedure (pre, intra-, and post-procedure).
Documentation should include:
- Names of all staff involved in the procedure.
- Findings from history, physical examination, and investigations.
- Drug dosages and their administration times.
- Vital signs (pulse rate, oxygen saturation, and blood pressure) recorded pre-, during, and post-procedure.

Assessment of Patient Status
The physician in charge should document patient assessment using the American Society of Anesthesiologists (ASA) classification system [13]:

ASA Class 1: Normal healthy patient with no significant systemic disturbances.
ASA Class 2: Patient with mild systemic disease without functional limitations.
ASA Class 3: Patient with severe systemic disease causing some functional limitation.
ASA Class 4: Patient with severe systemic disease posing a constant threat to life.
ASA Class 5: Moribund patient not expected to survive without surgery.
ASA Class 6: Brain-dead patient whose organs are being harvested for donation.

Note: PSA performed by non-anesthesiologists is recommended only for ASA Class 1 and 2 patients.

Indications for Involvement of an Anesthesiologist

The presence of an anesthesiologist may be required for patients at increased risk of airway, respiratory, or cardiovascular compromise, or those prone to serious adverse events during sedation [14]. These include patients with:

Advanced age, particularly with significant co-morbidities.
Significant cardiovascular, pulmonary, renal, or hepatic disease.
Morbid obesity.
Obstructive sleep apnea.
Known or suspected difficult airway/intubation cases.
Acute gastrointestinal bleeding associated with cardiovascular compromise or shock.
Risk of aspiration of gastric contents.
History of adverse events from sedation, analgesia, or anesthesia.
History of substance abuse.

The decision to involve an anesthesiologist should be made by the clinician after carefully weighing the risks to the patient [14].

For non-emergency cases, PSA should adhere to general fasting guidelines to minimize the risk of aspiration during the procedure. The recommended fasting durations vary by age and the type of substance ingested, summarized as the “2-4-6 rule” [15]. For children, the guidelines are as follows: 2 hours for clear fluids, 4 hours for breast milk, and 6 hours for formula milk or solid foods. For adults, the fasting guidelines recommend 2 hours for clear fluids and 6 hours for milk or solids. Clear fluids include water, glucose drinks, cordial beverages, and clear fruit juices. These fasting protocols ensure adequate preparation and safety for PSA in non-emergency settings.

Steps in the Administration of Procedural Sedation [16]

Pre-Procedure

Proper preparation is essential to ensure the safety and success of PSA. The following steps should be undertaken:

Patient Selection: Assess the appropriateness of PSA for the patient based on clinical needs and risk factors.
Patient Assessment: Conduct a thorough review of relevant medical history, physical examination, and investigations as outlined in institutional protocols.
Pre-Procedural Instructions: Provide patients with written instructions on preparation and post-procedural care, including contact details for emergencies. Instructions should be available in multiple languages to enhance accessibility.
Consent: Obtain verbal or written consent according to institutional requirements. In cases of altered mental status or unconscious patients, PSA may proceed without written consent if close relatives provide authorization.
Personnel: Ensure a minimum of two qualified and experienced personnel are present—one to perform the procedure and the other to administer drugs and monitor vital signs.

During the Procedure

To maintain patient safety and achieve the desired sedation level, adhere to the following steps during PSA administration:

IV Access: Establish intravenous access for drug administration and potential resuscitation needs.
Monitoring: Continuously monitor the patient’s vital signs, including pulse oximetry, non-invasive blood pressure (NIBP), and electrocardiography (ECG). Document all findings in accordance with protocol.
Oxygen Administration: Deliver supplemental oxygen using appropriate devices such as nasal prongs or face masks, as indicated.
Drug Administration: Administer sedation drugs exclusively by trained registered medical practitioners or registered dental practitioners.
Continuous Observation: Assign a dedicated assistant to monitor the patient throughout the procedure, ensuring early detection and management of potential complications.

Post-Procedure

Post-procedural care focuses on monitoring recovery, ensuring patient safety, and providing clear discharge instructions:

Documentation: Record all details of the procedure, including the drugs used and vital signs monitored.
Recovery Monitoring: Continue observation of the patient’s vital signs using pulse oximetry and NIBP until full recovery is achieved.
Discharge: Patients should be discharged only when accompanied by a responsible adult. Provide written instructions on post-procedural care.
Reinforce Instructions: Before discharge, verbally review post-procedural care instructions to ensure patient understanding and compliance.

Recommendations for PSA Monitoring by Target Sedation Level

Monitoring requirements vary depending on the desired level of sedation:

Minimal Sedation:

Level of Consciousness: Observe frequently.
Heart Rate: Measure every 15 minutes.
Respiratory Rate: Measure every 15 minutes.
Blood Pressure: Measure every 15 minutes and after sedative boluses.
Oxygen Saturation: Monitor continuously.
Capnography End-Tidal CO2: Not required.

Moderate or Dissociative Sedation:

Level of Consciousness: Observe constantly.
Heart Rate: Monitor continuously.
Respiratory Rate: Continuous direct observation.
Blood Pressure: Record every 5 minutes and after sedative boluses.
Oxygen Saturation: Monitor continuously.
Capnography End-Tidal CO2: Consider continuous monitoring.

Complications

Performing PSA requires close monitoring and is associated with potential adverse events. Numerous analgesic, sedative, and anesthetic agents can be used in combination for PSA in the ED. However, adverse event reporting for PSA has been heterogeneous.

Known complications of PSA include agitation, apnea, aspiration, bradycardia, bradypnea, hypotension, hypoxia, intubation, laryngospasm, and nausea/vomiting [17-19]. Among these, the most frequently observed adverse events are hypoxia, occurring at a rate of 40.2 per 1,000 sedations, followed by vomiting, hypotension, and apnea.

Severe adverse events requiring emergent medical intervention are less common but include aspiration (%0.12), laryngospasm (%0.42), and intubation (%0.16).

The routine use of capnography monitoring during PSA is recommended as it allows earlier detection of hypoventilation and apnea compared to pulse oximetry and/or clinical assessment alone [20]. Studies have shown that the combination of Ketamine and Propofol (Ketofol) results in a lower incidence of adverse events, including agitation, apnea, hypoxia, bradycardia, hypotension, and vomiting, compared to each medication used individually [21].

Although the incidence of serious adverse events during PSA in the ED is rare, it is essential to practice shared decision-making and obtain informed consent, as PSA is not a completely benign procedure [22].

Hints and Pitfalls

Pitfalls of PSA

The common pitfalls of procedural sedation and analgesia are often attributed to inadequate practitioner skills, improper patient selection, or insufficient knowledge of the pharmacological agents being used. When these factors are combined, they may result in either under-sedation or over-sedation, compromising the airway, cardiovascular, or respiratory system, and increasing the risk of adverse outcomes [23-26].

Failure to administer safe and effective PSA can lead to unnecessary complications, heightened anxiety, and delays in the patient’s return to normal function following emergency department procedures. Barriers to achieving optimal PSA outcomes, especially when performed by non-anaesthesiologists, often include knowledge gaps among providers and inadequate efforts toward quality improvement. It is critical that PSA be performed by competent and experienced practitioners who follow established guidelines and standard operating procedures, which should be readily available in all facilities where PSA is conducted (e.g., emergency physicians, internal physicians, surgeons, dental practitioners).

For painful procedures, alternative pain management strategies, such as nerve blocks, should be considered when they are safer and equally effective. Additionally, it is essential to complete a checklist for pre-, intra-, and post-PSA to ensure patient safety and optimize outcomes.

Key Considerations for PSA

Most sedative agents lack significant analgesic effects; therefore, analgesia should be administered beforehand and given sufficient time to achieve its maximal effect prior to administering the sedative agent.
PSA agents and doses should always be tailored to the individual patient, taking into account factors such as age, comorbidities, and the patient’s clinical status. Elderly, debilitated, and acutely ill patients require lower initial doses of sedative agents than healthy young adults.
Sedative agents should be titrated gradually to avoid complications, and sufficient time should be allowed for the sedative to take full effect before starting the procedure.
Regular audits and quality assurance programs should be conducted to monitor and improve PSA practices over time.

Indicators of Sedation Failure

Sedation failure may occur if:

The patient experiences undue discomfort during the procedure.
Adverse events such as hypotension or hypoxia arise.
Prolonged observation is required following the procedure.

Common Pitfalls in PSA Administration [23]

Inadequate provision of analgesia prior to administering sedatives.
Insufficient time allowed for analgesics or sedatives to achieve their maximal effect.
Failure to adjust doses for elderly or chronically ill patients, leading to over-sedation or complications.
Rapid titration of sedative agents, increasing the risk of adverse events.
Premature discontinuation of monitoring or transferring a sedated patient from a controlled environment (e.g., from the procedure room to the x-ray department).
Discharge of patients without adequate supervision or clear written instructions; sedative agents may cause amnesia, making verbal instructions ineffective.
Failure to address the specific needs of vulnerable populations, such as pediatric, geriatric, or pregnant patients, as well as adults with significant comorbidities.

Special Patient Groups

Pediatrics [27,28]

Procedural sedation for pediatric patients requires thorough preparation and specific considerations due to their unique anatomical and physiological characteristics. Consent must be obtained from parents or guardians, except in emergent situations where two senior practitioners may assess and provide consent. Special attention should be given to airway assessment to prevent respiratory compromise. Pharmacological agents with known respiratory adverse effects should be avoided or dosages adjusted as necessary.

Assessment Prior to Procedural Sedation in Children:

Evaluate fasting status.
Perform a focused medical examination, emphasizing airway assessment.
Utilize the American Society of Anesthesiologists (ASA) classification (only ASA I & II patients are considered suitable).
Review previous sedation or general anesthesia experiences and outcomes.

Key Considerations:

A history of severe sleep apnea or airway abnormalities necessitates additional precautions when planning sedation.
Paradoxical reactions, such as increased agitation with benzodiazepines or barbiturates, are more common in younger children.
Adverse effects like agitation upon emergence, diplopia, nausea, and vomiting have been reported with ketamine use.
Selection of sedation agents and administration routes should align with the patient’s individual needs, the procedure type, and the anticipated level of pain.
Early consultation with a pediatric anesthesiologist is recommended for patients with chronic airway diseases or a history of drug-related adverse events.
Discharge should only occur with a responsible adult and comprehensive post-discharge instructions for home observation

Geriatrics [29]

Procedural sedation is generally safe in older adults; however, under-treatment of pain or inadequate sedation should be avoided. Initial assessment must include a thorough review of comorbidities and medication history to identify potential interactions with sedatives or analgesics.

Special Precautions for Geriatric Patients:

Patients with chronic respiratory or cardiovascular diseases require additional monitoring.
Older adults typically require lower doses of sedative agents due to increased sensitivity, slower metabolism, reduced physiological reserves, and smaller volume of distribution.
These patients are at higher risk for oxygen desaturation, but most respond well to supplemental oxygen.

Pregnant Patients [30,31]

Procedural sedation may be appropriate for pregnant patients experiencing significant pain, distress, or requiring surgical intervention, provided it is conducted under the supervision of a physician skilled in obstetric anesthesia. Pregnancy induces hemodynamic changes such as decreased blood pressure (due to vasodilation and aortocaval compression), increased cardiac output, and reduced maternal hematocrit.

Key Considerations for Sedation in Pregnancy:

Exposure to PSA medications is typically brief, with low doses, making significant adverse effects on pregnancy outcomes unlikely.
Over-sedation can lead to maternal hypotension and hypoxia, which may result in fetal hypoxia.
Medications used in PSA can influence uterine activity, placental perfusion, and fetal oxygenation. They may also directly affect fetal heart rate by crossing the placenta or indirectly via maternal hemodynamic changes.

Pharmacological Agents in Pregnancy:

Midazolam: Frequently used due to its rapid onset and short duration. Although it crosses the placenta via passive diffusion, no conclusive evidence suggests it adversely affects fetal development at clinically recommended doses. Animal studies indicate potential effects when combined with other anesthetics.
Propofol: Clinically recommended doses are not associated with fetal defects and are widely used for obstetric and non-obstetric procedures. However, excessive doses may result in fetal depression due to its lipophilic nature and placental transfer.
Ketamine: Generally not recommended due to limited human data. It is known to cross the placenta, and animal studies suggest potential neurotoxicity with prenatal and early postnatal exposure.

Author

Nik Hisamuddin Nik Ab Rahman

Professor Dr. Nik Hisamuddin Nik Ab Rahman graduated with an MBChB from the University of Glasgow in 1994. He completed the Emergency Medicine trainee program (Master of Medicine) at Universiti Sains Malaysia (USM) in 2002. He further honed his expertise as a Clinical Fellow in Emergency Medicine at Edinburgh Royal Infirmary, Scotland, and in Hyperbaric & Diving Medicine at Key Largo, Florida, USA. In 2016, he earned his PhD in Health Informatics & GIS in Health, specializing in road traffic injuries. Professor Nik Hisamuddin spearheaded the development of the Department of Emergency Medicine at Hospital USM, introducing Malaysia’s first Trauma Intensive Care Unit (TICU). He currently serves as the Director of Hospital USM and a Professor in Emergency Medicine and Hyperbaric/Diving Medicine at the School of Medical Sciences, USM. Additionally, he is a committee member of the USM Management Team, the Malaysia National Specialist Registry (Emergency Medicine; 2009–present), and the Specialty Conjoint Committee in the Master of Medicine in Emergency Medicine (2005–2017). He has been awarded numerous research grants from national and international sources. His research and clinical interests include trauma and injury prevention, community life support education, hyperbaric medicine, and acute pain management. He is currently supervising seven PhD and eight Master's candidates, with a focus on Design and Developmental Research (DDR) approaches. With approximately 70 peer-reviewed journal articles to his name, Professor Nik Hisamuddin is a leading figure in his field. His hobbies include traveling, golfing, and shopping.

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References

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Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

Urinary Catheterization (2024)

December 11, 2024December 11, 2024 ~ iEM Education Project Team ~ Leave a comment

by Tejasvi Chikatla

Introduction

Urinary catheterization is a critical procedure commonly performed in emergency departments (EDs) for both therapeutic and diagnostic purposes. It is particularly essential for critically ill individuals. However, common indications include acute urinary retention, where immediate bladder drainage is necessary to relieve obstruction or neurological issues, and trauma, where urine output monitoring helps assess potential kidney or bladder damage in patients with significant abdominal or pelvic injuries. The procedure involves the retrograde insertion of a flexible catheter through the urethra into the bladder, typically performed by a doctor or nurse in hospital or community settings. Various catheter types are available, including indwelling catheters, which remain in the bladder for a period of time and are commonly inserted through the urethra or, when necessary, surgically through the abdominal wall (suprapubic catheters). Intermittent catheters are used for temporary bladder drainage and are immediately removed, while external catheters, designed for male patients, adhere to the penis to collect urine. Each catheter type is selected based on the clinical indication, patient condition, and procedural requirements, ensuring appropriate management in the ED setting. Depending on the indication and type of catheter used, it may be removed after a few minutes, hours, or days, or remain in place for a longer duration. [1-3]

Anatomy and Physiology

The urinary system is integral to the processes of urine production, storage, and excretion, serving as a critical pathway for the elimination of metabolic waste. It comprises the kidneys, ureters, urinary bladder, and urethra, each contributing to the system’s overall function [2, 4-5]:

Kidneys: Paired retroperitoneal organs, producing approximately 1500 mL of urine daily in the average adult.
Ureters: Muscular conduits that transport urine from the renal pelvis to the bladder via peristalsis.
Urinary Bladder: A detrusor muscle-lined reservoir capable of accommodating 350–500 mL of urine under normal conditions before initiating micturition reflexes.
Urethra: A muscular tube facilitating the excretion of urine from the bladder to the external environment. Urethral length differs significantly between sexes, with males having a 15–20 cm urethra and females a considerably shorter one, influencing catheterization approaches and techniques.

Male Urethra:
- Approximately 15–20 cm long, divided anatomically into the prostatic, membranous, and spongy (penile) urethra.
- A sharp angulation occurs at the membranous urethra as it passes through the urogenital diaphragm. During catheterization, the penis must be extended and elevated to minimize urethral resistance.
- The urethral meatus is located at the distal tip of the glans penis.
Female Urethra:
- A short urethra (~4 cm in length), originating at the bladder neck and terminating at the external urethral orifice, located approximately 2.5 cm posterior to the clitoral glans.
- In postmenopausal females, the urethral meatus may migrate superiorly and posteriorly into the vaginal introitus due to tissue atrophy, where it is often surrounded by periurethral tissue and can be identified via palpation.

Urinary continence is maintained by three primary muscle groups:

Internal urethral sphincter: An involuntary smooth muscle located at the bladder neck.
External urethral sphincter: A voluntary striated muscle encompassing the membranous urethra.
Pelvic floor musculature: Comprised of the levator ani and associated structures, providing additional support and aiding continence mechanisms.

Anatomical Considerations for Catheterization:

Male Catheterization:
- The curved anatomy of the male urethra, particularly at the membranous segment, requires the penis to be held taut and perpendicular to the body during catheter insertion to facilitate atraumatic passage through the urethra.
Female Catheterization:
- The shorter urethra and variability in the location of the external urethral orifice in certain populations (e.g., obese or elderly females) may necessitate the use of a Trendelenburg position or assistance for proper visualization and insertion of the catheter.

Indications

Indications of urinary catheterization can be classified in therapeutic and diagnostic indications [2-7].

Therapeutic Indications

Acute Urinary Retention:
A medical emergency characterized by the sudden inability to void, often associated with bladder volumes exceeding 300–500 mL. Immediate bladder decompression via catheterization is necessary to relieve discomfort and prevent complications.

Causes:
- Obstructive: Benign prostatic hyperplasia (BPH), urethral strictures, or pelvic masses.
- Infectious/Inflammatory: Prostatitis, cystitis, and urethritis.
- Neurological: Stroke, multiple sclerosis, spinal cord injuries.
- Pharmacologic: Anticholinergic or alpha-adrenergic drugs.

Chronic Urinary Retention:
Patients with chronic retention, often due to neurogenic bladder dysfunction, may require catheterization when non-invasive methods are inadequate.

Perioperative Management:

Indicated during and after abdominopelvic, urological, and gynecological surgeries to prevent urinary retention, monitor intraoperative urine output, and manage postoperative pain.
Early catheter removal is encouraged to promote ambulation and reduce the risk of infection.

Management of Urinary Incontinence:
When behavioral therapies or medications fail, catheterization can provide relief, particularly in patients at risk of skin breakdown from severe incontinence (e.g., stage III/IV pressure ulcers).

Bladder Irrigation:
Essential for flushing the bladder to remove clots, debris, or infections, particularly in cases of hematuria or post-surgical complications.

Drug Delivery:
In specific cases, chemotherapy agents may be instilled directly into the bladder via catheterization. This is not a routine in the emergency department setting.

Palliative and Comfort Care:
Used to enhance comfort in end-of-life care or for patients experiencing significant urinary-related discomfort. For these patients, urinary catheters are needed to be changed in the ED because of catheter’s malfunction.

Social and Hygiene Needs:
Indicated in patients unable to maintain urinary hygiene due to severe disability or immobility.

Diagnostic Indications

Monitoring of Urine Output:

Continuous urinary output measurement is critical for hemodynamic monitoring in critically ill patients and during major surgical procedures.
Provides valuable data for assessing renal perfusion and fluid balance.

Sterile Urine Collection:

Facilitates the collection of uncontaminated urine samples for culture and sensitivity testing or urinalysis, especially in cases where non-invasive methods are unreliable.

Radiographic Studies:

Catheters are used during diagnostic imaging such as cystograms to assess bladder anatomy, detect structural abnormalities such as bladder rupture, or evaluate vesicoureteral reflux.

Urodynamic Studies:

Employed to measure bladder capacity, compliance, and flow rates in patients with suspected lower urinary tract dysfunction. This is not a common indication in the ED setting.

Measurement of Post-Void Residual Volume:

Catheterization allows accurate determination of residual urine, aiding in the diagnosis of incomplete bladder emptying or outlet obstruction. This is not a common indication in the ED setting.

Contraindications

Urethral catheterization is a common and essential procedure; however, careful consideration of contraindications is imperative to ensure patient safety and avoid complications. These contraindications are categorized into absolute and relative types based on the severity of risks involved [2,4,5,7].

Absolute Contraindications

Absolute contraindications are situations where urethral catheterization is strictly avoided due to the high risk of significant harm. The most critical contraindication is suspected urethral injury, which is commonly associated with blunt trauma. Key clinical indicators include:

Blood at the urethral meatus: A hallmark sign of potential urethral trauma.
Inability to void despite a full bladder.
Perineal, scrotal, or penile ecchymosis and/or edema in males or perineal or labial ecchymosis in females.

In such cases, imaging studies such as retrograde urethrography are mandatory to confirm or exclude urethral disruption before attempting catheterization. Proceeding without confirmation could exacerbate the injury or create a false passage.

Relative Contraindications

Relative contraindications are conditions where catheterization may proceed, but only with caution after weighing the risks and benefits. These include:

History of Urethral Strictures: Patients with strictures are at higher risk of urethral trauma or false passage during catheter placement. A urology consult is often recommended in such cases.
Current Urinary Tract Infection (UTI): Introducing a catheter may worsen the infection or lead to ascending complications like pyelonephritis. Careful assessment and, if necessary, antibiotic prophylaxis are recommended.
Prior Urethral Reconstruction: Surgical alterations to the urethra can make catheterization technically challenging, necessitating expertise or specialized equipment.
Recent Urological Surgery: Catheterization soon after urologic procedures may disrupt healing tissues, cause bleeding, or predispose to infection.
History of Difficult Catheter Placement: Patients with prior traumatic or challenging catheterization experiences may require advanced techniques or urological intervention to avoid complications.
Gross Hematuria: Significant bleeding in the urinary tract increases the risk of obstructing the catheter with blood clots or worsening hemorrhage during insertion.
Evidence of Urethral Infection: Infection within the urethra increases the risk of sepsis or further complications if a catheter is inserted.
Urethral Pain or Discomfort: Pain suggests underlying inflammation, trauma, or infection, which increases procedural risks.
Low Bladder Volume or Poor Compliance: Inadequate bladder capacity or compliance may complicate catheter insertion and increase the risk of bladder trauma.
Patient Refusal: Respect for patient autonomy is critical. Catheterization should only proceed with informed consent unless in life-threatening emergencies.

Equipment and Patient Preparation

Equipment

The equipment for urinary catheterization includes sterile supplies to maintain asepsis and ensure patient comfort [2,4,7]:

Sterile gloves and drapes: Maintain a sterile field and minimize contamination risks.
Antiseptic solution (e.g., povidone-iodine): Cleanses the urethral meatus to reduce bacterial load.
Water-soluble lubricant: Eases catheter insertion and minimizes trauma to the urethra.
Local anesthetic gel: Often used in male patients to reduce discomfort during insertion.
Urethral catheters: A 16 French Foley catheter is standard for most adults. Smaller sizes (e.g., 14 French) may be used for patients with urethral strictures.
- Coudé catheter: Features a curved tip, beneficial for patients with prostatic hypertrophy or urethral stricture.
Syringe with sterile water: Inflates the catheter balloon to secure its placement.
Sterile collection device with tubing: Enables urine drainage and minimizes infection risks when used in a closed-catheter system.
Waterproof pad: Protects bedding during the procedure.

Types of Catheters

The choice of catheter depends on clinical indications, duration of use, and patient-specific considerations. Common types include:

Indwelling Catheters (Foley Catheters):

Designed for long-term use with a balloon at the tip to secure placement.
Inserted via the urethra or through a suprapubic route for cases involving urethral injury or chronic obstruction.
Connected to a drainage bag for continuous urine collection.

Intermittent Catheters:

Used for short-term drainage. Inserted and removed after bladder emptying.
Suitable for patients who self-catheterize or require periodic drainage.

External (Condom) Catheters:

Non-invasive option for male patients with incontinence.
Requires daily replacement to prevent infection.

Catheter composition and coating (e.g., silicone, Teflon, antimicrobial coatings) are selected based on patient needs, such as reducing infection risks in short-term catheterizations (<14 days).

Patient Preparation

Proper preparation is critical for the safe and effective placement of urinary catheters, ensuring both patient comfort and a reduction in procedural complications. This involves thorough communication, appropriate positioning, meticulous hygiene, and a sterile environment. Below is a comprehensive guide to preparing patients for urinary catheterization [2,4,5,7].

Communication and Consent

Explain the Procedure: Provide the patient with clear, concise instructions regarding the procedure, including its purpose, steps, and what sensations they might experience. Address their concerns to alleviate anxiety and foster cooperation.
Informed Consent: Verbal or written informed consent should be obtained after ensuring the patient understands the risks and benefits.
Answer Questions: Allocate sufficient time to respond to any queries, building trust and enhancing the patient’s confidence in the procedure.

Ensuring Patient Privacy and Comfort

Privacy: Maintain the patient’s dignity by using curtains, closing doors, and limiting exposure.
Positioning:
- Men: Place the patient in the supine position with hips abducted.
- Women: Position the patient in the lithotomy or frog-leg position with hips and knees flexed and rotated outward.
- Use pillows for head support and a waterproof disposable pad under the buttocks to protect the bedding.
Lighting: Ensure adequate lighting to facilitate visualization of the urethral meatus.

Preparation of the Procedure Area

Sterility and Hygiene:
- Perform thorough hand hygiene with soap and water or an alcohol-based sanitizer before donning sterile gloves.
- Use sterile drapes to create a clean field around the procedure area.
Cleaning the Urethral Meatus:
- Men: Using the non-dominant hand, retract the foreskin (if uncircumcised) and stabilize the penis. With the dominant hand, clean the glans penis and urethral meatus using an antiseptic solution (e.g., povidone-iodine) in a circular motion from the meatus outward.
- Women: With the non-dominant hand, separate the labia to expose the urethral meatus. Clean the meatus using the dominant hand, applying antiseptic solution in a circular motion outward from the meatus. The non-dominant hand is considered contaminated and must not touch sterile equipment.
Special Considerations:
- In morbidly obese female patients, consider the Trendelenburg position or assistance from a second provider to improve visualization of the urethral meatus.

Procedure Steps

Male Patient

Urinary catheterization in male patients requires meticulous preparation, sterile technique, and proper execution to ensure patient safety and comfort. Below is a detailed and organized guide [4,7];

Preparation Before the Procedure

Gather Equipment:

See equipment section

Patient Communication and Consent:

Explain the procedure, its purpose, and what the patient can expect.
Address any concerns and obtain informed consent to alleviate anxiety and establish trust.

Patient Positioning:

Place the patient in the supine position with hips comfortably abducted.
Maintain privacy by using curtains or closing the door.
Use drapes or towels to cover non-essential areas, exposing only the genital region.

Hand Hygiene and Sterile Field Setup:

Perform thorough handwashing or use an alcohol-based hand sanitizer.
Don sterile gloves and set up a sterile field with all necessary equipment.

Step-by-Step Catheterization Procedure

Prepare the Urethral Meatus:

Retract the foreskin if the patient is uncircumcised (using the non-dominant hand, which becomes non-sterile).
Clean the glans penis and urethral meatus using antiseptic solution in a circular motion from the meatus outward.
Discard used swabs or gauze appropriately.

Anesthetize the Urethra:

Insert 5–10 mL of lidocaine gel into the urethral meatus using a syringe.
Compress the urethra gently to retain the anesthetic for at least one minute. This step reduces discomfort, dilates the urethra, and facilitates catheter insertion.

Insert the Catheter:

Generously lubricate the catheter tip.
Hold the penis upright at a 90° angle to the abdomen and gently advance the catheter through the urethral meatus.
If using a Coudé catheter, ensure the curved tip faces upward to follow the natural urethral curvature.
Encourage the patient to relax and take slow, deep breaths to ease catheter passage through the prostatic urethra.
Advance the catheter until urine flows, ensuring the catheter is fully inserted to the level of the side port.

Inflate the Balloon:

Once urine flow is established, inflate the catheter balloon with 5–10 mL of sterile water using the syringe.
Gently pull the catheter back until resistance is felt, indicating that the balloon is snug against the bladder neck.
If the patient experiences pain or resistance during balloon inflation, deflate the balloon, withdraw the catheter slightly, and reposition it before reattempting inflation.

Secure the Catheter:

Return the foreskin to its normal position to prevent paraphimosis in uncircumcised patients.
Secure the catheter to the patient’s thigh using adhesive tape or a catheter securement device.
Place the drainage bag below the level of the bladder to allow gravity-assisted drainage.

Monitor and Finalize:

Verify proper urine flow into the drainage bag.
Remove sterile drapes and clean the surrounding area.
Ensure the drainage bag is positioned to prevent backflow and contamination.

Post-Procedure Care

Documentation:

Record the catheter size, balloon volume, urine characteristics, and any patient responses during the procedure.
Document any complications or additional interventions.

Observation:

Regularly check for kinks or obstructions in the catheter or tubing.
Monitor the patient for signs of discomfort, infection, or other complications.

Patient Education:

Provide instructions on catheter care, including hygiene and recognizing potential complications such as infection or blockages.
Ensure follow-up care and reassessment as necessary.

Key Precautions and Potential Complications

Sterility: Maintain a strict sterile technique to minimize the risk of catheter-associated urinary tract infections (CAUTIs).
Gentle Insertion: Avoid excessive force to prevent urethral trauma or creation of a false passage.
Balloon Positioning: Ensure the balloon is inflated within the bladder and not in the urethra to avoid severe injury or bleeding.
Paraphimosis Prevention: Always reposition the foreskin after the procedure in uncircumcised patients.

Female Patient

Urinary catheterization in female patients is a routine yet sensitive medical procedure requiring a meticulous approach to ensure safety, comfort, and sterility. Below is a detailed guide incorporating key steps and considerations for performing the procedure effectively [5,7].

Preparation Before the Procedure

Gather Equipment:

See equipment section

Communicate with the Patient:

Explain the procedure, including its purpose, steps, and potential sensations, to alleviate anxiety.
Address any concerns and obtain informed consent.

Prepare the Catheter:

Attach the catheter to the collection system.
Test the retention balloon for leaks by inflating it with sterile water.
Generously lubricate the catheter tip.

Position the Patient:

Ensure privacy by using curtains or closing the door.
Place the patient in a lithotomy position (hips and knees flexed, heels on the bed) or a frog-leg position (hips abducted and knees bent outward).
Place a disposable waterproof pad beneath the patient’s buttocks.

Step-by-Step Procedure

Hand Hygiene and Sterile Setup:

Perform thorough handwashing or use an alcohol-based hand sanitizer.
Don sterile gloves and create a sterile field using the drapes.

Expose the Urethral Meatus:

Use the non-dominant hand to gently separate the labia, exposing the urethral meatus. This hand is now considered non-sterile and must not touch sterile equipment.
Maintain exposure throughout the procedure.

Cleanse the Area:

Clean the area around the urethral meatus with povidone-iodine or another antiseptic solution.
Apply the solution using a circular motion, starting at the meatus and working outward.
Discard each swab after use to prevent contamination.

Insert the Catheter:

Hold the lubricated catheter with your dominant (sterile) hand.
Gently advance the catheter through the urethra. Encourage the patient to relax and breathe deeply to reduce discomfort.
If the catheter enters the vagina, discard it and use a new, sterile catheter.

