A 19-year-old female presents with sharp right flank pain and shortness of breath

by Stacey Chamberlain

A 19-year-old female presents with sharp right flank pain and shortness of breath that started suddenly the day prior to arrival. The pain is worse with deep inspiration but not related to exertion and not relieved with ibuprofen. She denies anterior chest pain, cough, and fever. She denies leg pain or swelling and recent travel, immobilization, trauma, or surgery. She has no anterior abdominal pain, no dysuria or hematuria and no personal or family history of gallstones, kidney stones, or blood clots. She’s never had this pain before, has no significant past medical history and her only medication is birth control pills. On exam, her vital signs are within normal range, she has normal cardiac and pulmonary exams, no costovertebral angle tenderness, no chest wall or abdominal tenderness and no leg swelling.

Do you need to do any studies to evaluate this patient for a pulmonary embolism?

Pulmonary Embolism Rule-Out Criteria (PERC)

  • Age ≥ 50
  • Heart rate ≥ 100
  • O2 sat on room air < 95%
  • Prior history of venous thromboembolism
  • Trauma or surgery within 4 weeks
  • Hemoptysis
  • Exogenous estrogen
  • Unilateral leg swelling

The PERC CDR was originally derived and validated in 2004 and with a subsequent multi-study center validation in 2008. In the larger validation study, the rule was only to be applied in those patients with a pre-test probability of < 15%, therefore incorporating clinical gestalt prior to using the rule. PERC is a one-way rule, as mentioned above, which tried to identify patients who are so low-risk for pulmonary embolism (PE) as to not require any testing. It does not imply that testing should be done for patients who do not meet criteria, and it is not meant for risk stratification, as opposed to the Wells’ and Geneva scores.

Case Discussion

In order to apply the PERC CDR to the case study patient, the ED physician pre-supposes a pre-test probability of < 15%. If the ED physician has a higher pre-test probability than that, he/she should not use the PERC CDR. If the ED physician, in this case, did indeed have a pre-test probability of < 15%, the case study patient would fail the rule-out due to her use of oral contraceptives. In that case, the ED physician would need to determine if he/she would do further testing which could include a D-dimer, CT chest with contrast, ventilation/perfusion scan, or lower extremity Doppler studies to evaluate for deep vein thromboses (DVTs). The PERC CDR gives no guidance in this case.

Cite this article as: iEM Education Project Team, "A 19-year-old female presents with sharp right flank pain and shortness of breath," in International Emergency Medicine Education Project, June 17, 2019, https://iem-student.org/2019/06/17/a-19-year-old-female-presents-with-sharp-right-flank-pain-and-shortness-of-breath/, date accessed: November 17, 2019

A 28-year-old man presents to the ED with left ankle pain

by Stacey Chamberlain

A 28-year-old man presents to the ED with left ankle pain after twisting his ankle playing basketball. He is able to bear weight and notes pain and swelling to the lateral aspect of the ankle (he points to just below the lateral malleolus). He denies weakness, numbness, or tingling and has no other injuries. On exam, he is neurovascularly intact. Edema and tenderness are noted slightly anterior and inferior to the lateral malleolus. There is no point tenderness to the distal posterior malleoli bilaterally.

Should you get an X-ray to rule out fracture?

Ottawa Ankle Rule

Pain in the malleolar zone and any one of the following:

  • Bone tenderness along the distal 6 cm of the posterior edge or tip of the tibia (medial malleolus), OR
  • Bone tenderness along the distal 6 cm of the posterior edge or tip of the fibula (lateral malleolus), OR
  • An inability to bear weight both immediately after the trauma and in the ED for four steps.

Ottawa Foot Rule

Pain in the midfoot zone and any one of the following:

  • Bone tenderness at the base of the fifth metatarsal, OR
  • Bone tenderness at the navicular bone, OR
  • An inability to bear weight both immediately after the trauma and in the ED for four steps.

Case Discussion

In the above case, using either CDR, an X-ray is unnecessary.

