Question Of The Day #100

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

This patient arrives to the Emergency department with 1 week of melena and fatigue.  His medication list includes an antiplatelet and an anticoagulant medication.  There is tachycardia and melena noted on examination.  This patient likely has an upper GI bleed based on his signs and symptoms with peptic ulcer disease as the most common cause.  The patient’s anticoagulation serves as a risk factor for GI bleeding and is an important contributing factor in this scenario.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

Gastroenterology consultation for emergent endoscopy (Choice B) is not necessary as the patient is not acutely unstable.  He may need a diagnostic and therapeutic endoscopy during an inpatient admission, but the GI consultants do not need to be called emergently for this procedure.  An acutely unstable upper GI bleed patient, such as a patient with hemodynamic instability, requiring intubation for airway protection, receiving multiple blood product transfusions, or with brisk (rapid) bleeding on exam should prompt GI consultation for an emergent endoscopy for source control.  Surgery consultation for gastrectomy (Choice C) is not a first-line treatment for upper GI bleeding.  Gastroenterology should first perform a diagnostic and therapeutic endoscopy for most upper GI bleed patients.  Surgical esophageal transection, gastrectomy, colectomy, and other surgical procedures are last resort measures to control GI bleeding.  Administration of IV Ceftriaxone (Choice D) is not needed in this scenario and should not be given routinely in upper GI bleeds.  This patient has no infectious signs or symptoms.  Antibiotics, such as Ceftriaxone or quinolones, should be given to upper GI bleed patients with chronic liver disease (i.e., cirrhosis), or presumed gastroesophageal variceal bleeds.  Antibiotics have been found to have a mortality benefit in this patient population with GI bleeds. 

The best next step in management is to treat the patient’s tachycardia with normal saline (Choice A) for volume resuscitation.  This patient may eventually need blood products, but crystalloid IV fluids are okay to start until the Complete Blood Count results return.  This patient is not in overt hemorrhagic shock, so blood products can be held until there is evidence that the hemoglobin is below 7g/dL.  Reversal of the patient’s anticoagulation with Vitamin K and fresh frozen plasma may also be needed depending on the INR level.  Reversal can wait until coagulation studies are complete since the patient is not acutely unstable. An unstable patient should have their anticoagulant reversed immediately. Correct Answer: A

References

 
 
Cite this article as: Joseph Ciano, USA, "Question Of The Day #100," in International Emergency Medicine Education Project, August 12, 2022, https://iem-student.org/2022/08/12/question-of-the-day-100/, date accessed: October 4, 2022

Question Of The Day #99

question of the day

Complete Blood Count

Result

(Reference Range)

BUN

36.2

5 -18 mg/dL

Creatinine

1.1

0.7 – 1.2 mg/dL

Hemoglobin

9.2

13.0 – 18.0 g/dL

Hematocrit

27.6

39.0 – 54.0 %

Which of the following is the most appropriate advice for this patient’s condition?

This patient arrives to the Emergency department after a single hematemesis episode.  On exam he has a borderline low blood pressure and tachycardia.  The laboratory results demonstrate an elevated BUN and a low hemoglobin and hematocrit.  The patient’s vital signs in combination with the laboratory values point towards a diagnosis of an upper GI bleed with early signs of hemorrhagic shock.  The history of alcohol abuse also should raise concern for possible gastro-esophageal variceal bleeding as the cause of the GI bleed.

Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

Although this patient is not acutely unstable, his vital signs are abnormal and he should receive volume resuscitation and close observation in the Emergency department.  After initial resuscitation and treatment, it is sometimes difficult to know the best disposition for the patient (admit versus discharge).  The Glasgow-Blatchford Score isa validated risk satisfaction tool used to assist in determining the disposition of patients with an upper GI bleed.  The scoring criteria and instructions on how to use the score are below.

Glasgow-Blatchford Score

 

A validated risk stratification tool for patients with upper GIB

Scoring Criteria

Numerical Score

BUN (mg/dL)

<18.2

18.2-22.3

22.4-28

28-70

>70

 

0

+2

+3

+4

+6

Hemoglobin (g/dL) for men

>13

12-13

10-12

<10

 

0

+1

+3

+6

Hemoglobin (g/dL) for women

>12

10-12

<10

 

0

+1

+6

Systolic blood pressure (mmHg)

>110

100-109

90-99

<90

 

0

+1

+2

+3

Other criteria

Pulse >100 beats/min

Melena present

Syncope

Liver disease history

Cardiac failure history

 

+1

+1

+2

+2

+2

Instructions:

Low risk= Score of 0.  Any score higher than 0 is high risk for needing intervention: transfusion, endoscopy, or surgery. Consider admission for any score over 0. 

