Question Of The Day #66

question of the day
40.1 - Pneumothorax 1

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

This man presents to the Emergency Department with pleuritic chest pain, shortness of breath after a penetrating chest injury. He has tachypnea and low oxygen saturation on exam, but he is not hypotensive or tachycardic.  The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

This patient should immediately be given supplemental oxygen for his low oxygen saturation.  The history of penetrating chest trauma and hypoxemia also should raise concern for a traumatic pneumothorax, and oxygen supplementation is part of the treatment for all pneumothoraces.  The patient’s chest X-ray shows a large left sided pneumothorax indicated by the absence of left sided lung markings.  There is some left to right deviation of the heart and the primary bronchi.  There is no large left sided pleural effusion in the costodiaphragmatic recess to indicate a pneumo-hemothorax.  There is also no deviation of the trachea, hypotension, or tachycardia to indicate a tension pneumothorax (Choice B).  The patient is hemodynamically stable, so he cannot be in hemorrhagic shock (Choice A) or have cardiac tamponade (Choice C).  Although the pneumothorax is large with mild deviation of the heart, the lack of hemodynamic instability supports the diagnosis of a traumatic non-tension pneumothorax (Choice D).  The treatment for this would include 100% oxygen supplementation and placement of a chest tube.  A CT scan of the chest is more sensitive imaging test than a chest X-ray and should be considered to evaluate for additional injuries (blood vessel injuries, rib fractures, etc.). Correct Answer: D

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #66," in International Emergency Medicine Education Project, December 3, 2021, https://iem-student.org/2021/12/03/question-of-the-day-66/, date accessed: December 4, 2021

Question Of The Day #65

question of the day
Longitudinal Orientation

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

This patient arrives in the Emergency Department after an assault with penetrating abdominal trauma and is hemodynamically stable on exam.  The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries.  The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas.  The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam.  The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid.  In the setting of trauma, free fluid is assumed to be blood.  The presence of free fluid on a FAST exam is considered a “positive FAST exam”.   This patient has no free fluid between the right kidney and liver.  There also is no free fluid above the diaphragm to indicate a hemothorax. The question stem notes that all other FAST exam views are nonremarkable.  Therefore, this patient has a negative FAST exam.  See labelling of the FAST exam image below.

An exploratory laparotomy (Choice A) would be indicated in a patient with penetrating or blunt trauma, a positive FAST exam, and hemodynamic instability. This patient has a negative FAST exam and is hemodynamically stable.  Packed red blood cell infusion (Choice B) would be indicated in the setting of hemodynamic instability and trauma, as this is assumed to be hemorrhagic shock.  This patient is not tachycardic or hypotensive. A urinalysis to check for hematuria (Choice D) may be a helpful adjunctive investigation to evaluate for renal or bladder injury, but it is not the most crucial next step in management. Performing a CT scan of the abdomen and pelvis (Choice C) is the best next step as the patient is hemodynamically stable with a negative FAST exam and a penetrating abdominal injury.  The CT scan will help further evaluate for any internal injuries that may require operative repair.  See the algorithm below for further detail on an abdominal trauma work flow. Correct Answer: C

undifferentiated trauma patient
undifferentiated trauma patient

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #65," in International Emergency Medicine Education Project, November 26, 2021, https://iem-student.org/2021/11/26/question-of-the-day-65/, date accessed: December 4, 2021

Question Of The Day #62

627.15 - Figure 15 - lentiform epidural hematoma in the right hemisphere

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

This patient presents to the Emergency Department after a high-speed motor vehicle accident.  On examination, he is tachycardic, mildly tachypneic, and has an altered mental status (somnolent).  The first step in evaluating this trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.

After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history.  A noncontrast CT scan of the head is a reasonable test for this patient given his significant mechanism of injury and altered mental status on exam.  The CT scan shows a hyperdense (white) biconvex area on the right side of the brain.  This white area indicates the presence of fresh blood on the CT scan.  Keep in mind that CT scans are read as if you are looking up from the patient’s feet to their head.  This means left-right directionality is reversed.  See image below.