Verify Placement:

Confirm proper placement by observing urine flow into the tubing.
Advance the catheter an additional 1–2 cm after urine is visible to ensure it is fully inside the bladder.

Inflate the Balloon:

Inflate the catheter balloon with 10 mL of sterile water.
If resistance or pain occurs during inflation, deflate the balloon, advance the catheter further into the bladder, and reattempt inflation.

Secure the Catheter:

Gently withdraw the catheter until the inflated balloon rests snugly against the bladder neck.
Secure the catheter to the patient’s thigh using adhesive tape or a catheter stabilization device.

Position the Drainage Bag:

Hang the drainage bag below the level of the bladder to allow urine to flow via gravity.
Ensure the bag is not placed on the floor to maintain sterility.

Post-Procedure Care

Documentation:

Record the catheter size, balloon volume, urine characteristics, and any patient responses or complications.
Include details about the procedure’s success and any deviations from standard protocol.

Observation:

Regularly check for kinks or blockages in the tubing.
Monitor the patient for signs of discomfort or infection.

Patient Education:

Provide instructions on catheter care and signs of potential complications, such as fever, pain, or cloudy urine.
Emphasize the importance of hygiene to prevent infections.

Important Considerations and Precautions

Sterility: Adherence to strict sterile technique is critical to minimize the risk of catheter-associated urinary tract infections (CAUTIs).

Proper Insertion: Never use excessive force during catheter insertion, as this can cause urethral trauma.

Balloon Positioning: Ensure the balloon is fully within the bladder before inflation to prevent urethral injury.

Special Situations:

In obese or anatomically challenging cases, assistance or placing the patient in a Trendelenburg position may improve visualization of the urethral meatus.

Complications

Urinary catheterization carries the risk of various complications that can affect patient safety, comfort, and overall health outcomes. These complications are influenced by the type of catheter, duration of use, and underlying patient conditions [1-2, 4-6, 7].

Common Complications

Urinary Tract Infection (UTI):

Prevalence: The most common complication, particularly with long-term catheterization.
Pathophysiology: The normal urine flow prevents microbial ascent into the bladder. Catheterization disrupts this mechanism, increasing the risk of colonization and infection.
Etiology: Common pathogens include Escherichia coli and Klebsiella pneumoniae.
Impact: UTIs account for approximately 70% of healthcare-associated infections, with catheter-associated UTIs (CAUTIs) being the primary contributor.
Clinical Considerations:
- Risk of bacterial colonization rises daily (3–10% per day, reaching 100% in long-term catheters).
- Diagnosed via bacteriuria and fever in patients with indwelling catheters for ≥2 days.
- Recurrent UTIs increase antibiotic resistance.

Urethral Trauma and Injury:

May result from improper insertion techniques or use of excessive force.
Symptoms include urethral bleeding, microscopic hematuria, or scarring that can lead to strictures.

Bladder Spasms:

Painful contractions caused by the bladder attempting to expel the catheter.
Managed with anticholinergic agents such as oxybutynin.

Catheter Obstruction:

Caused by sediment accumulation or debris, often in patients with subclinical bacteriuria.
Management includes flushing the catheter or replacing it if flushing is ineffective.

Urine Leakage:

May occur due to bladder spasms, catheter obstruction, a catheter that is too small, or constipation.

Paraphimosis (in males):

Results from failure to reduce the foreskin after catheter insertion.
Prevented by repositioning the foreskin immediately after the procedure.

Bladder Stones:

Prolonged catheter use can lead to the formation of calculi requiring further medical intervention.

Hematuria:

May be associated with trauma, infections, or balloon inflation in the urethra.

Bladder and Kidney Damage:

Chronic bladder infections and stasis at the catheter balloon base may lead to complications, including bladder or kidney damage.

Impact on Quality of Life:

Long-term catheterization adversely affects patients’ psychological and physical well-being.

Risk Factors

Pelvic Injuries: Increased risk of urethral disruption.
Prostatic Hypertrophy: Leads to increased resistance during catheter insertion in older males.
Recent Urological Surgery: Predisposes to infections and structural complications.

Preventive Measures

Aseptic Technique:

Strict adherence to sterile procedures during catheter insertion and care minimizes infection risks.

Minimizing Duration:

Regular assessment of catheter necessity and removal as soon as clinically feasible.

Appropriate Catheter Selection:

Use of the correct size and type of catheter tailored to the patient’s anatomy and clinical needs.

Regular Monitoring:

Routine checks for catheter kinks, blockages, and signs of complications like UTIs or hematuria.

Patient Education:

Inform patients on catheter care and early signs of complications.

Indications for Catheter Removal

Routine assessment of catheter necessity should guide removal.
Early removal improves recovery post-surgery, such as following intraperitoneal or colorectal procedures.
For chronic urinary retention, intermittent catheterization is often preferable.

Hints and Pitfalls [1,2, 4-7]

Hints for Successful Catheterization

Patient Positioning and Assistance:

Women: Position the patient in the lithotomy or frog-leg position for optimal exposure of the urethral meatus. In obese patients or those with pelvic organ prolapse, an assistant may be necessary to facilitate visualization.
Men: Position the patient supine with hips comfortably abducted for ease of insertion.

Generous Lubrication:

Ensure adequate lubrication of the catheter tip, particularly in men, to reduce resistance and discomfort.
For male patients, cooling the lubricant gel to 4°C can help minimize the stinging sensation.

Catheter Selection:

Choose the appropriate catheter size, material, and tip shape based on the patient’s anatomy and clinical needs.
Use a Coudé catheter for men with prostatic hypertrophy or urethral strictures due to its curved tip, which facilitates navigation through anatomical challenges.

Balloon Inflation:

Inflate the catheter balloon only after confirming proper placement in the bladder. Resistance or pain during inflation suggests incorrect positioning.
If resistance is encountered, deflate the balloon, advance the catheter further, and reattempt inflation.

Sterile Technique:

Maintain strict sterility throughout the procedure to minimize the risk of catheter-associated urinary tract infections (CAUTIs). This includes proper hand hygiene, sterile gloves, and cleansing of the urethral meatus.

Hydration and Bowel Management:

Encourage patients to stay well-hydrated and manage constipation, as both factors can reduce the risk of complications like UTIs and catheter blockage.

Early Removal:

Remove the catheter as soon as it is no longer clinically indicated to reduce the risk of infection and other complications.

Flushing the Catheter:

If urine does not flow initially, flush the catheter with 30–60 mL of normal saline to clear potential lubricant blockage and confirm placement.

Pitfalls to Avoid

Misplaced Catheter:

In women, accidental insertion into the vagina is common. Discard the contaminated catheter and use a new sterile one.

Urethral Trauma:

Avoid forcing the catheter during insertion, as this can lead to urethral injury, bleeding, or the creation of a false passage.
In cases of significant resistance or suspected urethral injury, stop the procedure and consult a urologist.

Incorrect Balloon Inflation:

Inflating the balloon in the urethra rather than the bladder can cause severe pain and trauma. Always advance the catheter fully before inflation.

Paraphimosis:

In uncircumcised men, ensure the foreskin is returned to its natural position after the procedure to prevent paraphimosis.

Ignoring Resistance:

Resistance during insertion may indicate anatomical challenges such as strictures or obstructions. Evaluate the situation and consider using a different catheter type, such as a Coudé, or seek urological consultation.

Catheter Obstruction:

Monitor for kinks or sediment buildup in the catheter. If blockage occurs, attempt gentle flushing with saline. Replace the catheter if flushing is ineffective.

Inadequate Lubrication:

Insufficient lubrication increases the risk of urethral trauma and patient discomfort, particularly in male patients with longer and more curved urethras.

Additional Considerations

Consultation with Urologists:

Seek urological consultation for difficult catheterizations, patients with complex anatomical variations, or persistent challenges during insertion.

Patient Education:

Provide clear instructions to patients, addressing their concerns and explaining the procedure to alleviate anxiety and improve cooperation.

Monitoring for Complications:

Regularly assess patients with urinary catheters for signs of complications, such as UTIs, hematuria, or catheter obstruction. Early detection and intervention are critical to preventing more severe outcomes.

Special Patient Groups

Pediatrics [8-10]

Urinary catheterization in pediatric patients requires meticulous attention to their unique anatomical and physiological characteristics. The indications for catheterization include urinary retention, neurogenic bladder, and post-surgical care, with efforts to minimize the duration of catheter use to reduce catheter-associated urinary tract infections (CAUTIs). Selecting an appropriately sized catheter, usually between 6 French (Fr) and 10 Fr, is crucial to avoid trauma and ensure comfort. Specialized catheters with hydrophilic or antimicrobial coatings can help minimize infection risks. Parental education plays a vital role; caregivers should be trained in catheter care and clean intermittent catheterization to maintain hygiene and bladder health. Clear communication and child-friendly techniques can reduce anxiety and improve cooperation during the procedure.

Geriatrics [11-14]

In geriatric patients, catheterization poses unique risks due to factors such as reduced mobility, cognitive impairments, and comorbidities. Older adults are particularly vulnerable to CAUTIs, making it essential to use catheters only when absolutely necessary. Employing antimicrobial catheters and adhering to strict aseptic techniques can help minimize infection risks. Cognitive impairments, including dementia, may necessitate additional monitoring to prevent unintentional self-removal or trauma. Alternatives to catheterization, such as non-invasive methods of urine collection, should be considered to enhance patient mobility and reduce complications. Regular reassessment of catheter necessity, coupled with early removal, is crucial to mitigating risks and promoting better outcomes in this population.

Pregnant Patients

Pregnant patients present specific challenges due to physiological changes in the urinary system, including increased renal workload and bladder compression by the growing uterus. These changes heighten the risk of urinary retention and catheter-associated complications. Catheterization may be required during labor, especially with epidural anesthesia, or postpartum for urinary retention. In such cases, strict adherence to sterile techniques is vital to prevent UTIs, which pose risks to both maternal and fetal health. Prompt treatment of asymptomatic bacteriuria (ASB) and UTIs is essential to avoid adverse outcomes. Early catheter removal and the use of clean intermittent catheterization when needed can reduce infection risks and improve recovery.

Author

Tejasvi Chikatla

Dr. Tejasvi Chikatla, a Consultant in the Emergency Department at Apollo Hospitals, Hyderabad, has over 9 years of experience in Emergency Medicine. With qualifications including MBBS, a Diploma in Emergency Medicine (Royal Liverpool Academy), and Membership of the Royal College of Emergency Medicine (UK), Dr. Chikatla is a dedicated educator and clinical supervisor. A lifetime member and instructor for SEMI, they are also a Master Trainer for WHO's Basic Emergency Care and serve on committees for IFEM.

Listen to the chapter

References

Urinary catheterisation. NHSInform. From: https://www.nhsinform.scot/tests-and-treatments/medicines-and-medical-aids/medical-aids/urinary-catheterisation#:~:text=Urinary%20catheterisation%20is%20a%20procedure,in%20hospital%20or%20the%20community. Accessed December 1, 2024
Haider MZ, Annamaraju P. Bladder Catheterization. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560748/
(5) Urinary catheterisation. Victoria State Government. From: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/urinary-catheterisation#bhc-content Accessed: December 1, 2024
(3) Chung PH. How To Do Urethral Catheterization in a Male. From: https://www.msdmanuals.com/en-in/professional/genitourinary-disorders/how-to-do-genitourinary-procedures/how-to-do-urethral-catheterization-in-a-male Accessed: December 1, 2024
(4) Chung PH. Chung PH. How To Do Urethral Catheterization in a female. From: https://www.msdmanuals.com/en-in/professional/genitourinary-disorders/how-to-do-genitourinary-procedures/how-to-do-urethral-catheterization-in-a-female Accessed: December 1, 2024
(6) Urinary catheters. MedlinePlus. From: https://medlineplus.gov/ency/article/003981.htm Accessed: December 1, 2024
Haider MZ, Annamaraju P. Bladder Catheterization. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560748/
Robson WL, Leung AK, Thomason MA. Catheterization of the bladder in infants and children. Clin Pediatr (Phila). 2006;45(9):795-800. doi:10.1177/0009922806295277
Crigger C, Kuzbel J, Al-Omar O. Choosing the Right Catheter for Pediatric Procedures: Patient Considerations and Preference. Res Rep Urol. 2021;13:185-195. Published 2021 Apr 28. doi:10.2147/RRU.S282654
Carlson D, Mowery BD. Standards to prevent complications of urinary catheterization in children: should and should-knots. J Soc Pediatr Nurs. 1997;2(1):37-41. doi:10.1111/j.1744-6155.1997.tb00198.x
Getliffe KA. Urinary Catheter Use in Older People. Aging Health, 2008;4(2), 181–189. https://doi.org/10.2217/1745509X.4.2.181
Kang SC, Hsu NW, Tang GJ, Hwang SJ. Impact of urinary catheterization on geriatric inpatients with community-acquired urinary tract infections. J Chin Med Assoc. 2007;70(6):236-240. doi:10.1016/S1726-4901(09)70365-X
Inelmen EM, Sergi G, Enzi G. When are indwelling urinary catheters appropriate in elderly patients?. Geriatrics. 2007;62(10):18-22.
Pader ML, Rolland Y, Castex A, et al. Le sondage vésical chez le sujet âgé [Urinary catheterization in the elderly patient]. Soins Gerontol. 2008;(72):11-14.

Reviewed and Edited By

Erin Simon, DO

Dr. Erin L. Simon is a Professor of Emergency Medicine at Northeast Ohio Medical University. She is Vice Chair of Research for Cleveland Clinic Emergency Services and Medical Director for the Cleveland Clinic Bath emergency department. Dr. Simon serves as a reviewer for multiple academic emergency medicine journals.

Arif Alper Cevik, MD, FEMAT, FIFEM

Spontaneous Pneumothorax (2024)

December 10, 2024December 10, 2024 ~ iEM Education Project Team ~ Leave a comment

by Mohd Fazrul Mokhtar &
Raja Amir Fikri Raja Sulong Ahmad

You have a new patient!

A 24-year-old male with no significant medical history presents to the emergency department for shortness of breath for two days duration. The symptom is associated with left-sided pleuritic chest pain. He denies fever, cough, constitutional symptoms, or trauma. He is an active smoker.

On assessment, the patient was mildly tachypneic and well-perfused. Auscultation reveals reduced breath sounds over the left lung. There is hyperresonance on percussion over the left lung as well. There is no tracheal deviation. Vital signs are as follows:

Blood pressure – 108/75 mmHg
Pulse rate – 74/minute
Respiratory rate – 24/minute
Oxygen saturation – 98% under room air
Temperature – 36.8o Celcius
Pain score – 4/10

What do you need to know?

Importance

Pneumothorax is defined as the presence of air in the pleural space. Pneumothoraces can be further divided into primary spontaneous pneumothorax (PSP), which occurs in patients spontaneously without any apparent underlying pleural disease, or secondary pneumothorax in patients with underlying diseases such as tuberculosis and lung malignancy [1,2]. Iatrogenic pneumothorax can also occur due to procedures such as thoracocentesis and central venous line insertion [2].

Identifying a pneumothorax is important, as a delay in management can lead to hemodynamic instability. In unstable patients with respiratory and circulatory compromise, the differential diagnosis of tension pneumothorax must be excluded.

Epidemiology

The incidence of primary spontaneous pneumothorax varies significantly between genders. Among the male population, it is reported to occur at a rate of 7.4 to 18 cases per 100,000 individuals annually. In contrast, the incidence in the female population is comparatively lower, ranging from 1.2 to 6 cases per 100,000 individuals per year [1].

Pathophysiology

Under normal circumstances, the pressure in the pleural space is negative compared to atmospheric pressure. This negative pressure is generated due to the opposing forces between the lung’s tendency to collapse because of elastic recoil and the outward expansion of the chest wall [2]. When there is communication between the alveoli and pleural space, the introduction of air alters the gradient until pressure equilibrium is reached, resulting in partial or total lung collapse. Tension pneumothorax occurs when inhaled air accumulates in the pleural space but cannot exit due to a one-way valve mechanism [2].

This condition leads to the clinical presentation of dyspnoea and chest pain. In tension pneumothorax, the increased intrathoracic pressure can decrease venous return and restrict lung function, ultimately leading to shock and hypoxia [2].

Medical History

In patients with a primary spontaneous pneumothorax, mild symptoms may be reported as they often tolerate the consequences of a pneumothorax better compared to those with underlying respiratory problems. The most common symptoms are chest pain and shortness of breath [3].

When inquiring about pain, the SOCRATES mnemonic may be helpful:

Site: Pain on the affected side
Onset: Usually, sudden onset of pain
Character: Typically described as sharp
Radiation: Radiation to the ipsilateral shoulder
Associated symptoms: Breathlessness
Time: Although the onset of pain may be acute, patients may present late if they can tolerate symptoms
Exacerbating/relieving factors: Pleurisy (pain worsening on inspiration) is common
Severity: Quantify the pain score when possible

Asking about risk factors may also help in strengthening the diagnosis of pneumothorax, including cigarette smoking, male gender, mitral valve prolapse, Marfan’s syndrome, and changes in ambient pressure. It is also important to ask about the history of trauma and recent medical procedures. Family history may be relevant as there may be a genetic predisposition to the condition.

Finally, enquire about the presence of a chronic cough and constitutional symptoms such as weight loss, loss of appetite, and fatigue to help ascertain whether the pneumothorax may be due to an underlying pleural disease.

Physical Examination

When assessing a patient with a potential pneumothorax, examine systematically using the ABC approach to avoid missing potential signs, especially those of a tension pneumothorax, as this condition requires immediate intervention [4].

Airway: Tracheal deviation is a late sign of tension pneumothorax, though it is not always indicative.
Breathing: Signs include tachypnoea, hypoxia, unequal chest rise, subcutaneous emphysema, hyperresonance, and absent or reduced breath sounds.
Circulation: Hypotension (a key sign of tension pneumothorax), tachycardia, and cold peripheries may be present.

Differential Diagnoses

The patients present mostly with shortness of breath (SOB). Therefore, pulmonary, cardiac and other causes of SOB should be considered first.

Pulmonary
- Airway obstruction
- PE
- Pulmonary edema
- Anaphylaxis
- Asthma
- Cor pulmonale
- Aspiration
Cardiac
- MI
- Tamponade
- Pericarditis
Others
- Esophageal rupture
- Toxin ingestion
- Epiglottitis
- Anemia

Acing Diagnostic Testing

The diagnosis of spontaneous pneumothorax is confirmed by imaging. After the diagnosis is confirmed, the clinical evaluation, including the history obtained and the patient’s clinical condition, should determine the management strategy.

Chest X-ray

The standard view is the erect PA chest x-ray. However, in a polytrauma patient, when the patient must be kept in the supine position, supine and lateral decubitus views can be performed.

Chest X-ray has been the mainstay diagnostic modality for pneumothorax. Typically, it demonstrates the visceral pleural edge, which appears as a thin, sharp white line. The peripheral space is more radiolucent compared to the adjacent lung (Image 1). A deep sulcus sign can be observed on a supine X-ray (Image 2).

More x-ray images can be found in iEM’s Flickr account – https://www.flickr.com/search/?user_id=158045134%40N08&view_all=1&text=pneumothorax

A chest x-ray provides information about the size of the pneumothorax and assists in determining the next steps in management.

In a patient with suspected pneumothorax, a chest x-ray should be performed [5]. However, if clinical assessment suggests features of tension pneumothorax (e.g., hypotension, tracheal deviation, distended neck vein), a needle thoracocentesis must be performed first, as a chest x-ray may delay this life-saving intervention.

CT scan

The presence of bullous lung disease can lead to a misdiagnosis of pneumothorax on a chest x-ray. In patients with chronic lung disease who develop bullae, a chest x-ray may show features similar to pneumothorax. Therefore, if uncertainty exists, a CT scan of the thorax is strongly recommended.

More CT images can be found in iEM’s Flickr account – https://www.flickr.com/search/?user_id=158045134%40N08&view_all=1&text=pneumothorax

CT scan is considered the “gold standard” for detecting small pneumothoraces and is the most accurate method to determine the size of a pneumothorax [6]. However, practical drawbacks, such as limited availability, make it unsuitable as the first imaging modality for diagnosing pneumothorax.

Lung Ultrasound

In the emergency department, a lung ultrasound can be performed at the bedside immediately after a physical examination to evaluate undifferentiated respiratory failure. It is part of the point-of-care ultrasound protocol in emergency settings.

In a lung ultrasound, the normal lung interface with pleura shows lung sliding with Z-lines, which appear as vertical comet tails descending from the pleural surface. In pneumothorax, this sliding and the comet tail artifacts from the pleura are absent. Visualizing the intersection between the sliding lung sign and the absence of sliding is referred to as the lung point, which is nearly 100% specific for pneumothorax [7].

Additional ultrasound findings:

Absence of B-lines
Cessation of lung pulse (lung oscillation in tandem with cardiac contraction)

On M-mode, the following signs are observed:

Seashore sign: Indicates normal lung sliding.
Barcode/stratosphere sign: Indicates pneumothorax.

More US images can be found in iEM’s Flickr account – https://www.flickr.com/search/?user_id=158045134%40N08&view_all=1&text=pneumothorax

Laboratory Tests

ABG is indicated when oxygen saturation is below 90% on room air. It is performed to assess the patient’s oxygenation level, as some patients with pneumothorax may present with hypoxemia [8].

Risk Stratification

Pneumothorax is classified into primary spontaneous pneumothorax (PSP) and secondary pneumothorax (SSP). PSP occurs in healthy patients; hence, it is termed “spontaneous,” while SSP is associated with underlying lung diseases such as chronic obstructive pulmonary disease and pulmonary tuberculosis. PSP patients are typically taller than healthy controls [9-11]. Within the first four years, the risk of recurrence of PSP is as high as 54%, with isolated risk factors including smoking, height, and age above 60 years [10, 12,13]. Age, pulmonary fibrosis, and emphysema are risk factors for the recurrence of SSP [11,13].

Since patients with pre-existing lung diseases tolerate a pneumothorax less well, distinguishing between PSP and SSP at the time of diagnosis is critical for determining the next steps in care. Many patients, particularly those with PSP, do not seek medical attention until several days after their symptoms first appear. Meanwhile, the majority of patients with SSP present with more severe clinical symptoms.

Management

General Principle

Airway

The majority of patients with pneumothorax experience breathing issues rather than airway compromise. However, it is essential to assess the airway and breathing simultaneously.

Breathing

Provide supplemental oxygen with a high-flow mask. Oxygen treatment accelerates the resolution of pneumothorax by lowering the partial pressure of nitrogen in the alveoli relative to the pleural cavity. This creates a diffusion gradient for nitrogen, which hastens recovery.

The diagram from the British Thoracic Society guideline summarizes the management of pneumothorax [14].

When To Admit This Patient

Patients requiring chest tube thoracostomy insertion must be admitted for monitoring and removal prior to discharge home. Those utilizing a pigtail catheter experience fewer complications, shorter hospital stays, and faster time-to-device removal. While many patients will require hospitalization, some can be discharged after a period of observation, aspiration, or with a Heimlich valve in pigtail catheters [14,15].

Revisiting Your Patient

The patient presented to the Emergency Department in a stable condition, showing no signs of respiratory distress, and was initially seen in the non-critical zone. After a chest X-ray confirmed the diagnosis of pneumothorax, the patient was transferred to the resuscitation zone for management and close monitoring.

A systematic assessment and management plan for patients with pneumothorax should prioritize the identification and stabilization of hemodynamically unstable patients.

Airway
There was no airway compromise in this patient, so no intervention was needed. The examination also revealed no tracheal deviation, which decreases the suspicion of a tension pneumothorax.

Breathing
Although the patient did not appear to be in respiratory distress, high-flow oxygen was administered through a non-rebreather mask to expedite the resorption of the pneumothorax.

Circulation
The patient was not in a tension pneumothorax state, as he remained hemodynamically stable. Therefore, he did not require immediate needle decompression or chest drain insertion.

The next step was to decide on the treatment approach. Following the algorithm set out by the British Thoracic Society, needle aspiration is recommended for this patient with a spontaneous pneumothorax, especially since he was experiencing breathlessness.

Needle aspiration is preferred in cases of spontaneous primary pneumothorax, as it is associated with a higher rate of successful discharges and fewer complications. However, if needle aspiration fails, chest drain insertion and admission will be necessary. The failure rate of needle aspiration in cases of secondary pneumothorax is high, which is why chest drains are typically favored in those instances.

Authors

Mohd Fazrul Mokhtar

Dr Mohd Fazrul Mokhtar is a Consultant Emergency Physician at Faculty of Medicine Universiti Teknologi MARA, Malaysia. He obtained his postgraduate training in emergency medicine at Universiti Kebangsaan Malaysia. He has special interest in sepsis, medical simulation; and emergency critical care. He is currently the Coordinator of the Clinical Simulation Centre. His research niche includes CPR educational technologies, cardiac arrest and sepsis. He is the council member of Malaysian Sepsis Association and Malaysian Resuscitation Association.

Raja Amir Fikri Raja Sulong Ahmad

I am currently a second year postgraduate trainee in Emergency Medicine in Malaysia. My interests are point of care ultrasound and critical care.

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References

Noppen M. Spontaneous pneumothorax: epidemiology, pathophysiology, and cause. European Respiratory Review. 2010;19(117):217-219. doi:https://doi.org/10.1183/09059180.00005310
McKnight CL, Burns B. Pneumothorax. Nih.gov. Published 2019. https://www.ncbi.nlm.nih.gov/books/NBK441885
Aljehani YM, Almajid FM, Niaz RC, Elghoneimy YF. Management of Primary Spontaneous Pneumothorax: A Single-center Experience. Saudi J Med Med Sci. 2018 May-Aug;6(2):100-103. doi: 10.4103/sjmms.sjmms_163_16. Epub 2018 Apr 16. PMID: 30787829; PMCID: PMC6196700.
Newman MJ. A mistaken case of tension pneumothorax. BMJ Case Rep. 2014 May 16;2014:bcr2013203435. doi: 10.1136/bcr-2013-203435. PMID: 24835806; PMCID: PMC4024963.
Matsumoto, S., Kishikawa, M., Hayakawa, K., Narumi, A., Matsunami, K., & Kitano, M. (2011). A method to detect occult pneumothorax with chest radiography. Annals of emergency medicine, 57(4), 378–381. https://doi.org/10.1016/j.annemergmed.2010.08.012
Do, S., Salvaggio, K., Gupta, S., Kalra, M., Ali, N. U., & Pien, H. (2012). Automated quantification of pneumothorax in CT. Computational and mathematical methods in medicine, 2012, 736320. https://doi.org/10.1155/2012/736320
Volpicelli G. (2011). Sonographic diagnosis of pneumothorax. Intensive care medicine, 37(2), 224–232. https://doi.org/10.1007/s00134-010-2079-y
Inoue S, Egi M, Kotani J, Morita K. Accuracy of blood-glucose measurements using glucose meters and arterial blood gas analyzers in critically ill adult patients: systematic review. Crit Care. 2013 Mar 18;17(2):R48. doi: 10.1186/cc12567. PMID: 23506841; PMCID: PMC3672636.
Withers JN, Fishback ME, Kiehl PV, et al. Spontaneous pneumothorax. Am J Surg 1964;108:772–6.
Sadikot RT, Greene T, Meadows K, et al. Recurrence of primary pneumothorax. Thorax 1997;52:805–9.
Videm V, Pillgram-Larsen J, Ellingsen O, et al. Spontaneous pneumothorax in chronic obstructive pulmonary disease: complications, treatment and recurrences. Eur J Respir Dis 1987;71:365–71.
West JB. Distribution of mechanical stress in the lung, a possible factor in the localisation of pulmonary disease. Lancet 1971;1:839–41.
Lippert HL, Lund O, Blegrad S, et al. Independent risk factors for cumulative recurrence rate after first spontaneous pneumothorax. Eur Respir J 1991;4:324–31.
MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug;65 Suppl 2:ii18-31. doi: 10.1136/thx.2010.136986. PMID: 20696690.
Thelle A, Gjerdevik M, SueChu M, Hagen OM, Bakke P. Randomised comparison of needle aspiration and chest tube drainage in spontaneous pneumothorax. European Respiratory Journal. 2017;49(4). doi:https://doi.org/10.1183/13993003.01296-2016

FOAm and Further Reading

CDEM curriculum – https://cdemcurriculum.com/pneumothorax/ – link
FLIPPED EM Classroom – https://flippedemclassroom.wordpress.com/2013/05/26/pneumothorax/ – link

Reviewed and Edited By

Erin Simon, DO

Arif Alper Cevik, MD, FEMAT, FIFEM

Acute Mesenteric Ischaemia (2024)

December 10, 2024December 17, 2024 ~ iEM Education Project Team ~ Leave a comment

by Colin NG

You have a new patient!

An 80-year-old gentleman presents to our department with a two-day history of abdominal pain accompanied by diarrhea and nausea. He describes the pain as recurrent, having occurred periodically over the past two years, with a crescendo pattern. However, this current episode has not been resolved and is excruciating.

A review of his medical records reveals a history of hypertension, dyslipidemia, a previous transient ischemic attack, and atrial fibrillation (AF). He underwent cholecystectomy many years ago for biliary colic. There is no other significant medical history.

On examination, his vital signs are as follows:

Blood pressure is 95/57 mmHg.
Pulse is 126 beats per minute.
Respiratory rate is 26 breaths per minute.
Oxygen saturation is 95%.
He is afebrile.

The patient appears pale, diaphoretic, and in significant discomfort. There is no clinical jaundice. Abdominal examination reveals diffuse tenderness, most prominent centrally, without guarding. Bowel sounds are sluggish. A cholecystectomy scar is noted in the right hypochondrium. Cardiac examination reveals irregular tachycardia, and the lungs are clear. Examination of the lower limbs is unremarkable, with no swelling. Stool is brown, with no visible blood or melena.

How would you proceed with further evaluation for this patient?

What do you need to know?

Acute mesenteric ischemia (AMI) refers to the sudden loss of blood flow to the small intestine, typically due to arterial insufficiency caused by an embolus or thrombus. AMI falls under the broader category of intestinal ischemia, which includes ischemia of the colon and, more rarely, the stomach and upper gastrointestinal tract. Other forms of intestinal malperfusion include venous occlusion as well as chronic or non-occlusive mesenteric ischemia [1].

Importance

Acute mesenteric ischemia carries an alarmingly high mortality rate, estimated between 60–80%. This is exacerbated by its nonspecific presentation, which often delays diagnosis and increases the likelihood of complications. Early recognition, timely resuscitation and treatment, and prompt advocacy for intervention are essential to improving outcomes [2,3].

Epidemiology

The incidence of AMI in developed countries is approximately 5 per 100,000 people annually, with a prevalence of around 0.1% of all hospital admissions.

AMI primarily occurs in patients with pre-existing atherosclerotic disease of arteries, often associated with risk factors such as advanced age, hypertension, diabetes, and atrial fibrillation [4].

A non-exhaustive list of risk factors includes [1]:

Cardiac conditions (e.g., atrial fibrillation, recent myocardial infarction)
Aortic surgery or instrumentation
Peripheral artery disease
Haemodialysis
Use of vasoconstrictive medications
Prothrombotic disorders
Systemic inflammation or infections
Hypovolaemic states
Bowel strangulation (e.g., volvulus, hernias)
Vascular compression syndromes.