This patient has a Glasgow-Blatchford score of 15, and should not be discharged home.  A plan to discharge with gastroenterology follow up in 1 week (Choice A) or discharge with instructions to return if there are repeat hematemesis episodes (Choice B) should not be followed. This patient may have future hematemesis episodes in the Emergency department, be at risk for aspiration, require endotracheal intubation, and become more hypotensive.  A Sengstaken-Blakemore tube (Choice C) is a specialized oro-gastric tube with a gastric and esophageal balloon.  Placement of this tube is considered an invasive procedure that is only used after a patient has been endotracheally intubated to prevent aspiration.  Once placed correctly, the balloons in the tube can be inflated to tamponade any bleeding variceal vessels in the distal esophagus or stomach.  This tube is used as a last resort measure prior to endoscopic treatment for presumed gastro-esophageal variceal bleeds. 

The best advice for this patient would be to admit the patient for monitoring and endoscopy (Choice D).

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #99," in International Emergency Medicine Education Project, August 5, 2022, https://iem-student.org/2022/08/05/question-of-the-day-99/, date accessed: October 4, 2022

Question Of The Day #98

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

This man presents to the Emergency department with epigastric pain and hematemesis.  His exam shows hypotension, tachycardia, pale conjunctiva, and a tender epigastrium and left upper quadrant.  This patient likely has an upper GI bleed based on his signs and symptoms. 

Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

Risk factors for GI bleeds include alcohol use, anticoagulant use, NSAID (non-steroidal anti-inflammatory drug) use (i.e., ibuprofen, aspirin, naproxen), recent gastrointestinal surgery or procedures, prior GI bleeds, and a history of conditions that are associated with GI bleeds (i.e., gastritis, peptic ulcers, H. Pylori infection, ulcerative colitis, Chron’s disease, hemorrhoids, diverticulosis, or GI tract cancers).  Fatty meals (Choice A) can trigger gastroesophageal reflux disorder (GERD) symptoms or biliary colic symptoms from cholelithiasis.  However, fatty meals do not increase the risk for GI bleeding.  Physiological stress, such as sepsis or bacteremia (Choice B), can increase the risk for GI bleeding.  This patient does not have any infectious exam signs or symptoms that would support the presence of bacteremia. Acetaminophen use (Choice D) can cause liver failure if taken in excess, but acetaminophen does not cause GI bleeding.  NSAIDs, unlike Tylenol, are associated with GI bleeding. 

Systemic steroid use (Choice C) can increase the risk for GI bleeding and is the likely cause of this patient’s upper GI bleed. Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #98," in International Emergency Medicine Education Project, July 29, 2022, https://iem-student.org/2022/07/29/question-of-the-day-98/, date accessed: October 4, 2022

Question Of The Day #97

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

This patient arrives to the Emergency department after multiple episodes of hematemesis.  Her exam shows tachycardia, borderline hypotension, and mild tachypnea.  While in the Emergency department the patient decompensates after more hematemesis episodes and develops altered mental status.  This patient has an upper GI bleed most likely from a gastroesophageal variceal bleed.  Gastro-esophageal (GE) varices are dilated blood vessels at the GE junction that result from portal hypertension.  Variceal bleeding can be catastrophic and cause hemorrhagic shock and problems with airway patency as seen in this scenario.  The management of GE variceal bleeding, like other GI bleeds, begins with management of the “ABCs” (Airway, Breathing, and Circulation).  Unlike in other causes of upper GI bleeds, IV antibiotics and IV octreotide are used in GE variceal bleeds.  IV antibiotics have a mortality benefit when used in this setting.  Early gastroenterology consultation is another important component of GE variceal bleed management for definitive diagnosis and treatment with variceal banding or ligation.  Please see the chart below for further details on general GI bleed causes, signs and symptoms, and ED management.

This patient with a depressed mental status needs to have a definitive airway established to prevent aspiration with bloody vomitus.  IV Pantoprazole (Choice B) is used in upper GI bleeds from peptic ulcers but has no role in this acutely ill variceal bleed patient.  The airway should be established prior to medications, such as pantoprazole are considered.  A cricothyrotomy (Choice D) would establish an airway, but this is an invasive approach to airway management and not the best approach in this patient.  A cricothyrotomy involves piercing a needle or scalpel in the anterior neck (cricothyroid membrane) to establish an airway surgically.  This procedure is performed in special situations where a patient cannot be intubated through the trachea (i.e., angioedema of the lips and tongue, facial mass, facial trauma) and cannot ventilate independently (i.e., depressed mental status).  This patient does not meet the criteria for this invasive procedure.  Endotracheal intubation should be attempted first on this patient.  A Sengstaken-Blakemore tube (Choice A) is a specialized oro-gastric tube with a gastric and esophageal balloon.  Once placed correctly, the balloons on the tube can be inflated to tamponade any bleeding variceal vessels in the distal esophagus or stomach.  This tube should be placed only after intubating a patient and is used as a last resort measure prior to endoscopic treatment.  The best next step in management of this patient is to perform endotracheal intubation (Choice C) for airway protection. Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #97," in International Emergency Medicine Education Project, July 22, 2022, https://iem-student.org/2022/07/22/question-of-the-day-97/, date accessed: October 4, 2022

Question Of The Day #96

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

This patient arrives to the Emergency department with upper abdominal pain and hematemesis.  The exam demonstrated hypotension, tachycardia, pale conjunctiva, and abdominal ascites. The patient decompensates during the exam requiring endotracheal intubation for airway protection. This patient has an upper GI bleed most likely from gastro-esophageal varices given her history of liver cirrhosis and stigmata of chronic liver disease.  Gastro-esophageal (GE) varices are dilated blood vessels at the GE junction that result from portal hypertension.  Variceal bleeding can be catastrophic and cause hemorrhagic shock and problems with airway patency as seen in this scenario.  The management of GE variceal bleeding, like other GI bleeds, begins with management of the “ABCs” (Airway, Breathing, and Circulation).  Unlike in other causes of upper GI bleeds, IV antibiotics and IV octreotide are used in GE variceal bleeds.  IV antibiotics have a mortality benefit when used in this setting.  First line antibiotics are IV ceftriaxone or IV ciprofloxacin.  Early gastroenterology consultation is another important component of GE variceal bleed management for definitive diagnosis and treatment with variceal banding or ligation.  

An abdominal paracentesis (Choice A) is not the best next step in this unstable cirrhotic patient.  Antibiotics are routinely given in gastro-esophageal variceal bleeds due to their mortality benefit, so there is no need for an emergent paracentesis to evaluate for spontaneous bacterial peritonitis (SBP) with an ascitic fluid sample. IV Tranexamic acid (Choice C) is an anti-fibrinolytic agent with pro-coagulative effects.  Its use is recommended in post-partum hemorrhage and traumatic hemorrhages, but it has no utility in the setting of GI bleed.  Early gastroenterology consultation for endoscopy is preferred over general surgery consultation (Choice D).  Surgery consultants can assist in a TIPS procedure (Transjugular intrahepatic portosystemic shunt) to reduce portal hypertension, esophageal resection, or gastrectomy, but less invasive endoscopic therapies with GI specialists are preferred over these procedures.

IV Ceftriaxone (Choice B) is the best next step in this scenario due to the mortality benefit of antibiotics in chronic liver disease patients with variceal bleeds.      

Please see the chart below for further details on general GI bleed causes, signs and symptoms, and ED management.

    

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #96," in International Emergency Medicine Education Project, July 8, 2022, https://iem-student.org/2022/07/08/question-of-the-day-96/, date accessed: October 4, 2022

Question Of The Day #95

question of the day

Complete Blood Count

Result

(Reference Range)

WBC Count

16.2

4.0 – 10.5 X 103/mL

Hemoglobin

10.8

13.0 – 18.0 g/dL

Hematocrit

32.4

39.0 – 54.0 %

Platelets

220

140 – 415 x 103/mL

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

This patient arrives to the Emergency department with bright red bloody stools and lower abdominal pain.  The exam shows fever, tachycardia, and left-sided abdominal tenderness.  The laboratory results provided show leukocytosis and anemia.  This patient likely has a lower GI bleed based on her signs and symptoms.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

All choices provided are causes of lower GI bleeding and are possible in this patient.  However, that patient’s signs, symptoms, and risk profile make certain diagnoses less likely than others.  Diverticulosis (Choice A) is the most common cause of lower GI bleeding.  Diverticulosis often occurs in older patients and should not be associated with pain or fever, which support a diagnosis of an inflammatory or infectious etiology (i.e., diverticulitis, Shigellosis, ulcerative colitis, chron’s disease, etc.).  This patient is young and has fever and leukocytosis, making diverticulosis less likely.  Colon malignancy (Choice B) is also possible but is less likely given the patient’s young age, the presence of fever, and the acute onset of symptoms over 2 days.  Colon malignancy tends to cause slow GI bleeding over a longer period of time, rather than acutely over 2 days.  Ischemic colitis (Choice C), such as mesenteric ischemia, is less likely in a young patient without any cardiac risk factors or recent abdominal surgeries. 

Ulcerative colitis (Choice D) is the most likely diagnosis in this scenario.  Peak incidence for ulcerative colitis occurs in the second and third decades of life, and women are more likely than men to have this diagnosis.  Definitive diagnosis requires a biopsy and colonoscopy, but a CT scan of the abdomen and pelvis can show findings consistent with ulcerative colitis for a new diagnosis.  Treatment of an ulcerative colitis flare includes general supportive care, IV steroids, and IV antibiotics if there is concern for a concurrent infectious process.  Intestinal perforation and toxic megacolon also should be evaluated for with CT imaging.    

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #95," in International Emergency Medicine Education Project, July 1, 2022, https://iem-student.org/2022/07/01/question-of-the-day-95/, date accessed: October 4, 2022

Question Of The Day #94

question of the day

Complete Blood Count

Result

(Reference Range)

WBC Count

4.5

4.0 – 10.5 X 103/mL

Hemoglobin

5.3

13.0 – 18.0 g/dL

Hematocrit

15.9

39.0 – 54.0 %

Platelets

138

140 – 415 x 103/mL

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

This patient arrives to the Emergency Department with bright red bloody stools in the setting of warfarin use.  His exam shows hypotension and tachycardia.  The laboratory results show a low hemoglobin and hematocrit, but no INR or other coagulation studies are provided.  This patient is in hemorrhagic shock due to a lower gastrointestinal bleed.  This patient’s condition may be due to coagulopathy from his warfarin (i.e., supratherapeutic INR), diverticulosis, or other conditions.  Initial management of this unstable patient should include management of the airway, breathing, and circulation (“ABCs”).  This includes aggressive and prompt treatment of the patient’s hypotension and tachycardia and reversal of the patient’s anticoagulation.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

This patient’s platelet level is just below the lower limit of normal, so administration of a platelet transfusion (Choice A) would not be the next best step.  Platelet administration should be considered if the platelet count is below 50,000-100,000, or if a massive transfusion protocol is initiated to prevent coagulopathy.  No INR value is provided in the question stem, but prompt reversal of warfarin should not be delayed for an INR level (Choice D).  Reversal of warfarin should be promptly initiated when a patient is unstable (i.e., hypotensive GI bleed, traumatic wound hemorrhage, intracranial bleed, etc.).  Medication reversal in these settings includes both IV Vitamin K 10mg and IV Fresh Frozen Plasma 10-20cc/kg.  IV Vitamin K helps reverse the Vitamin K antagonistic effect of Warfarin, but it does not acutely provide new Vitamin K-dependent coagulation factors (Factors X, V, II, VII).  IV Vitamin K gives the liver the ‘materials’ needed to regenerate these coagulation factors, but this process takes time.  Fresh frozen plasma contains ‘ready-to-use’ coagulation factors that will help control the hemorrhage acutely.  For this reason, both Vitamin K and FFP are given together in an unstable patient.  An alternative to fresh frozen plasma (FFP) is prothrombin complex concentrate (PCC), which is a concentrated version of coagulation factors.  PCC is not broadly available in all countries, and is generally more expensive than FFP. 

