Question Of The Day #5

question of the day
qod 5 trauma

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

This patient has sustained blunt abdominal trauma from his seat belt. This is indicated by the linear area of ecchymoses, known as a “seat belt sign”. This is a worrisome physical exam finding that should raise a concern about a severe intra-abdominal injury. All trauma patients presenting to the emergency department should be assessed using an organized approach, including a primary survey (“ABCs”) followed by a secondary survey (more detailed physical examination). The FAST (Focused Assessment with Sonography in Trauma) examination is part of the primary survey in a trauma patient. Some sources abbreviate the primary survey in trauma as “ABCDEF”, which stands for Airway, Breathing, Circulation, Disability, Exposure, FAST exam. The primary survey attempts to identify any life-threatening diagnoses that need to be addressed in a time-sensitive manner. Examples include cardiac tamponade, tension pneumothorax, and intra-abdominal bleeding. The FAST exam includes 4 basic views: the right upper quadrant view (liver and right kidney), pelvis view (bladder), left upper quadrant view (spleen and left kidney), and cardiac/subxiphoid view (heart). An E-FAST, or extended FAST, includes the four standard FAST views plus bilateral views of the lungs to evaluate for pneumothorax. An abnormal FAST exam demonstrates the presence of free fluid on ultrasound. In the setting of trauma, free fluid is assumed to be blood. Free fluid on ultrasound appears black, or anechoic (indicated by yellow arrows in below image).

question of the day 5 trauma

The space between the liver and right kidney (“Morrison’s Pouch”) is often the first location or blood to accumulate in a patient with intra-abdominal bleeding. Trauma patients who are hemodynamically unstable with a positive FAST exam (this patient) should go to the operating room for emergent exploratory laparotomy (Choice C) to determine the source of their bleeding. Performing a CT scan of the abdomen and pelvis (Choice A) would be the correct answer if the patient was hemodynamically stable and had a positive FAST exam. Allowing this patient to leave the emergency department for a CT scan would be dangerous as this patient could rapidly decompensate. Performing a Diagnostic Peritoneal Lavage (Choice B) would be the correct answer if the patient was hemodynamically stable but had a normal FAST exam. An emergent thoracotomy (Choice D) is more typically performed in patients with penetrating trauma who have cardiac arrest shortly before presenting to the emergency department. This intervention attempts to identify and treat any reversible causes of cardiac arrest. Correct Answer: C

References

Butler, M. (2015). “Boring question: What is the role of the FAST exam for blunt abdominal trauma?” Canadiem. https://canadiem.org/boring-question-what-is-the-role-of-the-fast-exam-for-blunt-abdominal-trauma/

Franzen, D. (2016). “FAST examination”. SAEM. https://www.saem.org/cdem/education/online-education/m3-curriculum/bedside-ultrasonagraphy/fast-exam

Cite this article as: Joseph Ciano, USA, "Question Of The Day #5," in International Emergency Medicine Education Project, July 22, 2020, https://iem-student.org/2020/07/22/question-of-the-day-5/, date accessed: September 28, 2020

NEXUS Criteria

nexus criteria
Cite this article as: Keerthi Gondy, USA, "NEXUS Criteria," in International Emergency Medicine Education Project, July 6, 2020, https://iem-student.org/2020/07/06/nexus-criteria/, date accessed: September 28, 2020

The First Nexus Criteria Reference

Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998;32(4):461-469. doi:10.1016/s0196-0644(98)70176-3

eFAST Course for Medical Students

Dear students,

We are pleased to open our second course for you; Extended Focused Assessment with Sonography for Trauma (eFAST).

As a part of our social responsibility initiative, iem-course.org will continue to provide free open online courses related to emergency medicine. We hope our courses help you to continue your education during these difficult times.

Please send us your feedback or requests about courses.

We are here to help you.

Best regards.

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

iEM Course is a social responsibility initiative of iEM Education Project

Extended Focused Assessment With Sonography In Trauma (eFAST) is one of the most commonly used emergency ultrasound or Point-Of-Care Ultrasound protocols. It is a protocol that we use in trauma patients. However, the eFAST examination can also be a part of another protocol, such as RUSH protocol.

The early diagnosis of a bleeding trauma patient is essential for better patient care. Unfortunately, it is proven that our physical exam findings are not perfect in every case. Therefore, using a bedside tool in addition to the physical examination can improve patient management.

As a 21st-century medical student/young physician, you must learn how to use this tool to provide more comprehensive and accurate care to your patients.

This course aims to provide the necessary information on ultrasonography, its use in a multiply injured trauma patient, and to prepare you for an eFAST practice session.

Cite this article as: Arif Alper Cevik, "eFAST Course for Medical Students," in International Emergency Medicine Education Project, May 18, 2020, https://iem-student.org/2020/05/18/efast-course-for-medical-students/, date accessed: September 28, 2020

Trauma and Public Health

Trauma is a leading cause of preventable morbidity and mortality. Each reader will have a different context regarding what causes traumatic injuries locally, from different types of motor vehicles, various weapons or security concerns, unique household and workplace injuries, among others. There are several generalizable public health level considerations that we can all benefit from.

Traumatic injuries occur “at the organic level, resulting from acute exposure to energy (mechanical, thermal, electrical, etc.) in amounts that exceed the threshold of physiologic tolerance” [1]. Historically, humans have viewed traumatic injuries as “accidents”; it’s even what we often call them. This view has made trauma a neglected subset of public health focus and funding, though more recently, there has been an increased recognition from public health entities that traumatic injuries are often preventable and treatable [1].

Every year, more than 5 million people die from injury, which is a mortality rate of more than 1.5 times that of HIV, tuberculosis, and malaria combined [2]. Beyond deaths, nearly one billion people sustain injuries that require health care each year from around the globe [3]. Notably, for every death from injury, there are 20–50 nonfatal injuries that result in some disability [4]. Further, the morbidity from trauma is often long-lasting and impacts the quality of life, productivity, and the financial security of individuals, families, and entire communities [5].