Pathophysiology

The intestinal system exhibits relatively low oxygen extraction; residual oxygenated blood from intestinal veins is delivered to the liver via the portal vein. For ischaemic damage to occur, blood flow must be reduced by at least 50% of normal levels [1].

Interestingly, mesenteric arteries are less affected by atherosclerosis compared to other similarly sized vessels, likely due to protective hemodynamic factors. As a result, patients with AMI often have concurrent atherosclerotic conditions elsewhere, such as cerebrovascular disease, ischaemic heart disease, or peripheral vascular disease. Regarding the mechanism,

Embolism of the mesenteric artery accounts for ~50% and
Thrombosis of the mesenteric artery accounts for ~25% of AMI cases.

Mesenteric venous thrombosis can mimic AMI in a minority of cases, often presenting as nonspecific abdominal pain with diarrhea lasting 1–2 weeks. In some instances, these thrombi resolve spontaneously.

Medical History

The primary symptom of acute mesenteric ischemia (AMI) is central and severe abdominal pain, classically described as being “out of proportion” to physical examination findings. The initial pain is due to visceral ischemia, which initially spares the parietal peritoneum. Peritonism with abdominal rigidity typically develops later, indicating full-thickness ischemia, necrosis, or perforation [5].

Early symptoms may include persistent vomiting and defecation. As the condition progresses, passage of altered blood may occur. Unfortunately, associated gastrointestinal symptoms such as nausea, vomiting, and diarrhea can mimic infective causes, potentially leading to misdiagnosis. While bloody diarrhea is more commonly associated with colonic ischemia, it is less frequent in small bowel ischemia.

In some cases, AMI is preceded by symptoms of chronic non-occlusive mesenteric ischemia. Patients often report recurrent, postprandial abdominal pain resulting from an inability to increase blood flow to meet intestinal vascular demands. This may lead to a fear of eating and significant weight loss. In patients with chronic non-occlusive mesenteric ischemia, symptoms tend to be even more vague. Pain may be less severe and poorly localized, and patients may present with subtle signs such as abdominal distension or occult gastrointestinal bleeding [6].

In addition to embolic causes, mesenteric ischemia can be worsened by systemic conditions that restrict blood flow, such as hemorrhage, hypovolaemia, shock, and low-output cardiac states.

Physical Examination

In the early stages of AMI, physical examination findings are often sparse. The patient will typically appear to be in severe pain without relief, and abdominal tenderness is common. Suspicion should be heightened in frail patients of advanced age who may lack sufficient abdominal musculature to produce guarding during the examination.

Patients may appear pale due to pain or anemia, but specific physical signs are limited in this condition. Diagnosis often relies on a combination of clinical history and thorough investigation.

AMI is a critical condition characterized by reduced blood flow to the intestines, leading to severe complications if not diagnosed early. The physical examination findings should be combined with clinical history and specific symptoms. Understanding these findings is essential for timely intervention.

Key Findings

Severe Abdominal Pain: Patients typically present with a sudden onset of severe abdominal pain, which is a hallmark symptom of AMI.
Painless Interval: Following the initial pain, a transient painless period may occur, potentially misleading the diagnosis.
Signs of Peritonitis: Physical examination may reveal tenderness, guarding, or rebound tenderness, indicating peritoneal irritation and necessitating immediate surgical evaluation.
Bowel Sounds: Diminished or absent bowel sounds can suggest intestinal ischemia.

Importance of Clinical History to Guide Physical Exam

Risk Factors: A thorough history should include predisposing factors such as cardiovascular disease, recent surgeries, or conditions leading to hypercoagulability.
Chronic Symptoms: In cases of arterial thrombosis, patients may report a history of intermittent abdominal pain, weight loss, or diarrhea.

Alternative Diagnoses

The nonspecific symptoms of AMI mean it can be mimicked by many other conditions that are not easily excluded based on history and examination alone. Risk factors such as advanced age, prothrombotic states, atherosclerosis, and conditions causing hypovolaemia should raise clinical suspicion.

Differential diagnoses include:

Acute gastroenteritis: Main differential due to similar gastrointestinal symptoms (nausea, diarrhea, vomiting), especially at the initial stages of AMI, but pain and tenderness are typically less severe, more intermittent, and responsive to analgesia. Gastroenteritis is also less likely to cause metabolic acidosis or other significant biochemical abnormalities.
Acute cholecystitis: Presents with pain mainly in the right upper quadrant (RUQ) radiating to the right shoulder, often triggered by fatty meals, with accompanying nausea, vomiting, and fever. Murphy’s sign (pain and inspiratory arrest on palpation of the gallbladder) is often positive, particularly in those with a history of gallstones or biliary colic.
Acute pancreatitis: Epigastric pain radiating to the back, along with nausea and vomiting, is common. Associated with gallstones or alcohol use. Physical findings include epigastric tenderness, reduced bowel sounds, and, in severe cases, Grey-Turner’s or Cullen’s sign. Diagnosis is supported by elevated serum lipase or amylase levels.
Peptic ulcer disease: Characterized by burning or gnawing epigastric pain, often relieved by food or antacids. Common risk factors include NSAID use and Helicobacter pylori infection. Examination is typically unremarkable unless perforation occurs, which may result in acute peritonitis.
Bowel perforation: Sudden severe, diffuse abdominal pain with signs of peritonitis (rebound tenderness, guarding), fever, and tachycardia. A history of PUD or diverticulitis may be present. Diagnosis is supported by imaging, showing free air under the diaphragm on X-ray.
Diverticulitis: Presents with localized left lower quadrant (LLQ) pain, fever, and altered bowel habits (diarrhea or constipation). LLQ tenderness or a palpable mass is often noted in older patients.
Bowel obstruction: Crampy, intermittent abdominal pain, nausea/vomiting, abdominal distension, and constipation, potentially progressing to obstipation. Examination reveals a distended abdomen with high-pitched or absent bowel sounds. Plain X-rays typically show air-fluid levels and dilated bowel loops.
Ureteric calculus: Sudden colicky flank pain radiating to the groin, often with hematuria, nausea, and vomiting. A history of kidney stones is common. Findings include costovertebral angle tenderness, with a generally unremarkable abdominal exam. Hematuria is detected on urinalysis.

Acing Diagnostic Testing

Bedside Tests

Bedside diagnostics are limited but can provide valuable clues:

ECG: May reveal atrial fibrillation, a common risk factor.
Blood glucose: Hyperglycaemia due to physiological stress.
Point-of-Care Testing (POCT) for lactate: Elevated levels may indicate tissue hypoxia, though not specific to AMI.
Ultrasound: Limited in diagnosing AMI but useful for ruling out other causes of abdominal pain (e.g., cholecystitis, abdominal aneurysm, or ureteric colic). Ultrasound can also assess fluid status and response to fluid resuscitation via the inferior vena cava (IVC) and right heart function, particularly in patients with cardiac or renal comorbidities or failure.

Laboratory Tests

No serum markers are sufficiently sensitive or specific to diagnose AMI reliably:

Complete blood count (CBC): It may reveal haemoconcentration or leukocytosis but lacks specificity.
Serum lactate: Highly sensitive in bowel infarction but nonspecific; elevated levels may not occur in the early stages.

Leucocytosis and elevated lactate levels are the two most frequently observed abnormalities in acute mesenteric ischemia; however, both lack specificity for this condition [7,8].

Blood gas analysis: Metabolic acidosis is a late finding; its presence should heighten suspicion in the appropriate clinical context.
Serum amylase: Moderately elevated in more than half of cases; highly elevated levels suggest pancreatitis, which should guide further diagnostic steps.

Imaging

X-rays (Chest/Abdomen): Chest and abdominal X-rays are often normal in the early stages of acute mesenteric ischemia but are useful for identifying complications or alternative diagnoses (e.g., perforation, ureteric calculus) [9]. Early findings may include adynamic ileus, distended air-filled bowel loops, or bowel wall thickening. Late findings such as pneumatosis or portal venous gas strongly suggest bowel infarction.
CT Scanning: The primary imaging modality in diagnosing AMI. When enhanced with contrast, CT can detect bowel wall edema, mesenteric edema, abnormal gas patterns, intramural gas, ascites, and mesenteric venous thrombosis. Sensitivity and specificity are high (82.8–97.6% and 91.2–98.2%, respectively), though contrast use may be limited by renal function [10]. However, delaying diagnosis poses greater risks than the small chance (~1%) of contrast-induced nephropathy requiring dialysis [11].

Catheter Angiography: is considered the gold standard but rarely available in emergency settings [10]. It may still be necessary if CT is inconclusive and clinical suspicion remains high.
Diagnostic Laparotomy: it may be required for definitive diagnosis in cases of high suspicion when imaging is non-diagnostic.

Risk Stratification

No validated tools exist for risk stratification in AMI. However, specific features indicate late-stage disease and worse prognosis:

Prolonged symptoms before presentation.
Evidence of bowel necrosis or perforation.
Severe biochemical derangements (e.g., high lactate, metabolic acidosis).
Hemodynamic instability, such as septic or hemorrhagic shock.

Management

Initial Stabilization

Initial stabilization of the patient, if required, is straightforward but must follow a systematic approach, following airway, breathing, circulation, disability, and exposure.

Airway and Breathing:

The airway should be secured if necessary, especially in cases where the patient appears drowsy due to cerebral hypoperfusion or septic encephalopathy, or if they are actively vomiting and at high risk of aspiration. Rapid correction of hypovolaemia before administering sedatives or paralytics is recommended. Breathing is not commonly compromised in this condition; however, supplemental oxygen may be required for patients experiencing atelectasis or tachypnoea secondary to pain.

C: Circulation – Circulation management necessitates aggressive and rapid resuscitation with fluids or blood products. Fluid resuscitation should not be delayed due to difficulty in obtaining IV access. Ultrasound guidance can be used if venous access proves challenging. If the patient is hypotensive, an initial 10–20 mL/kg (Crystalloids: Normal saline / Hartmann’s / Ringer’s lactate / Plasmalyte etc.) bolus delivered rapidly over 5–15 minutes is appropriate. This usually requires at least one large-bore IV line (20G or larger).

Many of these patients have comorbidities such as congestive heart failure (CHF), which requires judicious fluid management. Careful hemodynamic monitoring, including repeated clinical assessments and sonographic evaluation of inferior vena cava (IVC) collapsibility, is crucial. If required, more invasive hemodynamic monitoring may be employed.

Vasoactive agents should be avoided due to their role as predisposing factors; however, if vasopressors are essential, it is advisable to avoid alpha-agonist medications.

D: Disability – In patients with acute mesenteric ischemia (AMI), mental status may become altered if ischemia progresses to sepsis or shock, leading to cerebral hypoperfusion. This may present as confusion, agitation, or lethargy. Tools such as the AVPU scale or Glasgow Coma Scale (GCS) are valuable for assessing consciousness and monitoring neurological status during treatment. Clinicians should also consider the presence of sequelae from prior strokes, as these may indicate underlying atherosclerotic disease, which is a risk factor for AMI. Additionally, severe pain can interfere with the patient’s ability to engage fully in the assessment, even when mental status remains intact.

E: Exposure – The patient should be fully exposed to enable a thorough examination, while ensuring measures are taken to maintain warmth and prevent hypothermia, as this can worsen shock. A systematic palpation of the abdomen is critical to identify tenderness, guarding, or masses. In the early stages of AMI, there may be no external signs, but central or generalized abdominal tenderness is typically present. As the condition advances, abdominal distension and signs of peritonitis, such as rebound tenderness and rigidity, may develop.

Clinicians should also observe for secondary indicators, including surgical scars or stomas, which may suggest a history of abdominal pathology. Systemic signs of hypoperfusion and shock, such as mottled skin or cool extremities, should also be noted. Regular and frequent reassessment is essential to detect any progression or subtle changes in the patient’s condition, ensuring timely and appropriate intervention.

Early and empirical administration of broad-spectrum antibiotics is critical and should not be delayed for blood culture collection, as the risk of bacterial translocation across the bowel wall is high. Oral intake must be avoided since these patients are likely to undergo urgent surgery under general anesthesia. Electrolyte imbalances should also be corrected promptly.

Antibiotic Administration

Ceftriaxone

Dose per kg: 1–2 g
Frequency: Stat (given immediately)
Maximum Dose: 2 g
Category in Pregnancy: Category B (safe for all trimesters)
Cautions/Comments: None specified.

Metronidazole

Dose per kg: 500 mg
Frequency: Stat (given immediately)
Maximum Dose: 500 mg
Category in Pregnancy: Category B (safe for all trimesters)
Cautions/Comments: None specified.

An urgent surgical consultation is imperative, as acute mesenteric ischemia is a time-sensitive condition. Delays to definitive treatment significantly increase morbidity and mortality. High clinical suspicion alone should prompt surgical involvement, even before imaging results are available. In critically ill patients, surgical teams may decide to proceed directly to the operating theatre without advanced imaging. Such decisions are typically made collaboratively by the emergency department, surgical, anesthetic, and intensive care teams.

The definitive treatment for acute mesenteric ischemia depends on the underlying cause and whether necrotic bowel is present. Necrotic bowel or signs of peritonitis necessitate immediate resection. Specific interventions include embolectomy with distal bypass grafting for mesenteric artery embolism, bypass grafting or stenting for mesenteric artery thrombosis, and removal of underlying stimuli in nonocclusive ischemia, sometimes supplemented with direct transcatheter papaverine infusion. Mesenteric venous thrombosis typically requires anticoagulation [7].

Special Patient Groups

Special populations, such as those with communication barriers or cognitive impairments, may require a lower threshold for advanced imaging since history-taking and physical examination may be unreliable. Pregnant and pediatric patients are rarely affected by this condition.

When To Admit This Patient

Given the critical nature of acute mesenteric ischemia and its high mortality rates, all affected patients should be admitted to the intensive care unit for postoperative management following surgery.

Revisiting Your Patient

Our patient was triaged to a high-acuity area of the emergency department (ED) and placed on continuous monitoring, including cardiac leads, blood pressure, and oximetry. Stabilization proceeded in a structured, prioritized manner, focusing on critical areas from A to E:

Airway and Breathing: The patient’s airway was intact, and there were no signs of active vomiting. Mild dyspnoea was reported, so supplemental oxygen was administered via nasal cannula.
Circulation: Two large-bore intravenous cannulae were inserted, and a liter of crystalloids was infused. This led to visible hemodynamic improvement, including better IVC collapsibility observed on ultrasound.
Disability and Exposure: Disability and exposure did not reveal anything abnormal except for a generalized tenderness on the abdomen.

With the patient stabilized, the team moved on to investigations. Blood samples were taken, including a point-of-care venous gas test with serum lactate, coagulation profile, and a group and cross-match. Leucocytes were elevated at 12,000, and serum lactate was elevated at 8. Cardiac monitoring revealed atrial fibrillation. Bedside ultrasound did not reveal other causes of abdominal pain, such as a ruptured aneurysm or cholecystitis. Chest and abdominal X-rays were normal.

Based on the clinical presentation, risk factors, and lab results, the treating team suspected acute mesenteric ischemia. A surgical consult was requested, and a CT scan of the abdomen and pelvis was ordered. Maintenance IV crystalloids and broad-spectrum antibiotics (ceftriaxone and metronidazole) were started empirically. A urinary catheter was placed to monitor fluid balance.

The CT scan revealed:

A thickened small bowel wall with dilated bowel loops
An embolism in the superior mesenteric artery

The patient was immediately taken to the operating theatre for definitive treatment.

In summary, the role of the ED physician is to:

Stabilize the patient through targeted resuscitation
Make an early diagnosis based on clinical suspicion supported by available investigations
Understand the limitations of laboratory tests in ruling out acute mesenteric ischemia
Prioritize aggressive resuscitation and management
Ensure urgent surgical involvement

Authors

Colin NG

Woodlands Health

Listen to the chapter

References

Tendler DA, Lamont JT. Overview of intestinal ischemia in adults. UpToDate. https://www.uptodate.com/contents/overview-of-intestinal-ischemia-in-adults Updated January 29, 2024. Accessed December 9, 2024.
McKinsey JF, Gewertz BL. Acute mesenteric ischemia. Surg Clin North Am. 1997;77(2):307-318.
Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ, Burger CD. Acute mesenteric ischemia: a clinical review. Arch Intern Med. 2004;164(10):1054-1062.
Szuba A, Gosk-Bierska I, Hallett RL. Thromboembolism. In: Rubin GD, Rofsky NM, ed. CT and MR Angiography: Comprehensive Vascular Assessment. Philadelphia, PA, USA: Lippincott Williams & Wilkins; 2009: 295-328.
Marc Christopher Winslet. Intestinal Obstruction. In: R.C.G. Russell ed. Bailey & Love’s Short Practice Of Surgery 24th ed. London, UK: Arnold; 2004:1202.
Tendler DA, Lamont JT. Nonocclusive mesenteric ischemia. UpToDate. https://www.uptodate.com/contents/nonocclusive-mesenteric-ischemia Updated December 13, 2023. Accessed December 9, 2024.
Park WM, Gloviczki P, Cherry KJ Jr, et al. Contemporary management of acute mesenteric ischemia: Factors associated with survival. J Vasc Surg. 2002;35(3):445-452.
Cudnik MT, Darbha S, Jones J, Macedo J, Stockton SW, Hiestand BC. The diagnosis of acute mesenteric ischemia: A systematic review and meta-analysis. Acad Emerg Med. 2013;20(11):1087-1100.
Smerud MJ, Johnson CD, Stephens DH. Diagnosis of bowel infarction: a comparison of plain films and CT scans in 23 cases. AJR Am J Roentgenol. 1990;154(1):99-103.
Menke J. Diagnostic accuracy of multidetector CT in acute mesenteric ischemia: systematic review and meta-analysis. Radiology. 2010;256(1):93-101.
Mehran R, Aymong ED, Nikolsky E, et al. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation. J Am Coll Cardiol. 2004;44(7):1393-1399.

FOAM and Further Reading

CDEM Curriculum – Patel S, Mesenteric Ischemia – June 2018, https://cdemcurriculum.com/mesenteric-ischemia/ Accessed May 2023

EMdocs – Seth Lotterman. Mesenteric Ischemia: A Power Review. Nov 2014. http://www.emdocs.net/mesenteric-ischemia-power-review/ Accessed May 2023

Reviewed and Edited By

Elif Dilek Cakal, MD, MMed

Arif Alper Cevik, MD, FEMAT, FIFEM

Abdominal Pain in Children (2024)

December 9, 2024December 9, 2024 ~ iEM Education Project Team ~ Leave a comment

by Prassana Nadarajah

You have a new patient!

An 18-month-old boy is brought to the emergency department (ED) by his parents due to lethargy that has persisted for the last few hours. He is a term-born child with no significant antenatal history or pre-existing medical conditions. The child had been well until five days ago when he experienced a case of viral gastroenteritis. His feeding and urine output were adequate until about three hours ago, after which he began experiencing progressive episodes of crying, accompanied by vomiting and abdominal distension. There was no diarrhea or dark-colored stools noted.

During the triage assessment, the child appeared unsettled but was afebrile, with other vital signs within age-appropriate ranges. There were no rashes observed on his body, and there were no blood-stained stools in his diaper.

What do you need to know?

Importance

Abdominal pain is a common reason for children to present to the Emergency Department (ED) and represents up to 5% of all presentations in some institutions [1]. The most common causes are non-surgical, and at times it may be difficult to arrive at a specific diagnosis before discharge. However, it is crucial to identify causes of abdominal pain that require early surgical intervention, particularly when a clear diagnosis cannot be made before discharge. Pay special attention to red flags such as lethargy (in neonates and infants), severe pain or irritability, bilious emesis, abdominal distension, peritoneal signs, or signs of sepsis.

The differential diagnoses (DDx) for abdominal pain vary with age groups. In younger children who cannot express themselves, reliance on parental history and a thorough physical examination is essential. Blood investigations and radiology may not be helpful, especially in early presentations, making serial examinations and observation more valuable. Additionally, remember that pain from other sites can be referred to the abdomen, particularly testicular pain.

Epidemiology

Pediatric abdominal pain is a common reason for emergency department (ED) visits, accounting for approximately 12% of all visits [2]. The median age of children presenting with abdominal pain is around 9 years, with a higher incidence in girls [2, 3]. Non-specific abdominal pain is the most prevalent diagnosis, affecting 40% of children, followed by functional abdominal pain (FAP), constipation, and viral infections [2, 4]. Despite the high prevalence of abdominal pain, a significant portion of children (62.7%) are discharged directly from the ED, while 37.3% require admission [3]. However, follow-up studies indicate that about 50% of children report ongoing pain after discharge, highlighting the chronic nature of abdominal pain [3].

Pathophysiology

The sensation of abdominal pain is transmitted either by somatic or visceral afferent fibres [5]. Visceral pain from the visceral peritoneum is poorly localised and is often referred to its corresponding dermatome on the abdominal wall. If you recall the human embryological development of abdominal organs, the organs developing from the foregut (oesophagus to the second part of the duodenum) have pain referred to the T8 dermatome (i.e., the epigastric area), those developing from the midgut (from the third part of the duodenum to the proximal two-thirds of the transverse colon) have pain referred to the T10 dermatome (i.e., the umbilical area), and those from the hindgut (distal one-third of the transverse colon to the rectum) refer to the T12 dermatome [6].

Somatic pain from the parietal peritoneum is more localised. Thus, any abdominal condition that progresses to involve the parietal peritoneum will result in the patient complaining of migrating pain. In unfortunate situations where this advances to bowel rupture or peritonitis (i.e., surgical abdomen), the patient will exhibit signs of peritonism. You can observe this in the history of appendicitis, where the pain initially starts in the periumbilical region and migrates to the right lower quadrant.

Referred pain also occurs due to the convergence of visceral and somatic pathways in the spinal column. Two examples of referred pain are diaphragmatic irritation leading to pain at the shoulder tip due to the convergence of visceral and somatic pathways at C4, and somatic pain from pneumonia leading to T10–11 pain perceived in the lower abdomen [5].

Initial Assessment and Stabilization

Airway & Breathing

Provide supplemental oxygen and attach an SPO2 probe.

Circulation

Assess for signs of sepsis, shock, dehydration, or the need for IV pain relief. If any of these are present, obtain IV access.
If in shock, administer an IV crystalloid fluid bolus of 20 ml/kg. Reassess and repeat if necessary.
If sepsis is suspected, obtain blood cultures via IV and administer Ceftriaxone 50 mg/kg (up to 2 g) AND metronidazole 10 mg/kg (up to 500 mg). Follow your local antibiotic guidelines.
If not in shock but dehydrated, initiate IV maintenance therapy.
Provide adequate pain control. Consider IV morphine 0.05–0.1 mg/kg or IV fentanyl 1 μg/kg.

Disability

Check a point-of-care glucose level in sick children. Consider hypoglycemia or DKA as alternative diagnoses.

Exposure

Examine the abdomen for abdominal distension, masses, or peritonism. Involve the surgical team early. This is further discussed in the physical examination section.
Always examine the genitals (e.g., for testicular torsion or strangulated hernia).

Medical History

In history, focus on the following:

Age of the child – DDx varies with the child’s age and the initial presenting complaints. Remember that neonates and infants often present with lethargy, irritability, poor feeding, or vomiting.

Age	Surgical diagnoses	Medical diagnoses
Birth to 3 months	Necrotizing enterocolitis Pyloric stenosis Malrotation with Midgut volvulus Incarcerated hernia Duodenal atresia Testicular torsion Non-Accidental Injury	Constipation Reflux Colic
3 months to 3 years	Malrotation with midgut volvulus Intussusception Appendicitis Testicular torsion Trauma Non-Accidental Injury	Henoch-Schönlein purpura (HSP) Anaphylaxis Acute gastroenteritis Urinary tract infection Constipation Mesenteric adenitis Sickle cell–related vaso-occlusive crisis
3 years and above	Appendicitis Ectopic pregnancy Cholecystitis Malignancy Trauma Testicular or ovarian torsion	Henoch-Schönlein purpura Diabetic ketoacidosis Urinary tract infection Pancreatitis Anaphylaxis Constipation Acute gastroenteritis Mesenteric adenitis Strep pharyngitis Pneumonia Renal stones Inflammatory bowel disease Irritable bowel disease Functional abdominal pain Gastritis/gastric ulcer Ovarian cyst Pregnancy Pelvic inflammatory disease Toxic ingestion

Timing of the symptoms:
a. Intussusception may follow a bout of diarrhoeal illness.
b. Appendicitis typically presents as a gradual onset of pain migrating from the periumbilical area to the right lower quadrant.

Pain character – Episodic pain is observed in intussusception and mesenteric adenitis.

Blood in stool – Consider necrotizing enterocolitis, intussusception, and volvulus.

Bilious or non-bilious vomiting – Bilious vomiting is indicative of obstruction below the ampulla of Vater. It is a classic presentation of malrotation with midgut volvulus and may also present in incarcerated/strangulated hernia or Hirschsprung disease with enterocolitis. Non-bilious vomiting is classically associated with pyloric stenosis.

Associated symptoms – A rash may be present in Henoch-Schönlein purpura. Fever, when associated with inflammation (e.g., appendicitis) or the translocation of gut bacteria, may lead to sepsis.

Oral intake, urine output (UOP), and activity levels – These are important. Escalate to a senior opinion for admission or IV hydration if these parameters are below 50% of the child’s baseline.

Other relevant history:

Past medical and surgical history, including birth history such as prematurity in neonates and infants.
Social history, especially when suspecting non-accidental injury.
Menstrual and sexual history in adolescent females.

Physical Examination

A good history and physical examination are very important in managing undifferentiated paediatric abdominal pain patients. You must perform an abdominal examination, including genitourinary and inguinal exams, especially in children who cannot express themselves. Remember that you may find little or no helpful clinical signs initially; however, serial examinations may reveal the condition as it evolves. A digital rectal examination is very rarely indicated, and even then, it should ideally be limited to once and performed by the surgeon [7].

Also, remember that these are children, and they may intentionally exhibit voluntary guarding during palpation if they are distressed, regardless of the cause. Covering the art of paediatric abdominal examination is beyond the scope of this chapter, but consider providing analgesia, employing distraction techniques, and building good rapport with the child.

Please ensure that your patients receive adequate analgesia before the examination, as this will make the patient cooperative, simplify the examination, and highlight clinical signs.

General Examination

Assess general appearance and determine whether the child looks ill or well.
Record temperature and other vital signs.
Observe for pallor and jaundice. Obtain an accurate body weight.
Observe the child walking to the examination bed or within the department. Children with peritonism may refuse to walk or walk slowly with a stooped posture.
Observe for signs of pain when coughing or jumping.

Inspection

Look for asymmetry and abdominal distension. Abdominal distension is less pronounced in higher bowel obstructions (e.g., midgut volvulus) than in lower bowel obstructions.
Check for purpuric patches, which are diffusely seen in Henoch-Schönlein purpura (HSP).

Palpation

Feel for any masses, tenderness, and peritonism. Remember that classic presentations of masses (e.g., an olive-shaped mass in pyloric stenosis or a sausage-shaped mass in intussusception) may not be palpable in the emergency department, as the condition may be intermittent or in an early stage.
Palpable bowel loops are classically associated with necrotizing enterocolitis.
Pyloric stenosis typically presents with a non-tender abdomen.
For most surgical causes, peritoneal findings can occur late. Consider the possibility of septic shock in a drowsy child presenting with abdominal tenderness on palpation.

Other Systems to Examine for Abdominal Pain [7]

Respiratory: Assess for signs of basal pneumonia.
ENT: Consider upper respiratory tract infections (URTI), tonsillitis, or adenopathy.
Neurological: Rule out meningitis.
Endocrine: Check blood glucose levels for diabetic ketoacidosis.
Haematological: Look for pallor and lymphadenopathy.
Dermatological: Look for rashes, particularly purpura/petechiae in Henoch-Schönlein purpura or zoster.
Renal: Check for oliguria, haematuria, or hypertension in haemolytic uraemic syndrome.

In Our Patient

Physical Examination: Abdominal examination revealed an ill-defined mass in the right upper quadrant (RUQ). No pain was elicited on testicular palpation. No anal fissures or bleeding were noted on rectal examination. There were no signs of peritonism.

When To Ask for Senior Help

Do not hesitate to contact your seniors if you are concerned about your patient. The points below serve as a guide:

An ill-looking patient.
May require IV access for hydration or analgesia.
Presence of peritoneal signs.
Signs of sepsis.
Bilious vomiting.
Non-accidental injury or inconsistent history.
Neonates (especially premature babies), if you lack experience in treating them.
Parental anxiety.

Not-To-Miss Diagnoses

Pediatric abdominal pain is a common and complex issue in emergency departments, requiring a thorough differential diagnosis to identify serious underlying conditions [8]. The etiologies of abdominal pain vary by age, with infants (<2 years) commonly presenting with congenital anomalies, malrotation, and intussusception [8]. In children aged 2-5 years, appendicitis, gastroenteritis, and mesenteric adenitis are frequent diagnoses [9], while school-aged children (5-12 years) are more likely to experience constipation, urinary tract infections, and respiratory infections [8]. Adolescents (>12 years) are at risk for pelvic inflammatory disease, pregnancy-related issues, and ovarian torsion [8]. Common conditions such as appendicitis, constipation, and gastroenteritis are prevalent across different age groups, and non-gastrointestinal causes like pneumonia and acute asthma can also manifest as abdominal pain [10]. A comprehensive approach to diagnosis and management is essential to identify serious underlying conditions that may require urgent intervention.

Causes Requiring Early Surgical Intervention

Peritonitis.
Appendicitis.
Testicular torsion.
Incarcerated hernia.
Necrotizing enterocolitis.
Intussusception.
Volvulus.
Hirschsprung’s disease.
Pregnancy or ectopic pregnancy in adolescent girls.
Ovarian torsion in adolescent girls.

Medical Causes Not to Miss

UTI in very young children (<5 years).
Diabetic ketoacidosis.
Sepsis.
Haemolytic uraemic syndrome.
Non-accidental injury.

Acing Diagnostic Testing

Remember that blood investigations are useful as supportive evidence for your history and physical examination, but they can be normal in surgical conditions. Avoid unnecessary venepuncture and/or IV cannulation in children unless the patient is sick or you are concerned about a not-to-miss diagnosis.

Bedside Tests

In sick patients, useful point-of-care tests include blood sugars, urine analysis, and capillary gas analysis. Blood sugars can indicate hypoglycaemia or DKA, and capillary gas analysis is useful for assessing lactate levels and metabolic acidosis. Urine analysis is helpful in confirming UTI, but ensure a proper uncontaminated sample has been collected [11]. Point-of-care ultrasound can be used for diagnosing intussusception, pyloric stenosis, or appendicitis.

Laboratory Tests

If venipuncture is performed, a full blood count, CRP, and renal function tests should be considered for all children. These tests may reveal evidence of inflammation or infection, as well as the extent of dehydration. You may also consider adding VBG and blood cultures for sicker children and tailor other testing depending on the patient (e.g., lipase for pancreatitis or beta HCG if pregnancy is suspected).