Cite this article as: iEM Education Project Team, "A 28-year-old man presents to the ED with left ankle pain," in International Emergency Medicine Education Project, June 10, 2019, https://iem-student.org/2019/06/10/a-28-year-old-man-presents-to-the-ed-with-left-ankle-pain/, date accessed: November 17, 2019

A 36-year-old woman slipped on ice. CT or Not CT?

by Stacey Chamberlain

A 36-year-old woman slipped on ice and fell and hit her head. She reports loss of consciousness for a minute after the event, witnessed by a bystander. She denies headache. She denies weakness, numbness or tingling in her extremities and no changes in vision or speech. She has not vomited. She remembers the event except for the transient loss of consciousness. She doesn’t use any blood thinners. On physical exam, she has a GCS of 15, no palpable skull fracture and no signs of a basilar skull fracture.

Should you get a CT head for this patient to rule out a clinically significant brain injury?

Canadian CT Head Rule

High-Risk Criteria (rules out the need for neurosurgical intervention)

Medium Risk Criteria (rules out clinically important brain injury)

  • GCS < 15 at two hours post-injury
  • Suspected open or depressed skull fracture
  • Any sign of basilar skull fracture (hemotympanum, Raccoon eyes, Battle’s sign, CSF oto or rhinorrhea)
  • Retrograde amnesia to event  ≥ 30 minutes
  • Dangerous mechanism (pedestrian struck by motor vehicle, ejection from the motor vehicle, fall from > 3 feet or > 5 stairs)

The Canadian CT Head Rule (CCHR) only applies to patients with an initial GCS of 13-15, witnessed loss of consciousness (LOC), amnesia to the head injury event, or confusion. The study was only for patients > 16 years of age. Patients were excluded from the study if they had “minor head injuries” that didn’t even meet these criteria. Patients were also excluded if they had signs or symptoms of moderate or severe head injury including GCS < 13, post-traumatic seizure, focal neurologic deficits, or coagulopathy. Other studies have looked at different CDRs for traumatic brain injury including the New Orleans Criteria (NOC). However, CCHR has been found to have superior sensitivity and specificity.

Case Discussion

By applying this rule to the above case, the patient should be considered for imaging due to the mechanism. A fall from standing for an adult patient would constitute a fall from > 3 feet; therefore, although the patient would not likely be high risk and need neurosurgical intervention, the patient might have a positive finding on CT that in many practice settings would warrant an observation admission.

Cite this article as: iEM Education Project Team, "A 36-year-old woman slipped on ice. CT or Not CT?," in International Emergency Medicine Education Project, June 7, 2019, https://iem-student.org/2019/06/07/a-36-year-old-woman-slipped-on-ice/, date accessed: November 17, 2019

A 24-year-old woman presents with headache

by Stacey Chamberlain

A 24-year-old woman presents with headache that began three hours prior to arrival to the ED. The patient was at rest when the headache began. The headache was not described as “thunderclap,” but it did reach maximum severity within the first 30 minutes. The headache is generalized and rated 10/10. She denies head trauma, weakness, numbness, and tingling in her extremities. She denies visual changes, changes in speech and neck pain. She has not taken anything for the headache. She does not have a family history of cerebral aneurysms or polycystic kidney disease. On physical exam, she has a normal neurologic exam and normal neck flexion.

Should you do a head CT and/or a lumbar puncture to evaluate for a sub-arachnoid hemorrhage in this patient?

Ottawa SAH Rule

Investigate if ≥1 high-risk variables present

  • Age ≥ 40
  • Neck pain or stiffness
  • Witnessed loss of consciousness
  • Onset during exertion
  • Thunderclap headache (instantly peaking pain)
  • Limited neck flexion on exam

A CDR to determine risk for sub-arachnoid hemorrhage (SAH) was derived and has been externally validated in a single study. The CDR’s purpose was to identify those at high risk for SAH and included those with acute non-traumatic headaches that reached maximal intensity within one hour and who had normal neurologic exams. Of note, the rule has many inclusion and exclusion criteria that the ED physician must be familiar with and was only derived for patients 16 years or older. The study authors note that the CDR is to identify patients with SAH; it is not an acute headache rule. In the validation study, of over 5,000 ED visits with acute headache, only 9% of those met inclusion criteria. Also, clinical gestalt again plays a role as the authors suggest not to apply the CDR to those who are ultra-high risk with a pre-test probability for SAH of > 50%.