Of the 5 million annual trauma deaths, an estimated 1.3 million people are killed in road traffic crashes each year, and projections indicate these will likely increase by another 65% over the coming two decades [6]. Common throughout the world, pedestrians and two-wheel vehicle users are at greater risk of injury and death than vehicle occupants [7]. As vehicles like cars and trucks are owned and operated by more individuals around the world, such projections make logical sense.

After a traumatic injury occurs, the aim is the progress of a patient through a continuum of trauma care, as represented in the below figure:

Yet, such systems and continuums of care lack around the world. In one 2017 review of trauma systems from around the globe, Dijkink et al. found only 9 of 23 high incomes countries had well-defined and documented national trauma systems. Very few low and middle income (LMIC) countries had a formal trauma system or trauma registry [9]. Of note, most injuries occur in low-income and middle-income countries, and most trauma care research comes from high-income countries [10].

In their review of LMICs developing trauma care system, Reynolds et al. identified several common strengths, including training, prehospital systems, and organization, but also found weaknesses in LMICs’ lack of focus on performing quality-improvement, costing, rehabilitation, and policy around trauma care [10].

Each context, even within countries, has a unique set of advantages and barriers, ranging from well-developed to non-existent: EMS systems, in-hospital diagnosis and treatment, and rehabilitation care. Estimates derived from the Global Burden of Disease data suggest that nearly 2 million lives could be saved every year if case fatality rates among seriously injured persons in low- and middle-income countries were similar to those achieved in high-income countries [10,11].

Moving towards such improvements is a monumental task that requires stepwise action. One tool that can help is something I have written about previously: the World Health Organization’s Basic Emergency Care course. The multi-day course curriculum has been developed to teach a high-yield approach to emergent health problems systematically. The course focuses on triage interventions for treating trauma, breathing, shock, and altered mental status. This framework for knowledge and skills can help to improve the acute care of a traumatic injury in almost any location.

I strongly encourage every reader to take a few minutes to consider what are the local causes of traumatic injury, to think about how your current trauma care system is both doing well and where it needs help. I would ask that you think about what ways you could focus on this crucial public health issue and find ways either through education, advocacy, or otherwise, to improve the health of your local and global community.

References

  1. Krug et al. The global burden of injuries. Am J Public Health. 2000 Apr;90(4):523-6. DOI: 10.2105/ajph.90.4.523.
  2. World Health Organization, 2014. Injuries and Violence: The Facts. Geneva: WHO
  3. Haagsma et al. 2016. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj. Prev. 22(1): 3–18
  4. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, eds. 2015. Essential Surgery: Disease Control Priorities, Vol. 1. Washington, DC: Int. Bank Reconstr. Dev./World Bank. 3rd ed.
  5. Wesson HKH, Boikhutso N, Bachani AM, Hofman KJ, Hyder AA. 2014. The cost of injury and trauma care in low- and middle-income countries: a review of economic evidence. Health Policy Plan. 29(6): 795–808.
  6. Global Road Safety Facility (2014) Transport for health: the global burden of disease from motorized road transport. Washington, DC, The World Bank.
  7. Jayanth Paniker, et al. Global trauma: the great divide. SICOT J. 2015; 1: 19. Published online 2015 Jul 21. doi: 10.1051/sicotj/2015019.
  8. National Academy of Sciences, Committee on Military Trauma Care’s Learning Health System; Health and Medicine Division. Berwick D, Downey A, Cornett E, editors. Washington (DC): National Academies Press (US); 2016 Sep. https://doi.org/10.17226/23511
  9. Dijkink S et al. Trauma systems around the world: A systematic overview. J Trauma Acute Care Surg. 2017 Nov;83(5):917-925. doi: 10.1097/TA.0000000000001633
  10. Reynolds TA et al. The Impact of Trauma Care Systems in Low- and Middle-Income Countries. Annu Rev Public Health. 2017 Mar 20;38:507-532. doi: 10.1146/annurev-publhealth-032315-021412. Epub 2017 Jan 11.
  11. Mock C, Joshipura M, Arreola-Risa C, Quansah R. 2012. An estimate of the number of lives that could be saved through improvements in trauma care globally. World J. Surg. 36(5): 959–63.

 

Cite this article as: J. Austin Lee, USA, "Trauma and Public Health," in International Emergency Medicine Education Project, May 11, 2020, https://iem-student.org/2020/05/11/trauma-and-public-health/, date accessed: September 28, 2020

Salter-Harris Fractures

salter harris

Case Presentation

You are a medical student doing your first clinical shift as part of your Emergency Medicine rotation. A 9-year-old boy is brought in by his father after an injury to his left hand approximately 1 hour back. As explained by the father, the child was playing at home with his elder brother when his left index finger became caught in between a door that had quickly slammed shut. Following the injury, the child was reported to be crying due to severe pain, but had no lacerations or other associated injuries. He was rushed to the hospital and presented in the ED as an anxious, weeping boy who held out his left index finger and pointed to the tip as the region of maximal pain. Mild swelling was noted at the distal interphalangeal joint as well as at the tip of the affected finger. After appropriate analgesia was initiated, the child was sent to the Radiology department for X-ray imaging. The images obtained by the department are shown below in Figures 1.1 and 1.2.

Figure 1.1
Figure 1.1
Figure 1.2
Figure 1.2

Findings

Due to the lack of ideal positioning and suboptimal cooperation from the child and his parent, the radiology technician reports back to you stating that the best images they could obtain were the ones displayed above. Although unclear, you can confidently identify a small break in the bone at the base of the distal phalanx. You mention to the father that you see a fracture on the X-ray and report back to your Attending Physician. 