Imaging

Consider avoiding radiation or utilizing the lowest possible radiation dose. Ultrasound is the initial imaging modality of choice. In addition to point-of-care ultrasound, arrange an urgent departmental ultrasound if needed. If x-ray facilities are available, you can obtain a supine abdomen and upright/lateral decubitus view to look for free air. Computed tomography can be considered for life-threatening conditions when other modalities have failed. Magnetic resonance imaging is used in some parts of the world. It avoids radiation but may be time- or cost-prohibitive.

In Our Patient

Point-of-care ultrasound (POCUS) showed a target sign over the abdominal mass.
A diagnosis of intussusception was made.

Risk Stratification

Effective clinical decision rules (CDRs) for risk stratification of pediatric abdominal pain in emergency departments include the Pediatric Appendicitis Score (PAS) and the Pediatric Emergency Care Applied Research Network (PECARN) Pediatric Intra-Abdominal Injury rule. The PECARN rule is for trauma patients and out of the discussion in this chapter. The PAS is a valuable tool for assessing the likelihood of acute appendicitis in children presenting with abdominal pain, with studies showing that PAS scores correlate significantly with the severity of appendicitis [12]. A score below 4 has been found to rule out appendicitis, while higher scores indicate a higher risk of appendicitis [12]. Additionally, a recent Non-Specific Abdominal Pain (NSAP) Model has been developed to differentiate non-specific abdominal pain from organic causes, identifying key clinical predictors such as pain location and associated symptoms, and achieving a sensitivity of 71.8% [13]. These CDRs assist clinicians in identifying patients at risk for serious conditions, optimizing diagnostic processes, and reducing unnecessary interventions.

Management

Empiric and Symptomatic Treatment

Correct dehydration either orally in stable children or via IV in children who may need to be kept nil-by-mouth or are too sick to tolerate oral intake.

Consider keeping possible surgical patients nil-by-mouth. For bowel obstruction, consider inserting a nasogastric tube for gastric decompression.

Treat pain and distress.

Consider non-pharmacological methods (e.g., examine the child on the parent’s lap).

Paracetamol

Dose per kg: 15 mg/kg
Frequency: Every 4 hours (q4h)
Maximum Dose: 60 mg/kg/day
Cautions/Comments:
- Ask for allergies.
- Check if/when the patient took acetaminophen at home.

Fentanyl

Dose per kg: Intranasal 1.5 mcg/kg (for >12 months of age)
Frequency: Every 15 minutes
Maximum Dose: 3 mcg/kg
Cautions/Comments:
- Not recommended for children <12 months of age.
- Divide the dose between nostrils.
- Consider alternative analgesia after the second dose.

Morphine

Dose per kg:
- IV/Subcutaneous: 0.05–0.1 mg/kg
Frequency: Every 2–4 hours
Maximum Dose:
- For <1 month: 0.1 mg/kg every 4–6 hours
- For 1–12 months: 0.1 mg/kg every 2–4 hours
- For >12 months: 0.2 mg/kg every 2–4 hours
Cautions/Comments:
- There is a chance of respiratory depression if the dose exceeds the recommended amount.

If sepsis is suspected, administer IV Cefotaxime and IV Metronidazole, or follow your local antibiotic guidelines.

Cefotaxime

Dose per kg: IV 50 mg/kg
Frequency: Every 12 hours
Maximum Dose: 2000 mg
Cautions/Comments:
- Can be given intramuscularly (IM) if IV access is difficult.

Metronidazole

Dose per kg: IV 10 mg/kg
Frequency: Every 8 hours
Maximum Dose: 500 mg
Cautions/Comments:
- Consider alternative analgesia after the second dose.

Piperacillin + Tazobactam

Indication: For pseudomonal coverage in sepsis or hospital-acquired infections.
Dose per kg:
- 2 months to 9 months: IV 80 mg/kg
- 9 months: IV 100 mg/kg
Frequency: Every 8 hours
Maximum Dose: 3000 mg
Cautions/Comments:
- The dose is calculated based on the piperacillin component.

IV Fluids

Use isotonic crystalloids. Avoid hypotonic solutions in the ED, except in rare circumstances as advised by paediatric nephrologists or paediatricians.
For resuscitation, use 0.9% saline in 10–20 ml/kg boluses for all ages. You can repeat the boluses as necessary, but assess for signs of heart failure before administering each bolus.
For IV maintenance, use a 0.9% saline and 5% dextrose combination if available. This can be prepared by mixing 450 ml of 0.9% saline with 50 ml of 50% dextrose. Alternatively, you can use 0.9% saline, Hartmann’s solution, or follow local guidelines.

When To Admit This Patient

If you are able to arrive at a diagnosis for these patients, then the disposition is often straightforward. On the other hand, patients with severe pain despite a negative physical examination and unclear diagnosis will require admission for observation and serial physical examinations.

If parents confirm that oral intake, UOP, and activity levels are less than 50% of the child’s baseline, the child should be admitted for IV hydration and observation. A short-stay unit may be suitable for such patients.

If there is a suspicion of non-accidental injury or any social circumstances (e.g., inability to return for review due to financial constraints or travel issues in rural areas), discuss admission with your senior doctor. Consider reviewing well-appearing neonates with seniors, especially if you think they can be safely discharged home.

Otherwise, well children with likely benign causes can be discharged home. Ensure that clear and close follow-up is arranged with their general practitioner or pediatrician.

Advise parents on when to return (e.g., if the child’s oral intake, UOP, or activity level reduces to less than 50% of their usual baseline, or if symptoms of sepsis or shock develop) and provide guidance on follow-up (either with their general practitioner or the nearest hospital with surgical capacity to review the child). If any outpatient radiological investigations are planned for the coming days, educate parents about the importance of attending these procedures as well.

Revisiting Your Patient

Our 18-month-old patient was confirmed to have an intussusception by point-of-care ultrasound.

On reviewing his history, the episodic crying and preceding viral illness are supportive of this diagnosis, and the lack of fever or other associated symptoms rules out most other diagnoses. The classical triad of abdominal pain, vomiting, and red-currant jelly stool described in patients is present in less than 50% of patients with the disease [14]. However, a better clue is that it is associated with lethargy even without signs of sepsis or dehydration.

His examination revealed normal vital signs, was afebrile, and had a soft, non-tender abdomen with an ill-defined lower abdominal mass, which also supports this diagnosis.
The ABCDE or primary survey did not show any other abnormalities.

He was kept nil-by-mouth, IV maintenance fluids were started, and an urgent surgical referral was made. Antibiotics were not needed at this stage as there was no other supportive evidence of associated sepsis. He was prescribed PRN pain relief with fentanyl and morphine but did not require any during the ED stay.

The surgical team reviewed him and took him to the operating theatre for air enema reduction.

Authors

Prassana Nadarajah

Listen to the chapter

References

Scholer SJ, Pituch K, Orr DP, Dittus RS. Clinical outcomes of children with acute abdominal pain. Pediatrics. 1996;98(4):680-685. doi:10.1542/peds.98.4.680
Magnúsdóttir MB, Róbertsson V, Þorgrímsson S, Rósmundsson Þ, Agnarsson Ú, Haraldsson Á. Abdominal pain is a common and recurring problem in paediatric emergency departments. Acta Paediatr. 2019;108(10):1905-1910. doi:10.1111/apa.14782
Lee WH, O’Brien S, Skarin D, et al. Pediatric Abdominal Pain in Children Presenting to the Emergency Department. Pediatr Emerg Care. 2021;37(12):593-598. doi:10.1097/PEC.0000000000001789
Pant C, Deshpande A, Sferra TJ, Olyaee M. Emergency department visits related to functional abdominal pain in the pediatric age group. J Investig Med. 2017;65(4):803-806. doi:10.1136/jim-2016-000300
Simpson E, Smith A. The management of acute abdominal pain in children. Journal of Paediatrics and Child Health. 1996;32(2):110-112. doi:10.1111/j.1440-1754.1996.tb00905.x
Sadler TW, Langman J, Langman J. In: Langman’s Medical Embryology. Wolters Kluwer Health; 2012:208-229.
Cameron P, Brown G, Biswadev M, Dalziel S, Craig S. Textbook of Paediatric Emergency Medicine. Elsevier; 2019.
Reust CE, Williams A. Acute Abdominal Pain in Children. Am Fam Physician. 2016;93(10):830-836.
Yang WC, Chen CY, Wu HP. Etiology of non-traumatic acute abdomen in pediatric emergency departments. World J Clin Cases. 2013;1(9):276-284. doi:10.12998/wjcc.v1.i9.276
Kandamany N, O’Neill M. The Aetiology of Acute Abdominal Pain in Children 2–12 Years of Age. Archives of Disease in Childhood 2012;97:A478.
The Royal Children’s hospital melbourne. The Royal Children’s Hospital Melbourne. Accessed May 25, 2023. https://www.rch.org.au/kidsinfo/fact_sheets/Urine_samples/#:~:text=Clean%20the%20skin%20around%20the%20genital%20area%2C%20using%20gauze%20if,sample%20container%20touch%20the%20skin.
Vevaud K, Dallocchio A, Dumoitier N, et al. A prospective study to evaluate the contribution of the pediatric appendicitis score in the decision process. BMC Pediatr. 2024;24(1):131. Published 2024 Feb 19. doi:10.1186/s12887-024-04619-z
Bouënel M, Lefebvre V, Trouillet C, Diesnis R, Pouessel G, Karaca-Altintas Y. Determining clinical predictors to identify non-specific abdominal pain and the added value of laboratory examinations: A prospective derivation study in a paediatric emergency department. Acta Paediatr. 2023;112(10):2218-2227. doi:10.1111/apa.16911
Simon R.A, Hugh T.J, Curtin A.M. Childhood intussusception in a regional hospital. Aust N Z J Surg. 1994;64:699–702.

Reviewed and Edited By

Erin Simon, DO

Arif Alper Cevik, MD, FEMAT, FIFEM

Burns and Smoke Inhalation (2024)

December 9, 2024December 9, 2024 ~ iEM Education Project Team ~ Leave a comment

by Michaela Banks, Anthony Dikhtyar, Jacquelyne Anyaso, & Ashley Pickering

You have a new patient!

A 26-year-old male presents to the emergency department with burns on his face, arms, hands, and torso. He states that he was burning trash in his front yard without his shirt on when a big explosion occurred. He appears distressed and short of breath. The presence of singed nasal hairs is also noted. Examination reveals multiple partial- and full-thickness burns with blisters and surrounding redness. His vitals are as follows: HR: 130 BP (taken on R calf): 130/80 RR: 30 SpO2: 75%. His weight: 75kg

What do you need to know?

Importance

Burn injuries result from various sources and can range in severity. The mortality rate from thermal burns is directly related to the size of the burn [1]. Large and deep burns can trigger systemic responses, such as shock, which can lead to death. Three key risk factors that increase the likelihood of complications include: age over 60 years, inhalation injuries, and non-superficial burns (partial and full-thickness) covering more than 40% of the total body surface area (TBSA) [2].

Epidemiology

Burn injuries are a significant public health issue, with approximately 450,000 individuals seeking medical attention annually, and about 45,000 requiring hospitalization [2]. Residential fires are the leading cause of burn-related deaths, contributing to nearly 3,500 fatalities per year. Smoking materials, such as cigarettes, are the primary cause of fire-related deaths, while other fatal injuries stem from motor vehicle crashes, electrical contact, or exposure to chemicals. Men constitute 71% of burn patients, with children under five representing 17% [2]. Most burns occur at home (65%) and involve less than 10% total body surface area (67%). Advances in burn care have improved survival rates to 96% [2]. Roughly 86% of all burns are caused by thermal injury. Flame and scald burns are the leading causes of burns in children and adults. Inhalation injury is present in two-thirds of patients with burns greater than 70% of TBSA.

Pathophysiology

Burn injuries, caused by heat, chemicals, electricity, or radiation, trigger a complex interplay of local and systemic responses. At the cellular level, burn wounds are divided into three distinct zones: coagulation, stasis, and hyperemia. The central zone of coagulation undergoes irreversible cell death due to protein denaturation, necessitating surgical intervention in many cases. Surrounding it, the zone of stasis contains viable but at-risk cells that can either recover with proper care or progress to necrosis. The outer zone of hyperemia typically recovers fully within days due to its inflammatory response and intact blood flow [2-4].

Burns prompt a robust inflammatory response, increasing capillary permeability and causing fluid shifts that lead to edema. Local edema compromises blood flow and cell survival in the zone of stasis, while systemic edema in large burns contributes to hypovolemia, the primary cause of burn shock. Immediate and adequate fluid resuscitation is critical to prevent worsening injury and maintain organ perfusion [2-4].

Specific burn types exhibit unique pathophysiologies. Inhalation injuries from superheated gases or toxic smoke cause airway edema, inflammation, and potentially fatal complications like carbon monoxide poisoning and ARDS [5]. Chemical burns differ by agent, with acids causing coagulation necrosis and alkalis leading to deeper liquefaction necrosis. Electrical burns often involve extensive internal damage along the current’s path, risking cardiac arrhythmias and systemic effects. Radiation burns, though rarer, involve cellular damage through ionizing radiation exposure [2-4].

Systemically, extensive burns induce a hypermetabolic state, immune suppression, and systemic inflammatory responses affecting multiple organs. Cardiovascular effects, such as burn shock, respiratory compromise, and heightened infection risks, are key complications. Patient outcomes hinge on factors like burn depth, TBSA, age, inhalation injury presence, and quality of initial management, underscoring the importance of specialized burn center care.

Burn Depth

Burn depth classification is fundamental to assessing burn injuries, guiding treatment decisions, and predicting outcomes. Accurate determination of burn depth, particularly for partial-thickness burns, remains challenging, even for skilled clinicians. This underscores the need for continued research and advanced technologies to enhance diagnostic precision.

Traditionally, burns are categorized into four classes based on the extent of tissue damage [4]:

Superficial Thickness (First-Degree) Burns: These affect only the epidermis, presenting with redness, pain, and warmth without blistering. Healing occurs within a few days without scarring.
Partial-Thickness (Second-Degree) Burns: These penetrate the dermis and are subdivided into:
1. Superficial Partial-Thickness Burns: Involving the upper dermis, they are painful, moist, and blistered, typically healing within 2–3 weeks with minimal scarring.
2. Deep Partial-Thickness Burns: Reaching deeper dermal layers, these burns cause damage to sweat glands and hair follicles. They are less painful due to nerve damage, appear mottled and dry, and may require 3–8 weeks or longer to heal, often resulting in scarring or contractures.
Full-Thickness (Third-Degree) Burns: These burns destroy the entire epidermis and dermis, extending into subcutaneous tissue. They appear white, brown, or charred with a leathery texture and are insensate due to nerve destruction. Healing requires surgical intervention, such as skin grafting, and leaves significant scars.
Fourth-Degree Burns: Extending into muscles, bones, tendons, or ligaments, these burns are characterized by blackened tissue and often result in loss of the affected part.

These classifications provide a framework for clinicians to tailor interventions and anticipate patient needs, particularly in severe or complex burn cases. The illustration below displays the various categories of burn depth [4].

Medical History

Accurately gathering a burn history is critical for evaluating the injury’s severity, identifying risks, and tailoring management. The AMPLET mnemonic is widely recommended for systematic collection of essential information regarding the event and the patient’s medical background. Additionally, specific questions based on the type of burn provide crucial details for precise assessment and treatment [2-4, 6].

Allergies (A):
Identifying drug and environmental allergies is essential to avoid adverse reactions during treatment.

Medications (M):
A detailed list of current medications, including prescription drugs, over-the-counter remedies, herbal supplements, and home treatments, is vital to anticipate potential drug interactions or complications.

Past Medical History (P):
Knowledge of pre-existing conditions, such as diabetes, cardiovascular disease, lung disorders, or bleeding tendencies, helps predict how the patient may respond to burn injuries and resuscitation. Tetanus immunization status should also be reviewed and updated if necessary (see “T”).

Last Meal or Drink (L):
Documenting the patient’s last meal or drink is crucial for surgical planning, as recent food intake may require delays in procedures involving anesthesia.

Events/Environment Relating to Incident (E):
A detailed account of the burn incident helps identify the mechanism of injury, the risk of inhalation injury, and associated trauma. Important elements to document include:

Type of burn: Thermal, chemical, electrical, or radiation.
Cause of burn: Flame, scald, contact with hot objects, chemicals, or electricity.
Incident location: Indoor/outdoor, enclosed space, smoke presence.
Duration of exposure: Time spent in contact with the burn source.
First aid administered: Cooling, cleaning, or dressing of the burn before medical evaluation.
Suspicion of abuse or neglect: Look for inconsistencies in the history, patterns of injury, or delays in seeking care. Specific questions include:
- How did the burn occur?
- Who was present?
- How long to extinguish flames?
- Was the area cooled? With what and for how long?
- Were explosions, blasts, or chemical spills involved?
- Was the patient trapped or unconscious?

Tetanus and Childhood Immunizations (T):
Ensuring tetanus immunization is current (within five years) is crucial. In children, assessing overall immunization status helps anticipate potential complications.

Specific Questions Based on Burn Type [2-4,6]

Thermal Burns:

How did the burn occur?
What was the heat source (e.g., flame, scald, or hot object)?
Was clothing involved, and how quickly was it removed?
Was a flammable liquid (e.g., gasoline) involved?

Chemical Burns:

What was the chemical agent?
How did exposure occur, and how long was contact?
What decontamination measures were taken?
Is a Material Safety Data Sheet (MSDS) available?

Electrical Burns:

What type of electricity was involved (high voltage/low voltage, AC/DC)?
What was the duration of contact?
Was the patient thrown or did they fall?

Physical Examination

The physical examination of a burn patient is a systematic process designed to assess the severity of the burn injury, identify associated injuries or complications, and guide treatment decisions. A comprehensive and thorough examination is critical for determining the need for transfer to a burn center and predicting potential outcomes [2-6]. Make sure to assess for concomitant trauma (especially after a blast injury or fall).

First, perform decontamination if the person has been exposed to a chemical substance. If possible, expose the patient to a warm room. Immediately assess the airway, breathing, and circulation (ABCs), see details below.

Primary Survey

The primary survey prioritizes life-threatening conditions using the ABCDE approach [2,4,6]:

A. Airway

Assess for patency: Check for obstruction, swelling, or soot in the mouth and nose. Examine for posterior oropharynx edema and singed facial and nasal hairs carefully.
Listen for abnormal breath sounds: Stridor, wheezing, or decreased breath sounds may indicate inhalation injury or airway compromise.
Consider early intubation: Severe facial burns, inhalation injury, or altered mental status may necessitate securing the airway. Please do not delay airway procedure if you suspect inhalation injury.

B. Breathing

Assess respiratory rate and effort: Look for tachypnea, labored breathing, or cyanosis.
Auscultate lung sounds: Wheezing, rales, or rhonchi may suggest inhalation injury or pulmonary complications.
Administer high-flow oxygen: Use 100% oxygen via a non-rebreather mask, particularly for moderate to severe burns patients or patients with suspected inhalation injury.

C. Circulation

Monitor heart rate and rhythm: Look for tachycardia, bradycardia, or arrhythmias.
Measure blood pressure: Hypotension may indicate shock or blood loss.
Assess capillary refill and skin color: Delayed refill, pallor, or cyanosis indicates poor perfusion.
Establish IV access: Insert two large-bore IVs for moderate to severe burn patients, particularly for burns covering >20% TBSA.
Control bleeding: Bleeding suggests additional injuries.

D. Disability

Assess level of consciousness: Use the AVPU scale (Alert, Verbal, Pain, Unresponsive) or Glasgow Coma Scale (GCS).
Evaluate neurological status: Check pupils, motor strength, and sensation.

E. Exposure and Environmental Control

Remove clothing and jewelry: Fully expose the patient to assess burns but prevent further constriction.
Identify deformities: Look for fractures or dislocations.
Maintain warmth: Use clean, dry sheets and blankets to prevent hypothermia.

Secondary Survey

Once the primary survey stabilizes life-threatening conditions, conduct a detailed evaluation [2,4]:

A. History
Obtain a complete history using the AMPLET mnemonic, covering allergies, medications, past medical history, last meal, events surrounding the burn, and tetanus immunization status (see Medical History above).

B. Head-to-Toe Examination

Head and Neck: Assess for burns, singed hair, soot, inhalation injury, corneal damage, and tympanic membrane injury.
Chest: Listen to breath sounds, observe chest expansion, and evaluate for circumferential burns that may impair breathing.
Abdomen: Inspect for burns, palpate for tenderness, and consider the risk of abdominal compartment syndrome with circumferential burns.
Extremities: Look for burns, fractures, diminished pulses, or signs of compartment syndrome. Assess sensation and motor function.
Genitalia and Perineum: Inspect for burns and swelling, and assess urinary retention.
Back and Buttocks: Examine these areas during log rolling, ensuring full exposure and injury identification.

C. Burn Wound Assessment

Burn size: Estimate TBSA using the Rule of Nines (see images below) [7] or the Lund and Browder chart.
Burn depth: Classify burns as superficial, partial-thickness (superficial or deep), full-thickness, or fourth-degree. Note that burn depth may evolve over time (see figure about burn depth above).
Document wound characteristics: Describe color, texture, moisture, blisters, and eschar.

Burns are classified into degrees based on the depth of tissue damage, with each classification displaying distinct pathophysiological features, clinical findings. The following section covers specific clinical information related to burn depth.

Superficial (First-Degree) Burns
Superficial burns involve only the epidermis, the outermost layer of the skin. These burns are characterized by warm, dry, and red areas that blanch with pressure. Blistering is absent, and the skin typically heals within a few days without scarring. Sunburn is a classic example of a superficial burn.

Partial-Thickness (Second-Degree) Burns
Partial-thickness burns extend beyond the epidermis into the dermis and are further divided into superficial and deep categories.

Superficial Partial-Thickness Burns: These burns affect the upper dermis and are very painful. Surrounding erythema, moisture, and blistering are common features. These burns blanch when pressed and typically heal with minimal scarring in 2–3 weeks.
Deep Partial-Thickness Burns: These penetrate deeper into the dermis, potentially damaging sweat glands and hair follicles. They are less painful due to nerve ending destruction and appear drier, with a mottled red or white surface that does not blanch. Healing takes longer and often results in scarring or contractures. Scalds and flash burns are typical causes of partial-thickness burns.

Full-Thickness and Beyond (Third- and Fourth-Degree) Burns
Full-thickness burns destroy the entire epidermis and dermis, often extending into subcutaneous fat and, in severe cases, deeper structures such as muscle and bone (fourth-degree burns). These burns result in decreased sensation due to nerve destruction. The affected areas appear white, brown, or leathery, with a dry texture, and they do not blanch when pressed. Examples include chemical burns, electrical burns, fully immersed thermal burns, and severe frostbite. Healing requires surgical intervention, such as skin grafting, and significant scarring is inevitable.

Clinical Images of Selected Burn Injuries

Acing Diagnostic Testing

The diagnostic approach to burn patients varies based on the severity of the burn, the suspected complications, and the presence of associated injuries. A systematic evaluation using targeted laboratory tests and imaging helps guide treatment decisions and monitor potential complications.

Patients with Minor Burns

For patients with minor burns and no associated injuries, laboratory testing is generally unnecessary unless other trauma or medical conditions are present.

Patients with Moderate to Severe Burns

Moderate to severe burns necessitate a more comprehensive diagnostic evaluation [2,6]:

Complete Blood Count (CBC): Assesses anemia, infection, or thrombocytopenia.
Comprehensive Metabolic Panel (CMP): Monitors electrolyte imbalances, fluid shifts, and kidney or liver function.
Creatine Kinase (CK): Detects muscle damage.
Arterial Blood Gases (ABG) and Carboxyhemoglobin Levels: Essential for suspected inhalation injury to evaluate oxygenation, carbon monoxide poisoning, and acidosis.
Blood Cyanide Levels: Performed if cyanide poisoning is suspected, though results may take time. Treatment is often initiated based on clinical suspicion [2].
Serum Lactate: Elevated levels indicate tissue hypoperfusion, inadequate resuscitation, or exposure to carbon monoxide or cyanide [6].
Coagulation Studies: Identifies coagulopathies, which are common in severe burns.
Chest X-Ray (CXR): Evaluates lung damage in inhalation injury and confirms endotracheal tube placement in intubated patients [2,6].

Patients with Electrical Burns

Electrical burns require specialized evaluation due to the unique nature of the injuries:

Electrocardiogram (EKG): Necessary for detecting cardiac dysrhythmias, especially in high-voltage injuries. Patients with abnormal EKG findings should be observed until normalization [6].
Creatine Kinase (CK): Elevated levels indicate rhabdomyolysis caused by muscle damage [6].
Urinalysis: Detects myoglobinuria, a sign of rhabdomyolysis, which can impair kidney function. However, urinalysis has limited specificity [6].

Imaging for Burn Patients

Imaging studies provide critical insights, particularly for inhalation or electrical injuries:

Chest X-Ray (CXR): Evaluates lung damage in inhalation injury and confirms endotracheal tube placement in intubated patients. Useful for identifying pulmonary complications, such as pneumothorax, and confirming intubation tube placement [6].
Fiberoptic Bronchoscopy: A definitive tool for diagnosing inhalation injury, revealing findings like soot, edema, mucosal blisters, and hemorrhages [5].
Chest CT Scan: Offers detailed imaging of lung injuries and is particularly helpful when CXR findings are inconclusive [5].

Risk Stratification

Burn injuries are categorized as minor, moderate, or severe based on several factors that help predict outcomes and guide management. These include the depth of the burn, the percentage of total body surface area (TBSA) affected, and the age of the patient, with burns in individuals under 10 years or over 50 years considered more severe. The presence of associated injuries, such as smoke inhalation or other traumas, also increases the severity. Burns involving high-risk areas—the face, hands, feet, or genitalia—are particularly concerning due to their potential impact on function, aesthetics, and quality of life.

Risk Stratification Criteria

Minor
- Adults: Partial-thickness burns affecting < 15% TBSA
- Pediatrics: Partial-thickness burns affecting < 10% TBSA
- No full-thickness burns
- No involvement of the face, hands, feet, or genitalia
- No cosmetic impairment
- Note: Superficial burns are not included in TBSA calculations.
Moderate
- Adults: Partial-thickness burns affecting 15–20% TBSA
- Pediatrics: Partial-thickness burns affecting 10–15% TBSA
- Full-thickness burns affecting < 10% TBSA
- No involvement of the face, hands, feet, or genitalia
- No cosmetic impairment
Severe
- Adults: Any burn depth affecting > 25% TBSA
- Pediatrics: Any burn depth affecting > 20% TBSA
- Full-thickness burns affecting > 10% TBSA
- Involvement of the face, hands, feet, or genitalia
- Cosmetic impairment
- Circumferential burns: Burns extending completely around the chest or a limb:
  - Can cause compartment syndrome or increased pressure in the affected area.
  - This is particularly dangerous in the chest, where it can restrict breathing and may require escharotomy (incisions into the burned tissue) to relieve the pressure.

Referral to a Burn Center
Referral to a specialized burn center is recommended based on the following criteria from the American Burn Association (ABA) [8]:

Partial-thickness burns >10% TBSA.
Burns involving the face, hands, feet, genitalia, perineum, or major joints.
Full-thickness (third-degree) burns in any age group.
Electrical or chemical burns.
Inhalation injury.
Burns in patients with pre-existing conditions that complicate management.
Burns with concomitant trauma or special care needs.

Management

Effective management of burn patients begins with prompt stabilization of the airway, breathing, and circulation (ABC). Airway management is critical in cases of full-thickness facial burns, significant soot in the nose or mouth, hoarseness, stridor, respiratory depression, or altered mental status. In such scenarios, establishing a definitive airway through endotracheal intubation is necessary to prevent airway compromise. Breathing should be assessed by monitoring oxygen saturation and providing supplemental oxygen as needed to address hypoxemia, especially in patients with inhalation injuries. Circulation assessment involves evaluating distal pulses, particularly in patients with circumferential burns, which may restrict blood flow and necessitate escharotomy. For burns exceeding 20% TBSA, prompt initiation of intravenous fluid (IVF) resuscitation is essential to maintain hemodynamic stability and prevent burn shock. This systematic approach ensures early intervention to mitigate life-threatening complications. Extensive details on primary and secondary survey was given in the physical examination section.

General Principles in Management of Burns

Burn management follows consistent principles across all mechanisms of injury, prioritizing first aid, pain control, and fluid resuscitation.

First Aid

Immediate first aid involves removing the causative agent and any clothing, jewelry, or objects that may retain heat or constrict circulation. Cooling the affected area with water is effective for small burns but must be used cautiously with larger burns to prevent hypothermia [9].

Analgesia

Burn injuries and wound care are extremely painful, making pain management a critical component of care. Opioid pain medications should be considered to provide adequate relief, particularly for severe burns or during dressing changes [2,6].

Fluid Resuscitation

Fluid replacement is essential for patients with extensive burns to prevent hypovolemia and burn shock. Adults with partial- or full-thickness burns covering >20% TBSA require fluid resuscitation, while this threshold is lower (>10% TBSA) for pediatric and elderly patients [2,6].

Two common formulas guide fluid calculations:

Parkland Formula: Volume (mL) = 4 × weight (kg) × % TBSA burned. Half of the total volume is given in the first 8 hours, and the remaining half over the subsequent 16 hours.
Modified Brooke Formula: Volume (mL) = 2 × weight (kg) × % TBSA burned for adults, or 3 × weight (kg) × % TBSA burned for children, administered evenly over 24 hours.

Hartmann’s solution or lactated Ringer’s is the preferred replacement fluid. Fluid titration, based on urine output, ensures appropriate volume without overloading:

Adults: Maintain urine output at 0.5–1.0 mL/kg/hour.
Pediatrics: Maintain urine output at 1.0–1.5 mL/kg/hour.

Fluid resuscitation is a dynamic process requiring hourly re-evaluation to ensure adequacy and prevent complications [2,6]. The fluid rate must be carefully titrated based on the patient’s urinary output and physiological response. Hourly urine output, measured using an indwelling bladder catheter, serves as a reliable indicator of resuscitation adequacy in patients with normal renal function.

Adults: Maintain urine output at 0.5 mL/kg/hour (approximately 30–50 mL/hour).
Young Children (≤30 kg): Target 1 mL/kg/hour.
Pediatric Patients (>30 kg, up to age 17): Maintain output at 0.5 mL/kg/hour.
Adults with High-Voltage Electrical Injuries and Myoglobinuria: Ensure a urine output of 75–100 mL/hour until urine clears.

This individualized approach to fluid management helps maintain renal perfusion, ensures effective resuscitation, and minimizes the risk of under- or overhydration.

Thermal Burns

Thermal burns occur when excessive heat is applied to the skin, resulting in tissue destruction. Initially, this process may cause inflammation and initiate the healing response. However, if the heat intensity or duration is sufficient, coagulative necrosis ensues, leading to irreversible cell death and localized tissue loss. The severity and type of burn depend on various factors, including the heat source, duration of exposure, and depth of tissue involvement.

The treatment of thermal burns varies based on severity [2, 6, 10].

Minor burns are managed by cleaning the area and applying topical aloe and a barrier dressing. Pain is controlled with oral analgesics, such as NSAIDs or acetaminophen/paracetamol. Patients can be discharged with outpatient follow-up for wound monitoring.