A hyperdense area with a sickled or crescent-shaped appearance would indicate an acute subdural hemorrhage (Choice A).  This is caused by tearing of the cerebral bridging veins.  Hyperdense areas throughout the brain tissue itself would indicate an intraparenchymal hemorrhage (Choice B).  Hyperdense areas around the sulci of the brain and a starfish appearance would indicate a subarachnoid hemorrhage (Choice D). Subarachnoid bleeding is caused by rupturing of a brain aneurysm or an arteriovenous (AV) malformation.  Subarachnoid bleeding can also be associated with trauma. 

This patient’s CT image shows an epidural hemorrhage (Choice C), indicated by the biconvex lens shaped area of blood.  This is caused by tearing of the middle meningeal artery.  Treatment of all types of intracranial bleeding involves general supportive care, airway management (i.e., endotracheal intubation for GCS < 8), elevating the head of the bed to 30 degrees to lower intracranial pressure (ICP), managing pain and sedation (lowers ICP), blood pressure maintenance (goal SBP <140mmHg), reversal of coagulopathy, neurosurgical evaluation for possible operative intervention, and providing ICP lowering treatments (mannitol or hypertonic 3% NaCl) when concerned about elevated ICP or brain herniation.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #62," in International Emergency Medicine Education Project, November 5, 2021, https://iem-student.org/2021/11/05/question-of-the-day-62/, date accessed: December 4, 2021

Focused Assessment with Sonography in Trauma (FAST): An Overview

Traumatic injuries are one of the leading causes of death, and intraperitoneal bleeds occur in approximately 12% of blunt traumas [1]. A quick assessment of trauma and detection of intraperitoneal fluid is increasingly essential in trauma patients’ assessment. The implementation of point-of-care ultrasound (POCUS) has had a significant impact on patient management, especially in a trauma setting. POCUS is easy to use at the bedside, non-invasive and inexpensive.

The Focused Assessment with Sonography in Trauma (FAST) is an ultrasound protocol used to assess hemoperitoneum and hemopericardium [2]. The FAST protocol is sensitive and specific for detecting intraperitoneal free fluid. According to previous studies, sensitivity ranges from 75-100%, and specificity ranges from 88-100% [3]. The FAST exam is rapid and can be completed in less than 5 minutes. It also has multiple advantages, including decreased time to interventions like surgery and length of stay at the hospital [4]. The Extended FAST (eFAST) protocol, which involves examinations of each hemithorax for hemothorax and pneumothoraces, has recently been introduced by several institutions [2].

Regions Examined

The FAST exam assesses the pericardium and multiple potential spaces within the peritoneal cavity for free fluid. The patient is often assessed in the supine position.

The right flank or right upper quadrant (RUQ) view assesses the hepatorenal recess (also known as Morrison’s pouch), as well as the right paracolic gutter, the hepato-diaphragmatic area, and the caudal edge of the left liver lobe [2]. The pericardial view, also known as the subcostal or the subxiphoid, is usually assessed next. The liver is commonly used as a sonographic window of the heart to evaluate pericardium. Ultrasound can detect little pericardial fluid with sensitivity and specificity approaching 100% [5]. The pericardial view also helps to differentiate between pleural and pericardial effusions and visualize right ventricular collapse during diastole [2]. Next, the left upper quadrant (LUQ) is used to visualize the splenorenal recess, the subphrenic space and the left paracolic gutter. If the eFAST protocol is being conducted, the RUQ and LUQ views are also used to examine the left and right hemithorax. Lastly, the pelvic or the suprapubic view is used to assess for free fluid in the rectovesical pouch in males and rectouterine and vesicouterine pouches in women [2]. The bladder acts as a sonographic window for this view.

Complications

While there are no complications related to the FAST exam itself, the use of ultrasound does have some limitations, one of which is the requirement for at least 150-200 cc of intraperitoneal fluid for an ultrasound to be able to detect. This can lead to false negatives when free fluid is in fact present [6]. False positives in the FAST exam may also occur and can be due to the presence of ascites, pre-existing pleural or pericardial effusions unrelated to the trauma, ruptured ovarian cysts or ruptured ectopic pregnancies [2]. Healthcare workers should be aware that POCUS and the FAST protocol have limitations dependent on the provider’s experience and the patient’s body habitus.   

Further Reading and Free Online Course

References

  1. Poletti, P. A., Mirvis, S. E., Shanmuganathan, K., Takada, T., Killeen, K. L., Perlmutter, D., Hahn, J., & Mermillod, B. (2004). Blunt abdominal trauma patients: can organ injury be excluded without performing computed tomography?. The Journal of Trauma57(5), 1072–1081. https://doi.org/10.1097/01.ta.0000092680.73274.e1
  2. Bloom, B. A., & Gibbons, R. C. (2020). Focused Assessment with Sonography for Trauma. https://www.ncbi.nlm.nih.gov/books/NBK470479/
  3. Brenchley, J., Walker, A., Sloan, J. P., Hassan, T. B., & Venables, H. (2006). Evaluation of focussed assessment with sonography in trauma (FAST) by UK emergency physicians. Emergency Medicine Journal23(6), 446–448. https://doi.org/10.1136/emj.2005.026864
  4. Melniker, L. A., Leibner, E., McKenney, M. G., Lopez, P., Briggs, W. M., & Mancuso, C. A. (2006). Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Annals of Emergency Medicine48(3), 227–235. https://doi.org/10.1016/j.annemergmed.2006.01.008
  5. Mandavia, D. P., Hoffner, R. J., Mahaney, K., & Henderson, S. O. (2001). Bedside echocardiography by emergency physicians. Annals of emergency medicine38(4), 377–382. https://doi.org/10.1067/mem.2001.118224
  6. Von Kuenssberg Jehle, D., Stiller, G., & Wagner, D. (2003). Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. The American journal of emergency medicine21(6), 476–478. https://doi.org/10.1016/s0735-6757(03)00162-1
Cite this article as: Maryam Bagherzadeh, Canada, "Focused Assessment with Sonography in Trauma (FAST): An Overview," in International Emergency Medicine Education Project, September 20, 2021, https://iem-student.org/2021/09/20/sonography-in-trauma-fast/, date accessed: December 4, 2021

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: December 4, 2021

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: December 4, 2021

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

Triads in Medicine – Rapid Review for Medical Students

triads in medicine

One of the most convenient ways of learning and remembering the main components of disease and identifying a medical condition on an exam are Triads, and medical students/interns/residents swear by them.

Be it a question during rounds, a multiple-choice exam question to be solved, or even in medical practice, the famous triads help physicians recall important characteristics and clinical features of a disease or treatment in an instant.

Since exam season is here, this could serve as a rapid review to recall the most common medical conditions.

While there are a vast number of triads/pentads available online, I have listed the most important (high-yy) ones that every student would be asked about at least once in the duration of their course.

1) Lethal Triad also known as The Trauma Triad of Death
Hypothermia + Coagulopathy + Metabolic Acidosis

2) Beck’s Triad of Cardiac Tamponade
Muffled heart sounds + Distended neck veins + Hypotension

3) Virchow’s Triad – Venous Thrombosis
Hypercoagulability + stasis + endothelial damage

4) Charcot’s Triad – Ascending Cholangitis
Fever with rigors + Right upper quadrant pain + Jaundice

5) Cushing’s Triad – Raised Intracranial Pressure
Bradycardia + Irregular respiration + Hypertension

6) Triad of Ruptured Abdominal Aortic Aneurysm
Severe Abdominal/Back Pain + Hypotension + Pulsatile Abdominal mass

7) Reactive Arthritis
Can’t See (Conjunctivitis) + Can’t Pee (Urethritis) + Can’t Climb a Tree (Arthritis)

8) Triad of Opioid Overdose
Pinpoint pupils + Respiratory Depression + CNS Depression

9) Hakims Triad – Normal Pressure Hydrocephalus
Gait Disturbance + Dementia + Urinary Incontinence

10) Horner’s Syndrome Triad
Ptosis + Miosis + Anydrosis

11) Mackler’s Triad – Oesophageal Perforation (Boerhaave Syndrome)
Vomiting + Lower Thoracic Pain + Subcutaneous Emphysema

12) Pheochromocytoma
Palpitations + Headache + Perspiration (Diaphoresis)

13) Leriche Syndrome
Buttock claudication + Impotence + Symmetrical Atrophy of bilateral lower extremities

14) Rigler’s Triad – Gallstone ileus
Gallstones + Pneumobilia + Small bowel obstruction

15) Whipple’s Triad – Insulinoma
Hypoglycemic attack + Low glucose + Resolving of the attack on glucose administration

16) Meniere’s Disease
Tinnitus + Vertigo + Hearing loss

17) Wernicke’s Encephalopathy- Thiamine Deficiency
Confusion + Ophthalmoplegia + Ataxia

18) Unhappy Triad – Knee Injury
Injury to Anterior Cruciate Ligament + Medial collateral ligament + Medial or Lateral Meniscus

19) Henoch Schonlein Purpura
Purpura + Abdominal pain + Joint pain

20) Meigs Syndrome
Benign ovarian tumor + pleural effusion + ascites

21) Felty’s Syndrome
Rheumatoid Arthritis + Splenomegaly + Neutropenia

22) Cauda Equina Syndrome
Low back pain + Bowel/Bladder Dysfunction + Saddle Anesthesia

23) Meningitis
Fever + Headache + Neck Stiffness

24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex

25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia

Further Reading

Cite this article as: Sumaiya Hafiz, UAE, "Triads in Medicine – Rapid Review for Medical Students," in International Emergency Medicine Education Project, June 12, 2020, https://iem-student.org/2020/06/12/triads-in-medicine/, date accessed: December 4, 2021

Selected Orthopaedic Problems and Injuries section is added.

Selected Orthopaedic Problems and Injuries

Fundamentals of research in medicine
iEM Education Project Team

Fundamentals Of Research

Fundamentals of Research In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management.

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Global Emergency Medicine Student Leadership Program (GEMS LP) Blog Posts Activities Leadership Mentors Contact about The Global Emergency Medicine Student Leadership Program (GEMS LP) is

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question of the day
iEM Education Project Team

Question Of The Day

Welcome to our new initiative, “Question of the Day.” We will share emergency medicine-related questions regularly here. You can test yourselves with new questions on

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Seat Belt Sign

722.1 - seat belt sign 1

A 32 years old male was involved in an MVC where he was in the front seat as a passenger and had his seatbelt on. It was a direct front collision. The patient is stable. He is in moderate pain. Displacement of the lower part of the sternum as well as a retrosternal hematoma was noted after the ED care.

Trauma care is very important as globally recognized. It is also important to prevent injury. Seat belts are doing their part to prevent further injury. However, they may not be protective, or even cause injury if the other prevention measures were not applied such as speed limit.

This case shows dramatic skin lesions caused by the seatbelt. You can see various images of this in the clinical image archive (just click the image). What seatbelt sign says to us? INVESTIGATE FURTHER INNER INJURY… This patient has neck, chest, abdomen skin findings. Therefore, vascular injuries (aorta, vein), viscus injuries (perforation, bleeding), solid organ lacerations (spleen, liver, pancreas), contusions (cardiac) in the neck, chest, and abdomen should be investigated.

To learn more about trauma management read below chapter.

Multiple Trauma by Pia Jerot and Gregor Prosen by Dan O’Brien

Electrical injury

In case you didn’t encounter electrical injury today!

685.1 - electrical injury entry

The above picture shows entry wounds of electrical injury. One of the important hints is DO NOT DELAY TO TAKE OFF RINGS for any hand injury!

684.4 - electrical injury exit

The above picture shows exit wounds of the same patient. 

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

Red urine

684.1 - electrical injury - rhabdomyolysis

In case you didn’t encounter a construction worker who presented with high voltage electrical injury today!

683.4 - electrical burn entry

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

Unilateral or bilateral?

644 - C-spine dislocation

In case you didn’t encounter another trauma today!

You are working in a rural hospital. A 55-year-old female was brought to the ED by EMS. She was found at home, lying on the ground, in front of the stairs. She is vitally stable but unconscious (GCS: E1, V:2, M:3). You applied trauma surveys. After inline stabilization, you intubated the patient. The facility does not have a CT scan, and you order standard X-ray series for trauma including c-spine.

What are abnormal findings in this x-ray?

Facet dislocation? Unilateral or Bilateral?

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!