The Attending Physician decides to take a break from his morning coffee and utters the dreaded question: “What kind of fracture is this?” You try to recall a lecture you had about Salter-Harris fractures but cannot recall the classification of these fractures. As if on cue, the father of the patient finds you shuffling your weight in front of the Attending Physician and asks: “You said he has a fracture, will he have to get surgery for his finger?”

“What kind of fracture is this?”

Salter-Harris Fractures

Salter-Harris Fractures refer to fractures that involve the growth plate (physis). Therefore, these fractures are applicable specifically to the pediatric population, occurring most often during periods of rapid growth (growth spurts) when the growth plate is at its weakest, close to age ranges where children tend to participate in high-risk activities (11-12 in girls and 12-14 in boys) [1].

Originally described in 1963 by Dr Robert Salter and Dr Robert Harris [2], the now infamous Salter-Harris fractures are classified by the region of bone that is affected. Figure 2 displays the gross anatomy of a normal distal phalanx similar to the picture we examined in the X-ray, labelled to reflect the different areas of the bone relative to each other. The types of fractures that can occur are outlined below.

SALTER HARRIS ANATOMY
Figure 2
  • Type I Salter-Harris Fractures (Slipped)

    Type I fractures occur when a longitudinal force is applied across the physis, resulting in a displacement (“slip”) of the epiphysis from the metaphysis. Though relatively infrequent (5%), suspicion of this fracture is raised when the epiphysis is seen to either be displaced to the side of its original position relative to the metaphysis or when the gap between the two segments is widened.

Salter-Harris Type I
Salter-Harris Type I
  • Type II Salter-Harris Fractures (Above)

    Type II fractures are the most common (75%) of the Salter-Harris fractures. As with our patient above, this fracture only involves structures “Above” the epiphysis (Metaphysis + Physis/growth plate) with virtually no fracture or displacement of the epiphysis itself. Fortunately, type I and most type II fractures can be managed conservatively with cast immobilization and splinting.

Salter-Harris Type II
Salter-Harris Type II
  • Type III Salter-Harris Fractures (Lower)

    Type III fractures involve both the physis and the epiphysis. Although relatively uncommon (10%), the involvement of the epiphysis and consequent disruption of the growth plate makes this an intra-articular fracture that usually requires surgical fixation.

Salter-Harris Type III
Salter-Harris Type III
  • Type IV Salter-Harris Fractures (Through)

    Continuing the trend of worse outcomes with higher classification types, Type IV fractures involve all three layers (metaphysis, physis and epiphysis) and thus harbor more adverse outcomes and risks, with management primarily consisting of operative internal fixation. Similar to Type III fractures, this is an intra-articular fracture and also occurs at a similar rate of 10%.

Salter-Harris Type IV
Salter-Harris Type IV
  • Type V Salter-Harris Fractures (Rammed/Crushed)

    The rarest of all the Salter-Harris fractures, type V fractures occur due to high impact compression of the growth plate. Potential disruption of the germinal matrix and compromised vascular supply to the growth plate can lead to growth arrest.

Salter-Harris Type V
Salter-Harris Type V

A convenient method to recall the Salter-Harris classifications is outlined below using the mnemonic “SALTR”

Salter-Harris Classification
Salter-Harris Classification

Case Resolution

You ascertain the patient’s fracture to be a type II Salter-Harris fracture, justifying your answer to the Attending Physician by pointing out that the affected region in the X-ray is limited to the metaphysis and physis with no epiphyseal involvement. Recognizing the potential for parental misconceptions surrounding the diagnosis of fractures in pediatric patients [3], you approach the father and explain that, though there is a fracture present, there is likely no need for any surgical intervention. You advise that the left index finger will be immobilized using a splint and further elaborate on the unlikelihood of this injury to manifest any long-term developmental or growth arrest in the affected region.

References and Further Reading

  1. Levine RH, Foris LA, Nezwek TA, et al. Salter Harris Fractures. [Updated 2019 Aug 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan
  2. Salter, Robert B.; Harris, W. Robert: Injuries Involving the Epiphyseal Plate, The Journal of Bone and Joint Surgery (JBJS): April 1963 – Volume 45 – Issue 3 – p 587-622
  3. Sofu H, Gursu S, Kockara N, Issin A, Oner A, Camurcu Y. Pediatric fractures through the eyes of parents: an observational study. Medicine (Baltimore). 2015;94(2):e407. doi:10.1097/MD.0000000000000407
Cite this article as: Mohammad Anzal Rehman, UAE, "Salter-Harris Fractures," in International Emergency Medicine Education Project, December 23, 2019, https://iem-student.org/2019/12/23/salter-harris-fractures/, date accessed: September 28, 2020

I woke up like that! – Bilateral Shoulder Pain

bilateral shoulder pain

Case Presentation

A 35-year-old male presented to fast track complaining of bilateral severe shoulder pain for one-day duration. He reports waking up like that, and not being able to move his shoulders much due to the pain.

He denied any recent falls, injuries, or direct trauma to his shoulders. He also denied any fever, rashes, skin changes, headaches, numbness or weakness. No further findings found upon review of systems. Past medical history revealed a history of epilepsy. Otherwise, he’s not on any medications and denies any known allergies.

Physical examination showed slim male, with flattened anterior shoulders and normal inspection of the skin overlying his shoulders. He had internally rotated upper extremities, flexed elbows, and arms held in adduction. Upon attempts on any passive or active test of the range of motion, he experienced reluctance and pain on external rotation or abduction of his shoulders. Bilateral Shoulder X-rays were obtained.

shoulder dislocation and fracture 1
shoulder dislocation and fracture 2

This patient had bilateral posterior shoulder dislocation, with associated fractures.