Moderate burns require cleaning with water and debridement of large blisters. Wound care involves the application of a topical antibiotic with a dressing or an antibiotic-impregnated bandage. Pain management may include oral or intravenous analgesia, with narcotics as needed. Fluid resuscitation, either oral or intravenous, is determined by the percentage of total body surface area (%TBSA) affected. Tetanus immunization should be updated if the last dose was over 10 years ago. Consultation with a burn specialist is advised, with possible admission or transfer to a burn center.

Severe burns necessitate cleaning with water, pain management with oral or intravenous analgesia, and application of a dressing without antibiotics or ointments if transfer to a burn center is confirmed. Intravenous fluid resuscitation is essential, along with prompt referral and admission to a burn center. Circumferential full-thickness burns may require escharotomy to prevent complications such as compartment syndrome.

Electrical Burns

Electrical burns can present with a wide range of injuries due to the effects of electrical current and the conversion of electrical energy into thermal injury. High-voltage electrical exposure can also result in blunt trauma caused by the patient being propelled away from the electrical source.

Extent of injuries depends on the voltage type:

Low voltage: Commonly seen in children who come into contact with electrical cords or outlets.
High voltage: Typically occupational injuries from power lines or utility poles, often leading to deep tissue and organ damage.
Lightning: Frequently occurs during outdoor recreational or work activities, especially in rainy seasons.

Deep tissue injury assessment:
Patients presenting with full-thickness burns, painful passive range of motion, and elevated creatine kinase (CK) levels should be presumed to have deep tissue injury.

These patients require fluid resuscitation and referral to a burn center when possible.

Muscle damage results in a breakdown known as rhabdomyolysis, which can lead to renal failure and multi-organ failure if not treated promptly.

Management [2,3,11]

General Principles

Cardiac Monitoring: Patients with suspected electrical burns should undergo continuous cardiac monitoring for 12–24 hours to detect dysrhythmias.
Compartment Syndrome Monitoring: Close monitoring is essential for signs of compartment syndrome.
Stress Ulcer Prophylaxis: Administer proton pump inhibitors (PPIs) or H2 blockers, especially in patients who are NPO, as electrical burns carry a higher risk of ulcer formation compared to other burns.

Analgesia

Severe pain from deep tissue injuries often necessitates IV narcotic analgesia.

Fluids

Initiate fluid resuscitation with 1L/hr isotonic fluids in adults.
Avoid using the Parkland or Modified Brooke formula, as the %TBSA burned does not accurately reflect the extent of deep tissue injury in electrical burns.
Titrate fluid administration to maintain urine output:
- Adults: 100 mL/hr
- Children: 1.5–2 mL/kg/hr

Referral
Patients with suspected deep tissue injury should be referred to a burn center when available to ensure comprehensive care.

Chemical Burns

Superficial chemical burns may conceal deeper tissue injuries, making them more challenging to assess than thermal burns. Tissue damage is often underestimated, necessitating frequent reassessment of wounds and clinical status.

Management [2,12]

Fully expose the patient as soon as possible to minimize ongoing tissue damage. Providers should wear personal protective equipment (PPE) before starting decontamination.
Copious irrigation is critical and should be performed immediately, continuing for at least 30 minutes or until neutral skin or eye pH is achieved (using serial litmus paper).
Exceptions to irrigation: Dry lime, elemental metals, and phenol require alternative treatments instead of water irrigation.
Patients with chemical burns should be referred to a burn center for specialized care.

Radiation Burns

Cutaneous manifestations of radiation exposure have a slower onset compared to thermal burns [2,13]. Symptoms such as erythema, calor (warmth), and pruritus may appear hours to days after exposure.
Waxing and waning of symptoms:
- A latent phase without visible cutaneous symptoms often follows initial erythema, calor, and pruritus (1–2 days post-exposure).
- A second wave may occur days to a week later, presenting as erythema, calor, pruritus, desquamation, ulceration, or necrosis.
- Subsequent waves of symptoms are more common with potent radiation forms (e.g., beta- and gamma-waves), occurring months post-exposure.
High radiation doses are associated with systemic effects, including hair loss and acute radiation syndrome (ARS):
- ARS symptoms include loss of appetite, fatigue, headache, nausea, vomiting, and diarrhea.

Management

Anti-inflammatory medications should be administered during the latent phase when cutaneous symptoms are absent.
As with chemical burns, all patients with significant radiation burns should be referred to a burn center for evaluation and management.

Inhalation Injuries

General Overview

Inhalational injuries are a leading cause of mortality in burn patients. They are commonly associated with thermal injuries, which cause upper airway edema, and chemical injuries, which result in damage to the lower airway and lung parenchyma.

Assessment

Evaluating for inhalational injuries involves identifying key clinical signs, such as soot in the oropharynx, singed facial hair, or other indications of airway compromise. For chemical burns, determining the substances burned or combusted is critical to understanding the nature of the injury. Diagnostic tools include obtaining arterial blood gas (ABG) analysis and chest X-ray when available to assess respiratory function and lung involvement.

Management [2,5]

Maintaining a Patent Airway

Ensuring a clear airway is critical in burn patients. Prompt airway management is crucial in inhalational injuries. A low threshold for endotracheal intubation is necessary in cases of airway compromise, severe burns, or full-thickness/circumferential burns involving the chest or neck. If progressive airway edema is observed, fiberoptic intubation is preferred, provided it is available. Given the rapid progression of airway edema, early intubation is advised to prevent airway obstruction and ensure adequate ventilation.

Oxygen Therapy
Patients with suspected inhalation injuries should receive humidified 100% oxygen via a non-rebreather mask immediately. This is particularly important in cases of carbon monoxide poisoning, as high-flow oxygen effectively reduces carboxyhemoglobin levels, improving oxygen delivery to tissues.

Fluid Resuscitation
Inhalation injuries increase fluid requirements beyond those predicted by burn size alone. Fluid resuscitation must be carefully balanced to avoid under-resuscitation, which risks hypoperfusion, and over-resuscitation, which can lead to complications such as pulmonary edema or compartment syndrome.

Medications
Several medications may be employed to address specific symptoms:

Bronchodilators: Relieve bronchospasm and improve airway patency.
Mucolytics: Help thin and loosen mucus, facilitating its clearance from the airways.
Nebulized Heparin: Prevents fibrin cast formation in the airways, reducing the risk of airway obstruction.

Ventilatory Support

Mechanical ventilation may be required for patients with severe respiratory compromise. Ventilator settings must be carefully optimized to prevent ventilator-induced lung injury. Techniques such as low tidal volume ventilation and high-frequency percussive ventilation may offer benefits in managing patients with compromised pulmonary function.

This comprehensive approach ensures effective airway management and respiratory support in burn patients with inhalation injuries.

Special Patient Groups

Pediatric Patients

Thermal Burns

Fluid Resuscitation:
- In addition to using the Parkland formula for fluid replacement, pediatric patients require maintenance intravenous fluids (mIVF) to meet baseline hydration needs.
- Children under 5 years of age should have glucose added to their mIVF to prevent hypoglycemia.

Electrical Burns

The majority of management principles are similar to those for adults.
Oral Burns:
- Oral burns, often caused by chewing on electrical cords, require special attention. Burns at the commissure (corner of the lips) have a high risk of bleeding due to erosion of the labial artery.
- All significant oral burns should be admitted for observation and plastic surgery consultation to prevent and manage complications.

Pregnant Patients

Electrical Burns

For pregnant patients with electrical burns, obstetric consultation is essential to assess maternal and fetal health.
Continuous monitoring of fetal heart tones is necessary to evaluate the well-being of the fetus following an electrical injury.

When To Admit This Patient

The American Burn Association released updated guidelines in December 2022 for burn patient referral and management.

According to these guidelines:

Moderate to Severe Burns: Patients with moderate to severe burns, as defined by burn depth and total body surface area (TBSA), require hospital admission for comprehensive burn staging and treatment.
Minor Burns: Patients with minor burns, such as superficial burns or those involving <10% TBSA superficial partial-thickness burns, can be managed in an outpatient setting.

To prevent secondary infection, patients discharged with minor burns must have access to appropriate topical ointments and dressings. Patients with partial-thickness burns should undergo regular wound checks following discharge to monitor healing and prevent complications.

Revisiting Your Patient

The patient’s burns were classified as moderate to severe, and he was intubated due to the presence of singed nasal hairs and significant respiratory distress. Using the Rule of 9s, the total burn area was calculated to be 31.5% TBSA, including the face (4.5%), the front of both arms and hands bilaterally (4.5% each), and the torso (18%).

Given the depth of the burns, lactated Ringer’s IV resuscitation was initiated, with a target of delivering 4725 mL in the first eight hours, as calculated using the Parkland formula. A Foley catheter was placed, and urine output was titrated to 0.5 mL/kg/hr. The patient also received IV analgesia and was subsequently transferred to a burn center for further management.

Authors

Michaela Banks

Michaela Banks is a current resident at Louisiana State University in New Orleans in Emergency Medicine. She graduated with a degree in Psychology and Global Health from Duke University and went on to obtain her MD and MBA from the University of Virginia. During residency, she has become particularly interested in burns and outcomes, and gave an oral presentation on the “Association Between Compliance with an Organized State Burn Triage Center and Burn Outcomes” at ACEP 22. Michaela also serves on the Emergency Medicine Residents’ Association Board of Directors.

Anthony Dikhtyar

Dr. Dikhtyar is a graduate of St. George’s University School of Medicine and recently matched into Emergency Medicine at TriStar Skyline Medical Center in Nashville, TN. His professional interests include medical education, medical photography, and global health in the former Soviet Union. His most recent publications can be found in the Visual Journal of Emergency Medicine.

Jacquelyne Anyaso

Jackie Anyaso, MD, MBA is a second-generation Nigerian immigrant born and raised in Chicago, Illinois. She attended medical school at the University of Illinois at Chicago and will be completing her emergency medicine training at Harvard-Affiliated Emergency Residency Program. Her ultimate goal is to serve vulnerable populations in efforts to reduce healthcare disparities. Her clinical interests include critical care medicine, global health, and the intersection between medicine and business. Outside of medicine, she enjoys community service, traveling, and spending time with family and friends.

Ashley Pickering

Before medical school I had a diverse career path, which included biomedical engineering, outdoor education, working as an EMT on a Colorado ski patrol, and critical care nursing. I lived out west for 15 years, mainly in CO, and went to medical school at University of Arizona in Tucson before moving to Baltimore for residency at University of Maryland. Currently I am a Global Emergency Medicine Fellow at University of Colorado. Throughout my training I have found ample opportunities to pursue my interest in building emergency care globally. I have researched the barriers to accessing emergency care in rural Uganda, helped to provide emergency care training in Sierra Leone and Liberia and am currently the Executive Director of Global Emergency Care a non-profit training non-physician clinicians in Uganda. My current focus is on quality of emergency care in LMICs. I am working on an WHO Emergency Care Toolkit implementation project which explores the impact of basic emergency care educational and process improvements on clinical indicators of quality, as well as the experiences patients and staff.

Listen to the chapter

References

Jeschke MG, Mlcak RP, Finnerty CC, et al. Burn size determines the inflammatory and hypermetabolic response. Crit Care. 2007;11(4):R90. doi:10.1186/cc6102
American Burn Association. (2018). Advanced Burn Life Support Course Provider Manual 2018 Update. https://ameriburn.org/wp-content/uploads/2019/08/2018-abls-providermanual.pdf
Schaefer TJ, Szymanski KD. Burn Evaluation And Management. [Updated 2022 Aug 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430741/
Jeschke MG, van Baar ME, Choudhry MA, Chung KK, Gibran NS, Logsetty S. Burn injury. Nat Rev Dis Primers. 2020;6(1):11. Published 2020 Feb 13. doi:10.1038/s41572-020-0145-5
Foncerrada G, Culnan DM, Capek KD, et al. Inhalation Injury in the Burned Patient. Ann Plast Surg. 2018;80(3 Suppl 2):S98-S105. doi:10.1097/SAP.0000000000001377
Emergency Care of Moderate and Severe Thermal Burns in Adults. UpToDate. Feb. 2023. https://www.uptodate.com/contents/emergency-care-of-moderate-and-severe-thermal-burns-in-adults?topicRef=349&source=see_link#H4430737.
Department of Health. Determining Total Body Surface Area. From: https://www.health.state.mn.us/communities/ep/surge/burn/tbsa.pdf Accessed December 1, 2024.
Guidelines for Burn Patient Referral. From: https://ameriburn.org/resources/burnreferral/ Accessed: December 1, 2024.
Burns. WikiEM. 21 Nov. 2021; 4:1-2. https://wikem.org/wiki/Burns#Evaluation.
Treatment of Minor Thermal Burns. UpToDate. Feb. 2023. https://www.uptodate.com/contents/treatment-of-minor-thermal-burns#H20.
Electrical injuries and lightening strikes: Evaluation and management. UpToDate. Mar 2023. https://www.uptodate.com/contents/electrical-injuries-and-lightning-strikes-evaluation-and-management#H3065280448
Topical chemical burns: Initial assessment and management. UpToDate. Mar 2023. https://www.uptodate.com/contents/topical-chemical-burns-initial-assessment-and-management
Cutaneous Radiation Injury (CRI): A Fact Sheet for Clinicians. 4 Apr. 2018. https://www.cdc.gov/nceh/radiation/emergencies/criphysicianfactsheet.htm
Guidelines for Burn Patient Referral. From: https://ameriburn.org/wp-content/uploads/2023/01/one-page-guidelines-for-burn-patient-referral-16.pdf

FOAm and Further Reading

Burns. Stanford Medicine: Healthcare. https://stanfordhealthcare.org/medical-conditions/skin-hair-and-nails/burns.html

http://www.webmd.com/first-aid/tc/burns-topic-overview

http://www.nationalburnservice.co.nz/emergencyplan.htm

https://flippedemclassroom.wordpress.com/2012/12/02/burn/

http://www.mdcalc.com/parkland-formula-for-burns/#about-equation

Reviewed and Edited By

Erin Simon, DO

Arif Alper Cevik, MD, FEMAT, FIFEM

How to Interpret C-Spine X-ray (2024)

December 7, 2024December 7, 2024 ~ iEM Education Project Team ~ Leave a comment

by Maitha Mohammed Alneyadi & Mansoor Masarrat Husain

Introduction

Cervical spine x-ray interpretation is a vital skill in emergency medicine. This is particularly important as cervical spine injuries can leave patients with permanent neurological damage or death. While CT scans have overtaken X-rays as the primary form of cervical spine imaging, X-rays can be handy in rural areas or areas with limited resources. If in doubt, always ask for an expert opinion.

Cervical spine injuries commonly arise from motor vehicle accidents or falls from heights. They more commonly occur in men, and worse outcomes often happen to patients with underlying degenerative changes. Mechanisms of injuries causing fractures include flexion, extension, rotational, or vertical compression—these will be elaborated on further in this chapter. Cervical spine x-rays are somewhat useful if the patient is awake, stable, and has isolated injuries. In addition, they can be ordered in patients with upper airway obstruction symptoms, to look for soft tissue infections, foreign body demonstration, or if there is neck pain with no significant trauma.

Remember, cervical spine x-rays require manipulation of the neck to get clear views. Consider an alternative diagnostic choice like CT (Computed Tomography) or MRI (Magnetic Resonance Imaging) if cervical spine movement is restricted by a cervical collar. X-rays are also not advisable when neurological symptoms are present following trauma, in an uncooperative patient, or when a more accurate radiological modality is easily available.

Plain radiographs that display the lateral projection of the cervical spine, along with an open mouth view, are quite effective at identifying cervical spine fractures. Statistics indicate that the risk of overlooking a significant fracture is less than 1%. Including the anteroposterior (AP) projection raises the sensitivity to almost 100%. All three essential projections mentioned above can be seen in the figure below.

Before analyzing cervical radiographs, some additional facts need to be presented. Most spinal injuries occur at the junctions of the spine: craniocervical, cervicothoracic, thoracolumbar, and lumbosacral.

The only c-spine radiograph one should be satisfied with is the one showing all seven cervical vertebrae (C1–Th1). The C7–Th1 vertebrae may be obscured in muscular or obese patients, or in patients with spinal cord lesions that affect the muscles that normally depress the shoulders. Such lesions, which leave the trapezius muscle unopposed, occur in the lower cervical region. Shoulders can be depressed by pulling the arms down slowly and steadily or, if the patient is capable, by asking them to depress one shoulder and lift the other hand above their head to achieve the swimmer’s position, which better visualizes the lower vertebrae.

We will now present a systematic method for interpreting cervical spine x-rays. First, identification—make sure details are correctly matched to the patient by name, date of birth, record number, and the time the scan was done. Use an old x-ray of the patient as a comparison if the study has been done previously.

Interpretation

We utilize the ABCD system to comprehensively interpret cervical spine X-rays.

A: Alignment and adequacy
B: Bones
C: Cartilages
D: Dense soft tissue

Cervical spine X-rays typically include three views: the lateral view (or cross-table view), the odontoid view (or open mouth view), and the anterolateral view. If the lateral view is inadequate, an additional view called the “Swimmer’s view” may be requested to visualize the C7 and T1 vertebrae.

Lateral View

A: Adequacy and Alignment

An adequate image includes the base of the skull to the upper border of T1.

There are four parallel lines to note, from front to back (See image on the left, Courtesy of Dr Hussain Aby Ali). The front line (in purple), referred to as the anterior longitudinal line, runs along the anterior border of the vertebrae.

The second line, or the middle line, referred to as the posterior longitudinal line (in yellow), runs along the posterior border of the vertebrae.

Next, the spinolaminar line (in green) runs between the spinous process and lamina, along the anterior edge of the spinous process.

Lastly, the posterior spinous line (in blue) runs smoothly along the tips of the spinous processes.

The spinal cord lies between the posterior spinous and spinolaminar lines. Disruption of any of these lines indicates a fracture [1].

An important exception to the usual guidelines involves pseudo-subluxation of C2 and C3 in the pediatric population, which can lead to confusion. In these cases, it is essential to examine the spino-laminar line from C1 to C3. Be cautious of injury if the base of the C2 spinous process is more than 2 mm away from this line. Additionally, correlate your findings with any relevant soft tissue observations (see below under “D”).

On the lateral view, also assess the predental space, which is the distance between the anterior surface of the odontoid process and the posterior aspect of the anterior ring of C1. This distance should not exceed 3 mm in adults or 5 mm in children (see image below).

B: Bones

Examine the vertebrae for a normal bony outline and bone density. It is important to note any subtle changes in bone density, as these may indicate a compression fracture. Areas with decreased bone density are more vulnerable to fractures and are often seen in patients with conditions such as rheumatoid arthritis, osteoporosis, or metastatic osteolytic lesions. Acute compression fractures, in contrast, typically present as areas of increased bone density.

To check the integrity of the vertebrae, we must trace each vertebra individually. If there are any irregularities in the cortex of the bone, there may be a fracture.

As you trace the vertebrae on the right side (the image above), you may note that the sixth vertebra has slipped forward and is not continuous, which is an example of a vertebral fracture.

This is followed by scanning vertebrae C3–C7 in the usual manner, with no specific shadows or rings. The rest of the vertebral spaces must be equal, with a rectangular shape. Follow the spinous processes to look for any fractures [1].

Other examples are given below. See the fracture on 7th vertebral body (image A below), and fracture on spinous process of the 7th vertebrae (image B below).

Let us zoom in into the same image and focus on C1 and C2.

Start your day with a coffee—or rather, a coffee bean shadow—when interpreting c-spines. This shadow corresponds to the anterior arch of the atlas found in C1. Bear in mind that the peg might get in your way. With that, make sure the coffee bean shadow is adjacent to the odontoid peg. If not, think of a fracture!

When looking at C2, trace the ring, referred to as Harris’ ring (black color in the image above), which is the lateral mass of the vertebra. Discontinuity of the ring demonstrates a fracture.

C: Cartilage space assessment

n the assessment, examine the disc spaces, facet joint spaces, and interspinous spaces for any misalignments or increased space. Subluxations or facet dislocations can be identified by disruptions in the demarcated boxes, while any interspinous height exceeding 50% of the vertebral body indicates ligament disruption. On a good-quality lateral view x-ray of a healthy person, uniform intervertebral spaces should be evident.

An emergency physician may diagnose subluxations and dislocations of the facet joints by assessing the cartilage space between the vertebral corpora, facet joints, and spinous processes. However, increased interspinous distance by more than 50% suggests a ligamentous injury, and protective muscle spasms may complicate interpretation.

D: Dense soft tissue

Subsequently, we check the prevertebral space (in yellow), with the trachea sitting right in front of it (in red) (see the image below, courtesy of Hussain Aby Ali). Take C4 as your reference point (in purple). As a rule of thumb, the prevertebral space at or above C4 should be less than one-third the width of the vertebral body, while below C4 it should measure less than the width of the adjacent vertebra. In pediatrics, the prevertebral space at C4 is 7 mm, and at C6 it measures 14 mm or less, depending on age. In adults, the prevertebral space at C6 measures 22 mm. Enlarged measurements may indicate a hematoma related to a fracture, although normal measurements do not rule out a fracture [1].

The prevertebral soft tissues can serve as an indicator of acute swelling or hemorrhage resulting from an injury, and in some cases, may be the only indicator of an acute injury visible on an x-ray. The normal width of the prevertebral tissue decreases from C1 to C4 and increases from C4 downward. Normal measurements are less than 7 mm from C1 to C4 (less than half the vertebral body width at this level) and less than 22 mm below C5 (less than the vertebral body width at this level, as shown in Figure 9). The presence of air within the soft tissue could suggest a rupture of the esophagus or trachea.

Odontoid – Open Mouth View

A: Adequacy and Alignment

The odontoid x-ray is typically the second standard view obtained in the emergency department. Its primary goal is to visualize the odontoid process of the C2 vertebra and the C1 vertebra. This view can be taken with the patient’s mouth either open or closed.

When examining the odontoid x-ray, two key aspects are assessed: first, the distance between the odontoid process and the lateral masses of the C1 vertebra should be equal. If there is an inequality, it may indicate a slight rotation of the head. Second, considering the previous point, the margins of the C1 and C2 vertebrae should remain aligned.

The distance between the odontoid process and the lateral masses of the C1 should be equal, if not inequality may be due to the slight rotation of the head. (If the patient has the upper central incisor teeth, we can check if the space between those two teeth aligns with the middle of the odontoid process, this might give the slight idea about rotation in case process itself is not broken and misaligned). Even with the slight rotation of the head we can still check alignment by looking at the lateral margins of the C1 and C2, which should remain aligned.

B: Bones

The odontoid view is most helpful for assessing peg fractures and examining the lateral masses and spaces at C1 and C2. Start by drawing a line from the end of the lateral mass (in purple), along the shaft, up around the odontoid peg, and down to the other lateral end (in green), which marks C2. Next, demarcate C1’s lateral masses on each side and look for any irregularities or fractures.

C: Cartilage space assessment

The space between the peg and C1’s lateral masses must be equal (green asterisks), as should the spaces between C1 and C2 lateral masses (blue asterisks). Unequal lateral mass spaces could raise suspicion of subluxation, which may indicate that the transverse ligament holding the peg in place is torn. Alternatively, consider a Jefferson fracture, which will be discussed later in this chapter.

Draw an imaginary line along the lateral edges of C1 and C2, and check for any misalignment or displacement (red circles). It is important to note that when a patient’s cervical spine is rotated, the images may be inaccurate due to artifacts, which could be misconstrued as fractures, as shown in the image below [1].

An inappropriate imaging angle can result in an inconclusive image. In such cases, you may notice unequal spaces between the odontoid and C1 lateral masses, even when no underlying fractures are present. This situation should prompt a discussion with the radiologist or the consideration of further imaging, such as a CT scan or MRI.

Beware of the Mach effect!
The Mach effect is an optical illusion that can occur during imaging interpretation. It creates the appearance of a lower density at specific levels of the odontoid peg, which may falsely mimic an odontoid fracture. This illusion arises from the way edges and contrasts in the image are perceived by the human eye, often giving the impression of a discontinuity or fracture when none is present. It is crucial to recognize this phenomenon to avoid misdiagnosis, especially when interpreting odontoid fractures on radiographs. Careful examination and, if needed, correlation with additional imaging modalities such as CT or MRI can help confirm the true nature of the findings.

Anteroposterior View

A: Adequacy and Alignment

Images taken in this projection are usually less clear than the two mentioned above. The tips of the spinous processes should lie in a straight line along the midline, and the distances between the spinous processes should also be checked. Anomalies, such as bifid spinous processes, can complicate interpretation. The laryngeal and tracheal shadows should align down the middle, and the alignment of the lateral masses of the vertebrae should also be assessed.

An adequate image includes the vertebral bodies of the cervical vertebrae along with the superior border of the thoracic vertebrae. Vertical lines running across and along the spinous processes and vertebral bodies help assess alignment. Three lines are particularly important: the spinous process line (in blue), which runs through the spinous processes of C1 to C7, ensuring vertical alignment, and two lateral lines (in green), which run smoothly along the transverse processes, confirming their normal alignment.

B: Bones

The anteroposterior (AP) view of the cervical spine is one of the standard projections used during imaging. It is taken with the x-ray beam directed from the front (anterior) to the back (posterior) of the neck. While it provides a general overview of the alignment of the vertebrae and highlights features such as the spinous processes and transverse processes, this view may not always clearly demonstrate fractures.

Fractures, especially those involving the odontoid peg, vertebral bodies, or certain types of subtle cortical disruptions, can be challenging to detect due to the overlapping structures in this projection. Additionally, anomalies such as misalignment or crowding of the spinous processes might not be easily discernible. As a result, this view is often supplemented with lateral or oblique views and, in cases of doubt, with advanced imaging techniques like CT or MRI for a more definitive diagnosis.

The AP view remains an important tool for assessing gross abnormalities, vertebral alignment, and pathological conditions, such as tumors or significant bone density changes. However, its limitations in detecting subtle fractures underscore the need for careful correlation with clinical findings and additional imaging.

C: Cartilage space assessment

In an AP cervical spine x-ray, the assessment of cartilage spaces is crucial for evaluating alignment and potential injuries. A key rule to follow is the 50% rule: any increase in the cartilage space by more than 50% compared to adjacent spaces suggests anterior cervical dislocation. This finding is often associated with trauma, such as ligamentous injury or vertebral subluxation, but it is important to note that the 50% rule does not apply in cases of muscle spasm, particularly when the neck is in a flexed position.

To confirm the diagnosis and exclude vertebral slippage, it is essential to examine the lateral view. The lateral view provides additional details regarding the vertebral alignment, anterior displacement, and associated injuries that may not be visible on the AP view. Ensuring that the vertebrae are properly aligned without slippage is vital for accurate assessment and diagnosis.

By correlating findings from both the AP and lateral views, a clearer picture of cervical spine integrity can be obtained, helping to differentiate between conditions caused by trauma and those related to positional factors or muscle spasms.

D: Dense soft tissue

In the AP cervical spine view, it is important to assess for the presence of surgical emphysema or pneumothorax, as these findings can indicate significant underlying trauma.

Surgical Emphysema: Look for evidence of air trapped in the soft tissues of the neck. This appears as dark, radiolucent (black) streaks in areas where soft tissues should normally appear opaque. Surgical emphysema in the cervical region can result from tracheal or esophageal injury, penetrating trauma, or fractures that disrupt the airways. Its presence warrants immediate attention and further investigation to locate the source of the air leakage.

Pneumothorax: Although primarily evaluated using a chest x-ray, a pneumothorax might be visible on an AP c-spine x-ray, especially if significant. This is seen as an absence of lung markings on the affected side, with a radiolucent (black) space outlining the lung. Pneumothorax may occur in association with rib fractures or blunt trauma extending to the thoracic region and can contribute to respiratory distress.

Other Views

Swimmer’s view

When C7 or T1 is not clearly visible on the lateral view due to dense body musculature, obtaining a “Swimmer’s view” can be helpful. This imaging technique specifically focuses on the alignment of C7 and T1 at the cervico-thoracic junction. To achieve this view, patients are instructed to lower the shoulder on the same side as the area being examined [5].

Flexion and Extension Views

Oblique and flexion/extension views are not recommended in the emergency department setting as they can lead to further neurological injuries caused by manipulation. These views are only useful when interpreted by an experienced physician. Flexion and extension views are often contraindicated due to suspected unstable trauma or are impossible to perform because of spastic musculature following the injury (see Figure below). Additionally, unsupervised or forced flexion or extension in a patient with ligamentous injury can result in significant neurological damage. Therefore, other imaging modalities are necessary when a suspected injury is present.

Abnormal findings on cervical spine x-rays

C1 (Jefferson) fracture

A C1 fracture, also known as a Jefferson fracture, is best visualized on the odontoid view. This type of fracture typically results from axial loading, such as a heavy blow to the top of the head. The force compresses the cervical spine, leading to fractures in both the anterior and posterior arches of C1. These fractures are considered unstable because the transverse ligament, which stabilizes the relationship between the odontoid peg (dens) and the lateral masses of C1, is often disrupted.

Key imaging findings include widened spaces between the odontoid peg and the lateral masses of C1 (marked by orange asterisks). Additionally, the lateral masses of C1 may appear misaligned with those of C2 (marked by green circles), indicating instability [6]. The widening of these spaces and misalignment reflects the ligamentous injury and mechanical instability associated with this fracture.

Due to its unstable nature, a Jefferson fracture requires prompt recognition and further imaging, such as CT scans, to confirm the diagnosis and assess the extent of injury. Management often involves immobilization or surgical intervention, depending on the severity of the ligament disruption and alignment abnormalities.

C2 fractures

Odontoid peg fracture

To identify a C2 fracture, it is essential to evaluate both the open mouth (odontoid) view and the lateral view, as these complementary perspectives provide critical information about the integrity of the C2 vertebra.

Open Mouth (Odontoid) View:
This view is particularly useful for assessing the odontoid peg, also known as the dens. A discontinuity of the peg process, as shown in the image above, is a hallmark feature of a C2 fracture. This disruption indicates a break in the odontoid peg, which is often caused by significant trauma. The open mouth view allows for a clear examination of the alignment and spacing between the odontoid peg and the lateral masses of C1, helping to confirm the fracture.
Lateral View:
The lateral view provides additional details about the alignment and integrity of the C2 vertebra. In cases of a C2 fracture:
- Alignment Disruption: The normal alignment of the vertebral bodies is disturbed, indicating instability.
- Harris Ring Discontinuity: The Harris ring, a radiographic marker of the lateral mass of C2, appears interrupted, further confirming the presence of a fracture.
- Posterior Displacement of the Odontoid Peg: The odontoid peg may be displaced posteriorly, which can compromise the spinal canal and potentially compress the spinal cord.

Types of Odontoid Fractures

The graphical presentation above illustrates the three types of odontoid fractures, as labeled below:

Type I:

Location: Fracture at the tip of the dens.
Associated Injury: Alar ligament avulsion.
Stability: This is considered a stable fracture.

Type II:

Location: Fracture at the base of the odontoid process.
Stability: This is an unstable fracture. It is the most common type of odontoid fracture and is associated with a high risk of nonunion due to poor blood supply at the fracture site.