The Ottawa SAH Rule was 100% sensitive but did not lead to reduction of testing vs. current practice. The authors state that the value of the Ottawa SAH Rule would be to standardize physician practice in order to avoid the relatively high rate of missed sub-arachnoid hemorrhages.

Case Discussion

By applying the Ottawa SAH Rule, this patient is low risk and does not require further investigation for a SAH.

Cite this article as: iEM Education Project Team, "A 24-year-old woman presents with headache," in International Emergency Medicine Education Project, May 29, 2019, https://iem-student.org/2019/05/29/a-24-year-old-woman-presents-with-headache/, date accessed: November 17, 2019

Mnemonic for Right Lower Quadrant Pain

Open fracture! Antibiotic choice.

ERic Motorcycle accident

A 20-year-old male presents to your ED with a 5 cm wound after he fell off his motorbike. On physical exam, the wound overlays a fractured left tibia but does not show extensive soft tissue damage nor any signs of periosteal stripping or vascular injury. 

Which antibiotic should you give to this patient?

To learn more about it, read chapters below.

Read "Scores" Chapter
Read "Lower Extremity Injuries" Chapter

Quick Read

Gustilo-Anderson Classification

Gustilo-Anderson classification is used for fractures with open wounds and antibiotic coverage.

Gustilo-Anderson Classification

TypeDefinition
Type IOpen fracture, clean wound, wound <1cm in length
Type IIOpen fracture, wound >1cm in length without extensive soft tissue damage, flaps, avulsions
Type IIIOpen fracture with extensive soft tissue laceration, damage, or loss or an open segmental fracture. This type also includes open fractures caused by farm injuries, fractures requiring vascular repair, or fractures that have been open for 8 hours prior to treatment.
Type III AType III fracture with adequate periosteal coverage of the fractured bone despite extensive soft tissue laceration or damage
Type III BType III fracture with extensive soft tissue loss and periosteal stripping and bone damage. Usually associated with massive contamination. It will often need further soft tissue coverage procedure (i.e. free or rotational flap).
Type III CType III fracture associated with arterial injury requiring repair, irrespective of degree of soft tissue injury

According to the above classification, each class should receive the following antibiotics:

  • Type I: 1st generation cephalosporin
  • Type II: 1st generation Cephalosporin +/- Gentamycin
  • Type III: 1st generation Cephalosporin + Gentamycin +/- Penicillin

To learn more about it, read chapters below.

Read "Scores" Chapter
Read "Lower Extremity Injuries" Chapter

Shock Index

A 57-year-old male presented to the ED with severe abdominal pain for 1 day. No allergies or significant past medical history. His vitals are: Temp 37.6 Celsius, BP 100/55, HR 110/min, RR 20/min and O2 Saturation is 99% on room air. 

What level of care does this patient require?

To learn more about it, read chapters below.

Read "Shock" Chapter

Read "Scores" Chapter

Quick Read

Shock Index

SHOCK INDEX (SI) = Heart Rate / Systolic Blood Pressure

Application

SI can be used to identify patients needing a higher level of care despite vital signs that may not appear strikingly abnormal. This index is a sensitive indicator of left ventricular dysfunction and can become elevated following a reduction in left ventricular stroke work.

Interpretation

  • Normal SI = 0.5 to 0.7
  • If SI > 0.9 was helpful to identify patients in the ED requiring admission and/or intensive care despite apparently stable vital signs
  • Persistent high SI has been associated with poor outcome

The answer to the above clinical scenario: By applying the above equation, (110/100 = 1.1), this patient has a high shock index and requires a high level of care.

To learn more about it, read chapters below.

Read "Shock" Chapter

Read "Scores" Chapter

AEIOU TIPS Card

ALTERED MENTAL STSTUS

Causes of ST Elevation

Classifications and Scores in Emergency Medicine

Classifications and Scores chapter written by Sarah Attwa and Marwan Galal from Egypt and UAE is just uploaded to the Website!

Lovely Mnemonics of Emergency Medicine

Mnemonics chapter by Ozlem Dikme from Turkey is just uploaded to the Website!

Assessing Airway Difficulty – LEMON