The management of stable patients with a supratherapeutic INR includes holding warfarin doses and sometimes providing PO Vitamin K, depending on the INR level.  Administration of IV Vitamin K only (Choice C) is not the correct treatment in this scenario.  IV Vitamin K and IV Fresh Frozen Plasma (Choice B) is the best next step to reverse this patient’s anticoagulant. 

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #94," in International Emergency Medicine Education Project, June 24, 2022, https://iem-student.org/2022/06/24/question-of-the-day-94/, date accessed: October 4, 2022

Question Of The Day #93

question of the day

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

This patient arrives to the Emergency Department with bright red bloody stools and generalized abdominal pain.  His exam shows hypotension, tachycardia, a diffusely tender abdomen, and pale conjunctiva.  He also takes warfarin daily for anticoagulation.  This patient is in hemorrhagic shock due to a lower gastrointestinal bleed.  This patient’s condition may be due to coagulopathy from his warfarin (i.e., supratherapeutic INR), diverticulosis, ischemic colitis (i.e., mesenteric ischemia), and other conditions.  Initial management of this unstable patient should include management of the airway, breathing, and circulation (“ABCs”).  This includes aggressive and prompt treatment of the patient’s hypotension and tachycardia.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

A CT Angiogram of the abdomen and pelvis (Choice A) may be helpful in clarifying the etiology and site of the patient’s bleeding, but this is not the best next step in management.  The patient’s shock state first should be managed prior to any imaging studies.  Gastroenterology consultation for colonoscopy (Choice B) may be important later in this patient’s management, but it is not the best next step in management. His shock state should be treated prior to calling any consultants. An IV Pantoprazole infusion (Choice C) is helpful in upper GI bleeds due to peptic ulcer disease.  Proton pump inhibitor medications, like pantoprazole, help reduce findings of ulcer bleeding during endoscopy.  Proton pump inhibitor use has been controversial in upper GI bleeds as there is no evidence that their use decreases mortality, decreases blood product requirements, or ulcer rebleeding, but these medications are often given due to their generally small risk profile.

 

The best next step for this patient in hemorrhagic shock is administration of packed red blood cells (Choice D).  He also should have reversal of his warfarin with IV Vitamin K and fresh frozen plasma to prevent continued bleeding.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #93," in International Emergency Medicine Education Project, June 17, 2022, https://iem-student.org/2022/06/17/question-of-the-day-93/, date accessed: October 4, 2022

Question Of The Day #92

question of the day

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

This elderly patient arrives to the Emergency Department with painless hematochezia.  His exam shows borderline hypotension, tachycardia, and a normal abdominal exam.  This patient most likely has a lower gastrointestinal bleed based on his signs and symptoms.  A brisk (fast) upper GI bleed is also possible but is less likely.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

All choices listed above are potential causes of bright red bloody stools.  Peptic ulcer disease (Choice C) is the most common cause of upper GI bleeding worldwide, not lower GI bleeding.  However, a profusely bleeding peptic ulcer can cause rapid blood transit through the GI tract to form hematochezia rather than melena.  The patient lacks any risk factors or symptoms of peptic ulcer disease, such as upper abdominal pain, hematemesis, NSAID use, or prior H. pylori infection.  Ischemic colitis, or mesenteric ischemia (Choice A), is often associated with abdominal pain and cardiac risk factors (i.e., atrial fibrillation).  Colon cancer (Choice B) is also possible, but typically colon malignancy causes slow, chronic bleeding, rather than acute large volume bloody stools with signs of shock as in this patient.  The most common cause of lower GI bleeding worldwide is diverticulosis (Choice D).  This is the most likely diagnosis in this patient with painless hematochezia.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #92," in International Emergency Medicine Education Project, June 10, 2022, https://iem-student.org/2022/06/10/question-of-the-day-92/, date accessed: October 4, 2022

Question Of The Day #91

question of the day

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

This patient arrives to the Emergency Department with upper abdominal pain and hematemesis.  He occasionally takes ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), which is a risk factor for GI bleeding. His examination shows tachycardia.  This patient likely has an upper gastrointestinal bleed given his signs and symptoms.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding.  

All choices listed above are potential causes of upper GI bleeding, with the exception of GERD (Choice D).  Erosive gastritis and esophagitis can cause an upper GI bleed, but GERD is not a cause of upper GI bleed.  The patient lacks risk factors for esophageal varices (Choice A), such as chronic liver disease, cirrhosis, or alcohol abuse.  Gastric malignancy (Choice B) is possible, but less likely given the patient’s young age and lack of risk factors mentioned in the question stem for gastric malignancy (i.e., prior H. pylori infection, tobacco smoking, chronic gastritis, weight loss, lymphadenopathy, etc.).  The most common worldwide cause of upper GI bleeding is peptic ulcer disease (Choice C).  For this reason, Choice C is the best answer.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #91," in International Emergency Medicine Education Project, June 3, 2022, https://iem-student.org/2022/06/03/question-of-the-day-91/, date accessed: October 4, 2022

Approach to the trauma patient – ABCDE of trauma care

Approach to the trauma patient – ABCDE of trauma care

Case

Jane Doe, 22-year-old female, was in a major car crash and is approaching the trauma bay via an ambulance. You are aware that the patient’s condition is critical, so you do a quick run-through in your head about the approach that you will have to care for them once they arrive to your emergency department. What should your approach to a trauma patient be?

The ABCDE of Trauma Care

The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is a clinically proven approach to any critically ill patient that needs emergent care and treatment. It has been proven to improve patient outcomes, optimize team performance and save time when patients are in life-threatening conditions [1]. This approach is applicable to all patients (both adults and children), regardless of their underlying condition. However, the ABCDE approach is not applicable to patients who are in cardiac arrest, in which case the cardiopulmonary resuscitation guidelines should be used [2].

With the ABCDE approach, initial assessment and treatment are performed simultaneously. Once the entire survey is completed, reassessment should be conducted until the patient is stable enough for the care team to be able to move on to the secondary survey and look for a definitive diagnosis.

A - Airway

First, the care team should assess if the patient’s airway is patent. If the patient responds to the team in a normal voice, then that is a good sign that the airway is intact. It is important to note that airway obstruction can be complete or partial, and can be caused by upper airway obstruction or reduced level of consciousness.

Signs of complete airway obstruction are lack of respiration despite great effort. Signs of partial airway obstruction include:
– Changes in the patient’s voice
– Snoring or gurgling
– Stridor (noisy breathing)
– Increased breathing effort

Assess the patient’s airway by looking for rocking chest wall motion and any signs of maxillofacial trauma or laryngeal injury. Perform the head-tilt and chin-lift maneuver to open the airway (note that caution should be conducted in patients with C-spine injury). If there is anything that is noticeably obstructing the airway, suction or remove it. If possible, remove foreign bodies that are causing airway obstruction. Provide high-flow oxygen to the critically ill patient and perform definitive airway if needed [1].

B – Breathing

Generally, airway and breathing are examined simultaneously. Determine if breathing is intact by assessing the respiratory rate, inspecting the chest wall movement for symmetry, depth, and respiratory pattern. Additionally, assess for tracheal deviation and use of respiratory muscles. Percuss the chest for dullness or resonance, auscultate for breath sounds and apply a pulse oximeter [1].

Injuries that impact breathing should be immediately recognized, and life-threatening injuries should be addressed and managed [3]. For example, tension pneumothorax must be promptly relieved by needle thoracocentesis, bronchospasms should be managed with inhalation and assisted ventilation should be considered if breathing continues to be insufficient [1].

C – Circulation

Conditions that threaten the patient’s circulation and can be fatal include shock, hypertensive crises, vascular emergencies such as aortic dissection and aortic aneurisms. These conditions should be immediately identified and managed [1].

Circulation can be assessed by looking at the general appearance of the patient, including signs of cyanosis, pallor, flushing and diaphoresis. Assess for any obvious signs of hemorrhage, blood loss and level of consciousness. Additionally, capillary refill time and pulse rate should be assessed. Auscultate the chest for heart sounds, and blood pressure measurement and electrocardiography should be performed as soon as possible [1].

Additionally, assess for signs of hypovolemia and shock. If these are identified, obtain an intravenous access and infuse saline to restore circulating volume [1]. If there are life-threatening conditions that are compromising the patient’s circulation, promptly identify and treat them as needed. For example, tension pneumothorax should be immediately treated with needle decompression and cardiac tamponade can be relived with pericardiocentesis.

D - Disability

The main disability in the primary survey to be assessed for is the brain. Abnormal neurological status can be caused by primary brain injury or systemic conditions that effect brain perfusion, such as shock, hypoxia, intoxication etc. Assess the level of consciousness by using the Glasgow Coma Scale [4], look for pupillary response and limb movement.

The best way to prevent injury to the brain is to maintain adequate airway, breathing and circulation. Glucose levels can be assessed at bedside for decreased level of consciousness due to low blood glucose levels, and corrected with oral or infused glucose [1].

E – Exposure

The exposure portion of the ABCDE approach involves assessment of the whole-body to avoid any signs of missing injuries. During this part of the management, undress the patient fully and examine the back for any signs of C-spine precautions. Additionally, check for clues for any signs of underlying conditions, such as:

  • Signs of trauma (i.e. burns, gunshot wounds, stab wounds)
  • Rashes
  • Causes of sepsis (i.e. infected wounds, gangrene)
  • Toxins and drugs (i.e. needle track marks, chemicals, patches)
  • Other wounds such as bite marks, insect bites, embedded ticks
  • Iatrogenic causes (i.e. catheters, tubes, implants, surgical sites and scars)

Concluding Remarks

The ABCDE approach to the critically ill patient is a strong and proven clinical tool for initial assessment and treatment of patients in medical emergencies. Widespread knowledge of this skill is critical for healthcare workers and any team providing emergent care to trauma patients. 

*Note that this is a general approach to the trauma patient. Always consult your care team for adequate management of trauma patients and resort to reliable resources for more information on the ABCDE approach. 

References and Further Reading

  1. Thim, T., Krarup, N. H. V., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International journal of general medicine5, 117.
  2. Koster, R. W., Baubin, M. A., Bossaert, L. L., Caballero, A., Cassan, P., Castrén, M., … & Sandroni, C. (2010). European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation81(10), 1277-1292.
  3. Subcommittee, A. T. L. S., & International ATLS Working Group. (2013). Advanced trauma life support (ATLS®): the ninth edition. The journal of trauma and acute care surgery74(5), 1363-1366.
  4. Sternbach, G. L. (2000). The Glasgow coma scale. The Journal of emergency medicine19(1), 67-71.
Cite this article as: Maryam Bagherzadeh, Canada, "Approach to the trauma patient – ABCDE of trauma care," in International Emergency Medicine Education Project, January 19, 2022, https://iem-student.org/2022/01/19/abcde-of-trauma-care/, date accessed: October 4, 2022

Seizure: Lethal Dissection

Lethal Dissection Seizure

Case Presentation

A 49-year old female without any co-morbidities presented to the emergency department (ED) with seizures. On arrival, she was in a postictal state.

She had recently visited a local hospital with complaints of severe dysmenorrhea and low back pain. The attenders informed us that she was very sleepy and weak at that time, was treated for pain and given tranexamic acid, and sent home. The next day, she had one episode of Generalized Tonic-Clonic Seizure, and she arrived in our ED in a postictal phase. She vomited twice in the ED.

Her vitals were as follows: 

  • Blood pressure (BP): 160/100 mmHg.
  • Heart rate (HR): 22/min
  • Peripheral capillary oxygen saturation (SPO2): 98% on room air
  • General Random Blood Sugar (GRBS): 233 mg/dl
  • Glasgow Coma Scale (GCS): E2V5M6

Her examination was as follows:

  • The patient was drowsy but arousable. 
  • Pupils bilateral reacting to light. No anisocoria.
  • CNS examination could not be completed as the patient was drowsy.
  • A normal pattern of breathing. The respiratory examination was normal.
  • The abdomen was soft, symmetric, and non-tender without distention.

Point-of-care ultrasound (POCUS) showed a flap in the abdominal aorta. (See Figure 1 and 2 for transverse and longitudinal views of the aorta, respectively) Upon this finding, cardiac surgery and neurology consultations were sought.

Transverse section of the abdominal aorta showing a flap.
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Image shows transverse section of the abdominal aorta showing a flap.

Abdominal aorta showing a flap
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Image shows abdominal aorta showing a flap.

The laboratory results were as follows:

  • D-dimer: 1192 ng/ml
  • Haemoglobin (Hb): 10 g/dl
  • The international normalized ratio (INR): 1.25
  • Platelets: 260000 per mcL
  • Total leucocyte count (TLC): 22000 cells/mm3
  • Creatinine :1.6 mg/dl.

Meanwhile, the patient was suffering multiple seizure-like episodes, characterized by staring, deviation of the mouth, and irregular limb movements, but these episodes lasted for few minutes and ended without the postictal phase. The patient was drowsy but obeyed commands and did not have any recollection of those few minutes.

Head computed tomography (CT) showed no infarct or bleeding. It was normal.

CT angiogram and aortogram revealed that the patient had Stanford Type A aortic dissection with the flap extending to the entire left subclavian artery, with severely occluding filling defects and thrombosis of the false lumen into bilateral common carotid arteries (See Figure 3, 4 and 5). On the other end, the dissection extended to the common iliac arteries (See Figure 6).

CT Aortogram showing bilateral common carotid artery filling defects
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Image shows CT Aortogram showing bilateral common carotid artery filling defects

And on the other loose of the string the dissection was extending till the common iliac arteries.
Ascending and descending aortic dissection
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Image shows ascending and descending aortic dissection

Dissection of the common iliac artery before bifurcation
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Image shows dissection of the common iliac artery before bifurcation.

 

Management

Initially, the patient was treated symptomatically by anti-epileptics and analgesics. After the cardio-thoracic and vascular surgeon consultations, we decided to airlift the patient to a higher centre as our hospital was tertiary care and there were no grafts for the urgent repair of the extensive aortic dissection. We intubated the patient for secure transportation. However, we learned that the patient expired in the higher centre before reaching the operating room.

Discussion

Before I shed light on the important part of this discussion, I know that the outcome of this case was unfortunately grave. However, I chose this case because of it.

In this case, the patient had low back pain in her previous hospital visit. However, she was sent home with symptomatic management, implying that it could have been addressed more carefully. She visited our ED one day later, and POCUS let us diagnose the dissection in 15 minutes, which was confirmed by a CT aortogram within 40 minutes. After consultations and finding the available facility, we airlifted the patient to a higher centre for urgent repair, but the patient could not make it to the operating room.     

We all know acute aortic dissection is the most common life-threatening disorder affecting the aorta. Over the first several hours, the mortality rate increase up to 1% per hour; therefore, early intervention is critical (1). In our case, the involvement of bilateral carotid arteries caused seizure-like episodes and altered mental status. Also, studies show that patients with similarly located dissections may experience neck pain, transient ischemic attacks (TIA), cerebral ischemia, transient monocular blindness and subarachnoid haemorrhage (SAH) but not seizure(2). In our case, the global hypo-perfusion caused recurrent TIAs, which resembled seizure-like clinical episodes. That’s why emergency physicians should be vigilant about the underlying causes of seizure-like activities, even if altered mental status similar to postictal state is present, especially if the patient does not have a history of seizures and the complaints are unclear. Keep the aortic dissection in mind as a differential. Also, I cannot stress the use of POCUS in the ED enough. It is a game-changer, and in our case, it detected a lethal disease successfully.

Learning Points

  1. Never ignore back pain that does not subside after adequate pain management.
  2. POCUS is always a game-changer. It saves a lot of time and lives, as in my case.
  3. Seizures or not, you must keep a high suspicion for lethal vascular diseases. Remember the basics: If unclear, go back to history.
  4. Once you confirm an aortic dissection, never delay treatment because time = life.
  5. Never ever send a patient back home unless you are completely sure about the cause of the presenting symptom. Over investigating is ok when compared to under investigating, when it might cost a life.

References and Further Reading

  1. Braverman AC. Acute aortic dissection: clinician update. Circulation. 2010;122(2):184-188. doi:10.1161/CIRCULATIONAHA.110.958975
  2. Debette S, Grond-Ginsbach C, Bodenant M, et al. Differential features of carotid and vertebral artery dissections: the CADISP study. Neurology. 2011;77(12):1174-1181. doi:10.1212/WNL.0b013e31822f03fc
Cite this article as: Naveen Paila, India, "Seizure: Lethal Dissection," in International Emergency Medicine Education Project, November 15, 2021, https://iem-student.org/2021/11/15/seizure-lethal-dissection/, date accessed: October 4, 2022