    • Posterior shoulder dislocations make up 2-4% of shoulder dislocations.
    • May go undiagnosed and often missed on physical exam and imaging
    • Epileptic seizures or electrical shocks, sports injuries are the most common causes.
    • Subtle signs on AP X-Ray include:
        • Light Bulb Sign: Fixed internal rotation of the humeral head, makes the greater tuberosity anterior, giving a symmetrical appearance of the humeral head, that looks like a light bulb.
        • Empty Glenoid Sign: Humeral Head and Glenoid fossa widened articular space
        • Trough Sign: Vertical Line on AP, can indicate compression fracture of the humeral head medially.
    • In suspected Posterior Shoulder Dislocations, you should always get multiple views, including Anterior-Posterior (AP), scapular (Y), and Axillary Views.
    • Rounded posterior shoulder.
    • Prominent coracoid and acromion.
    • Palpable posterior humeral head.
    • Flattened anterior shoulder contour.
    • Neurovascular injuries
    • Rotator cuff tears
    • Osteonecrosis of the humeral head
    • Recurrent posterior shoulder instability or re-dislocation
    • Joint stiffness and post-traumatic osteoarthritis
    • You need to evaluate each case separately. The cases like this patient, with associated fractures, can complicate your management, and hence consulting orthopedic services would be advised, as surgical interventions should be evaluated.
    • If closed reduction fails, usually open reduction is pondered by subspecialty, especially in cases with extensive damage to the humeral head.
    • In cases with no associated fractures, the approach is the reduction of the dislocation. Most of them would require procedural sedation and analgesia.
    • Consider discussing options of procedural sedation and analgesia, with or without intraarticular blocks with your attending, for better and successful procedures, and minimal pain for your patient. The most convenient procedure options should also be discussed with patients, and consent should be taken. 
    • Patients would require pre and post-reduction neurovascular examination and X-rays.
    • Make sure your patient is examined again after the procedure, assessing the stability of the joint for regained full range of motion. 
    • Shoulder immobilization and follow up care plans with orthopedics services should be arranged.
    • Don’t forget, patients with known epilepsy, non-adherence or uncontrolled seizures have to be evaluated as well, and referred to appropriate neurology evaluation.

Case Reflections

  • Bilateral shoulder dislocations are rare and of these, bilateral posterior shoulder dislocations are more prevalent than bilateral anterior shoulder dislocations.
  • Bilateral fracture-dislocation is even rarer, with a few cases reported in the literature.
  • In the rare case of an asymmetrical bilateral dislocation, attention may be distracted to the more evident lesion, which is the anterior dislocation. This may lead to delayed diagnosis, especially in an unconscious patient in a post-ictal state.
  • In the present case, open reduction and internal fixation was performed.

References and Further Reading

  1. Roberts & Hedges Clinical Procedures in Emergency Medicine (6th ed) 2014. Philadelphia. Elsevier Saunders Inc. – Chapter 49
  2. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (7th ed) 2011. New York. McGraw Hill Companies Inc. – Chapter 268
  3. Rosen’s Emergency Medicine: Concepts and Clinical Practice (8th ed) 2014. Philadelphia. Elsevier Saunders Inc. – Chapter 53
  4. Wikem – Posterior Shoulder dislocation: https://www.wikem.org/wiki/Posterior_shoulder_dislocation
  5. Canadiem – Posterior Shoulder Dislocation: Radiographic Evidence : https://canadiem.org/posterior-shoulder-dislocation-radiographic-evidence/ 
  6. Meena S, Saini P, Singh V, Kumar R, Trikha V. Bilateral anterior shoulder dislocation. J Nat Sci Biol Med. 2013;4(2):499–501. doi:10.4103/0976-9668.117003S – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783813/
  7. Sharma A, Jindal S, Narula MS, Garg S, Sethi A. Bilateral Asymmetrical Fracture Dislocation of Shoulder with Rare Combination of Injuries after Epileptic Seizure: A Case Report. Malays Orthop J. 2017;11(1):74–76. doi:10.5704/MOJ.1703.011 – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5393121/

Acknowledgement

Credit and acknowledgment for Dr. Eelaf Elhassan for sharing the case.

Cite this article as: Shaza Karrar, UAE, "I woke up like that! – Bilateral Shoulder Pain," in International Emergency Medicine Education Project, December 13, 2019, https://iem-student.org/2019/12/13/bilateral-shoulder-pain/, date accessed: September 28, 2020

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Torus Fracture – Diagnosed with ultrasound

torus fracture

Case Presentation

A 9-years old male patient brought to the ED by his parents because of the right forearm pain. The patient is alert, oriented, and moderately in distress. He described that he stepped on the ball and fell while playing soccer with his friends. He denies any other injury, loss of consciousness, etc.

Physical Exam

Torus Fracture - right arm 2

The patient complaints right forearm pain, especially distal 1/4 of the radius. There was no deformity or swelling recognized on inspection. 

Torus Fracture - right arm 1

The patient refuses any movement on the right arm because of pain during the movement, especially in rotational movements. He prefers to stay in the rest position, as shown in the picture.

There was no visible deformity and swelling in the inspection. However, the patient described palpation tenderness over the forearm, especially point tenderness over the distal 1/4 – 1/5 of the radius. The patient also described minimal pain on elbow and wrist movements. The neurovascular examination was unremarkable. There are no other findings regarding trauma. Patient parents deny any disease, medication, operation, etc. He has received 250 mg paracetamol in the school after consultation with the family. However, he still shows distress because of pain.

After the physical exam, 200 ibuprofen was given. X-ray is planned, and musculoskeletal ultrasound was applied while he waits for an X-ray.

We used Butterfly iQ to investigate the radius by using musculoskeletal settings. The ultrasound showed periosteal discontinuity with a 2-3 mm step-off sign at the distal radius. 