Type III:

Location: A fracture extending through the body of the axis (C2), curving laterally from one end to the other.
Stability: This is also considered an unstable fracture. These fractures may disrupt the lateral masses of C2, further compromising spinal stability.

Recommended Management

CT Scan: If any of these fractures are suspected or identified on plain x-rays, a CT scan is recommended for further evaluation to define the fracture line and assess the extent of bony disruption.
Immobilization: The cervical spine should be immobilized using a cervical collar (c-collar) to prevent further injury.
Consultation: Immediate consultation with neurosurgery is advised, as surgical intervention may be required, especially for unstable fractures (Type II and III).

These fractures, particularly Type II and III, have significant clinical implications due to their instability and proximity to critical neural structures, necessitating prompt diagnosis and intervention.

Hangman's fracture

A Hangman’s fracture is a bilateral fracture of the pars interarticularis of the C2 vertebra, often resulting in cervical spine instability. This type of fracture is best visualized on a lateral view, which reveals key findings:

Loss of Smooth Anterior Alignment

The normal, smooth anterior alignment of the cervical spine is disrupted and replaced by a visible step, indicating displacement.

Cortical Discontinuity

The fracture causes a break in the cortical bone, further demonstrating structural instability of the vertebra.

Mechanism of Injury

Hyperextension Trauma
- This fracture is commonly caused by hyperextension injuries, such as those sustained in motor vehicle accidents.
- It is also seen in diving accidents, where a diver’s head strikes the pool floor upon impact.

Clinical Significance

Hangman’s fracture is classified as unstable, as it compromises the integrity of the C2 vertebra and its supporting structures, potentially endangering the spinal cord.

Management

Immediate immobilization of the cervical spine with a cervical collar is essential. Advanced imaging (CT or MRI) is recommended to further evaluate the extent of the injury and rule out associated soft tissue or ligamentous damage.
Consultation with a neurosurgeon is critical for determining the need for surgical stabilization.

Importance of Recognizing C2 Fractures

C2 fractures, such as odontoid fractures or hangman’s fractures, are critical injuries due to their proximity to the spinal cord and brainstem. Prompt recognition using the open mouth and lateral views is vital to avoid neurological complications. Advanced imaging techniques, such as CT or MRI, are often required for further evaluation and to guide management strategies, which may include immobilization or surgical intervention.

Extension Teardrop Fracture

An extension teardrop fracture is a specific type of cervical spine injury in which a portion of the antero-inferior corner of the vertebra is fractured, resembling a teardrop shape. This injury is most commonly observed at C3 and is highly significant due to its association with instability and potential neurological compromise.

Fracture Appearance

The fracture is located at the antero-inferior corner of the vertebral body, creating a teardrop-shaped fragment.

Mechanism of Injury

Caused by sudden hyperextension of the neck, which disrupts the anterior longitudinal ligament.
Often occurs in activities like diving, particularly when the diver strikes their head against a hard surface such as the pool floor.

Associated Injuries

This type of fracture is frequently associated with central cord syndrome, a neurological injury caused by compression of the spinal cord, leading to weakness more pronounced in the upper limbs than the lower limbs.

Management

Immediate Stabilization
- Apply a cervical collar (C-collar) to immobilize the spine and prevent further injury.
Imaging
- A CT scan is the imaging modality of choice to confirm the diagnosis, evaluate the extent of the fracture, and assess for additional injuries or spinal canal compromise.
- Consultation
  - Immediate consultation with a neurosurgeon is essential for determining the best treatment approach. Depending on the severity, surgical intervention may be necessary.

Flexion Teardrop Fracture

A flexion teardrop fracture is a severe and unstable cervical spine injury resulting from high-energy flexion trauma, frequently occurring at the C5/C6 level. This type of fracture is significant due to its association with spinal instability and neurological damage.

Radiographic Findings (Lateral View):

The three longitudinal lines (anterior, posterior, and spinolaminar lines) are disrupted, indicating misalignment and instability.
A teardrop-shaped fragment is seen at the antero-inferior corner of the vertebral body, representing the avulsed piece of bone.

Mechanism of Injury

Caused by hyperflexion of the neck, which exerts excessive force on the cervical spine.
This leads to a disruption of the posterior longitudinal ligament, further contributing to instability.

Neurological Association

The injury often results in anterior cervical cord syndrome, characterized by loss of motor function and pain/temperature sensation below the level of injury, with preserved proprioception and vibration senses.

Management

Immediate Stabilization
- Apply a cervical collar (C-collar) to immobilize the cervical spine and prevent further injury.
Advanced Imaging
- A CT scan is the preferred imaging modality to confirm the diagnosis, evaluate the extent of the fracture, and identify associated injuries such as spinal canal compromise or ligamentous disruption.
- MRI may be indicated to assess soft tissue and spinal cord involvement.
Consultation
- Urgent consultation with a neurosurgeon is essential due to the unstable nature of this fracture. Surgical stabilization is often required to restore spinal alignment and prevent further neurological deterioration.

Clinical Importance

The flexion teardrop fracture is considered one of the most unstable cervical spine injuries. Prompt recognition, immobilization, and appropriate surgical management are critical to improving patient outcomes and minimizing long-term neurological deficits.

Clay Shoveler's Fracture

A Clay Shoveler’s fracture is a stable fracture that involves an avulsion of the spinous process, typically occurring in the lower cervical or upper thoracic spine (most commonly at C6, C7, or T1).

Clinical Presentation

Patients present with localized pain and tenderness over the affected area.
The pain is often exacerbated by movement or palpation of the spine.

Stability

This is considered a stable fracture as it does not involve the vertebral body, spinal canal, or neurological structures. However, the injury can still cause significant discomfort and impair mobility.

Examination and Management

Neurological Assessment
- A neurological examination should always be performed to rule out any associated injuries or deficits, even though this fracture typically does not affect the spinal cord or nerves.
Immobilization
- The patient should be placed in a cervical collar (c-collar) to immobilize the spine and alleviate pain during the acute phase of the injury.
Imaging
- A lateral cervical x-ray is often sufficient to diagnose the fracture, but a CT scan can provide additional details if needed.
Treatment
- Since this is a stable fracture, management is typically conservative, including pain control, immobilization, and physical therapy as needed.

Clay Shoveler’s fractures are generally associated with good outcomes, and patients can recover fully with appropriate care and immobilization.

Retropharyngeal abscess

Patients with a retropharyngeal abscess often present with:

Sore throat and fever.
Torticollis: The head is tilted to one side due to neck stiffness and discomfort.
Dysphagia: Difficulty swallowing.
Respiratory Distress: Severe cases may manifest with stridor, drooling, or increased breathing effort with retractions, indicating a compromised airway.

Management

Immediate Interventions
- Patients in respiratory distress should be closely monitored as the airway may become obstructed, necessitating emergency airway management, including the potential need for a surgical airway (e.g., tracheostomy).
Specialist Consultation
- A prompt otolaryngology consult is warranted for evaluation, incision and drainage (I&D) of the abscess, and initiation of intravenous antibiotics.

Radiographic Assessment

Measuring the Retropharyngeal Space
- The retropharyngeal space is evaluated using lateral cervical spine x-rays.
- Between C2 and C4, the vertebral bodies can be divided into thirds. The retropharyngeal space should not exceed one-third the width of the corresponding vertebral body.
- At C4 and below, the vertebral bodies should be divided in half, with the prevertebral space width being approximately equal to the anterior half of the vertebral body [8].
Signs of Retropharyngeal Abscess
- Widening of the retropharyngeal space beyond normal parameters is highly suggestive of an abscess.
- Additional findings may include air-fluid levels, soft tissue swelling, or displacement of adjacent structures.

Epiglottitis

Epiglottitis is a rapidly progressive and potentially life-threatening disease that primarily affects the upper airway. Patients often present with:

Fever and sore throat as initial symptoms.
Drooling and difficulty swallowing (dysphagia).
Inspiratory stridor, indicating partial airway obstruction.

These symptoms suggest an urgent need for airway evaluation and management.

Lateral Neck X-ray

The hallmark finding is the “thumb sign”, which represents the swollen epiglottis.
Swelling of the epiglottis and aryepiglottic folds is characteristic of this condition.
The epiglottis appears enlarged and rounded, resembling the shape of a thumb.

Importance of Early Recognition

Epiglottitis can rapidly progress to complete airway obstruction, particularly in children.
It is critical to recognize these findings on a lateral neck x-ray and act promptly to secure the airway.

Management

Patients showing signs of airway obstruction require immediate attention, with priority given to securing the airway. In severe cases, this may involve intubation, preferably using fiberoptic intubation in a sitting position, or tracheostomy if necessary. This procedure should be performed collaboratively with ENT surgeons and anesthesia professionals in a controlled environment.

As a temporary measure, nebulized racemic epinephrine can be administered to reduce airway swelling, and broad-spectrum antibiotics should be started promptly to treat the underlying infection. Supportive care, such as humidified oxygen, may also be beneficial. Additionally, a nasopharyngoscopy should be performed to directly visualize the epiglottis and assess the extent of swelling.

Laryngotracheobronchitis (Croup)

Laryngotracheobronchitis, commonly referred to as croup, presents with characteristic symptoms including:

Barking cough, often likened to a seal’s bark.
Inspiratory stridor, indicating upper airway obstruction.
Drooling or dysphagia, in some cases.
Signs of increased work of breathing, such as retractions and nasal flaring.

These symptoms are typically caused by inflammation and narrowing of the subglottic airway, often following a viral infection.

Radiographic Findings

An anteroposterior (AP) neck x-ray may reveal the steeple sign, which represents narrowing of the subglottic trachea [10].
The steeple sign is considered pathognomonic for croup, though it is also occasionally observed in bacterial tracheitis.
A neck x-ray is not required for diagnosing croup but may be helpful to confirm the diagnosis when the patient is stable and cooperative [11].

While croup is usually a clinical diagnosis, imaging may be considered in atypical presentations or to rule out other conditions like epiglottitis or retropharyngeal abscess. Prompt recognition of croup and appropriate management can prevent complications associated with airway obstruction.

Clinical Decision Rule

There are two widely used scoring systems for neck injuries, primarily for diagnostic purposes: the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine rules (CCR). Both have high sensitivity (89% and 98%, respectively) but low specificity (39% and 16%, respectively) [12]. Neither tool is used for patients over 65 years of age.

The NEXUS criteria can be easily remembered using the mnemonic NSAID:

N: Neurological deficit
S: Spine tenderness, midline
A: Altered mental state
I: Intoxicated
D: Distracting injury

A positive finding in any of these categories requires imaging.

The Canadian C-spine rule, on the other hand, categorizes patients into two groups based on severity: high risk and low risk. It uses a stepwise, question-based approach. Patients who are 65 years or older, those with a high-risk mechanism of injury, or those presenting with neurological symptoms always require imaging.

Refer to the diagram for a simplified explanation.

Specific Patient Groups

Pediatrics

Younger patients have anatomical differences compared to adults, including a larger head, incomplete ossification of the vertebrae, and firm attachment of the ligaments to the spine, which predispose them to injuries. Poor balance and a flexible spine further increase the risk of injury. As children reach the age of 8, their balance improves, and the injury rates decrease.

Nevertheless, pediatric patients can sustain spinal cord syndromes similar to those in adults, which may cause lifelong disabilities. Examples include central cord syndrome, anterior cord syndrome, posterior cord syndrome, Brown-Séquard syndrome, and spinal shock. The decision to perform imaging and the modality chosen are based on criteria similar to those used for adults.

In pediatric trauma patients, the ABCDE trauma evaluation must be followed, as with adults. An important entity to consider is SCIWoRA (Spinal Cord Injury Without Radiographic Abnormality), which is defined specifically for children under 8 years of age. This condition occurs when hyperextension forces injure the neck, leading to neurological deficits without abnormalities detected on x-rays or CT scans. MRI is required to assess the severity and prognosis. Favorable MRI findings include small hematomas and edema, whereas large hematomas or spinal cord transections are considered unfavorable [13].

Geriatrics

Motor vehicle accidents and falls from standing or sitting positions remain the two most common causes of cervical spine injuries in geriatric patients [14]. Due to anatomical degenerative changes and low bone density, even low-energy mechanisms can result in high-impact injuries. CT scanning is recommended for evaluating suspected cervical spine injuries in geriatric patients, who should always be considered trauma patients.

Pregnant Patients

Pregnant individuals involved in trauma require standard trauma protocols for evaluation and treatment, including CT imaging. Although CT imaging exposes both the mother and fetus to radiation, this exposure is not associated with an increased risk of fetal anomalies. However, the use of CT imaging should be carefully considered, with discussions involving the patient or their family, the radiologist, and a senior physician [15].

Authors

Maitha Mohammed Alneyadi

Emergency Medicine Department, Tawam Hospital, Al Ain, United Arab Emirates

Mansoor Masarrat Husain

Emergency Medicine Department, Tawam Hospital, Al Ain, United Arab Emirates

Listen to the chapter

References

Raby N, Berman L, Morley S, Gerald De Lacey. Accident & Emergency Radiology: A Survival Guide. Saunders; 2015, P. 171-198
Hurley CM, Baig MN, Callaghan S, Byrne F. Cervical spine hangman fracture secondary to a
gelastic seizure. BMJ Case Reports. 2019;12(8):e230733. doi: https://doi.org/10.1136/bcr-2019-230733
Gaillard F. Cervical spine fractures. Radiology Reference Article. Radiopaedia.org. Radiopaedia. https://radiopaedia.org/articles/cervical-spine-fractures
Czarniecki M, Niknejad M. Mach effect – mimicking odontoid fracture. Radiopaediaorg. Published online November 24, 2012. doi: https://doi.org/10.53347/rid-20528
Murphy A. Cervical spine (swimmer’s lateral view). Radiopaediaorg. Published online October 7, 2016. doi: https://doi.org/10.53347/rid-48437
Erskine J Holmes, Misra RR. A-Z of Emergency Radiology. Cambridge University Press; 2006, P. 23-31
Harvey H. Flexion teardrop fracture. Radiology Reference Article. Radiopaedia.org. Radiopaedia. https://radiopaedia.org/articles/flexion-teardrop-fracture-1?lang=us
Sheikh Y, Bickle I. Retropharyngeal abscess. Published online July 13, 2014. doi:https://doi.org/10.53347/rid-30018
Sutton AE, Guerra AM, Waseem M. Epiglottitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; October 5, 2024.
Murphy A, Gaillard F. Croup. Radiopaediaorg. Published online May 2, 2008. doi: https://doi.org/10.53347/rid-1185
Gaillard F. Steeple sign (trachea). Radiology Reference Article. Radiopaedia.org. Radiopaedia. https://radiopaedia.org/articles/steeple-sign-trachea?lang=us
Vazirizadeh-Mahabadi M, Yarahmadi M. Canadian C-spine Rule versus NEXUS in Screening of Clinically Important Traumatic Cervical Spine Injuries; a systematic review and meta-analysis. Arch Acad Emerg Med. 2023;11(1):e5. Published 2023 Jan 1. doi:10.22037/aaem.v11i1.1833
Szwedowski D, Walecki J. Spinal Cord Injury without Radiographic Abnormality (SCIWORA) – Clinical and Radiological Aspects. Pol J Radiol. 2014;79:461-464. Published 2014 Dec 8. doi:10.12659/PJR.890944
Lomoschitz FM, Blackmore CC, Mirza SK, Mann FA. Cervical spine injuries in patients 65 years old and older: epidemiologic analysis regarding the effects of age and injury mechanism on distribution, type, and stability of injuries. AJR Am J Roentgenol. 2002;178(3):573-577. doi:10.2214/ajr.178.3.1780573
Irving T, Menon R, Ciantar E. Trauma during pregnancy. BJA Educ. 2021;21(1):10-19. doi:10.1016/j.bjae.2020.08.005

FOAM and Further Reading

http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_spinal/x-ray_c-spine_normal

http://reference.medscape.com/features/slideshow/c-spine#8

http://www.slideshare.net/Rajaoct/x-ray-cspine

Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

Intraosseous (IO) Lines/Access (2024)

December 5, 2024December 7, 2024 ~ iEM Education Project Team ~ Leave a comment

by Yousif Al-Khafaji & Mustak Dukandar

Introduction

Obtaining intravascular access in the emergency department is one of the most essential steps in managing critically ill patients. While it is a simple step for most patients, it can be the most challenging procedure during resuscitation. The pediatric population has more body fat, making it difficult to localize their veins. In addition, they have tiny peripheral veins that easily collapse in states of shock. On the other hand, in adults, patients who are obese, those who suffer from extensive burns, or are in shock challenge the clinician in obtaining vascular access [1].

Intraosseous (IO) access involves inserting a hollow needle through the cortex of the bone and into the medullary space. This allows clinicians to infuse fluids, medication, or almost anything that can be administered through the intravenous (IV) route and achieve the same desired effect as the IV route. The IO line is merely a bridging tool to buy the clinician time to obtain IV access. In most cases, IO access is a simple procedure, and clinicians should not hesitate to insert an IO line if peripheral IV access attempts fail.

IO lines can safely remain in place for up to 24 hours and are often a bridge to either IV or Central Venous line placement.

Indications

There are clear indications for IO access. Each of these indications highlights the critical role of IO lines in emergency medicine, providing a swift and effective solution for vascular access in life-threatening situations [3]. When IV access cannot be achieved, IO access is safe, reliable, and quick. It can be accomplished in 30 to 60 seconds and even faster with an IO gun. This is especially helpful in pediatric emergencies when time is critical.

Emergency intravascular access when other methods have failed
IO access is indicated when IV access is not achievable in critical situations, such as trauma, shock, or severe dehydration. In critically ill patients, a maximum of two failed attempts is generally considered sufficient to shift to IO access. The IO line provides a rapid and reliable alternative to IV lines for administering fluids, medications, or blood products directly into the vascular system via the bone marrow [4].

Cardiac arrest
During cardiac arrest, time is critical, and establishing vascular access can be challenging. IO access is often used to administer life-saving medications like epinephrine when IV access cannot be obtained quickly. It ensures the rapid delivery of drugs into circulation during resuscitation [5].

Obtaining blood for laboratory evaluation
IO access allows for the collection of blood samples for laboratory testing, including complete blood count, electrolytes, and blood gas analysis [6]. This is especially useful in emergency situations where traditional venipuncture is impractical or impossible.

Contraindications

Physicians should be aware of a couple of important complications. These contraindications emphasize the importance of careful site selection and patient evaluation before performing IO access to minimize complications and maximize the effectiveness of the procedure [1].

Fractured bone
A fracture at the intended site of IO access is an absolute contraindication. Using a fractured bone for IO infusion can result in extravasation of fluids and medications, potentially worsening the injury and causing further complications.

Infection or burn overlaying insertion site
Localized infection or burns at the insertion site pose a significant risk of introducing pathogens into the bone marrow, leading to osteomyelitis or systemic infection. These conditions are absolute contraindications for IO placement.

Prior use of the same bone for IO infusion
Repeated use of the same bone for IO access can damage the bone marrow and structure, increasing the risk of complications such as extravasation or impaired drug delivery. A different site should be chosen for subsequent IO insertions.

Osteoporosis and osteogenesis imperfecta
These conditions result in fragile bones, increasing the likelihood of fractures or other complications during needle insertion. Alternative access methods should be considered for patients with these conditions.

Administration of ultra-short-acting medications like adenosine (relative contraindication)
Medications like adenosine, which rely on rapid systemic distribution, may not be as effective when administered via IO access due to potential delayed uptake into circulation. This is a relative contraindication, depending on the clinical scenario.

Equipment and Patient Preparation

Equipment

IO Needle

Ranges from 15-18 gauge needles
Color coding is common:
- Pink (15 mm): For patients weighing 3–39 kg
- Blue (25 mm): For patients ≥3 kg and above
- Yellow (45 mm): For patients ≥40 kg, excessive tissue, or dense bone sites (e.g., proximal humerus or anterior superior iliac spine)

IO Devices (to facilitate insertion)

Powered IO Drills (e.g., EZ-IO)
Manual IO Drills (e.g., Cook IO Needle or Jamshidi-type needle)

Skin Disinfectants

Chloraprep
Alcohol swabs
Optional: Povidine or Chlorhexidine

Syringe and Flush Materials

Saline flush (crystalloid solution, e.g., normal saline or lactated Ringer’s)
Intravenous tubing

Lidocaine 2% (without epinephrine)

For topical and subcutaneous infiltration in awake patients, as they may experience pain during fluid infusion rather than needle insertion.

Additional Equipment

Infusion pump (to regulate fluid delivery)
Tape (for securing the IO line)

Patient Preparation

Informed Consent
- Obtain informed consent by explaining the procedure, its benefits, and associated risks to the patient or their guardians. In emergency situations where consent cannot be obtained, implied consent applies.
Site Selection
- Choose the most appropriate insertion site based on the clinical scenario. Common sites include:
  - Humeral Head
  - Proximal Tibia
  - Medial Malleolus
  - Sternum
  - Distal Radius
  - Distal Femur
  - Anterior Superior Iliac Spine
- Note: The proximal tibia and humeral head are most commonly used during cardiac arrest as these locations do not interfere with other life-saving procedures like intubation [7].
Contraindication Assessment
- Ensure there are no contraindications (e.g., fractures, infections, burns, prior IO use at the same site, or certain bone conditions) at the intended site of insertion.
Site Exposure
- Properly expose the selected insertion site to facilitate accurate placement and reduce the risk of contamination.
Universal Precautions
- Apply universal precautions, such as wearing gloves at a minimum, to maintain aseptic conditions during the procedure.

Sites of IO insertion and some hints [8]

Proximal Tibia
- 2 finger breadths below the tibial tuberosity (1-3 cm) on the medial, flat aspect of the tibia.
- Commonly used for ease of access, especially in emergencies.
Distal Tibia
- Medial surface at the junction of the medial malleolus and the shaft of the tibia, posterior to the greater saphenous vein.
Proximal Humerus (Adults only; use the yellow needle)
- Preparation:
  - Keep the arm adducted and internally rotated (rest the patient’s hand on their bellybutton).
  - Slide fingers up the humerus until you feel the notch (surgical neck).
- Insertion:
  - Insert the IO needle 1 cm above the surgical neck into the greater tubercle.
  - Immobilize the arm to prevent displacement of the IO line (avoid shoulder abduction).
Distal Femur
- Primarily used in infants and children due to easier bone access and growth plate considerations.
Pelvic Anterior Superior Iliac Spine (ASIS)
- An alternative site, especially when lower extremity or upper extremity sites are unavailable.
Sternum
- Provides the highest flow rate of any location, making it suitable for rapid infusions during critical situations.

Procedure Steps

Preparation
- Identify the designated site using a sterile gloved finger.
- Disinfect the overlying skin using appropriate antiseptic (e.g., chlorhexidine).
- Administer local anesthetic if the patient is awake.
- Ensure the stylet is properly positioned on the needle prior to insertion.
- Prepare necessary equipment, including a 20 ml saline syringe, IV tubing, tape, medications, fluids, and infusion pump.
Needle Insertion
- Insert the needle perpendicularly through the skin down to the bone.
- Use an IO drill or manually twist the needle clockwise with firm, gentle pressure until a “give” is felt (loss of resistance), indicating entry into the marrow.
- Ensure the needle locks into place.
Confirmation of Placement
- The needle should stand upright without additional support if properly positioned.
- Remove the stylet and attach a syringe.
- Aspirate to confirm the presence of marrow or blood (not always visible).
- Gently flush the line with saline while observing for swelling at or around the insertion site.
Troubleshooting
- If swelling occurs or the test injection fails, remove the IO needle and repeat the procedure on a different site.
Securing and Using the IO Line
- If Io works properly, stabilize the needle using tape or gauze padding as necessary.
- Attach IV tubing to the needle hub.
- Begin infusion of fluids, blood products, or medications.
- If the patient is awake and experiences pain during infusion, administer lidocaine through the IO line for analgesia [2].

Complications [9]

Extravasation of Fluid

Occurs when fluid or medication leaks into surrounding soft tissues instead of the bone marrow cavity. This can cause localized swelling, tissue damage, and discomfort. Proper placement and observation for swelling during infusion are essential to avoid this complication.

Compartment Syndrome

Results from increased pressure within a muscle compartment due to extravasation of fluid. It can compromise blood flow, leading to tissue ischemia and potential necrosis. Immediate recognition and corrective action are necessary to prevent long-term damage [10].

Bone Fracture

More common in patients with pre-existing bone disorders, such as osteoporosis or osteogenesis imperfecta. Improper needle insertion technique can increase the risk of fracturing the bone at the insertion site. Physicians should be careful when inserting IO lines in small children because too much pressure during drilling may cause fractures.

Osteomyelitis

A rare but serious complication involving infection of the bone and marrow. This risk increases if aseptic technique is not followed or if there is a pre-existing infection near the insertion site.

Preventative Measures:

Use strict aseptic technique to minimize infection risks.
Properly assess the patient’s bone health and contraindications before insertion.
Monitor the insertion site for early signs of complications, such as swelling or pain, during and after infusion

Hints and Pitfalls

Purpose and Time Limit

IO access is a bridging tool used to buy time for obtaining peripheral or central IV access.
IO needles should not remain in place for more than 24 hours, as the risk of complications increases significantly after that time frame.

Site and Device Selection

Always use an uninjured limb for IO placement; if no uninjured limb is available, the sternum is preferred.
An IO drill or gun is recommended over manual insertion for consistent and reliable placement.
Needle selection must be appropriate for the selected site and the marrow cavity to ensure proper access.

Needle Placement and Security

IO needle displacement can sometimes occur, especially in pediatric patients with soft bones; this can be mitigated by securing the needle to the skin properly.
The anterior superior iliac spine may be considered as an alternative site in cases of soft bone structures.

Medication and Dosage

Any medication that can be administered via IV access can also be given through IO access without dose adjustment, as the bioequivalence between IO and IV routes is similar. [11,12]

Laboratory Sampling

Lab tests with good correlation from IO samples include hemoglobin/hematocrit, chloride, glucose, urea, creatinine, and albumin.
Other lab values, such as WBC, platelets, serum CO2, sodium, potassium, and calcium, may not correlate well with venous samples. [13]

Special Patient Groups

Pediatrics

Challenges: In pediatric patients, the bones can sometimes be too soft, which increases the risk of needle displacement even when placed correctly.
Recommendation: To mitigate this risk, consider using the anterior superior iliac spine as an alternative site. This site may provide a more stable placement in cases where traditional sites like the tibia are less effective.

Geriatrics

Challenges: Older adults often have pre-existing bone disorders such as osteoporosis, which make their bones more fragile.
Risks: IO insertion in such patients can lead to fractures, especially if not performed with careful technique and appropriate needle selection.
Recommendation: Perform a thorough assessment of bone health and use alternative vascular access methods if significant bone fragility is present.

Pregnant Patients

Considerations: There are no contraindications for IO insertion in pregnant women. This makes IO access a viable option during emergencies where quick vascular access is necessary.
Precautions: Ensure that the chosen site does not interfere with obstetric care and consider patient positioning to maintain comfort and safety during the procedure.

Authors

Yousif Al-Khafaji

Chief Emergency Medicine Resident - Tawam Hospital, Al Ain, UAE

Mustak Dukandar

Tawam Hospital Emergency Department

Listen to the chapter

References

Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Car-Elsevier (2017), chapter 25
ATLS Student course manual Tenth Edition (2018). Appendix G, 351
Phillips L, Brown L, Campbell T, et al. Recommendations for the use of intraosseous vascular access for emergent and nonemergent situations in various healthcare settings: a consensus paper. J Emerg Nurs. 2010;36(6):551-556. doi:10.1016/j.jen.2010.09.001
Oksan D, Ayfer K. Powered intraosseous device (EZ-IO) for critically ill patients. Indian Pediatr. 2013;50(7):689-691. doi:10.1007/s13312-013-0192-z
Leidel BA, Kirchhoff C, Bogner V, et al. Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Saf Surg. 2009;3(1):24. Published 2009 Oct 8. doi:10.1186/1754-9493-3-24
Tallman CI, Darracq M, Young M. Analysis of intraosseous blood samples using an EPOC point of care analyzer during resuscitation. Am J Emerg Med. 2017;35(3):499-501. doi:10.1016/j.ajem.2016.12.005
Wampler D, Schwartz D, Shumaker J, Bolleter S, Beckett R, Manifold C. Paramedics successfully perform humeral EZ-IO intraosseous access in adult out-of-hospital cardiac arrest patients. Am J Emerg Med. 2012;30(7):1095-1099. doi:10.1016/j.ajem.2011.07.010
Day MW. Intraosseous devices for intravascular access in adult trauma patients. Crit Care Nurse. 2011;31(2):76-90. doi:10.4037/ccn2011615
ACLS provider Manual Supplementary Material (2016). Intraosseous Access, 57-61
Vidal R, Kissoon N, Gayle M. Compartment syndrome following intraosseous infusion. Pediatrics. 1993;91(6):1201-1202.
Faga, M., & Wolfe, B. (2016). Vascular access in hospitalized patients. Hospital Medicine Clinics, 5(1), 1-16.
Von Hoff, D.D., Kuhn, J.G., Burris, H.A. 3rd, & Miller, L.J. (2008). Does intraosseous equal intravenous? A pharmacokinetic study. Am J Emerg Med, 26, 31-38
Miller LJ, Philbeck TE, Montez D, Spadaccini CJ. A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med. 2010;134(9):1253-1260.

FOAM and Further Reading

Arrow EZ Intraosseous Insertion Proximal Humerus Video: https://www.youtube.com/watch?v=o4A-T4A80uQ

Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

Intracerebral Hemorrhage (2024)

December 5, 2024December 7, 2024 ~ iEM Education Project Team ~ Leave a comment

by Muhammad I. Abdul Hadi, Iskasymar Ismail, Kamarul Baharuddin, and Erin Simon

You have a new patient!

A 60-year-old female was brought to the Emergency Department (ED) with a complaint of sudden onset of left-sided body weakness associated with facial asymmetry and vomiting. She was known to have hypertension. On arrival, she was drowsy with a Glasgow Coma Scale of 13/15 (E3, V4, M6). Her pupils were equal and reactive.

Her vital signs were as follows: blood pressure 210/118 mmHg, heart rate 96 beats per minute, respiratory rate 20 breaths per minute, oxygen saturation 98% on room air, and afebrile. Her left upper limb and lower limb examination showed hyperreflexia and reduced motor power to 0/5. Her left plantar response was extensor. Her right upper and right lower limbs were unremarkable. Capillary blood sugar was 9.3 mmol/L.

What is your differential diagnosis and outline your management?

What do you need to know?

Importance

Altered mental status (AMS) is a neurological emergency with many differential diagnoses. A general approach to AMS is to look for structural or metabolic causes. The most common structural cause of AMS is an acute stroke. Stroke can be classified into two major categories: ischemic and hemorrhagic. Hemorrhagic stroke can be further divided into two types: intracerebral hemorrhage (ICH) and subarachnoid hemorrhage [1]. ICH is associated with poor functional outcomes and carries high morbidity and mortality. In addition, most patients who survive an ICH have disabilities and cognitive decline and are at risk for recurrent stroke.

