by Sarah Attwa and Marwan Galal
Case 1
A 20-year-old male presents to your ED with a 5 cm wound after he fell off his motorbike. On physical exam, the wound overlays a fractured left tibia but does not show extensive soft tissue damage nor any signs of periosteal stripping or vascular injury. Which antibiotic should you give to this patient?
Gustilo-Anderson Classification
| Type | Definition |
|---|---|
| Type I | Open fracture, clean wound, wound <1cm in length |
| Type II | Open fracture, wound >1cm in length without extensive soft tissue damage, flaps, avulsions |
| Type III | Open fracture with extensive soft tissue laceration, damage, or loss or an open segmental fracture. This type also includes open fractures caused by farm injuries, fractures requiring vascular repair, or fractures that have been open for 8 hours prior to treatment. |
| Type III A | Type III fracture with adequate periosteal coverage of the fractured bone despite extensive soft tissue laceration or damage |
| Type III B | Type III fracture with extensive soft tissue loss and periosteal stripping and bone damage. Usually associated with massive contamination. It will often need further soft tissue coverage procedure (i.e. free or rotational flap). |
| Type III C | Type III fracture associated with arterial injury requiring repair, irrespective of degree of soft tissue injury |
Application: Gustilo-Anderson classification for open wounds and antibiotic coverage
Interpretation: According to the above classification, each class should receive the following antibiotics:
- Type I: 1st generation cephalosporin
- Type II: 1st generation Cephalosporin +/- Gentamycin
- Type III: 1st generation Cephalosporin + Gentamycin +/- Penicillin
Hint: In farm and war wounds, all 3 antibiotics must be given
The answer to the above clinical scenario: Type II, Cephazolin +/- Gentamycin
References: www.lifeinthefastlane.com/ortho-library/open-fractures/
Case 2
A 7-year-old boy was brought by his mother to the ED after a heavy object fell on his right hand earlier the same day. On physical exam, there is bony tenderness, swelling, and erythema over his right middle finger PIP joint. Distal pulses are intact and no neurological deficit. You decided to send the patient for imaging. XR is shown below. What is the classification of this fracture?
Salter-Harris Classification
Application: This a classification for long bone fractures involving epiphyseal growth plates.
Hints:
- Class II fractures are the most common injuries seen in the ED
- Class V and I are the least commonly picked up
- Class V carries the worst prognosis
The answer to the above clinical scenario: Class II
Links for extra information: Antrim ED Meducation www.gcs3.com.uk
References: http://emtutorials.com/2013/06/salter-harris-i-of-ankle/
Case 3
An 85-year-old female was brought to the ED by her son with a 2-day history of fever and altered mental status. She is known to be diabetic and hypertensive. Her vitals are Temp 38.6 Celsius, BP 85/53, HR 110/min and RR is 26/min, and O2 saturation is 98% on room air. On examination, she is alert but confused, and the rest of her physical exam is unremarkable. Random glucose level is 8.5 mmol/L, CXR is normal, CBC shows WBC of 3600 and urine dipstick is positive for nitrites and leukocytes. What is the next step in management?
SIRS (Systemic Immune Response Syndrome) Formula
- Temp > 38 c or < 36 c
- HR > 90/min
- RR > 20/min or PaCO2 < 32 mmHg
- WBC > 12000 or < 4000
Application: Any patient with suspected systemic inflammatory response and can help guide critical decisions and interventions
Interpretation: SIRS is met when the patient has 2 or more criteria of the above
Hints:
- SIRS + source of infection = Sepsis (16% Mortality)
- Sepsis + more than one organ’s system dysfunction (e.g. Oliguria) = Severe Sepsis (20% Mortality)
- Severe Sepsis + Hypotension (unresponsive to fluid resuscitation) = Septic Shock (69% Mortality)
The answer to the above clinical scenario: By applying the above criteria, this patient has SIRS + urinary tract infection; therefore, she is in sepsis. She needs adequate fluid resuscitation + Antibiotics, and if still hypotensive, she will be classified as septic shock and will require a higher level of care (e.g., Vasopressors) and close monitoring. Those patients should be admitted to the ICU.
References: www.lifeinthefastlane.com/ccc/sepsis-definitions/
Case 4
A 27-year-old female presented to the ED with severe abdominal pain for 1 day. No allergies or significant past medical history. Her vitals are: Temp 37.6 Celsius, BP 100/55, HR 110/min, RR 20/min and O2 Saturation is 99% on room air. What level of care does this patient require?
Formula
- SHOCK INDEX (SI) = HR / SBP
Application: It can be used to identify patients needing a higher level of care despite vital signs that may not appear strikingly abnormal. This index is a sensitive indicator of left ventricular dysfunction and can become elevated following a reduction in left ventricular stroke work.
Interpretation:
- Normal SI = 0.5 to 0.7
- If SI > 0.9 was helpful to identify patients in the ED requiring admission and/or intensive care despite apparently stable vital signs
- Persistent high SI has been associated with poor outcome
The answer to the above clinical scenario: By applying the above equation, (110/100 = 1.1), this patient has a high shock index and requires a high level of care.
References: www.foamem.com/2013/11/25/shock-index-a-predictor-of-morbidity-and-mortality/
Case 5
A 72-year-old female presented with a fever, cough, and sputum for the last 4 days. She has a past medical history of DM and hypertension. Her vitals are: Temp 38.9 Celsius, HR 110/min, BP 100/45, RR 27/min, and O2 sat 92% on room air. On exam, she is alert and oriented, and chest auscultation reveals crackles over the right lower chest. The remainder of the physical exam was normal. CXR reveals right lower lung lobe infiltrate. Labs showed mildly elevated white cell count with normal renal function and metabolic panel. How would you risk-stratify the severity of pneumonia in this patient? What would be her appropriate disposition?
CURB-65
| Category | Criteria | Score |
|---|---|---|
| C | Confusion | 1 |
| U | Urea > 7 mmol/L | 1 |
| R | Respiratory rate > 30 | 1 |
| B | Systolic BP <90mmhg or Diastolic BP <60 mmHg | 1 |
| 65 years | Age > 65 years | 1 |
| CURB-65 score | 30-day mortality | Management |
| 0-1 | <5% | Home |
| 2 | <10% | Likely to need admission |
| 3-5 | 15-30% | Admit, manage as severe |
Application: Clinical scoring system used for risk stratification and guide management in all adult patients presenting with evidence of pneumonia
The answer to the above clinical scenario: By applying the above tool, this patient has a CURB-65 score of 2 (age + diastolic BP). This patient will likely need admission for further treatment.
References: https://www.wikem.org/wiki/CURB-65
Case 6
A 61-year-old female presents to the ED with leg swelling over the past 2 days. Her past medical history is positive for DM, hypertension, treatment for ovarian cancer 4 months ago. Her vital signs are Temp, 37.8 C, HR: 98, BP: 109/72, RR: 16, and O2 sat 98%on room air. On exam, she is alert, oriented and in acute distress. Lung auscultation is clear; cardiac auscultation reveals normal S1-S2 with tachycardia, no lower limb edema or tenderness. Her left leg is swollen compared to right side. 12 lead ECG shows sinus rhythm with no abnormal findings. What is your next step in diagnosis?
Wells Score for Deep Vein Thrombosis
| Criteria | Score |
|---|---|
| Active cancer(treatment ongoing or within previous 6 months or palliative treatment) | 1 |
| Paralysis, paresis, or recent plaster immobilization or of the lower extremities | 1 |
| Recently bedridden for 3 days or more or major surgery within the previous 12 weeks requiring general or regional anesthesia | 1 |
| Localized tenderness along the distribution of the deep venous system | 1 |
| Entire leg swollen | 1 |
| Calf swelling > 3cm compared to asymptomatic leg (measuring 10 cm below tibial tuberosity) | 1 |
| Pitting edema confined to the symptomatic leg | 1 |
| Non varicose collateral superficial veins | 1 |
| Previously documented DVT | 1 |
| Alternative diagnosis at least as likely as DVT | 1 |
Application: To calculate pretest probability for all patients with clinically suspected DVT
Interpretation:
- 0: low pretest probability
- 1-2: Moderate pretest probability
- 3 or more: High pretest probability
References: https://www.wikem.org/wiki/Deep_venous_thrombosis
Case 7
A 54-year-old male with a past medical history of peripheral vascular disease comes in with on/off palpitations and lightheadedness for the past 2 weeks. His vital signs are normal. On exam, he is alert, oriented and chest is clear to auscultation and heart sounds are irregularly irregular. The remainder of his physical exam is unremarkable. His ECG shows Atrial Fibrillation with HR of 96 beats/min. What is this patient’s risk for developing stroke? What is the recommended therapy for him?
CHADS2 Score for Atrial Fibrillation
| Category | Criteria | Point Value |
|---|---|---|
| C | Congestive heart failure | 1 |
| H | Hypertension (>140/90 mmHg) | 1 |
| A | Age > 75 years | 1 |
| D | Diabetes Mellitus | 1 |
| S2 | Prior Stroke or TIA | 2 |
Application: Clinical prediction rule for assessing the risk of stroke in patients with non-rheumatic Atrial Fibrillation and is used to determine if treatment is required with anticoagulation therapy or antiplatelet therapy or not.
CHADS2 Interpretation
| Score | Risk | Anticoagulation Therapy | Recommendations |
|---|---|---|---|
| 0 | Low | No therapy OR Aspirin (ASA) | No therapy, if patient prefers give ASA |
| 1 | Moderate | Oral anticoagulant OR ASA | Oral anticoagulant, alternatives are ASA with Clopidogrel or ASA alone |
| 2 or greater | High | Oral anticoagulant | Oral anticoagulant, alternatives are ASA with Clopidogrel or ASA alone |
Special considerations
- In low-risk patients, female sex OR patients with vascular disease, ASA is recommended
- In low-risk patients, female sex AND vascular disease, oral anticoagulant is preferred
- In low-risk patients, if age > 65 years, oral anticoagulant is preferred
The answer to the above clinical scenario: Applying the above score, the patient is at low risk for stroke (Score of 0), and the recommended therapy for him, given his peripheral vascular disease is ASA.
References: www.lifeinthefastlane.com/ecg-library/atrial-fibrillation/
Case 8
A 70-year-old male with known ischemic heart disease and permanent pacemaker presents to the ED with chest pain for 2 hours. His initial vitals are stable and below is his ECG. How do you interpret this ECG?
Sgarbossa Criteria
- Concordant ST elevation ≥1 mm = 5 points
- ST depression ≥1 mm in V1-V3 = 3 points
- Discordant ST elevation ≥5 mm = 2 points
Application: Used in cases of left bundle branch block (LBBB) and suspicion of acute myocardial infarction (AMI)
Interpretation: At score-sum of 3 or greater, these criteria have specificity of 90% for detecting AMI
Hints: – These criteria can also be applied to Pacemaker rhythm
The answer to the above clinical scenario: This ECG is showing a paced rhythm, and you can clearly see the pacemaker spikes. By applying the above criteria, this patient has Concordant ST depression in V2 and V3 > 1mm, which gives him a Sgarbossa score of 3. This means this patient has Acute MI.
References: www.lifeinthefastlane.com/ecg-library/basics/sgarbossa/
Case 9
A 13-year-old boy comes in complaining of right lower quadrant abdominal pain for the past 2 days, associated with nausea, vomiting, and loss of appetite. His vitals are temperature 38.1, BP 110/77, HR 100, RR 18, and oxygen saturation 99% on RA. On physical exam, he has right iliac fossa tenderness with rebound. His initial labs are significant for leukocytosis with neutrophilic left shift. After pain relief, what is the next best step in management?
Alvarado Score for Appendicitis
| Category | Criteria | Point Value |
|---|---|---|
| Symptoms | Migratory right iliac fossa pain | 1 |
| Nausea/vomiting | 1 | |
| Anorexia | 1 | |
| Signs | Tenderness in right iliac fossa | 2 |
| Rebound tenderness in right iliac fossa | 1 | |
| Fever | 1 | |
| Lab findings | Leukocytosis | 2 |
| Neutrophil left shift | 2 |
Application: Used in all cases of clinically suspected acute appendicitis
Interpretation of Alvarado Score
| Score | Significance |
|---|---|
| 1-4 | Unlikely |
| 5-6 | Possible |
| 7-8 | Acute appendicitis present |
| 9-10 | Definite acute appendicitis requiring surgery |
The answer to the above clinical scenario: Using the above scoring system, the patient has a score of 9, and therefore, definitely has acute appendicitis requiring surgery. He should be urgently referred to the surgical team.
References: https://www.wikem.org/wiki/Appendicitis
Case 10 and 11
A 70-year-old male was brought to the ED by his son after he collapsed at home 2 hours ago. He has history of fever and URI symptoms for the past 3 days. On exam, patient stuporous, and opens his eye to a verbal prompt, moaning and withdraws from painful stimuli. What’s his GCS score?
A 18-year-old male involved in a motor vehicle collision was brought in by EMS with apparent facial and head injuries. On exam, with pinching his chest, he does not open his eyes nor makes any sounds but flexes both arms inwards. What’s his GCS score?
| Choose the best response of patient |
|---|
| EYE OPENING |
| 4: Spontaneously |
| 3: To verbal command |
| 2: To pain |
| 1: No response |
| BEST VERBAL RESPONSE |
| 5: Oriented and converses |
| 4: Disoriented and converses |
| 3: Inappropriate words; cries |
| 2: Incomprehensible sounds |
| 1: No response |
| BEST MOTOR RESPONSE |
| 6: Obeys command |
| 5: Localizes pain |
| 4: Flexion withdrawal |
| 3: Flexion abnormal (decorticate) |
| 2: Extension (decerebrate) |
| 1: No response |
Application: Part of neurological examination for any patient (e.g., trauma, altered mental status, intoxication, etc.)
Interpretation: Useful objective tool to assess and quantify neurological function of patients in ED to help guide critical decisions and interventions (e.g., Intubation to protect the airway )
Hints: Patients with a score of 8 or below due to irreversible causes need airway protection via intubation
Special consideration: Modified GCS score for the pediatric population
The answer to the above clinical scenarios:
- Case 10 – GCS score of 9
- Case 11 – GCS score of 5 (this patient needs airway protection)
Reference: http://lifeinthefastlane.com/ccc/glasgow-coma-scale-gcs/