Diagnosing fractures with ultrasound

Ultrasound showed high pooled sensitivity (91%) and specificity (94%) (Schmid et al., 2017). It is a very effective modality, especially in the detection of long bone fractures such as humerus, forearm, tibia, fibula, etc.

In forearm fractures, its’ sensitivity is between 64 and 100%, its’ specificity is between 73-100% (Katzer et al., 2016). Besides, ultrasound provides 25 minutes earlier diagnosis advantage compared to other modalities, namely X-rays. Ultrasound’s effectiveness has elbow, been shown in many articles, its’ best performance is on diaphysis fractures of long bones (Weingberg et al., 2010).

After the detection of Torus (Buckle) fracture by ultrasound, the patient was sent to X-ray in order to investigate elbow, forearm and wrist in more detail. X-rays showed Torus fracture at the distal radius, which the diagnosis aligned with the ultrasound result.​

Torus Fracture - right arm 4

Torus Fracture - right arm 3

AP X-ray showed minor periosteal step-off/bulging on both sides. Lateral X-rays showed periosteal discontinuity with a 2-3 mm step-off on the dorsal side of the radius.

The final diagnosis of the patient was Torus (Buckle) fracture.

A long arm splint was applied in the ED because of his elbow and wrist pain. The patient discharged with pain medication, ice and elevation recommendations. On the 4th day, the patient visited the orthopedic clinic, and his splint changed to short arm splint. He was pain-free on the elbow and wrist.

References

  1. Schmid GL, Lippmann S, Unverzagt S, Hofmann C, Deutsch T, Frese T. The Investigation of Suspected Fracture-a Comparison of Ultrasound With Conventional Imaging. Dtsch Arztebl Int. 2017 Nov 10;114(45):757-764. doi: 10.3238/arztebl.2017.0757. PubMed PMID: 29202925; PubMed Central PMCID: PMC5729224.
  2. Katzer C, Wasem J, Eckert K, Ackermann O, Buchberger B. Ultrasound in the Diagnostics of Metaphyseal Forearm Fractures in Children: A Systematic Review and Cost Calculation. Pediatr Emerg Care. 2016 Jun;32(6):401-7. doi: 10.1097/PEC.0000000000000446. Review. PubMed PMID: 26087441.
  3. Weinberg ER, Tunik MG, Tsung JW. Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults. Injury. 2010 Aug;41(8):862-8. doi: 10.1016/j.injury.2010.04.020. Epub 2010 May 13. PubMed PMID: 20466368.
 
Cite this article as: Arif Alper Cevik, "Torus Fracture – Diagnosed with ultrasound," in International Emergency Medicine Education Project, November 6, 2019, https://iem-student.org/2019/11/06/torus-fracture-diagnosed-with-ultrasound/, date accessed: September 28, 2020

Death on the Roads

Death on the Roads

Save the date:

Why? Because road victims will be remembered that day. Starting from 2005, The World Day of Remembrance for Road Traffic Victims is held on the third Sunday of November each year to remember those who died or were injured from road crashes (1).

Road traffic injuries kill more than 1.35 million people every year and they are the number one cause of death among 15–29-year-olds. There are also over 50 million people who are injured in non-fatal crashes every year. These also cause a real economic burden. Total cost of injuries is as high as 5% of GDP in some low- and middle-income countries and cost 3% of gross domestic product (2). It is also important to note that there has been no reduction in the number of road traffic deaths in any low-income country since 2013.

The proportion of population, road traffic deaths, and registered motor vehicles by country income, 2016 (Source: Global Status Report On Road Safety 2018, WHO)

Emergency care for injury has pivotal importance in improving the post-crash response. “Effective care of the injured requires a series of time-sensitive actions, beginning with the activation of the emergency care system, and continuing with care at the scene, transport, and facility-based emergency care” as outlined in detail in World Health Organization’s (WHO) Post-Crash Response Booklet.

As we know, the majority of deaths after road traffic injuries occur in the first hours following the accident. Interventions performed during these “golden hours” are considered to have the most significant impact on mortality and morbidity. Therefore, having an advanced emergency medical response system in order to make emergency care effective is highly essential for countries.

Various health components are used to assess the development of health systems by country. Where a country is placed in these parameters also shows the level of overall development of that country. WHO states that 93% of the world’s fatalities related to road injuries occur in low-income and middle-income countries, even though these countries have approximately 60% of the world’s vehicles. This statistic shows that road traffic injuries may be considered as one of the “barometer”s to assess the development of a country’s health system. If a country has a high rate of road traffic injuries, that may clearly demonstrate the country has deficiencies of health management as well as infrastructure, education and legal deficiencies.

WHO has a rather depressing page showing numbers of deaths related to road injuries. (Source: Death on the Roads, WHO, https://extranet.who.int/roadsafety/death-on-the-roads/ )

WHO is monitoring progress on road safety through global status reports. Its’ global status report on road safety 2018 presents information on road safety from 175 countries (3).

We have studied the statistics presented in the report and made two maps (All countries and High-income countries) illustrating the road accident death rate by country (per 100,000 population). You can view these works below (click on images to view full size).

References and Further Reading

  1. Official website of The World Day of Remembrance, https://worlddayofremembrance.org
  2. WHO. Road traffic injuries – https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries
  3. WHO. Global status report on road safety 2018 – https://www.who.int/violence_injury_prevention/road_safety_status/2018/en/
Cite this article as: Ibrahim Sarbay, Turkey, "Death on the Roads," in International Emergency Medicine Education Project, November 1, 2019, https://iem-student.org/2019/11/01/death-on-the-roads/, date accessed: September 28, 2020

Lover’s Fracture

A 35-year-old construction worker was brought in by the ambulance to the Emergency Department. He was reported to have fallen from scaffolding at the height of approximately 4 meters and landed onto the concrete floor below feet first. He was found conscious by paramedics but in obvious pain, holding his right leg. Upon initial examination in the ED, the patient remains vitally stable but complains of severe, persistent pain in his right ankle and heel. After adequate analgesia, an X-ray of the right ankle and foot revealed signs of a calcaneal "Lover’s" fracture (Figure 1).

Figure 1
Figure 1: Image courtesy of Annelies van der Plas, and J.L. Bloem - http://www.startradiology.com/internships/general-surgery/ankle/x-ankle/

Calcaneal Fractures

Before we begin our discussion on calcaneal fractures, it is important to highlight the major anatomical structures visible on a standard X-ray of the ankle and foot.

Figure 2
calcaneus and foot anatomy

Figure 2 shows a lateral x-ray of the right ankle, demonstrating the calcaneus as the bone – commonly referred to as the heel – that makes up the majority of the hindfoot.

As would be expected, the size and position of the calcaneus predispose the bone to various forms of injury. A calcaneal fracture is most often sustained after a road traffic accident or a fall from significant height onto the feet as was the case with our patient. Due to the mechanism of injury, it is often colloquially dubbed as “Lover’s fracture” or the “Don Juan fracture”(1).

Epidemiology

Among fractures of the hindfoot, calcaneal fractures comprise 50-60% of all tarsal bone fractures (2). These fractures are usually intra-articular (3) and occur more commonly in young men aged between 20 and 40 years. Diseases which decrease bone density, such as osteoporosis, invariably increase the risk for development of the fracture when injury occurs.

Patient evaluation

Patients with calcaneal fractures will often present in severe pain, though they may not always be able to localize the exact source for their pain. Swelling at the ankle or heel along with bruising (ecchymosis) can also be expected. Due to the mechanism of fall, injury usually occurs bilaterally. Most patients are unable to bear any weight onto the affected limb.

The lower extremity or extremities in question should undergo a thorough neurovascular exam, as diminished pulses distal to the injury (dorsalis pedis) could indicate arterial compromise and mandate aggressive investigation with angiography or Doppler scanning. Though the gold standard for diagnosing calcaneal fractures remains a CT scan, a plain film X-ray is usually obtained first which should include an Antero-Posterior (AP), a lateral, and an oblique view.

Bohler’s Angle and Critical Angle of Gissane

Historically, physicians would measure Bohler’s angle and the critical angle of Gissane in cases where a calcaneal fracture was not clearly evident on a plain X-ray. Outlined in Figure 3, a calcaneal fracture would be suspected if Bohler’s angle was below 20 degrees or the critical angle of Gissane was noted to be more than 140 degrees. Bohler’s angle was found to be a lot more diagnostically reliable when compared to the critical angle of Gissane (4). However, both these methods of diagnosis are now considered obsolete and the same research that studied that utility of the angles found that Emergency Physicians were able to accurately identify calcaneal fractures approximately 98% of the time without the measurement of either angle.

Figure 3
853 - bohler angle - calcaneus
854 - Gissane angle- calcaneus

Figure 3- Bohler’s Angle and Critical angle of Gissane

Management

The goal of initial management in the Emergency Department is centered on adequate pain relief, immobilization and wound care (including antibiotics when there are signs of a contaminated wound). [See the link for open fractures and antibiotic choices.]

An important point to note is that the mechanism of injury in calcaneal fractures (namely fall from height) is a form of axial loading. The energy from landing on the ground will often be transmitted up through the body, usually to the spine causing compression fractures of the vertebrae. The patient, however, may not complain about pain in other areas due to the overwhelming and distracting pain in the calcaneus. Therefore, all calcaneal fractures should be managed with a high index of suspicion for associated injuries.

Other potential complications include compartment syndrome, wound infection, malunion and osteomyelitis. All patients diagnosed to have calcaneal fractures should be managed by a multidisciplinary team that includes an Orthopedic Surgeon to ensure definitive management and repair of the fracture.

Take Home Points

  • High energy impact with axial loading, usually from a road traffic accident or a fall from height should raise suspicion of a calcaneal fracture.

  • Perform a thorough evaluation of the site of injury and suspect associated injuries (check the spine and remember to check the other foot for concomitant injury).

  • Maintain adequate analgesia (these fractures hurt!) and involve the Orthopedic Surgeon as soon as the diagnosis is made.

References and Further Reading

  1. Lee P, Hunter TB, Taljanovic M. Musculoskeletal colloquialisms: how did we come up with these names? Radiographics. 2004;24 (4): 1009-27. doi:10.1148/rg.244045015
  2. Davis D, Newton EJ. Calcaneus Fractures. [Updated 2019 Mar 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan
  3. Jiménez-Almonte JH, King JD, Luo TD, Aneja A, Moghadamian E. Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus. Clin. Orthop. Relat. Res. 2019 Feb;477(2):467-471
  4. Jason R. K., Eric A. G., Gail H. B., Curt B. H. & Frank L. Boehler’s angle and the critical angle of gissane are of limited use in diagnosing calcaneus fractures in the ED. American Journal of Emergency Medicine. 24, 423–427 (2006)
Cite this article as: Mohammad Anzal Rehman, UAE, "Lover’s Fracture," in International Emergency Medicine Education Project, June 28, 2019, https://iem-student.org/2019/06/28/lovers-fracture/, date accessed: September 28, 2020

Laceration Repair: A Rural Encounter

The word “emergency” carries some connotation with it. A lack of time to act, a situation that demands speed, a sense of acuity. Medicine on the other hand is related to healing, soothing and improving, a slow and gentle process. I sometimes wonder if the name of the specialty (Emergency Medicine) is an oxymoron.

Etymology aside, this specialty of medicine has meant at least two different things to me at two different settings. I have worked as an intern at Patan Hospital, a tertiary care center and as an in-charge of emergency services of Beltar Primary Healthcare Center (PHC), a government establishment in rural Nepal. I intend to describe my perspective and illustrate what different experiences of emergency medicine in different settings has to offer. I hope in doing so, I’ll be able to illustrate some of my workarounds that make the difference less overwhelming.

I have been posted at Beltar PHC, Nepal for the past 18 months. The center has been running primary emergency services. Initial stabilization and proper referral are two major ways Beltar PHC helps to save lives. The nearest city where cases are referred to are Dharan (50.5 km away) and Biratnagar (92 km away). Emergency personnel includes one doctor on call, one paramedic, two sisters for delivery and one office assistant. Laboratory and X-ray services are not available apart from office hours. Emergency investigations available include ECG, UPT and Obstetric USG. The government freely supplies medical equipment and a limited number of medicines.

Entrance to Emergency Services at Beltar PHC
Former Emergency Setup at Beltar PHC
Former Emergency Setup at Beltar PHC

A 27-year-old male

A 27-year-old male with a cut injury on his right forearm was brought to the PHC. It was a quiet day at the Emergency Department (ED) and most of the cases were OPD cases that did not make it on time.

One-way ED helps people here, albeit not an ideal way, is to act as a rescue for patients who travel long distances to get to the OPD if they do not make it on time.

The patient had a clean wound, about 5 cm long with smooth edges. We washed the wound using tap water; a practice equally efficacious to using saline but way more affordable for a rural setup. To suture the wound, we made our equipment ready. A long suture thread was cut from a nylon thread roll sterilized in betadine, some gauze pieces prepared by our office assistant that had been autoclaved and stored in an old dressing drum were taken out.

Suture materials at Beltar PHC
Dressing Drums at Beltar PHC

The thread was inserted into a needle, probably too big (turns out what needle size to use and when was a dilemma of privilege). Sometimes, we use needles that come with 2 ml syringes instead; they are sharper for skin penetration than the big suture needles our government freely supplies. The wound was sutured and the patient discharged.

That night I reflected on how things would have been subtly but significantly different at Patan Hospital. A sterilized suture set, autoclaved, packed and ready to use along with a ready to use surgical suture would be available. The procedure would have taken place in a more private space and not where visitors had the opportunity to peak in through our foldable privacy screen. Maybe the patient would have had to wait longer to get attention but the difference would not have been much, considering the time it takes to prepare every instrument here.

Each minor aspect of this difference deserves to be heard, talked about and their solution sought for. I plan to write about each of these as a series of article that follows. Proper resource allocation is a time and economy intensive goal; nevertheless the ultimate one. Maybe small workarounds are what we need during the period of transition, especially for places like Beltar.

Laceration repair is a common procedure in every emergency department. Setting differs and with it the availability of resources. Nevertheless, the core principles that govern patient care and the science behind it remains the same. While we wait for more convenient and sophisticated solutions, which all patients deserve, here are some points to remember regarding laceration repair that can help provide an acceptable standard of care even in resource-limited settings.

  • While working in rural, one should be well aware of its limitations. Some lacerations that require surgical consultation and need to be referred include (1):
    • Deep wounds of the hand or foot
    • Full-thickness lacerations of the eyelid, lip, or ear
    • Lacerations involving nerves, arteries, bones, or joints
    • Penetrating wounds of unknown depth
    • Severe crush injuries
    • Severely contaminated wounds requiring drainage
  • Non-contaminated wounds can be successfully closed up to 18 hours post-injury while clean head wounds can be repaired up to 24 hours after injury (2).

  • Drinkable tap water can be used for wound irrigation instead of sterile saline. At least 50 to 100 ml of irrigation solution per 1 cm of wound length is needed at a pressure of 5 to 8 psi for optimal dilution of wound’s bacterial load. The wound can be put under running water or can be irrigated using a 19-gauge needle with a 35 ml syringe (3).

  • Local hair should be clipped, not shaved, to prevent wound contamination(4).

  • Strict sterile techniques are unnecessary to be followed during laceration repairs. The instruments touching wound (sutures, needles, etc.) should be sterile, but everything else only needs to be clean(1). Clean non-sterile examination gloves can be used instead of sterile gloves during wound repair(5).
  • Local anesthesia with lidocaine 1% or bupivacaine 0.25% is appropriate for small wounds while large wounds occurring on limbs may require a regional block (1). Epinephrine should not be used in anatomic areas with end arterioles, such as fingers, toes, nose, penis, and earlobes.
  • Maximum doses of local anesthetic are as follow (6):
    • Lidocaine (without epinephrine): 3 – 5 mg/kg
    • Lidocaine (with epinephrine): 7 mg/kg
    • Bupivacaine (without epinephrine): 1 – 2 mg/kg
    • Bupivacaine (with epinephrine): 3 mg/kg
  • The suture used for skin repair include non-absorbable sutures (nylon and polypropylene) while absorbable sutures (polyglactin, polyglycolic) is used to close deep lacerations. For skin closure, silk sutures are no longer used because of skin abscess formation, their poor tensile strength and high tissue reactivity. In general, a 3–0 or 4–0 suture is appropriate on the trunk, 4–0 or 5–0 on the extremities and scalp, and 5–0 or 6–0 on the face (6).
    • Sterilization of sutures can be done by complete immersion in povidone-iodine 10% solution for 10 minutes followed by rinsing in sterile saline/water. Sutures that can be sterilized or re-sterilized include monofilament sutures (Prolene or Nylon) and coated sutures (Vicryl, Ethibond) (7).

Timing of Suture Removal (6)

Wound Location Time of Removal (Days)
Face
3 - 5
Scalp
7 - 10
Arms
7 - 10
Trunk
10 - 14
Legs
10 - 14
Hands or Feet
10 - 14
Palms or Soles
14 - 21

Tetanus Prophylaxis (8)

Wound Previous Vaccine Tetanus Vaccine
Clean Wound
Previous vaccine ≥3 doses - The last dose within 10 years
No Need
Previous vaccine ≥3 doses - The last dose more than 10 years
Yes
Previous vaccine ≥3 doses - NOT RECEIVED
Yes
Contaminated Wound
Previous vaccine ≥3 doses - The last dose within 5 years
No
Previous vaccine ≥3 doses - The last dose more than 5 years
Yes
Previous vaccine ≥3 doses - NOT RECEIVED
Yes + TIG

Factors that may increase chances of wound infection (9)

  • wound contamination,
  • laceration > 5 cm,
  • laceration located on the lower extremities,
  • diabetes mellitus

Antibiotics

  • Prophylactic systemic antibiotics are not necessary for healthy patients with clean, non-infected, non-bite wounds(10). 
  • Prophylactic antibiotic use is recommended for (11): 
    • human bite wounds 
    • deep puncture wounds
    • wounds involving the palms and fingers
  • Topical antibiotic ointments decrease the infection rate in minor contaminated wounds. 

References and Further Reading

  1. Forsch RT. Essentials of Skin Laceration Repair. Am Fam Physician. 2008 Oct 15;78(8):945-95
  2. Berk WA, Osbourne DD, Taylor DD. Evaluation of the ‘golden period’ for wound repair: 204 cases from a third world emergency department. Ann Emerg Med. 1988;17(5):496–500.
  3. Wheeler CB, Rodeheaver GT, Thacker JG, Edgerton MT, Edilich RF. Side-effects of high pressure irrigation. Surg Gynecol Obstet. 1976;143(5):775–778./ Moscati RM, Reardon RF, Lerner EB, Mayrose J. Wound irrigation with tap water. Acad Emerg Med. 1998;5(11):1076–1080.
  4. Howell JM, Morgan JA. Scalp laceration repair without prior hair removal. Am J Emerg Med. 1988;6(1):7–10.
  5. Perelman VS, Francis GJ, Rutledge T, Foote J, Martino F, Dranitsaris G. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial. Ann Emerg Med. 2004;43(3):362–370.
  6. Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. Am Fam Physician. 2017 May 15;95(10):628-636.
  7. Cox I. Guidelines for Re-Sterilising Sutures. Community Eye Health. 2004;17(50): 30.
  8. Kretsinger K, Broder KR, Cortese MM, et al. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55(RR-17):1–37.
  9. Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: what are the risks for infection and has the ‘golden period’ of laceration care disappeared? Emerg Med J. 2014;31(2):96–100.
  10. Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies. Am J Emerg Med. 1995;13(4):396–400.
  11. Worster B, Zawora MQ, Hsieh C. Common Questions About Wound Care. Am Fam Physician. 2015 Jan 15;91(2):86-92.
Cite this article as: Carmina Shrestha, Nepal, "Laceration Repair: A Rural Encounter," in International Emergency Medicine Education Project, June 21, 2019, https://iem-student.org/2019/06/21/laceration-repair-a-rural-encounter/, date accessed: September 28, 2020

A 57-year-old man fell from a height comes with neck pain

by Stacey Chamberlain

A 57-year-old man fell from a height of 12 feet while on a ladder. He did not pass out; he reports that he simply lost his footing. He fell onto a grassy area, hitting his head and complains of neck pain. He did not lose consciousness and denied headache, blurry vision, vomiting, weakness, numbness or tingling in any extremities. He denies other injuries. He was able to get up and ambulate after the fall and came in by private vehicle. He has not had previous spine surgery and does not have known vertebral disease. On exam, he is neurologically intact with a GCS of 15, does not appear intoxicated and has moderate midline cervical spine tenderness.

Should you get imaging to rule out a cervical spine fracture?

C-spine Imaging Rules

Canadian C-spine Rule

NEXUS Criteria for C-spine Imaging

  • Age ≥ 65
  • Extremity paresthesias
  • Dangerous mechanism (fall from ≥ 3ft / 5 stairs, axial load injury, high-speed MVC/rollover/ejection, bicycle collision, motorized recreational vehicle)
  • Focal neurologic deficit present
  • Midline spinal tenderness present
  • Altered level of consciousness present
  • Intoxication present
  • Distracting injury present

Both the Canadian C-spine Rule (CCR) and NEXUS Criteria are widely employed in clinical practice to reduce unnecessary cervical spine imaging in trauma patients with neck pain or obtunded trauma patients. The CCR uses mechanism and age criteria, whereas the NEXUS Criteria incorporates criteria including midline tenderness and additional factors that might limit a practitioner’s exam. The CCR can be difficult for some practitioners to remember all the criteria that qualify as a dangerous mechanism and is limited to ages > 16 and < 65. However, it can be used in intoxicated patients if the patients are alert and cooperative, allowing a full neurologic exam. The NEXUS Criteria are applicable over any age range (> 1 year old), but the sensitivity may be low in patients > 65 years of age. A single comparison study found the CCR to have better sensitivity (99.4% versus 90.7%); however, the study was performed by hospitals involved in the initial CCR validation study.

Case Discussion

By applying either criteria to this case, the patient would require C-spine imaging as by CCR, the patient would meet criteria for dangerous mechanism, and by NEXUS, the patient has midline tenderness to palpation.

Cite this article as: iEM Education Project Team, "A 57-year-old man fell from a height comes with neck pain," in International Emergency Medicine Education Project, June 14, 2019, https://iem-student.org/2019/06/14/a-57-year-old-man-fell-from-a-height-comes-with-neck-pain/, date accessed: September 28, 2020

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: September 28, 2020