Patients with ICH can present with an abrupt onset of focal neurological signs. The clinical features typically evolve over minutes to a few hours. However, in subarachnoid hemorrhage, the symptoms are typically maximal at onset [2]. Depending on the volume of the hemorrhage, location, and the extent of the affected brain tissue, the patient may experience vomiting, headache, hemiparesis, hemisensory loss, facial weakness, aphasia, dysarthria, visual disturbance, and AMS when the hemorrhage is significant. However, the patient may not have those typical symptoms if the hemorrhage is small and in an uncommon site.

Signs of significant elevation of intracranial pressure (ICP) due to mass effect or herniation from ICH are:

Unequal pupil size
Dilated pupils
Comatose
Cushing triad (bradycardia, respiratory depression, hypertension)

Epidemiology

ICH is a neurological emergency case that is frequently encountered in ED. It is the second leading cause of stroke, accounting for up to 27 percent of all stroke cases globally. There are over 12.2 million new strokes each year, and 6.5 million people die from stroke annually. The risk of developing a stroke in a lifetime is one in four people over age 25 [3].

Pathophysiology

The pathophysiology of spontaneous ICH depends on its etiologies. These include hypertensive vasculopathy, cerebral amyloid angiopathy, aneurysms, arterio-venous malformations (AVM), cerebral venous thrombosis, hemorrhagic infarction, reversible cerebral vasoconstriction syndrome, cerebral vasculitis, sickle cell disease, anticoagulation therapy, and bleeding disorder [2].

Common sites for ICH and its common presentation include [4]:

Basal ganglia (40-50%): contralateral hemiplegia, gaze preference to the side of bleeding
Lobar regions (20-50%): Focal neurologic deficits; hemiparesis, hemisensory loss, and gaze preferences
Thalamus (10-15%): contralateral hemiplegia, gaze preferences away from the side of bleeding
Brainstem (5-12%): impaired loss of consciousness, pinpoint pupils, cranial nerve palsies, absent or impaired horizontal gaze, and facial weakness
Cerebellum (5-10%): vertigo, vomiting, and limb ataxia

Medical History

Spontaneous ICH frequently presents with acute onset of stroke symptoms, such as acute focal neurological deficits (limb weakness and slurred speech), AMS, and features of increased intracranial pressure (vomiting and headache). The presence of AMS, vomiting, and headache are the essential features to differentiate hemorrhagic from ischemic stroke. AMS occurs in approximately 50% of the cases. In addition, neurological symptoms may develop during routine activity, exertion, or intense emotional activity. However, these symptoms may be absent with small hemorrhages [2]. Seizures may also develop if the hemorrhages involve cortical or cerebellar tissue.

Risk Factors for ICH

Risk factors for ICH can be simplified with the mnemonic of ABCDEFGH.

A: Age (elderly, the risk of ICH increases with advancing age) and alcohol consumption – Heavy alcohol use is associated with an approximately threefold increased risk of ICH

B: Blood pressure (hypertension) – the most important risk factor. This results in small vessel damage to deeper structures such as the basal ganglia and thalamus.

C: Cigarette smoking – In the Physicians Health Study, active smokers had a relative ICH risk of 2.06 percent compared with non-smokers

D: Drug (antiplatelet, anticoagulant, and stimulant drug abuse) – Anticoagulation (warfarin) increases the risk of ICH two to fivefold. Stimulant drugs have been associated with a risk of ICH due to possible spikes in blood pressure and vasospasm.

E: Exercise and healthy lifestyle – Inactivity and obesity are comorbidities that can lead to increased risk for ICH

F: Family history

G: Gender (ICH is more prevalent in men than women) and race (Black Americans have a higher risk than White Americans). Asian countries have a higher incidence of ICH than other regions [4].

H: Hypo/hypercholesterolemia – A systematic review and meta-analysis found that low cholesterol was associated with an increased ICH risk

Others:

Cerebral Amyloid Angiopathy- Risk increases with age. Amyloid protein deposition weakens vessels’ structural integrity.
Structural Abnormalities- aneurysms, connective tissue diseases, congenital AVMs, and family history of subarachnoid hemorrhage (SAH) increase ICH risk.

Physical Examination

The physical examination of a patient with ICH begins with ensuring the stability of airway, breathing, and circulation. Once stabilized, a thorough neurological examination is performed. On inspection, the patient may present with an altered sensorium, ranging from drowsiness to stupor or coma, along with hemiparesis or hemiplegia, with hemiplegia being more common. Facial asymmetry may also be observed.

The general examination should assess for high blood pressure and risk factors such as nicotine stains on fingernails, indicative of smoking, or signs of alcoholic liver disease. Using the ABCDEFGH approach for risk factor identification is advised.

The specific neurological examination typically reveals deficits that correspond to the site of the hemorrhage and the associated edema. Cranial nerve abnormalities may manifest as unequal pupil size, visual field defects, ptosis, facial asymmetry, dysphasia, and a reduced gag reflex. Nuchal rigidity may be noted. Examination of the motor system often shows features of upper motor neuron (UMN) lesions, such as hemiplegia, hypertonia, hyperreflexia, and a positive Babinski sign. Sensory examination may reveal hemisensory loss, while involvement of the cerebellar system can present as sudden, severe vertigo accompanied by akinesia.

An assessment of other systems is essential to identify risk factors and complications associated with ICH. The cardiovascular system may show signs of stress-induced cardiomyopathy or acute cardiac failure. The respiratory system should be evaluated for complications like aspiration pneumonia. Examination of the lower limbs may reveal venous thrombotic events, and systemic signs like fever and infections should also be assessed.

Progressive elevation of intracranial pressure (ICP) or herniation is associated with several clinical features that require immediate attention. Pupillary changes are commonly observed, including impaired reactivity to light, which may indicate worsening neurological status. Abducens nerve (cranial nerve VI) palsy can also occur, with alert patients potentially reporting horizontal diplopia. Additionally, progressive altered mental status (AMS) is a hallmark of increasing ICP. In more advanced stages, the Cushing triad, characterized by bradycardia, respiratory depression, and severe hypertension, may manifest as a critical sign of impending herniation.

Alternative Diagnoses

When evaluating a patient for ICH, it is essential to consider alternative diagnoses and inquire about specific risk factors. Acute ischemic stroke or transient ischemic attack (TIA) can present similarly to ICH and require neuroimaging for differentiation. A history of trauma may suggest a traumatic head injury, such as an epidural or subdural hematoma. Cerebral abscess should be considered if there is a history of fever, headache, and focal neurological deficits. Similarly, meningitis or encephalitis may present with fever, photophobia, neck stiffness, and seizures. A brain tumor often has a subacute to chronic onset with headache and focal neurological signs. Drug overdose or toxin-induced states warrant a thorough review of the patient’s medication and substance history. Metabolic disturbances, such as uremic encephalopathy or renal failure, and acute hypoglycemia or hyperglycemia, should also be considered. Post-epileptic paralysis (Todd’s paralysis), complicated migraine or hemiplegic migraine, and hypertensive encephalopathy are other important differential diagnoses that must be ruled out based on clinical history and investigations.

Acing Diagnostic Testing

Bedside Tests

In the evaluation of patients with suspected intracranial events, capillary blood sugar is a critical bedside test. Random blood glucose measurement helps exclude hypoglycemia or hyperglycemia, as hypoglycemia, in particular, can mimic stroke-like symptoms. Rapid identification and correction of blood glucose abnormalities are essential for accurate diagnosis and appropriate management.

Laboratory Tests

Several laboratory tests provide critical diagnostic insights. A full blood count is essential, as leukocytosis may indicate infection or infarction, lymphocytosis is associated with viral meningitis, and neutrophilia suggests bacterial meningitis. Thrombocytopenia may point toward a bleeding tendency. Renal function tests measuring urea and creatinine are crucial for identifying renal failure, while liver function tests are important in patients suspected of having liver disease. Measurement of INR helps identify coagulopathies, which may increase bleeding risk. Additionally, an arterial blood gas test is indicated in cases of respiratory distress to assess for respiratory failure or metabolic disorders.

Electrocardiogram (ECG)

ECG changes in patients with intracranial conditions can include a prolonged QT interval and ST-T wave changes. These findings may indicate catecholamine-induced cardiac injury [5], which is a potential complication in such cases.

Toxicology Screening

Toxicology screening is essential when drug poisoning or alcohol use is suspected in a patient. Plasma and urine samples should be sent for toxicology analysis to identify potential toxic substances, aiding in diagnosis and guiding appropriate treatment.

Imaging

Imaging plays a crucial role in the evaluation of ICH. A non-contrast head CT is the first-line modality for accurately identifying acute ICH, where a hyperdense lesion can be observed. It is also effective in ruling out other conditions such as brain tumors, cerebral metastasis, skull fractures, hydrocephalus, cerebral ischemia, and cerebral abscess. In addition, a CT angiogram can detect underlying causes like aneurysms or vascular malformations and is recommended for patients under 70 years old to assess for vascular origins of ICH [4].

While both MRI and CT are equally effective in detecting acute ICH, MRI is superior for identifying chronic ICH [4]. In cases with large vessel occlusions, CT may be used; however, for patients with an NIH stroke scale score >6 and a normal head CT, thrombolytic therapy may be considered after consultation with a stroke neurologist and evaluation of contraindications. Although MRI offers greater accuracy for acute strokes, its use in the emergency department is limited by time and availability.

Finally, a chest X-ray is helpful for identifying complications such as pulmonary edema or consolidation caused by aspiration or pneumonia, which may occur alongside intracranial events.

Risk Stratification

The ICH score is extensively used as a clinical grading scale and communication tool to estimate subsequent 30-day mortality and decide on the appropriate care option [6]. It is commonly used in conjunction with the FUNC (Functional Outcome in Patients with Primary Intracerebral Hemorrhage) score, which predicts the functional independence of ICH patients after 90 days [7].

ICH score

The ICH Score, ranging from 0 to 6, is a clinical grading system developed by to predict outcomes in ICH patients [6]. Points are assigned based on specific criteria: one point for age over 80 years, one point for an infratentorial origin of the hemorrhage, one point for an ICH volume exceeding 30 ml, one point for intraventricular extension of the hemorrhage, one point for a Glasgow Coma Scale (GCS) score between 5 and 12, and two points for a GCS score of 3 or 4. This scoring system provides a standardized approach to assessing the severity of ICH.

Glasgow Coma Score (GCS score of 5-12 = 1, GCS score of 3 or 4 = 2)
Age ≥80 = 1
Presence of ICH volume ≥30 mL = 1
Presence of intraventricular hemorrhage = 1
Presence of infratentorial origin of hemorrhage = 1

In the ICH score, 1 point corresponds to a 13% mortality rate, 2 points to 26%, 3 points to 72%, 4 points to 97%, and 5 or more points indicate a 100% mortality rate.

FUNC score

As previously mentioned, The FUNC score is a clinical tool utilized at hospital admission to estimate the probability of achieving functional independence (defined as a Glasgow Outcome Score of 4 or higher) within 90 days after an ICH. The FUNC score includes categories below.

ICH Volume (cm³):
- Less than 30 cm³: +4 points
- 30–60 cm³: +2 points
- Greater than 60 cm³: 0 points
Age:
- Younger than 70 years: +2 points
- 70–79 years: +1 point
- 80 years or older: 0 points
ICH Location:
- Lobar: +2 points
- Deep: +1 point
- Infratentorial: 0 points
GCS Score:
- Score of 9 or greater: +2 points
- Score of 8 or less: 0 points
Pre-ICH Cognitive Impairment:
- No cognitive impairment: +1 point
- Yes, cognitive impairment present: 0 points

Functional independence is defined as a Glasgow Outcome Score of 4 or higher. According to the score interpretation, patients with a FUNC Score of 0–4 have a 0% chance of achieving functional independence. A score of 5–7 corresponds to a 29% among survivors. For a score of 8, the likelihood rises to 48%. Patients scoring 9–10 have a 75% chance to have independence. The highest score of 11 corresponds to a 95% likelihood of functional independence among survivors.

Management

The initial treatment goals for ICH are focused on preventing secondary brain damage [8]. These include preventing hemorrhage expansion, monitoring for and managing elevated intracranial pressure (ICP), and addressing other neurologic and medical complications.

Triage

Prehospital management of acute ICH prioritizes airway maintenance, cardiovascular support, and rapid transport to the nearest acute stroke care facility [9].

ABCD Approach

Airway: Assess airway patency. Intubation should only be performed if the patient cannot protect their airway or is in respiratory distress.
Breathing: Ensure adequate oxygenation by administering supplementary oxygen if the patient is hypoxic, aiming to maintain oxygen saturation above 94%. Avoid hypoventilation, as increased partial pressure of carbon dioxide can cause cerebral vasodilation and elevate ICP.
Circulation: Evaluate hydration status. All suspected ICH patients should initially be placed nil by mouth and started on IV isotonic saline to maintain serum sodium levels above 135 mmol/L. Hypotension should be promptly treated with fluid replacement. Elevated blood pressure must be carefully managed to avoid further complications.
Disability: Assess the patient’s level of consciousness using the Glasgow Coma Scale (GCS). Conduct hourly neurologic evaluations to monitor for signs of deterioration or elevated ICP.

General Measures

Head Elevation: Elevate the head of the bed to greater than 30 degrees to promote venous drainage and reduce ICP [10].
Sedation: For intubated patients, use appropriate sedation, such as midazolam, to ensure patient comfort.
Temperature Control: Administer antipyretics, such as paracetamol, for temperatures above 38°C.
Head Positioning: Maintain a neutral head position, avoiding neck rotation or placing IV lines at the neck to prevent venous outflow obstruction.

Pharmacological Approach to Intracerebral Hemorrhage (Mnemonic: BCGO)

B: Blood Pressure Control
Blood pressure management is critical in ICH. The target systolic blood pressure (SBP) should be maintained between 140-160 mmHg, ideally achieved within the first hour of presentation using intravenous antihypertensive medications [11].

C: Coagulopathy Management
All anticoagulants and antiplatelet agents should be discontinued, and reversal agents should be administered when necessary [12, 13]. Platelet transfusion generally has a limited role. Examples of anticoagulants and their reversal strategies include:

Warfarin: Reversal with Vitamin K, fresh frozen plasma (FFP), or 4-factor Prothrombin Complex Concentrates (PCC), as it inhibits Vitamin K-dependent clotting factors (II, VII, IX, X).
Unfractionated Heparin: Reversal with Protamine, as it binds to antithrombin III.
Low Molecular Weight Heparin: Reversal is incomplete with Protamine, as it inhibits factor Xa.
Dabigatran: Reversal with Idarucizumab (Praxbind), which directly binds and inhibits thrombin (Factor IIa).
Oral Factor Xa Inhibitors (e.g., Apixaban (Eliquis), Edoxaban (Lixiana, Savaysa), Rivaroxaban (Xarelto)): Reversal options include Andexanet alfa (AndexXa) or 4-factor PCC.

G: Glucose Management
Blood glucose levels should be maintained within the range of 6-10 mmol/L to prevent hypoglycemia or hyperglycemia, both of which can exacerbate neurologic injury [14].

O: Osmotic Therapy
For patients with acute ICP elevation or life-threatening mass effect, treatment with mannitol or hypertonic saline may be considered. However, these therapies have not been shown to significantly improve outcomes in patients with acute ICH [15].

Patients with acute ICH are at risk for early seizures (within one to two weeks of ICH) and late (post-stroke) seizures. Early seizures may be self-limited, attributed to transient neurochemical changes associated with the acute ICH. For patients who have a seizure, immediate intravenous anti-seizure medication treatment should be initiated to reduce the risk of a recurrent seizure although anti-seizure treatments’ value is not clear [16].

Medications

Labetalol (Antihypertensive Medication)

Dose: (0.25-0.5 mg/kg). Initial bolus of 20 mg IV, followed by 20–80 mg IV bolus every 10 minutes (maximum total dose of 300 mg). Alternatively, 0.5 to 2 mg/minute can be administered as an IV loading infusion following an initial 20 mg IV bolus (maximum total dose of 300 mg).
Frequency: Administered every 10 minutes as required or as an infusion.
Maximum Dose: 300 mg total.
Cautions/Comments:
- Always inquire about food or drug allergies, a past medical history of bronchial asthma, or heart failure.
- Labetalol is classified as Category C in pregnancy for all trimesters.

Nicardipine (Antihypertensive Medication)

Dose: 5 to 15 mg/hour as IV infusion. Once the desired blood pressure is achieved, reduce the dose to a maintenance rate of 2–4 mg/hour.
Frequency: Continuous infusion.
Maximum Dose: 15 mg/hour.
Cautions/Comments:
- Avoid use in patients with acute heart failure.
- Use with caution in patients with coronary ischemia.

Phenytoin (Anti-Seizure Medication)

Dose: 15–20 mg/kg as a loading dose.
Frequency: Administered every 8 hours.
Maximum Dose: 100 mg.
Cautions/Comments:
- Always check for food or drug allergies and any history of heart problems.
- Phenytoin is classified as Category D in pregnancy for all trimesters.

Mannitol (For Treating High ICP – Osmotic Diuresis)

Dose: 2–4 ml/kg (12.5%), 1.25–2.5 ml/kg (20%), or 1–2 ml/kg (25%).
Frequency: Administer every 2 hours as required.
Cautions/Comments:
- Ask about food or drug allergies.
- Mannitol is classified as Category C in pregnancy for all trimesters.

Surgery

The surgical approach to managing intracerebral hemorrhage (ICH) often includes decompressive hemicraniectomy for hematoma evacuation. Immediate neurosurgical consultation is critical when imaging findings suggest the need for emergency surgery. Indications for urgent surgical intervention include cerebellar ICH that is either ≥3 cm³ in diameter or causing brainstem compression, intraventricular hemorrhage (IVH) with obstructive hydrocephalus and neurologic deterioration, and hemispheric ICH associated with life-threatening brain compression or obstructive hydrocephalus. These conditions demand prompt action to prevent further neurologic compromise and improve patient outcomes.

Special Patient Groups

Pediatrics

ICH in children is predominantly traumatic in origin, often resulting from head injuries caused by falls, vehicular accidents, or abuse (e.g., non-accidental trauma). Non-traumatic causes are less common but may include vascular anomalies like arteriovenous malformations, coagulopathies, or rare genetic conditions [17].

Geriatrics

The incidence of spontaneous ICH increases significantly with age, primarily due to the widespread use of anticoagulation and antithrombotic therapies for managing cardiovascular and cerebrovascular conditions [18]. In addition, older adults often have underlying medical conditions, such as hypertension, diabetes mellitus, and hypercholesterolemia, which predispose them to vascular fragility and hemorrhage. Careful monitoring and tailored management are required to address both the hemorrhage and these comorbidities in elderly patients.

Pregnant Patients

The risk of spontaneous ICH is elevated in pregnant women, especially in those with preeclampsia, eclampsia, or pregnancy-induced hypertension (PIH) [19]. These conditions are associated with endothelial dysfunction, elevated blood pressure, and increased risk of vascular rupture. Management in pregnant women involves a multidisciplinary approach, balancing maternal and fetal safety, with attention to blood pressure control and timely delivery if necessary.

When To Admit This Patient

All patients with ICH should be admitted to the intensive care unit (ICU) for comprehensive management [20]. ICU admission is crucial for close monitoring and intervention due to the potential for rapid deterioration in neurological status and the need for specialized care. These patients require the involvement of a multidisciplinary team, including neurosurgeons, neurologists, and critical care specialists, to address various aspects of care.

Key reasons for ICU admission include:

Further Investigation: Advanced imaging, such as CT angiography or MRI, is often necessary to identify the underlying cause of the hemorrhage (e.g., aneurysm, arteriovenous malformation) and to assess for complications like hydrocephalus or increased intracranial pressure.
Medical Management: Tight control of blood pressure, intracranial pressure, glucose levels, and coagulopathy is essential to prevent secondary brain injury and improve outcomes.
Surgical Operations: Patients may require urgent surgical interventions, such as hematoma evacuation, decompressive craniectomy, or ventriculostomy, particularly in cases of life-threatening mass effect, brainstem compression, or obstructive hydrocephalus.
Rehabilitation Planning: Early rehabilitation interventions should be initiated to minimize long-term disability. This includes physical therapy, occupational therapy, and addressing the patient’s psychological and cognitive needs post-ICH.

The ICU provides an ideal setting for continuous monitoring of neurological function, management of complications, and rapid response to emergencies such as rebleeding or sudden increases in intracranial pressure. Admission ensures a holistic and systematic approach to optimizing patient outcomes following spontaneous ICH.

Revisiting Your Patient

An urgent head CT was completed and revealed an intracranial hemorrhage in the caudate region.

During her ED stay, her GCS suddenly reduced to 7/15 (E2, V2, M3). She was intubated for airway protection. A repeated head CT demonstrated expansion of the right intracranial hemorrhage with intraventricular extension midline shift.

The neurosurgical team was consulted, and the patient was sent for an emergency craniectomy and evacuation of the clot. A postoperative head CT showed a grossly evacuated blood clot and corrected midline shift. The intensive care team weaned her off of mechanical ventilatory support, and her GCS improved to 10 (E3, V1, M6).

Authors

Muhammad Izzat Abdul Hadi

Muhammad Izzat Bin Abdul Hadi is a dedicated emergency medicine professional at Hospital Universiti Sains Malaysia in Kelantan, Malaysia. He completed his medical degree at Mansoura University in 2007 and later obtained a Master of Medicine in Emergency Medicine from Universiti Sains Malaysia in 2019. His contributions to medical research include two notable publications in the Malaysian Journal of Emergency Medicine (M-JEM) in 2021.

Iskasymar Ismail

Dr Iskasymar is an emergency physician, a senior medical lecturer at University Putra Malaysia (UPM) and Head of Unit of RESQ (Regional Emergency Stroke Quick Response) Stroke Emergency Unit in UPM teaching hospital, Hospital Sultan Abdul Aziz Shah (HSAAS). He is actively involved in making RESQ as niche service for hyperacute stroke care in HSAAS and working collectively with neurology team and radiology team in developing protocols and SOP. Dr Iskasymar is an active expert panel of stroke and intracranial hemorrhage Clinical Practice Guideline of Malaysia.

Kamarul Aryffin Baharuddin

Dr. Kamarul Aryffin Baharuddin is a Professor in Emergency Medicine and an Emergency Medicine Specialist at the Universiti Sains Malaysia (USM), Kelantan, Malaysia. He graduated with his medical degree in 1998 and completed his postgraduate specialization in 2006. His research interests are neurological emergency, pain management, medical education, and artificial intelligence in medicine. He is currently a Deputy Dean of Academics in the School of Medical Sciences, USM. He is also one of the team in neurology SIG (Special Interest Group) under the College of Emergency Physician, Malaysia.

Erin Simon

Listen to the chapter

References

Cheng Y lin.Molecular Mechanisms of Notch1-Mediated Neuronal Cell Death in Ischemic Stroke. PhD Thesis. The University of Queensland; 2014. doi:10.14264/uql.2014.547
Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis – UpToDate. Accessed December 4, 2024. https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis
Feigin VL, Brainin M, Norrving B, et al. World Stroke Organization (WSO): Global Stroke Fact Sheet 2022. Int J Stroke Off J Int Stroke Soc. 2022;17(1):18-29. doi:10.1177/17474930211065917
Sheth KN. Spontaneous Intracerebral Hemorrhage. N Engl J Med. 2022;387(17):1589-1596. doi:10.1056/NEJMra2201449
Pinnamaneni S, Aronow WS, Frishman WH. Neurocardiac Injury After Cerebral and Subarachnoid Hemorrhages. Cardiol Rev. 2017;25(2):89-95. doi:10.1097/CRD.0000000000000112
Hemphill JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32(4):891-897. doi:10.1161/01.str.32.4.891
Dusenbury W, Malkoff MD, Schellinger PD, et al. International beliefs and head positioning practices in patients with spontaneous hyperacute intracerebral hemorrhage. Ther Adv Neurol Disord. 2023;16:17562864231161162. doi:10.1177/17562864231161162
Pandey AS, Xi G. Intracerebral hemorrhage: a multimodality approach to improving outcome. Transl Stroke Res. 2014;5(3):313-315. doi:10.1007/s12975-014-0344-z
Gioia LC, Mendes GN, Poppe AY, Stapf C. Advances in Prehospital Management of Intracerebral Hemorrhage. Cerebrovasc Dis. Published online March 7, 2024. doi:10.1159/000537998
Simmons BJ. Management of intracranial hemodynamics in the adult: a research analysis of head positioning and recommendations for clinical practice and future research. J Neurosci Nurs. 1997;29(1):44-49. doi:10.1097/01376517-199702000-00007
Sato S, Carcel C, Anderson CS. Blood Pressure Management After Intracerebral Hemorrhage. Curr Treat Options Neurol. 2015;17(12):49. doi:10.1007/s11940-015-0382-1
Grzegorski T, Andrzejewska N, Kaźmierski R. Reversal of antithrombotic treatment in intracranial hemorrhage–A review of current strategies and guidelines. Neurol Neurochir Pol. 2015;49(4):278-289. doi:10.1016/j.pjnns.2015.06.003
Campbell PG, Sen A, Yadla S, Jabbour P, Jallo J. Emergency reversal of antiplatelet agents in patients presenting with an intracranial hemorrhage: a clinical review. World Neurosurg. 2010;74(2-3):279-285. doi:10.1016/j.wneu.2010.05.030
Godoy DA, Piñero GR, Svampa S, Papa F, Di Napoli M. Hyperglycemia and short-term outcome in patients with spontaneous intracerebral hemorrhage. Neurocrit Care. 2008;9(2):217-229. doi:10.1007/s12028-008-9063-1
Qureshi AI, Wilson DA, Traystman RJ. Treatment of elevated intracranial pressure in experimental intracerebral hemorrhage: comparison between mannitol and hypertonic saline. Neurosurgery. 1999;44(5):1055-1064. doi:10.1097/00006123-199905000-00064
Gilad R, Boaz M, Dabby R, Sadeh M, Lampl Y. Are post intracerebral hemorrhage seizures prevented by anti-epileptic treatment?. Epilepsy Res. 2011;95(3):227-231. doi:10.1016/j.eplepsyres.2011.04.002
Kumar R, Shukla D, Mahapatra AK. Spontaneous intracranial hemorrhage in children. Pediatr Neurosurg. 2009;45(1):37-45. doi:10.1159/000202622
Berhouma M, Jacquesson T, Jouanneau E. Spontaneous Intracerebral Hemorrhage in the Elderly. Brain and Spine Surgery in the Elderly. 2017:411-22.
Berhouma M, Jacquesson T, Jouanneau E. Spontaneous Intracerebral Hemorrhage in the Elderly. Brain and Spine Surgery in the Elderly. 2017:411-22.
Goldstein JN, Gilson AJ. Critical care management of acute intracerebral hemorrhage. Curr Treat Options Neurol. 2011;13(2):204-216. doi:10.1007/s11940-010-0109-2
Tenny S, Thorell W. Intracranial Hemorrhage. In: StatPearls. StatPearls Publishing; 2024. Accessed December 4, 2024. http://www.ncbi.nlm.nih.gov/books/NBK470242/

Reviewed and Edited By

Erin Simon, DO

Arif Alper Cevik, MD, FEMAT, FIFEM

Management of Pain in the Emergency Department (2024)

December 4, 2024December 4, 2024 ~ iEM Education Project Team ~ Leave a comment

by Kayla Peña, Kelsey Thompson, & Munawar Farooq

You have a new patient!

A 57-year-old woman with a PMH of peptic ulcer disease presents to the emergency department 20 minutes after slipping and falling while out for a jog. She twisted her left ankle awkwardly while stepping off the pavement and fell to the side. She did not hit her head. She got up after the fall but has not tried to put weight on the ankle. Her vital signs are stable. She has a temperature of 37°C, a heart rate of 110 beats per minute, respirations at 18 breaths per minute, a blood pressure of 128/60, and an oxygen saturation of 96% on room air.

She is currently seated in a chair and appears uncomfortable. On exam, the left ankle appears more swollen than the right, with no bruising. She has tenderness to palpation at the posterior edge of the left lateral malleolus but no left midfoot tenderness. The right foot is non-tender. Pulses are intact throughout with a 2-sec capillary refill distally. She states, “Please help me; I can’t take the pain!”

Introduction

Pain is one of the most common reasons patients seek care in the ED. Pain is a signal from the body to alert the patients of actual or potential tissue damage. Addressing pain is a key part of the emergency department practice. However, doing so appropriately requires understanding our options to treat pain and a clear process to assess the factors causing the patient’s pain [1]. Pain treatment offers numerous advantages, such as alleviating pain-induced tachycardia in specific cases like acute MI and aortic dissection. Additionally, improved pain relief contributes to higher patient satisfaction.

Pain Assessment

When administering analgesics to patients in pain, there are no definitive contraindications. However, several factors should be considered when selecting the appropriate analgesic agent, including its route and dose. These factors encompass the pain’s intensity, probable cause, and the patient’s age, weight, medical history (including comorbidities and drug allergies), and vital signs. Pain is a complex and subjective experience that is unique to each patient. Appropriately assessing pain requires a thorough history and physical exam that include:

Location: Where is the pain? Does it travel or go anywhere else?
Onset: When did the pain begin? Is this an acute, chronic, or exacerbation of a chronic issue?
Provocation: What makes the pain worse?
Palliation: Does anything make this pain feel better? What has the patient tried to make it feel better, even if it didn’t work? Has the patient taken any medication at home to help with this, and what was the impact? If this patient has had this pain before, what made it better last time?
Quality: How does the pain feel?
Radiation: Does the pain go to any other location?
Severity: How severe is the pain? Can they compare it to other experiences they’ve had? How does it limit their activities, such as movement, eating, and sleeping?
Timing: Is the pain constant, or does it come and go? Does it change severity or quality over time?

Pain intensity scale

Numerical ranking: Ask your patient to rank the severity from 0 to 10, with 0 being no pain at all and 10 being the worst pain possible.
Verbal descriptors: Use descriptions from the patient of the pain and its impact on their functionality to rank their pain.
Visual descriptors: Use visual cues from your patient to rank their pain. The most common of these scales is the Wong-Baker scale, which is commonly used in children or nonverbal patients.

It is also important to remember that patients in pain may become agitated or mentally altered due to their pain. Severe pain in one area of the body may mask other symptoms or signs the patient is experiencing; hence, it is crucial to re-examine these patients after analgesia.

Analgesics

In the emergency department, treatment plans are often tailored to moderate/severe and acute and/or chronic pain.

Severe Acute Pain

In the management of moderate to severe acute pain, parenteral opioids are the primary treatment choice. These opioids target specific receptors in the central and peripheral nervous systems, altering how painful stimuli are perceived and responded to. Initially, they are administered as a bolus dose based on the patient’s weight, followed by titration every 5-15 minutes after reassessment. Opioids provide excellent analgesia, but they come with a long list of side effects that can be detrimental to the patient, even in the acute pain setting. Nausea and respiratory depression are the most significant side effects of all opioids, albeit with varying degrees. Parenteral opioids can also trigger pruritus and/or urticaria due to mast cell destabilization. Medications such as antiemetics, antihistamines, and naloxone can help reverse these potential side effects. Morphine is often the preferred parenteral opioid, with fentanyl and hydromorphone serving as alternatives. A safe initial dose of morphine is 0.1 mg/kg administered intravenously, while subcutaneous administration can be used if IV access is not available (although it is more painful and slower in onset). Please refer to the complete list of opioids and their recommended initial dosing regimens provided below.

Fentanyl: 0.25-1 µg/kg IV push [2], Short-acting opioid q. 15-60 minutes for severe pain.
Hydromorphone: 0.015 mg/kg IV/SC [3], q. 2-4 hours, avoid large doses in naive patients.
Oxycodone: 0.05-0.15 mg/kg PO [4], q. 3-4 hours.
Morphine: 0.1 mg/kg IV/SC [5], q. 3-4 hours, may cause release of histamine.
Oxycodone/Acetaminophen: 5-10 mg oxycodone/325-650 mg acetaminophen PO [6], q. 4-8 hours, moderate or severe pain (max dose of acetaminophen 4,000 mg/day).
Hydrocodone/Acetaminophen: 5 mg hydrocodone/325 mg acetaminophen, 1 to 2 tablets PO [7], q. 4-8 hours, moderate or severe pain (max dose of acetaminophen 4,000 mg/day).

Moderate Acute Pain

In cases of mild to moderate pain, oral opioids provide a suitable choice after initial non-opioid analgesia. Among these options are oxycodone combined with acetaminophen or hydromorphone combined with acetaminophen to impose a maximum daily dosage. The recommended dose for the opioid component is 0.05-0.15 mg/kg, and it can be repeated every 4-6 hours. Refer to the full list of opioids and their initial dosing regimens above.

However, the primary recommendation for moderate acute pain is non-opioid analgesics like NSAIDs and acetaminophen. They can synergistically complement opioids, potentially reducing the overall required dose of medications and minimizing the likelihood of side effects.
Acetaminophen is the safest option among these analgesics, accessible in oral and intravenous forms. While its exact mechanism remains uncertain, it exerts its effects centrally. NSAIDs, such as ibuprofen and ketorolac, inhibit cyclooxygenase (COX), thereby blocking prostaglandin-mediated inflammation. However, inhibiting prostaglandin synthesis leads to renal vasoconstriction and thus should be avoided in those with kidney disease. Please refer to the complete list of non-opioids and their recommended initial dosing regimens provided below.

Acetaminophen: 10-15 mg/kg PO/IV [8], Avoid if taking other acetaminophen-containing drugs or in patients with liver failure.
Ibuprofen: 5-10 mg/kg PO [9], Avoid in elderly patients and those with renal disease and peptic ulcer disease.
Ketorolac: 0.5 mg/kg IV/IM [10], Should only be given q6 hours, No more than 5 days.

Chronic Pain

It is important to recognize that patients with conditions that cause chronic pain or recurrent episodes of severe pain, such as sickle cell, have frequent or even chronic usage of opioid medications that require an individualized pain management plan. While chronic pain is challenging to address in the ED setting, these patients frequently get undertreated for their acute exacerbations [11]. Chronic pain is treated similarly to acute pain, using opioids for severe pain and non-opioids for more moderate pain. Treatment depends on the severity and previous history of analgesic success [12]. A step ladder approach, including non-opioid and opioid therapy, will be appropriate as part of departmental guidelines.

In addition, patients with a past or current history of a substance use disorder, including opioid use disorder, can still present with real, severe pain that may require the use of opioids for management. It is essential to assess these patients carefully and treat their pain like any other patient. If there are concerns that the patient’s condition may be related to a substance use disorder, it may be appropriate to refer them to a multidisciplinary specialist for support. This should be done after conducting a thorough history and physical examination and addressing immediate medical needs [13]. It is also vital that the ED team sticks to an individualized pain management plan once made by a multidisciplinary team on every recurrent presentation.

When making decisions for your patient, it is crucial to prioritize awareness of the addictive nature of opiates. To aid in this challenging choice, assess the patient’s opioid tolerance, history of substance abuse, and the risk associated with prescribing short-term PRN opioids upon discharge. The NIH Opioid Risk Tool (ORT) is helpful for screening for opioid abuse risk [14].

Local Anesthesia

Local anesthetics obstruct pain signal transmission by temporarily obstructing sodium channels in sensory nerve membranes. In the emergency department, lidocaine is commonly used, with or without epinephrine, to enhance hemostasis and prolong anesthetic efficacy. Bupivacaine, a longer-acting agent, is typically employed for regional anesthesia. While local anesthetics are generally safe, systemic CNS and cardiovascular toxicity can occur at large doses. Traditional teaching states that local anesthetic administration should be avoided in end organs such as the ears, nose, and penis to prevent ischemia. However, strong evidence is lacking to support this concern [15]. Local departmental or hospital guidelines should be followed in this case.

Lidocaine:
- Dose: Nerve Block 5-300 mg (maximum 4 mg/kg or 300 mg),
  - Acute Pain (Patch) 4%-5% patch q24 hours.
- Rapid onset. The maximum dose of lidocaine is 4 mg/kg (without epinephrine) and 7 mg/kg with epinephrine [16,17].
- Lidocaine is safe in pregnancy and breastfeeding.
Bupivacaine:
- Dose: Max dose 2.5 mg/kg, 3 mg/kg with epinephrine [18].
- Slower onset and higher risk of cardiovascular toxicity.
Chloroprocaine:
- Dose: Max dose 10 mg/kg, 15 mg/kg with epinephrine [19].
- Used in the case of allergy to lidocaine and other amide local anesthetics.

Procedural Sedation

Procedural sedation refers to the administration of medications aimed at reducing anxiety and pain while enhancing tolerance to a particular medical procedure. This technique is reserved for hemodynamically stable patients who are expected to be able to maintain their airways throughout the procedure. Common indications of this technique include cardioversion, orthopedic reductions, and other painful procedures [20]

A common approach to procedural sedation:

Risk stratification to prepare for potentially difficult airway management
1. Use the Mallampati Score to assess the difficulty of the airway should the patient lose their airway during the procedure. Refer to UpToDate Mallampati Airway Classification.
2. Determine the ASA Score category. Refer to the ASA Physical Status Classification System.
Informed Consent
1. Typically, it is required before the procedure to discuss the complications and alternative options.
Gathering Supplies
1. IV, O2, Monitoring including capnography.
2. BVM and airway trolley
Assemble Team
- Depending on the complexity of the procedures, decide about the team members and their roles. A separate person should typically be responsible for sedation and airway monitoring while one or two other members perform the procedure. For details about team dynamics, refer to this book’s chapter on Teamwork.
Perform the procedural sedation
1. Administer procedural sedation medications (See below)
2. Perform the procedure while constantly assessing hemodynamic stability and respiratory status.
Post Sedation Care
- Provide post-sedation monitoring and reassessment, and then discharge instructions according to the individual case and departmental guidelines.

Most Common Procedural Sedation Medications

Midazolam:
- Dose: 0.1 to 0.5 mg/kg IV [21].
- Comments: No analgesic effect, administered before the procedure to reduce anxiety and provide amnesia.
Fentanyl:
- Dose: 1 mcg/kg IV [22].
- Comments: Reduces pain, commonly used in reductions and I&D as an adjunct to other medications or local anesthesia.
Propofol:
- Dose: 0.5-1 mg/kg IV [23].
- Comments: Used as a general short-acting anesthetic and causes respiratory depression and hypotension.
Etomidate:
- Dose: 0.15 mg/kg IV [24].
- Comments: Used as a general anesthetic; can cause myoclonus.
Ketamine:
- Dose: 1-2 mg/kg IV [25], 2-4 mg/kg IM (especially in pediatrics).
- Comments: The dissociative anesthetic that provides both amnesia and analgesia. Known to cause aggressive emergence reaction and rarely laryngospasm.

Hints and Pitfalls

Like all treatments, it is crucial to reassess the patient after giving them medication and understand how medication can change your ability to evaluate the patient. A patient in severe pain may be unable to provide a full history or participate in a complete physical exam until their pain has been controlled. For example, a patient with an extremely painful angulated fracture of the humerus may not be able to participate in an exam to evaluate their distal neurovascular status, or the same patient may have such severe pain in their arm that they do not notice that they are also having abdominal pain. Treating pain earlier in such encounters can help facilitate high-quality patient care.

Factors that can lead to undertreatment include atypical presentation, communication barriers, and implicit bias. Pediatric patients, patients with neurocognitive disorders, and patients from different cultural or linguistic backgrounds are frequently undertreated for their pain.

Special Patient Groups

It is essential to carefully evaluate pain in patients who cannot directly communicate with the physician [26].

Those patients may be:

Nonverbal at baseline
Speak a different language than the physician
Have a cognitive impairment
Geriatric patients
Underreporting of pain
Higher frequency of illness-causing cognitive impairment and communication barriers such as Alzheimer’s
Concerns for side-effects

Geriatric patients generally have poor physiological reserve and polypharmacy. While these factors need to be considered in the choice of analgesics, their dosage, and required monitoring, these concerns should not lead to undertreatment of pain in this population.

Revisiting Your Patient

How should we manage our 57-year-old female with peptic ulcer disease, who presented with a twisted ankle? Given that her left ankle is swollen and that she has bony 9/10 tenderness at the posterior edge of the left lateral malleolus but no left mid-foot pain, it is likely that she has an uncomplicated closed ankle fracture.

The initial step in management would be to start treating her pain soon after her presentation. An important KPI (Key Performance Indicator) in this regard is that the degree of pain is assessed on arrival in every patient who presents to ED with pain, and individually planned titrated analgesia is started as early as possible.
Given that she is in acute, moderately severe pain with a history of peptic ulcer disease (PUD), she would most likely benefit from a drug like Oral Hydromorphone and Oral/IV Paracetamol. In this patient’s case, NSAIDs, such as Ibuprofen, should specifically be avoided due to her history of PUD. Initial pain management in the emergency department can also be managed with “RICE,” which includes rest, ice, compression, and elevation of the injured body part. The RICE technique is an effective way to alleviate pain in patients who deny pain medication or who are still waiting to see a provider. It is important to reassess pain and vital signs after administering analgesics.

If this patient had an evident ankle deformity with weak pulses, she would have required procedural sedation and urgent reduction.

Authors

Kayla Peña

Rutgers Robert Wood Johnson Medical School

Kelsey Thompson

UCLA Harbor

Munawar Farooq

College of Medicine and Health Sciences, UAEU Al Ain, UAE

Listen to the chapter

References

Hachimi-Idrissi S, Coffey F, Hautz WE, et al. Approaching acute pain in emergency settings: European Society for Emergency Medicine (EUSEM) guidelines-part 1: assessment. Intern Emerg Med. 2020;15(7):1125-1139. doi:10.1007/s11739-020-02477-
In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
Oxycodone/Acetaminophen: Drug Information. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
Hydrocodone/Acetaminophen: Drug Information. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
Paracetamol: In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
Dora-Laskey, A. (2022). Acute Pain Control. Society for Academic Emergency Medicine (SAEM M3 Curriculum). Retrieved from https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m3-curriculum/group-acute-pain-control/acute-pain-control.
Busse JW, Wang L, Kamaleldin M, et al. Opioids for chronic noncancer pain: A Systematic Review and Meta-analysis. JAMA. 2018;320(23):2448-2460. doi:10.1001/jama.2018.18472
Nordt SP, Ray L. Lidocaine. In: Mattu A and Swadron S, ed. ComPendium. Burbank, CA: CorePendium, LLC. Updated May 12, 2023. Accessed May 13, 2023.https://www.emrap.org/corependium/drug/recUEl2x9lfeYKbws/Lidocaine#h.tuo0od96 muij.
Perry JS, Stoll KE, Allen AD, Hahn JC, Ostrum RF. The opioid risk tool correlates with increased postsurgical opioid use among patients with orthopedic trauma. Orthopedics. 2023;46(4):e219-e222. doi:10.3928/01477447-20230207-04
Schnabl SM, Herrmann N, Wilder D, Breuninger H, Häfner HM. Clinical results for use of local anesthesia with epinephrine in the penile nerve block. J Dtsch Dermatol Ges. 2014; Apr;12(4):332-339. doi: 10.1111/ddg.12287. Epub 2014 Mar 3. PMID: 24581175.
In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
Lidocaine with epinephrine. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
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In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
Miner James R., Paetow Glenn. Procedural Sedation. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: ComPendium, LLC. https://www.emrap.org/corependium/chapter/recCvtWt5In5h4fLJ/Procedural-Sedation#h.9du7441ga4gn. Updated September 15, 2021. Accessed May 13, 2023.
Midazolam. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
Fentanyl. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
Propofol. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
Etomidate. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
Ketamine. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
Tagliafico L, Maizza G, Ottaviani S, et al. Pain in non-communicative older adults beyond dementia: a narrative review. Front Med (Lausanne). 2024;11:1393367. PublishedAugust 15, 2024. doi:10.3389/fmed.2024.1393367

FOAM and Further Reading

Pediatric pain: Pediatric Pain Management

Chronic pain: I CAN’T GET NO SATISFACTION FOR MY CHRONIC NON-CANCER PAIN

Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

Bronchial Foreign Body Aspiration (2024)

December 3, 2024December 3, 2024 ~ iEM Education Project Team ~ Leave a comment

by Elhaitham Ahmed & Khalifa Alqaydi

You have a new patients!

Patient 1

A 72-year-old male was brought from an inpatient stroke rehabilitation center to the emergency department for a cough lasting the past ten days. Along with the cough, the patient was noted to have blood-tinged sputum, which is sometimes foul-smelling. His vital signs are as follows: temperature of 38.4°C, blood pressure of 138/78 mmHg, heart rate of 103 bpm, respiratory rate of 26 breaths/min, and oxygen saturation of 93% on room air. On physical examination, the patient exhibits tachypnea, dullness on percussion, bronchial breathing, egophony, and increased vocal fremitus upon examining the right side of his lung.

Patient 2

Thirty minutes later, the nurse calls you regarding a 5-year-old boy brought in by his mother, presenting with stridor and an ongoing cough. The mother mentions that she found her child playing with her wallet while she was in the next room and discovered him in this condition. The child is tachypneic, saturating at 90% on room air with subcostal retractions. Examination of the right lung revealed wheezing with decreased air entry.

What do you need to know?

Importance

Tracheobronchial foreign body aspiration (FBA) can be a potentially life-threatening event. FBA in children may be suspected based on a choking episode if such an episode is witnessed by an adult or remembered by the child. In contrast, the clinical presentation of unwitnessed FBA may be subtle, requiring careful review of the history, clinical assessment, and judicious use of radiography and bronchoscopy for diagnosis. Flexible and rigid bronchoscopy have become the cornerstone of both diagnosis and treatment in patients with suspected airway foreign bodies, which are most commonly seen in patients with FBA [1].

Epidemiology

FBA is more common in children than in adults. Data from the National Security Council report that approximately 80 percent of cases occur in patients younger than 15 years of age, with the remaining 20 percent presenting in those older than 15 years. Overall, death from FBA is the fourth leading cause of accidental home and community deaths in the United States, with over 5,000 fatal episodes of FBA reported during 2015. Death from FBA peaks in children under 1 year old and in adults over 75 years [2].

Pathophysiology

In children, nuts, seeds, and other organic material account for the majority of foreign bodies. However, in adults, the nature of inhaled objects is highly variable, ranging from organic to inorganic material. The type of foreign body significantly impacts the degree of tissue reaction in the airway. For example, some inorganic materials, such as metal or glass items, may cause little tissue inflammation but can result in direct airway injury if they are sharp. In contrast, some organic materials, such as nuts and a variety of pills, can cause significant inflammation, granulation tissue formation, and airway stenosis. Aspirated organic material can also expand from airway moisture, worsening obstruction. Aspiration of medications in pill form, such as iron tablets, aspirin, and potassium chloride, can also cause severe airway inflammation and ulceration [2].

Medical History

Clinical presentation can range from chronic nonspecific respiratory complaints to acute airway obstruction. In most cases of aspiration, the presence of a foreign body can be suspected after a thorough history. Patients with airway foreign bodies may present with noisy breathing, inspiratory stridor, rhonchi, vomiting, changes in voice, and hemoptysis [3]. Some patients may report a history known as penetration syndrome, which includes a choking sensation accompanied by wheezing and coughing. Coughing may not completely expel the foreign body but may instead cause its impaction in the subglottic region. Therefore, coughing after suspected aspiration should prompt a search for a foreign body, even if symptoms improve [4].

In pediatric patients with suspected foreign body aspiration, the sudden onset of choking or intractable cough associated with wheezing and respiratory distress occurs in more than 63% of cases [5,6]. In addition to coughing and choking, stridor is a frequent symptom. The absence of early coughing and choking is associated with delayed diagnosis and chronic presentations, such as recurrent pneumonia [4]. The sudden onset of dyspnea and odynophagia may indicate an impacted subglottic object. If the object is sharp and thin, the emergency clinician should suspect embedding between the vocal cords or in the subglottic region, resulting in partial obstruction [7].

Other components of the history can assist in diagnosing and characterizing foreign bodies in patients with aspiration of nonfood objects. Many types of items may be aspirated by children exploring their environment. Another at-risk population includes individuals who habitually store small items in their mouths for quick access; examples include construction workers (nails) and seamstresses (pins). The presentation of patients with a retained airway foreign object may involve only infectious complications. A foreign object can lead to a retropharyngeal abscess. Patients with atypical or recurrent pneumonia may have pulmonary infections caused by the persistence of a foreign object serving as a focus of infection [6].

Physical Examination

Physical findings depend on the degree of airway obstruction and the duration of the object’s presence. Depending on the size and location of the foreign body, the examination may reveal a normal patient, one with cyanosis and respiratory arrest, or any condition between these two extremes. Patients may exhibit stridor or hoarseness with upper airway foreign objects, and intercostal or sternal retractions may be observed in patients with high-grade obstruction caused by tracheal foreign bodies [8]. Hypoxemia may be present; however, normoxia does not rule out the presence of a foreign body. Patients with secondary infections may present with fever.

Oropharyngeal examination may reveal a foreign body posteriorly or donor sites of fractured teeth. The examination should also include a search for fractured or missing dental prostheses. Oropharyngeal examination can often be supplemented by indirect or direct laryngoscopy or nasopharyngoscopy, but these procedures should be performed only if the procedural stress does not pose an undue risk of airway compromise.

Coughing may result from local irritation caused by bronchial foreign bodies. Localized or apparently generalized wheezing is frequently auscultated in patients with lower respiratory tract foreign bodies [9]. Complete obstruction of a mainstem bronchus may result in absent ipsilateral breath sounds; however, breath sounds can sometimes be transmitted across the thorax, and the only physical abnormality may be asymmetric chest rise. Occasionally, a foreign body acts as a one-way valve, allowing air into the lung during inspiration but preventing its exit during expiration. The affected lung becomes hyperexpanded, which may be detected as hyper-resonance on percussion [6].

Alternative Diagnoses

The selected differential diagnoses for airway foreign bodies include anaphylactic reactions, acute pharyngitis, acute epiglottitis, retropharyngeal abscess, neck tumors, pulmonary carcinomas, pneumonia, bronchitis, bronchiolitis, and tuberculosis.

Acing Diagnostic Testing

Imaging should not delay intervention in cases of suspected acute asphyxiation but is indicated for stable patients [10].

Findings on imaging depend on the type and location of the material aspirated and the time elapsed. In practice, plain films of the neck and chest are often performed simultaneously and can be followed by site-specific CT if suspicion remains. The majority of foreign bodies are radiolucent and not easily identified on plain film. If obstruction of the upper airway (oropharynx and upper trachea) is suspected, initial imaging should include anterior-posterior and lateral soft tissue views of the neck [11]. If these tests are negative and suspicion for FBA persists, further imaging with CT may be indicated. When FBA of the lower airways (below the vocal cords) is suspected, a chest radiograph should be the initial radiographic test to look for an obvious radiopaque airway lesion. Negative scans may prompt further evaluation with CT. The reported sensitivity of chest radiography is approximately 60 to 80 percent in children, and clinical experience suggests similarly poor sensitivity in adults [12].

Given its widespread availability, flexible bronchoscopy is often the diagnostic procedure of choice for non-life-threatening FBA in adults, particularly in cases involving smaller foreign bodies in the lower airway. Flexible bronchoscopy allows precise identification and localization of foreign bodies and facilitates the selection of instruments necessary for retrieval [13]. Additionally, flexible bronchoscopy enables removal of the foreign body during the diagnostic procedure if the operator is skilled in these techniques. Standard diagnostic or therapeutic flexible bronchoscopes are usually adequate for the management of FBA in adults [6].

Risk Stratification

Risk factors in adults include loss of consciousness due to trauma, drug or alcohol intoxication, or anesthesia. Additional risk factors in older adults include age-related slowing of the swallowing mechanism, medication use (impairing cough and swallowing), stroke-related dysphagia, and various degenerative neurologic diseases such as Alzheimer’s or Parkinson’s disease [2].

Management

In a conscious adult, data support the efficacy of chest thrusts, back blows or slaps, blind finger sweeps, and abdominal thrusts in relieving complete foreign body airway obstruction [6, 14]. In cases of life-threatening asphyxiation, initial support should focus on treating airway obstruction and respiratory failure. Once the airway is secured, a laryngoscopic evaluation of the oropharynx should be performed immediately to diagnose and retrieve a supraglottic or glottic foreign body. If a foreign body is not seen, rigid bronchoscopy is generally the procedure of choice for suspected asphyxiating foreign bodies located in the trachea or major bronchi. In patients with non-life-threatening FBA, flexible bronchoscopy is typically performed [15].

When large foreign bodies completely or almost completely obstruct major upper airways (glottis, supraglottis, trachea), it is critical to ensure the patient is oxygenated and the airway is secured [16]. Support measures may include bag-valve-mask ventilation and endotracheal intubation. If ventilation is unsuccessful, an emergent cricothyrotomy or tracheotomy may be required if the foreign body is suspected to be above the vocal cords. Once the airway is secured, immediate inspection of the oropharynx (glottis, supraglottis) is indicated, as one-third of FBA cases presenting as acute asphyxiation are located in the supraglottis. Retrieval of the foreign body with Magill forceps can be safely performed using direct laryngoscopy (glottis, supraglottis) or with smooth or alligator forceps during rigid or flexible bronchoscopy (large central foreign body in the trachea or major bronchus) [17].

The choice of procedure for foreign body removal depends on the type of presentation, characteristics of the inhaled foreign body, its location, the duration it has been in the airway (if known), and local expertise. Anti-inflammatories and antibiotics are not routinely administered to patients with suspected or documented FBA. Antibiotics are indicated only in cases of clinically, radiologically, or microbiologically documented respiratory tract infections. However, their use should not delay foreign body extraction, even if pneumonia or sepsis is suspected [2].

Special Patient Groups

In the pediatric age group, moderate or high suspicion of FBA is suggested by any of the following:

Witnessed FBA, regardless of symptoms.
History of choking, with any subsequent symptoms or suspicious characteristics on imaging.
A young child with suggestive symptoms without another explanation, especially if there are suspicious characteristics on imaging. Suspicious symptoms include cyanotic spells, dyspnea, stridor, sudden onset of cough or wheezing (often focal and monophonic), and/or unilaterally diminished breath sounds.

The tracheobronchial tree should be examined in all cases with moderate or high suspicion of FBA, using rigid bronchoscopy (or, in some cases, computed tomography [CT]). On occasion, the adjunctive use of a flexible bronchoscope may be helpful. Normal chest radiographs are not sufficient to rule out FBA [19], primarily because most foreign bodies are radiolucent. Morbidity and mortality may increase if bronchoscopic evaluation is delayed.

When To Admit This Patient

Most patients improve clinically following FBA removal. Those with imaging abnormalities should undergo follow-up imaging six weeks to three months after extraction to confirm resolution. Patients presenting with a delayed presentation and belonging to high-risk groups should be admitted for management of complications and FBA retrieval and removal.

Revisiting Your Patients

The elderly patient, given his history of a recent stroke and being in a rehabilitation center, is at risk of FBA. His presentation with chronic cough and fever raises suspicion of pneumonia; however, the emergency medicine clinician should maintain a broad differential diagnosis based on further history, including foul-smelling sputum and nursing staff observations of difficulty swallowing and previous admissions for pneumonia. Such delayed presentations of FBA can occur in this age group. The patient’s management began with initial stabilization using oxygen support, along with workup for infection. Imaging modalities started with a chest plain film, which showed right lower lobe opacities but no clear foreign body. With suspicion for FBA still high, a chest CT scan was performed and revealed evidence consistent with FBA. The patient was started on broad-spectrum antibiotics, and bronchoscopy was scheduled as the definitive management for FBA. Follow-up bronchoscopy identified distal fragments of nuts impacted in the right lower lobe bronchus.

In the pediatric patient, the presentation is more acute and requires securing the airway. After placing the patient on a non-rebreather mask with 15L of oxygen, his saturation improved to 100%. Given the history of playing with a wallet, suspicion of coin aspiration was considered. A chest radiograph with posteroanterior and lateral views was performed, showing a rounded radiopaque structure in the right main bronchus. Airway support and supplemental oxygen should be provided until bronchoscopy is performed and the coin is retrieved.

Authors

Elhaitham Ahmed

Zayed Military Hospital, AbuDhabi

Khalifa Alqaydi

Zayed Military Hospital, AbuDhabi

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References

Ruiz, F.E. (2022) Airway foreign bodies in children, UpToDate. Available at: https://www.uptodate.com/contents/airway-foreign-bodies-in-children?search=airway+foreign+bodies+in+children&source=search_result&selectedTitle=1~83&usage_type=default&display_rank=1 (Accessed: 08 May 2023).
Shepherd, W. (2023) Airway foreign bodies in adults, UpToDate. Available at: https://www.uptodate.com/contents/airway-foreign-bodies-in-adults?search=adult+forign+body+&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3 (Accessed: 08 May 2023).
Bajaj D, Sachdeva A, Deepak D. Foreign body aspiration. J Thorac Dis. 2021;13(8):5159-5175. doi:10.21037/jtd.2020.03.94
Dabu J, Lindner M, Azzam M, et al. A Case of Chronic Cough and Pneumonia Secondary to a Foreign Body. Case Rep Med. 2017;2017:3092623. doi:10.1155/2017/3092623
Mîndru DE, Păduraru G, Rusu CD, et al. Foreign Body Aspiration in Children-Retrospective Study and Management Novelties. Medicina (Kaunas). 2023;59(6):1113. Published 2023 Jun 9. doi:10.3390/medicina59061113
Goodloe JM, Soulek J. Foreign Bodies . In: Rosen’s Emergency Medicine Concepts and Clinical Practice. 10th ed. Elsevier; 2023:666-681.
Hazra TK, Ghosh AK, Roy P, Roy S, Sur S. An impacted meat bone in the larynx with an unusual presentation. Indian J Otolaryngol Head Neck Surg. 2005;57(2):145-146. doi:10.1007/BF02907672
Swanson KL, Edell ES. Tracheobronchial foreign bodies. Chest Surg Clin N Am. 2001;11(4):861-872.
Kazmerski T, Dedhia K, Maguire R, Aujla S. Chronic Esophageal Foreign Body Presenting as Wheezing and Cough in a Toddler. Pediatr Allergy Immunol Pulmonol. 2014;27(3):151-153. doi:10.1089/ped.2014.0370
White JJ, Cambron JD, Gottlieb M, Long B. Evaluation and Management of Airway Foreign Bodies in the Emergency Department Setting. J Emerg Med. 2023;64(2):145-155. doi:10.1016/j.jemermed.2022.12.008
António P, Raffaella C, Luigia R. Plain Film and MDCT Assessment of Neck Foreign Bodies. 2014;1007/978-88-470-5406-6_1.
Svedström E, Puhakka H, Kero P. How accurate is chest radiography in the diagnosis of tracheobronchial foreign bodies in children?. Pediatr Radiol. 1989;19(8):520-522. doi:10.1007/BF02389562
Turk D, Moslehi MA, Hosseinpour H. Role of Flexible Fiberoptic Bronchoscopy in the Diagnosis and Treatment of Pediatric Airway Foreign Bodies: A 5-Year Experience at a Tertiary Care Hospital in Iran. Tanaffos. 2022;21(3):354-361.
Pavitt MJ, Swanton LL, Hind M, et al. Choking on a foreign body: a physiological study of the effectiveness of abdominal thrust manoeuvres to increase thoracic pressure. Thorax. 2017;72(6):576-578. doi:10.1136/thoraxjnl-2016-209540
Bodart E, Gilbert A, Thimmesch M. Removal of an unusual bronchial foreign body: rigid or flexible bronchoscopy?. Acta Clin Belg. 2014;69(2):125-126. doi:10.1179/2295333714Y.0000000006
Davis RJ, Stewart CM. Complete Glottic Obstruction by an Unusual Foreign Body. Otolaryngol Head Neck Surg. 2019;160(5):935-936. doi:10.1177/0194599818824298
Singh GB, Aggarwal D, Mathur BD, Lahiri TK, Aggarwal MK, Jain RK. Role of magill forcep in retrieval of foreign body coin. Indian J Otolaryngol Head Neck Surg. 2009;61(1):36-38. doi:10.1007/s12070-009-0031-7
White Upper Airway Foreign Bodies: Emergency department presentation, Evaluation and Management. emDOCs.net – Emergency Medicine Education. April 12, 2021. Accessed May 9, 2023. http://www.emdocs.net/upper-airway-foreign-bodies-emergency-department-presentation-evaluation-and-management/.
Pinto A, Scaglione M, Pinto F, et al. Tracheobronchial aspiration of foreign bodies: current indications for emergency plain chest radiography. Radiol Med. 2006;111(4):497-506. doi:10.1007/s11547-006-0045-0

You Have A New Patient!

Introduction

Approach

Investigation

Management

Specific Injuries

Hip

Introduction and Epidemiology

History and Physical Examination

Investigations

Emergency Management of Hip Injuries

Disposition

Knee

Introduction and Epidemiology

History and Physical Examination

Investigations

Emergency Management of Knee Injuries

Gustilo-Anderson Classification

Type I Injuries

Type II Injuries

Type IIIA Injuries

Type IIIB Injuries

Type IIIC Injuries

Special Considerations

Disposition

Ankle

Introduction and Epidemiology

History and Physical Examination

Investigations

Ottawa Ankle Rule

Ottawa Foot Rule

Emergency Management of Ankle Injuries

Disposition

Special Tests

Open Wound Injuries

Soft Tissue Hemorrhage

Compartment Syndrome

Vascular Injuries

Long Bone Fractures

Dislocations Of The Hip, Ankle, And Knee

Revisiting Our Patient

Authors

Nisreen Al Maghraby

Nasser AlJoaib

Faisal AlGhamdi

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Reviewed and Edited By

Jonathan Liow

James Kwan

Arif Alper Cevik, MD, FEMAT, FIFEM

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Introduction

Indications

Contraindications

Equipment and Patient Preparation

Choices of Sedative and Analgesic Agents

Facilities & Equipment

Patient Preparation

Procedure Steps

General Clinical Management and Documentation

Indications for Involvement of an Anesthesiologist

Steps in the Administration of Procedural Sedation [16]

Pre-Procedure

During the Procedure

Post-Procedure

Recommendations for PSA Monitoring by Target Sedation Level

Complications

Hints and Pitfalls

Special Patient Groups

Pediatrics [27,28]

Geriatrics [29]

Pregnant Patients [30,31]

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Nik Hisamuddin Nik Ab Rahman

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References

Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM