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ER7 Emergency Medicine Toronto Notes 2023

Traumatology

• epidemiology

4.9 million deaths are caused by injuries worldwide (data from 2016)

in Canada, traumatic injuries contributed more than 269000 hospitalizations and 17000 deaths

(data from 2018)

• leading cause of death in patients <45 yr

4th highest cause of death in North America

• causes more deaths in children /adolescents than all diseases combined

• trimodal distribution of death

• minutes: death usually at the scene from lethal injuries

• early: death within 4-6 h -

“golden hour" (decreased mortality with trauma care)

• days-weeks:death from multiple organ dysfunction,sepsis, VTE, etc,

• injuries fall into two categories

• blunt ( most common): M VC, pedestrian-automobile impact, motorcycle collision,fall, assault,

sports

• penetrating (increasing in incidence): gunshot wound, stabbing, impalement

Always completely expose and count the

number of wounds

Considerations for Traumatic Injury

Cardiac Box: sternal notch, nipples,

and xiphoid process:penetrating

injuries inside this area should increase

suspicion ol cardiac injury

• important to know the mechanism of injury to anticipate traumatic injuries

• always look for an underlying cause (alcohol, medications, illicit substances, seizure,suicide attempt,

medical problem)

• always inquire about HI, loss of consciousness, amnesia, vomiting, headache, and seizure activity

Table 5. Mechanisms and Considerations of Traumatic Injuries

Mechanism of Injury Special Considerations Associated Injuries High-Risk Injuries

• MVC at high speed,resulting in

ejection from vehicle

• Motorcycle collisions

• Vehicle vs. pedestrian crashes

• Fall from height >12 ft (3.6 m)

MVC Head-on collision:head/facial, thoracic (aortic), lower

extremity

Uleral/l- bone collision: head, C-spine, thoracic,

abdominal, pelvic,and lower extremity

Rear- end collision: hyper-extension of C-spine (whiplash

injury)

Rollover: all of the above may be associated injuries

Adults tend to be struck in lovrer legs (lower extremity

injuries), impacted against car (truncal injuries), and

thrown to ground (HI)

Vertical:lower extremity, pelvic, and spine fractures; HI

Horizontal: facial, upper extremity, and rib fractures:

abdominal, thoracic, and HI

Vehide(s) involved:weight,sire,speed, damage

location of patient in vehicle

Use and type of seatbelt

Ejection of patient Irom vehicle

Entrapment of patrentunder vehicle

Airbag deployment

Helmet usein motorcycle collision

High morbidity and mortality

Vehicle speed is an important factor

Site of impact on car

1storey*12 ft »

3.6 m

Distance of fall:$0% mortality at 4 storeys and 96%

mortality at 7storeys

Landing position (vertical vs. horizontal)

Pedestrian-Automobile

Impact

Vehicle vs. Pedestrian Crash

• In adults look for triad of injuries

• Waddell's triad

• Tibia-fibula or femur fracture

• Truncal injury

• Craniofacial injury

Falls

Head Trauma

• see Neurosurgery.XS35

Specific Injuries

• fractures

• Dx: non-contrast head CT and physical exam

A.skull fractures

vault fractures

linear, non-depressed

- most common

Signs of Basal Skull Fracture

• Battle's sign (bruised mastoid

process)

• Hemotympanum

• Raccoon eyes (periorbital bruising)

• CSF rhinorrhea/otorrhea - typically occur over temporal bone, in area of middle meningeal artery (commonest

cause of epidural hematoma)

- open (associated overlying scalp laceration and torn dura, skull fracture disrupting

paranasal sinuses or middle ear) vs. closed

depressed

basal skull fractures

typically occur through floor of anterior cranial fossa (longitudinal more common than

transverse)

can be a radiological or clinical diagnosis

associated with Battle’ssign, racoon eyes, hemotympanum, and/or (.

'

ST otorrhea /rhinorrhea

B. facial fractures(see Plastic Surgery, PL31)

• neuronal injury

beware of open fracture or sinus fractures(risk of infection)

• severe facial fractures may pose risk to airway from profuse bleeding

r “t

L J

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ER8 Emergency Medicine Toronto Notes 2023

• scalp laceration

can be a source ofsignificant bleeding

• achieve haemostasis, inspect and palpate for skull bone defects ± CT head (rule outskull fracture)

• neuronal injury

A.diffuse

• mild TB1 = concussion (GCS 13-15, patients are awake, may be confused but able to communicate

and follow commands)

• transient alteration in mental status that may involve loss of consciousness

• hallmarks of concussion: confusion and amnesia, which may occur immediately after the

trauma or minutes later

• loss of consciousness (if present) must be less than 30 min and post-traumatic amnesia must

be less than 24 h

• diffuse axonal injury

mild:coma 6-24 h,possibly lasting deficit

moderate:coma >24 h,little or no signs of brainstem dysfun

severe: coma >24 h, frequent signs of brainstem dysfunction

B.focal injuries

contusions

• intracranial hemorrhage (epidural,subdural, intracerebral)

ction

ASSESSMENT OF BRAIN INJURY

History

• prehospital status

• mechanism of injury

Physical Exam

• assume C-spine injury until ruled out

• vital signs

• shock (not likely due to isolated brain injury, except in infants)

Cushing'

s response to increasing ICP (bradycardia, HTN, irregular respirations)

• severity of injury determined by

1. LOG

GCS <8 intubate, any change in score of 3or more = serious injury

GCS of mild TBI = 13-15, moderate = 9-12,severe = 3-8

2.pupils:size, anisocoria >1 mm (in patient with altered LOC),response to light

3. lateralizing signs (motor/sensory)

may become subtler with increasing severity of injury

reassess frequently

Warning Signs of Severe Head Injury

. GCS <8

• Deteriorating GCS

• Unequal pupils

• Lateralizing signs

MJ.tunedIOC Itahallmaik ol bf«nInjury

Investigations

• labs:CBC, electrolytes, INR/PTT,glucose, toxicology screen

• Cl'

head (non-contrast) to exclude intracranial hemorrhage/hematoma

• C-spine imaging Canadian CT Head Rule

lancet 2001:357:1391-1396

C THeadis oily required lor patientswith minor

HI with airy one of the following

High-Risk (for neurological intervention)

. GCS score'

15 at2 h alter injury

• Sospeded open or depressed skull fracture

• Any ugn of basal tiiull fracture (hemolympanurn.

'

raccoon'

eyes. CSF otonhealihinorrhea.

Battle'

s vgn)

. Venting ;2 episodes

.

*

ge *65p

Medium-Risk (lor brain injury on Cl)

• trimesa before unpact >30min (i.e. cannot recal

events just before impact)

• Dangerous raecbansm (pedestrian strode by UVt.

occupant ejected Iron motor vehicle,tadlfrom

height »3 ft or five stairs)

Minor HIredefined as witnessed loss of

consciousness, definite amnesia.or witnessed

disorientationin a patient with a GCS score of 13-15.

HI:CanadianClHeadRule does nut apply lot mnIrautviuttv lot CCS «

13.090s «16.foe patlwnh on

Couitudai- jnd of hiving a bleeding tfcwdef.Of taring

an otntoaopen skullIroctuie.

Management

• goal in ED: reduce secondary injury by avoiding hypoxia, ischaemia, decreased CPP,seizure

• general

• ABCs

ensure oxygen delivery to brain through intubation and prevent hypercarbia

• maintain BP (sBP >90)

• treat other injuries

• early neurosurgical consultation for acute and subsequent patient management after imaging

• seizure treatment/prophylaxis

benzodiazepines, phenytoin, phenobarbital

• treatsuspected raised 1CP:

intubate (neuroprotective RSI where possible)

calm (sedate) if risk for high airway pressures or agitation

paralyze if agitated

• hyperventilate ( 100% 02) to a pCO:of 30-35 mmHg

• elevate head of bed to 20“

adequate BP to ensure good cerebral perfusion

give mannitol Ig/kg infused rapidly (contraindicated in shock/renal failure) or 3 ml./kg of

hypertonic (3%) saline r

i

_ J

^

Disposition

• neurosurgical 1CU admission for severe HI

• in a hemodynamically unstable patient with other injuries, prioritize most life-threatening injuries

and maintain cerebral perfusion

• for minor HI not requiring admission, provide 24 h HI protocol (regular assessment of the patient

for signs of loss of consciousness, confusion or amnesia) to competent caregiver, follow up with

concussion and/orsports clinic as even seemingly minor HI may cause lasting deficits

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ER9 Emergency Medicine Toronto Notes 2023

Mild Traumatic Brain Injury

Epidemiology

• TBI results in 1.7 million deaths, hospitalizations, and ED visits each year (US)

« 75% are estimated to be mild TBI; remainder are moderate orsevere (see Neurosurgery, NS37)

• highest rates in children 0-4 yr, adolescents 15-19 yr, and elderly >65 yr

Clinical Features

• somatic; headache,sleep disturbance, N/V, blurred vision

• cognitive dysfunction; attentional impairment, reduced processing speed, drowsiness, amnesia

• emotion and behaviour: impulsivily, irritability, depression

• severe concussion: may precipitate seizure, bradycardia, hypotension,sluggish pupils

Etiology

• falls, M VC,struck by an object, assault,sports

Extent o( retrograde amnesia correlates

with severity ol injury

Investigations

• neurological exam

• concussion recognition tool (see parachute.ca)

• imaging - CT as per Canadian CT Head Rules, or MR1 if worsening symptoms despite normalCT

Treatment

• close observation and follow-up; for patients at risk of intracranial complications, give appropriate

discharge instructions to patient and family; watch for changes to clinical features of more severe TBI

(see above), and if change, return to ED

• hospitalization with normal CT (CCS <15,seizures, bleeding diathesis), or with abnormal CT

• pharmacological management of pain, depression, headache

• follow Return to Flay/Return to Learn guidelines

For minor paediatric HI (up to16 yo

with CCS z13 and injury within the last

24 h), use Canadian Assessment of

Tomography for Childhood Head Injury

(CATCH) rule to determine need for CT.

CT head required if any of the following

findings are exhibited

• CCS <15 at two hours after injury

• Suspected open or depressed skull

fracture

• History of worsening headache

• Irritability on examination

• Signs of basal skull fracture

. Hematoma on scalp

• Dangerous mechanism of injury

(MVC.fall from >3ft or 5stairs,fall

from bicycle with no helmet)

Prognosis

• most recover with minimal treatment

athletes with previous concussion are at increased risk of cumulative brain injury

• repeat TBI can lead to life-threatening cerebral edema or permanent impairment

Spine and Spinal Cord Trauma

• assume cord injury with significant faUs (>12 ft),deceleration injuries, blunt trauma to head, neck,or

back

• spinal immobilization (cervical collar,spine board during patient transport only) must be maintained

untilspinal injury has been ruled out

• vertebral injuries may be present withoutspinal cord injury; normal neurologic exam does not

exclude spinal injur}'

• cord may be injured despite normal C-spine x-ray (spinal cord injury without radiologic abnormality)

• injuries can include:complete/incomplete transection, cord edema,spinal shock

History

• mechanism of injur}'

, previous deficits, SAMPLE

• neck pain, paralysis/weakness, paresthesia

Every Patient with One or More of the

Following Signs or Symptomsshould

be Placed in a C-Spine Collar

. Midline tenderness

. Neurological symptoms orsigns

• Significant distracting injuries

HI

• Intoxication

• Dangerous mechanism

. History of altered LOC

Physical Exam

. ABCs

• abdominal: ecchymosis, tenderness

• neurological: complete exam, including mental status

• spine:maintain neutral position, palpate C-spine:log roll, then palpate T-spine and L-spine, assess

rectal tone

when palpating, assess for tenderness, muscle spasm, bony deformities,step-off, and spinous

process malalignment

• extremities: check capillary refill,suspect thoracolumbar injury with calcaneal fractures

Of the investigations.CT is the best

modality to assess C-Spine injuries. If

unavailable and significant trauma is

suspected, protect C-Spine and transfer

for definitive imaging. If minor trauma of

C-Spine. may consider x-ray imaging

Cauda Equina Syndrome can occur

with any spinal cord injury below T10

vertebrae look for incontinence,

anterior thigh pain,quadriceps

weakness, abnormalsacral sensation,

decreased rectal tone, and variable

reflexes

Investigations

• bloodwork:CBC, electrolytes,Cr, glucose, coagulation profile, cross and type, toxicology screen

. imaging

CT of the spine;if not available, protect spines and transfer for definitive imaging

indications

C-spine injury

» unconscious patients (with appropriate mechanism of injury)

neurological symptoms or findings

deformities that are palpable when patient is log rolled

back pain

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ER10 Emergency Medicine Toronto Notes 2023

bilateral calcaneal fractures(due to fall from height)

- concurrent burst fractures of the lumbar or thoracic spine in 10% (T11-L2)

MRI (for soft tissue injuries) if appropriate

The Canadian C-Sp< neRule

JAMA200l:286:1841-48

For AlertlGCS Score= 181and Stable Trauma

Patientswhere C-Spine Injury is a Concern

Can Clear C-Spine if:

•oriented to person, place, time, and event

•no evidence of intoxication

•no posterior midline cervical tenderness

•no focal neurological deficits

•no painful distracting injuries(e.g. long bone fracture)

Management of Cord Injury

•immobilize

•evaluate ABCs

•treat neurogenic shock (maintain sBP >100 mmHg)

•insert NCi (for decompression of paralytic ileus) and holey catheter (only if no concerns about urethral

injury)

•complete imaging ofspine and consult spine service

•continually reassess high cord injuries as edema can travel up cord

•if cervical cord lesion, watch for respiratory insufficiency

low cervical transection (C5-T1) produces abdominal breathing (phrenic innervation of

diaphragm still intact but loss of innervation of intercostals and other accessory muscles of

breathing)

high cervical cord injury (above C4) may require intubation and ventilation

•if patient is in shock, treat with:warm blanket, Trendelenburg position (occasionally), volume

infusion, consider vasopressors

1. Any high -risk (actor that mandates

radiography?

Age >fi5vt

or

Oangerous mechanism*

or

Paresthesiasin extremities

No

2.Any low-risk factor

that allowssale

assessment oIROM?

Simple rear-end MVCt

or

Sitting position in ED

or

Ambulatoryat any time

or

Delayed (not immediate)

onsetofneck pain

or

Absence of midline

C-spine tenderness

Yes

No

Radiography

Yes Unable

i.Able toactively rotate neck?

>45* left and right

Able|

Approach to C-Spine Imaging |.o radiography

•CT of the spine is the screening modality of choice

•C-Spine CT can detect 97-100% of injuries

•compared to radiography,CT scans allows for more rapid clearance of the C-Spine

•MRI of C-Spine is the preferred technique for soft tissue injuries (spinal cord lesions, intervertebral

discs, and spinal ligaments)

•CT of C-Spine is the preferred modality. If only C-Spine x-rays are available, radiography can be

assessed as follows

'Dangerous Mechanism:

• Fa.’lfrom >1 meter, 5stairs

• Axial load*

to head le a. diving )

• MVC high speed < >100 km/hf i

ejection

• Motorized recreabonal vehicles

• Bicycle collision

tSimple reai-end MVC excludes:

• Pushed into oncoming tiallic

• Mil by busrlarge truck

• Rollover

• Hitbyhigli

-speedvehicle

rollover.

Table 6. Interpretation of Lateral View: The ABCS

A Adequacy and Alignment

Follow the anterior and posterior contour lines

Translation ol the vertebra >3.8 mm and angulation ol >11 dcgiccsis consideicd significant loi spinal instability

Next, follow the spinolaminar line:Ihe diameter between the posterior cortex and the spinolaminar line should be >18 mm

Fanning of spinous processessuggests posterior ligamentous disruption

Widening olfacet joints

Check atlanto-occipilal joint

line extending interiorly horn cirrusshould transect odontoid

Atlanto axial articulation, widening ol predentalspace ( normaI:<3mm in adults, <8 mm in children) indicates injury of C1 or C2

In children,(here isa phenomenon called pseudosubluxation where there Isa normal “translation" of C2 on C3 (less often C3 on C4)

The translation may be seen in Ihe flexed or neutral position and is not associated with soft tissue swelling (see below)

The line of Swlschuk is helpful in differentiating pathological cervical spine displacement Irom pseudosubluxation

The line is drawn from the anterior aspect ol the posterior arch Irom C1-C3

The anterior aspect of Ihe posterior arch olC2 should not be more than 2 mm from (hisline (>2mm isindicative of hue subluxation)

B Bones

Follow the bony contours of the vertebrae to look lor any breaks in Ihe cortex

Height,width,and shape of each vertebral body

Pedicles,facets,and laminae should appear as one -doubling suggests rotation

C Cartilage

look at thedisk spacesto ensure that they are of equal length throughout

The anterior and posterior aspect of the individual discsshould be equal

Intervertebral disc spaces- wedging anteriorly or posteriorly suggests vertebral compression

Measure the pre-dentalspace (distance from denslo C1body):itshould be <3 mm

The distance between the lowest part of the occiput base and Ihe densshould be <2 mm

The facet jointsshould be stacked on lop ol each other at a 45- degree angle

S Soft Tissues

The retropharyngeal space lies anteriorly to theC-Spine; it widens around C4 due to the esophagus

The retropharyngealspace normally measureslessthan 7mm at C2 and 21mm at C7; may be wide in children <2 yr on expiration

(alternatively,less than the height of the vertebra at C2 and lessthan the width ol Ihe vertebra at C7)

Assess relrotrachealspaces(normal:<22 mm at C6-11. <14 mm in children <8 yr)

1.Anterior vertebral line

2. Posterior vertebral line

(anterior margin of spinal canal)

3. Posterior border of facets

4. Laminar fusion line

( posterior margin ol spinal canal)

5. Posterior spinous line

^

(along tips of spinous processes)

^

Figure 3. Lines of contour on a

lateral C-spine x-ray

ri

• Plain films of C-Spine arc not reliable in patients with significant trauma and should he used with

caution

Prevertebral soft tissue swelling is only +

49% sensitive for injury

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ERll Emergency Medicine Toronto Notes 2023

Sequelae of C-Spine Fractures

• see Neurosurgery, XS39

• acute phase of SCI

spinalshock:absence of all voluntary and reflex activity below level of injur)'

decreased reflexes, no sensation, flaccid paralysis below level of injury, lasting days to months

• neurogenic shock:loss of vasomotor tone, SNS tone

watch for:hypotension (lacking SNS), bradycardia (unopposed PNS), poikilothermia (lacking

SNS so no shunting of blood from extremities to core)

occurs within 30 min of SCI at level T6 or above, lasting up to 6 wk

provide airway support, fluids, atropine (for bradycardia ),vasopressors for BP support

• chronic phase of SCI

autonomic dysreflexia: in patients with an SCI at level T6 or above

signs and symptoms: pounding headache, nasal congestion,feeling of apprehension or

anxiety, visual changes,dangerously increased sBP and dBP

common triggers

- GU causes:bladder distention, urinary tract infection,and kidney stones

- G1causes:fecal impaction or bowel distension

treatment:monitoring and controlling BP, prior to addressing causative issue

1.0ensofC2

2- Cl lateral-ass

3 C2

To clearthex-rayeraurethat

A.The dens is centred betweenthe

lateral masses of Cl

B.C1 and C2 are aligned laterally

C.The lateral masses of Cl are

symmetrical m size

T3

Chest Trauma t)

Figure 4. C-spine x-ray;odontoid

view • two types:those found and managed in 1°survey and those found and managed in 2°survey

Table 7.Life-Threatening Chest Injuries Found in Primary Survey

Physical Exam Investigations Management

Airway Obstruction Anxiety, sltidor.hoarseness,altered

mental status

Apnea, cyanosis

Oo not wadlor A 36 to intubate Definitive airway management

Intubate early

Remove foreign body with magill

forceps prior to the intubation Be

prepared for a potential surgical

airway

Non-radiographic diagnosis Needle thoracostomy -large bore

needle.2ndICS mid clavicular line

or finger thoracostomy.Definitive

management is a chest tube

Supine Oblique Views

• Rarely used

• Better visualization of posterior

element fractures (lamina,pedicle,

facet joint)

• Good to assess patency of neural

foramina

• Can be used to visualize the C7-T1

junction

Tension Pneumothorax

Clinical diagnosis

One-way valve causing

accumulation of air inpleural

space

Respiratory distress,tachycardia,

hypoxia,distended neckveins.

cyanosis,asymmetry ot chest wall

motion

Tracheal deviation away from

pneumothorax

Percussion hyperresonance

Unilateral absence of breath sounds

Gunshot or other wound

(hole >2/3 tracheal diameter)iexit

wound

Unequal breath sounds

Pallor,flat neck veins,shock

Unilateral dullness

Absent breath sounds

Hypotension

A8G:decreased p0

’

Open Pneumothorax

Air entering chest from wound

rather than trachea

Air-tightdressing sealed on

3 sides

Chest tube

Surgery

Restore bloodvolume

Chest tube

Thoracotomyit:

»1500 cc total blood loss

>200 cc/h continued drainage

20% of C-spine fractures are

accompanied by other spinal fractures,

so ensure thoracic and lumbar spine CT

is normal before proceeding to OR Massive Hemothorax

>1500 cc blood lossm chest

cavity

Usually only able to do supine

CXR - entire lung appears

radiopaque as blood spreads out

over posterior thoracic cavity

Trauma to the chest accounts for 50% of

trauma deaths

Flail Chest Paradoxical movement of flail VBG:decreased pOe.increased 02- fluid therapy *

pain control

pC02 Judicious fluid therapy in absence

CT:rib fractures,lung contusion of systemic hypotension

Positive pressure ventilation

iintubation and ventilation if

persistently hypoxic or unable to

ventilate

IV fluids

Open thoracotomy

Free-floatngsegmentot chest segment

wall due to >2rib fractures,each Palpable crepitus of ribs

at 2sites Decreased air entry on affected side

Underlying lung contusion (cause

of morbidity andmortality)

80% of all chest injuries can be managed

non-surgically with simple measures

such as intubation,chest tubes,and

pain control

Cardiac Tamponade

Clinical diagnosis

Pericardial fluidaccumulabon

impairing ventricular funebon

Penetrating wound (usually)

Bech's triad:hypotension,distended

neck veins,muffled heart sounds

Tachycardia.tachypnea

Kussmaul's sign (increased JVP with

inspiration)

Echocardiogram

-o

3-way Seal to

*

Open Pneumothorax

(i.e.sucking chest wound)

Allows air to escape during the

expiratory phase (so that you do not get

a tension pneumothorax) but seals itself

to allow adequate breaths during the

inspiratory phase

ri

L J

mmHg

Pulsus

with

Paradoxus

inspiration

:a

.

drop

Recall

inBP

that

of

BP

>10 +

normally drops with inspiration,but

what's -paradcuricar about this is that it

drops more than it should

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ER12 Emergency Medicine Toronto Notes 2023

Table 8. Potentially Life-Threatening Chest Injuries Found in Secondary Survey

Physical Exam Investigations Management

Pulmonary Contusion Cl: aicasol opacification ol lung

within 6 hoi trauma

Blunt trauma tochest

Interstitial edema impairs

complianceandgasenchange

Maintain adequate ventilation

Monitor with ABC. pulse oximeter,

and ECG

Chest physiotherapy

Positive pressure ventilation it

severe

Laparotomy for diaphragm repair

and associated intra-abdominal

injuries

Ruptured Diaphragm Blunt trauma to chest or abdomen CXR: abnormality of diaphragm/

le g. high lap bell in MVC| lower hing fieldsi'NG tube

placement

Clscan and endoscopy:

sometimes helpful for diagnosis

Esophageal Injury Usually penetrating trauma (pain CXR:mediastinal air (not always)

out of proportion to degree of

injury)

Sudden high speed deceleration CXR.Clscan, transesophageal

je.g. MVC. fall, airplane crash), echocardiogram, aortography

complaints of chest pain, dyspnea, (gold standard)

hoarseness(frequently absent)

Decreased femoral pulses,

differential arm BP larch tear)

Early repair (within 24 h) improves

Esophagram (Gastrograffin outcome)

'

)

flexible esophagoscopy

Aortic Tear

90% tear atsubclavian (near

ligamentum arleriosum). most

die atscene

Salvageable il diagnosis made

rapidly

Blunt Myocardial Injury

(rare)

Ihoracotomy (may treat other

severe injuriesfirst) Ruptured diaphragm is more often

diagnosed on the left side,as the liver

conceals right side defects

Blunt trauma to chest (usually in ECG: dysrhythmias. SI changes Of

setting of multi system trauma Cardiac blood work (e.g. troponin) Anlidysrhythmic agents

and therefore difficult to diagnose) 2-D Echo:Can assessfor

Physical exam:overlying injury

(e.g.fractures,chest wall

contusion)

Aortic Tear

Analgesia

tamponade, wall motion, valve

function,or thrombi.

Patients with a normal ECG.

ABC WHITE

Xtay features of Aortic tear

Depressed left mainstem Bronchus

pleural Cap

Wide mediastinum (most consistent)

Hemothorax

Indistinct aortic knuckle

Tracheal deviation toright side

Esophagus (NG tube) deviated to right

(Note:these features are present in85%

of cases, but cannot rule out if absent)

normal troponin, and normal

hemodynamics rarely get

dysrhythmias

Other Potentially Life-Threatening Injuries Related to the Chest

Penetrating Neck Trauma

• includes all penetrating trauma to the three zones of the neck

• management:injuries deep to platysma require further evaluation by angiography, contrast CT, or

surgery

• do not explore penetrating neck wounds except in the OR

Airway Injuries

• always maintain a high index of suspicion

• larynx

• history:strangulation, direct blow, blunt trauma,any penetrating injury involving platysma,

inhalational injury (e.g. burns)

• triad: hoarseness, subcutaneous emphysema, palpable fracture

other symptoms: hemoptysis, dyspnea, dysphonia

• investigations:CXR, CT scan, arteriography (if penetrating)

management

« airway:manage early because of edema

C-spine may also be injured, consider mechanism of injury

surgical:tracheotomy vs. repair

• trachea/bronchus

frequently missed

• history:deceleration, penetration, increased intrathoracic pressure, complaints of dyspnea,

hemoptysis

• examination:subcutaneous emphysema, Hamman'

s sign (crunching sound synchronous with

heartbeat)

• CXR: mediastinal air, persistent pneumothorax, or persistent air leak after chest tube inserted for

pneumothorax

• management

surgical repair if >1/3 circumference

If Penetrating Neck Trauma Present.

DON'T:

, Clamp structures (can damage

nerves)

• Probe

• Insert NG tube (leads to bleeding)

• Remove weapon/impaled object

Zone III

Zone II

Zone I

Zone III: Superior aspect of neck

Zone II: Midportion of neck(cricoidto the

angle of mandible)

Zone I: Base of neck (thoracic inlet to Abdominal Trauma . ciicoid cartilage)

Figure 5. Zones of the neck in trauma

•two mechanisms

• blunt: usually causessolid organ injury (spleen = most common, liver = second most common)

penetrating: usually causes hollow organ injury or liver injury (most common)

BLUNT TRAUMA

•resultsin two types of hemorrhage:intraperitoneal and retroperitoneal

•adopt high clinical suspicion of bleeding in multi-system trauma

L J

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ER13 Emergency Medicine Toronto Notes 202}

History

• mechanism of injury, SAMPLE history

Seatbelt Injuries May Cause

• Retroperitoneal duodenal trauma

• Intraperitonea! bowel transection

• Mesenteric injury

• l-spine Injury

Physical Exam

• often unreliable in multi-system trauma, wide spectrum of presentations

• slow blood loss not immediately apparent

• tachycardia, tachypnea, oliguria, febrile, hypotension

other injuries may mask symptoms

serial examinations are required

• abdomen

inspect: contusions, abrasions,seat-belt sign, distention

auscultate:bruits, bowel sounds

• palpate: tenderness, rebound tenderness, rigidity, guarding

DRE:rectal tone, blood, bone fragments, prostate location

• placement of N(i and l-

'

oley catheter should be considered part of the abdominal exam

• other systems to assess: cardiovascular, respiratory ( possibility of diaphragm rupture),genitourinary,

pelvis, back/neurological

Indications for Foley and NG Tube in

Abdominal Trauma

Foley catheter: unconscious or patient

with multiple injuries who cannot void

spontaneously

NG tube: used to decompress the

stomach and proximal small bowel.

Contraindicated if suspected facial or

basal skull fractures

Investigations

• labs:CBC, electrolytes, coagulation, cross and type, glucose,Cr,CK, lipase, amylase,liver enzymes,

VBG, blood EtOH, (3-hCG, U/A,toxicology screen Point-of-Care Ultrasonography for Diagnosing

Thoracoabdominal Injuries in Patients with

Sunl Trauma

Cochrane DB Syst Rev 20I8 CDOI 2669

Purpose: determine the diagnostic accuracy ol

FOCUS lor detect ngand excluding free Dull oigan

injuries, vascular lesions,and other injuries compared

to (agnostic reference standardsin patentswith

blunt trauma.

Methods:Systematic review of prospective or

retrospective diagnostic cohortstudies of patients

with any type ol Id unttrawna.

Results 34 studies. 8535 part (pintsfor

abdominal trau ma, FOCUS had a sensitivity ol 0.08

(9S\Cl 0.59 0.75) and a specificity ol 0.95|95% Cl

0.92-0-97|. In children, pooled sensitivity ol FOCUS

was 0.63 (95% Cl 0.46-0.77).as compared foO.78

(95% Cl 0.69-0.84|in an adultra red population.

For chest injuries,P0CUS had asensitivity of 0.96

(95%> CI 0.88-0-99) and a spetifierty of 0

_95(95%

O0.97-1.00).

Conclusions: In patients with blunt

thoracoabdominal trauma, positive FOCUS findings

ait helpful lot guiding treatment decisions. However,

with regard tu abdominal trauma, anegative P0CUS

Uses not tide out Injuries and must be verified. This is

of particular importancem paediatric trauma,where

the sensitivity of P0C US is poov.Based on a sma II

number olstudiesin a mined population.POCUS may

have a higher sensitivity in chest injuries.

Table 9. Imaging in Abdominal Trauma

Imaging Strengths Limitations

Ultrasound:FAST Identifies presence/absence of free fluid in peritoneal NOT used to identify specific organinjuries

cavity

RAPID exam:less than 5 min

Can also examine pericardium and pleural cavities

Can do serial examinations quickly

If patient has ascites. FAS1will be falsely positive

False negatives with small amounts of blood,retroperitoneal

blood,delayed presentations,prior abdominalsurgery,or

incorrect positioning

Technically difficult if patientis obese

Chest (looking lot free air under diaphragm,

diaphragmatic hernia,air fluid levels),pelvis,cervical.

Ilioradc. lumbar spines

Most specilie test

X -Ray Soft tissue not well visualized

CTScan Radiation exposure 20x more than x-ray

Use vrilh caution if hemodynamic instability

Cannot test for retroperitoneal bleed or diaphragmatic rupture

Cannot distinguish lethal from trivial bleed

Results can take up to1h

Diagnostic Peritoneal Most sensitive test

Lavage (rarely used) Tests for intraperitoneal bleed

•imaging must he done if:

• equivocal abdominal examination, altered sensorium, or distracting injuries(e.g. head trauma,

spinal cord injury resulting in abdominal anesthesia)

• unexplained shock/hypotension

• patients have multiple traumas and must undergo general anesthesia for orthopaedic,

neurosurgical, or other injuries

• fractures of lower ribs, pelvis,spine

positive EAST

Management

•general: ABCs, early blood products, and stabilization

•surgical: watchful waiting vs. laparotomy

•solid organ injuries: decision based on hemodynamic stability, not the specific injuries

•hemodynamicallv unstable or persistently high transfusion requirements:laparotomy

•hollow organ injuries: laparotomy

•even if low suspicion of injury:admit and observe for 24 h

Laparotomy is Mandatory if

Penetrating Trauma and:

• Shock

• Peritonitis

• Evisceration

• Free air in abdomen

• Blood in NG tube,Foley catheter, or

on DRE PENETRATING TRAUMA

• high-risk of gastrointestinal perforation and sepsis

• history: size of blade, calibre/distance from gun, route of entry

•local wound exploration under direct vision may determine lack of peritoneal penetration (not reliable

in inexperienced hands) with the following exceptions:

• thoracoabdominal region (may cause pneumothorax)

back or flanks (muscles too thick)

“Rule of Thirds" for Stab Wounds

• 1/3 do not penetrate peritoneal cavity

• 1/3 penetrate but are harmless

• 1/3 cause injury requiring surgery

ri

Management

•general: ABCs, tluid resuscitation, and stabilization

•gunshot wounds always require laparotomy

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HR11 Emergency Medicine Toronto Notes 2023

Genitourinary Tract Injuries

• see Urology, U35

Etiology

• blunt trauma: often associated with pelvic fractures

• upper tract

renal

- contusions (minor injury - parenchymal ecchymoses with intact renal capsule)

- parenchymal tears/laceration: non-communicating (hematoma) vs. communicating

(urine extravasation, hematuria)

ureter:rare,at uretero-pelvic junction

lower tract

bladder

- extraperitoneal rupture of bladder from pelvic fracture fragments

- intraperitoneal rupture of bladder from trauma and full bladder

urethra

- posterior urethral injuries:MVCs, falls, pelvic fractures

- anterior urethral injuries: blunt trauma to perineum,straddle injuries/direct strikes

external genitalia

• penetrating trauma

» damage to:kidney, bladder, ureter (rare),external genitalia

• acceleration/deceleration injury

renal pedicle injury: high mortality rate (laceration and thrombosis of renal artery, renal vein,

and their branches)

• iatrogenic

ureter and urethra (from instrumentation)

History

• mechanism of injury

• hematuria (microscopic or gross), blood on underwear

• dysuria, urinary retention

• history of hypotension

Physical Exam

• abdominal pain, flank pain,CVA tenderness, upper quadrant mass, perineal lacerations

• DRE:sphincter tone, position of prostate, presence of blood

• scrotum: ecchymoses, lacerations, testicular disruption, hematomas

• bimanual exam,speculum exam

• extraperitoneal bladder rupture: pelvic instability,suprapubic tendernessfrom mass of urine or

extravasated blood

• intraperitoneal bladder rupture:acute abdomen

• urethral injury: perineal ecchymosis,blood at penile meatus, high riding prostate, pelvic fractures

Investigations

• urethra: retrograde urethrography

• bladder: VIA,CT scan, urethrogram ± retrograde cystoscopy ± cystogram (distended bladder t postvoid )

• ureter: retrograde ureterogram

• renal:CT scan (best, if hemodynamically stable), intravenous pyelogram

Gross hematuria suggests bladder injury

Management

• urology consult

• renal

• minor injuries:conservative management

• bed rest, hydration, analgesia, antibiotics

• major injuries: admit

* conservative management with frequent reassessments,serial U/A ± re-imaging

surgical repair (exploration, nephrectomy): hemodynamically unstable or continuing to bleed

>48 h, major urine extravasation, renal pedicle injury, all penetrating wounds and major

lacerations, infections, renal artery thrombosis

• ureter

ureteroureterostomy

• bladder

extraperitoneal

minor rupture: Foley drainage x 10-14 d

major rupture:surgical repair

intraperitoneal

• urethra

anterior: conservative, if cannot void, Eoley or suprapubic cystostomy and antibiotics

posterior:suprapubic cystostomy (avoid catheterization) ± surgical repair

In the case of gross hematuria,the

genitourinary system is investigated

from distal to proximal (i.e. urethrogram,

cystogram. etc.)

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ERI5 Emergency Medicine Toronto Notes 2023

Orthopaedic Injuries

• see Orthopaedic Surtterv (see Shoulder OR2. Knee OR34, Wrist OR23, Ankle OIOII )

Description of Fractures

SOLARTAT

Goals of ED Treatment

• diagnose potentially life/limb-threatening injuries

• reduce and immobilize fractures (cast/splint) as appropriate

• proside adequate pain relief

• arrange proper follow-up if necessary

History

• use SAMPLE, mechanism of injury may be s'ery important

Physical Exam

• look (inspection ): “HEADS"

= swelling, erythema, atrophy, deformity, and skin changes (e.g. bruises)

• feel (palpation): all joints/bones for local tenderness,swelling, warmth, crepitus, joint effusions, and

subtle deformity

• move:joints affected plus those above and below injury - active ROM preferred to passive

• neurovascular status: distal to injury (before and after reduction )

Site

Open vs. closed

Length

Articular

Rotation

Translation

Alignment/Angulation

Type e.g. Salter-Harris. etc.

tiled ol a Single Dose of Oral Opioid and

Nonopioid Analgesics on Acute Eitremity Pain

in the ED

JAMA 2017:318:1661 166P

Purpose: lo compare the efficacy ol 4 aratjesnson

acute extremity pain.

Methods: K1 unhiding 416 patients«ith "ipdeiate

ta severe acute eitremity pam. Participants lecened

ibupiolen 400 mgard acetaminophen 1000 mg:

oiycodone S mg and acetaminophen 325 mg:

hydrocodone 5 mg and acetam nophen 300 mg;or

codeine 30 mg and acetaminophen 300 mg.Ihe

primary outcome wasthe difference m decline in

pain 2 h after ingestion.Pain was assessed using an

11-point numerical rating scale [MRS).

Results:At 2 h, the mean HRS pain score decreased

try 4.3 in the ihuprofen and acetaminophen group: by

4.4 in the oiycodone and acetaminophen group:by

3.5 in the hydrocodoneand acetaminophen group:

and by 3.9 in the codeine and acetaminophen group

(P-0.053).

Conclusions: For patients present ng to the ED with

acute eitremity pain, there were no statistically

significant or clinically important differeoces m pam

reduction at 2 h among single -dose treatment with

ibupiolen andacelaminophen or with 3different

opioid and acetaminophen combmationenelgesics.

LIFE- AND LIMB-THREATENING INJURIES

Table 10. Life- and Limb-Threatening Orthopaedic Injuries

Life-Threatening Injuries (usually blood loss) Limb-Thieatening Injuries (usually interruption of blood supply)

Major pelvic fractures

Traumatrcampulations

Massive long bone injuries and associated fat emboli

syndrome

Vascular injury proximal to knee/elbow

Fracture/dislocation ol ankle (talar AVN)

Crush injuries

Compartment syndrome

Open fractures

Dislocations olknee/hip

fractures above knee/elbow

Open Fractures

• communication between fracture site and external surface of skin - increased risk of osteomyelitis

• remove gross debris, irrigate, cover with sterile dressing -formal irrigation and debridement often

done in the OK

• control bleeding with pressure ( no clamping)

• splint

• antibiotics(1st generation cephalosporin and aminoglycoside) and tetanus prophylaxis

• standard of care is to secure definitive surgical management within 6 h, time to surgery may vary

from case-to-case

Vascular Injuries

• realign limb/apply longitudinal traction and reassess pulses (e.g. Doppler probe)

• surgical consult

• direct pressure if external bleeding

When Dealing with an Open Fractuie.

Remember "STAND"

Splint

Tetanus prophylaxis

Antibiotics

Neurovascular status (before and after)

Dressings (to cover wound)

Compartment Syndrome

• when the intracompartmental pressure within an anatomical area (e.g.forearm or lower leg) exceeds

the capillary perfusion pressure, eventually leading to muscle/nerve necrosis

• clinical diagnosis: maintain a high index of suspicion

pain out of proportion to the injury

• pain worse with passive stretch

• tense compartment

• look for “The 6 Hs” (note: radial pulse pressure is 120/80 mrnHg while capillary perfusion pressure

is 30 mrnHg,seeing any of the 6 Ks indicates advanced compartment syndrome, therefore do not

wait for these signs to diagnose and treat)

• in the unconscious patient, a Stryker compartment pressure monitor can be used

• requires prompt decompression: remove constrictive casts, dressings; emergent fasciotomv may be

needed

Vascular injury/compartment syndrome

Is suggested by “The 6 Ps” Injury

Compartment Syndrome •

6 Ps

Pulse discrepancies

Pallor

Parcsthesia/hypoesthesia

Paralysis

Pain (especially when refractory to

usual analgesics)

Polar (cold)

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F.RI6Emergency Medicine Toronto Notes 2023

UPPER EXTREMITY INJURIES

• anterior shoulder dislocation

axillary nerve (lateral aspect of shoulder) and musculocutaneous nerve (extensor aspect of

forearm) at risk

seen on lateral view:humeral head anterior to glenoid

• many techniques for reduction (e.g. traction,scapular manipulation), immobilize in internal

rotation,repeat x-ray,out-patient follow-up with orthopaedics

with forceful Injury, look for fracture

• Colics'fracture

• distal radius fracture with dorsal displacement from “Kail on Outstretched Hand"

(I

'

OOSH )

• anteroposterior film: radial shortening, radial deviation, radial displacement

• lateral film: dorsal displacement, volar angulation

reduce, immobilize with splint, out-patient follow-up with orthopaedics or immediate

orthopaedic referral if complicated fracture

if involvement of articularsurface, consider outpatient fracture clinic or orthopaedic referral if

unsatisfactory reduction in ED

• scaphoid fracture

• tenderness in anatomical snuffbox, pain on scaphoid tubercle, pain on axial loading of thumb

negative x-ray: thumb spica splint, repeat x-ray in I wk ± CT scan/bone scan

positive x-ray: thumb spica splint x 6-8 wk, repeat x-ray in 2 wk

• treat based on clinical suspicion even in absence of radiological scaphoid fracture

risk of AVN of scaphoid if not immobilized

outpatient orthopaedic follow-up

¥

Lateral view

A-P view

CN 1.Dorsaltilt

2.Dorsal displacement

3.Ulnar styloid fracture

4 Radial displacement

5.Radialtilt

6. Shortening

|

£

23

S

J

Figure 6. Codes’ fracture

LOWER EXTREMITY INJURIES

• knee injuries

• see Ottawa Knee Rules

• ankle and foot fractures

see Ottawa Ankle and l

'

oot Rules

• avulsion of the base of 5th metatarsal

occurs with inversion injury

• supportive tensor or below knee walking cast for 3 wk

• calcaneal fracture

associated with fall from height

associated with axial loading (other injuries may involve ankles, knees, hips, pelvis, lumbar

spine)

Ulna 1 Radius

-

Scaphoid

Trapezium

Trapezoid

"

Capitate

Lunate 14 si

Triquetrum

Pisiform*

Hamate /

Metacarpal

bones (1-51 i

SEIishova Marcus^

A luiec x-ray examination is required only for acute injury patients with one or more of:

• Age 55 yr or older

• Tenderness at head of fibula

• Isolated tenderness ol patella

• Inability to Ilex to 90'

• Inability to bear weight both immediately and in the ED Hour steps)

Figure 7. Carpal bones

Figure 8. Ottawa knee rules

Adapted Irom:SUell 16.Wells GA.Hoag RH. et aL JAMA 1997:278:2075-2079.

LATERAL VIEW An ankle radiographic series is

required only if there is any pain in

malleolar zone and any of these

findings:

Malleolar Zone A. Posterior

edge or tip of

lateral

malleolus

Midlout Zone

1. Bony tenderness at A

or

, 2 Bony tenderness atB -C. Base ol5th

metatarsal or

3.Inability to bear weight both

immediately andinED

A radiographic seriesisrequired

only if there is any painin midfoot

zone and any of these findings:

MEDIAL VIEW

B. Posterior

edge or tip

of medial

malleolus

MalleolafZODt 1 Bony tenderness atC

Midfoot or Zone

2 Bony tenderness atD

or

3.Inability to bear weight both

D immediately andinED . Navicular

(ENataiie Cormier 2016 +

Figure 9. Ottawa ankle and foot rules

Adapted Irom: Stiell 16. Mcknight RO.Greenbetg 6H.et al.JAMA1994:271:827-832.

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ER17 Emergency Medicine Toronto Notes 2023

Wound Management

Goals of ED Treatment

• identify injuries and stop any active bleeding - direct pressure

• manage pain

• wound examination and exploration

• cleansing ± antibiotic and tetanus prophylaxis

• closure and dressing

Acute Treatment ol Contusions

RICE

Rest

Ice

Compression

Elevation

Tetanus Prophylaxis

• both tetanus toxoid ( I

'

d) and immunoglobulin (TIG) are safe in pregnancy

Table 11. Guidelines for Tetanus Prophylaxis for Wounds High-Risk Factorsfor Infection

Wound Factors

• Puncture wounds

• Crush injuries

• Wounds >12 hold

• Hand or foot wounds

Patient Factors

• Age >50 yr

• Prosthetic joints or valves (risk of

endocarditis)

• Immunocompromised

Clean, Minor Wounds All Other Wounds'

Vaccination History

Unknown or fewer than3 doses Yes

3 or more doses

Tdaporld TIG TIG *

Tdap orId1

Ho Yes Yes

Hoi Ho

' Ho Ho

'Such as, but not limited to, woundscontaminated with dirt, feces,soil, and saliva:puncture wounds; uvulslons; and woundsresulting from

missiles, crushing,burns, and frostbite

’

Tdap Is preferred to Td for adults who have never received Tdap. Single antigen tetanustoxoid (IT) Is no longer available In the United Stales

SYes.It more than ten yearssince the last tetanustoxoid-containing vaccine dose

'

.Yes.if more than five yearssince the last tetanus toxoid-containing vaccine dose

Source:MM WR 1991:40(No.RR-10|:1-28

Bruises

• non-palpable = ecchymosis

• palpable collection (not swelling)

= hematoma following blunt trauma

• assess for coagulopathy (e.g. liver disease), anticoagulant use

Suture Use and Duration

Suture to: Close with Approx.

Nylon or Duration (d)

Other Nonabsorbable

Suture

Abrasions

partial to full thickness break in skin

• management

• clean thoroughly with brush to prevent foreign body impregnation ± local anesthetic antiseptic

ointment (Polysporin* or Vaseline*) for 7 d ± tetanus prophylaxis

Face 6-0or 5-0 5

Hot Joint 4-0

Joint 34)

Scalp

Mucous Absorbable N/A

Membrane

7

10

Lacerations

• see Plastic Suruerv. PL8,sidebar PL24

• consider every structure deep to a laceration injured until proven otherwise

• in hand injury patients, include the following in history:handedness,occupation, mechanism of

injury, previous history of injury

• physical exam

• think about underlying anatomy

• examine tendon function actively against resistance and neurovascular status distally

• clean and explore under local anesthetic; look for partial tendon injuries

• x-ray or U/S wounds if a foreign body is suspected (e.g.shattered glass) and not found when

exploring wound (remember:not all foreign bodies are radiopaque), or ifsuspect intra-articular

involvement

• management

• disinfectskin/use sterile techniques

• irrigate copiously with normal saline or tap water

analgesia ± anesthesia

• maximum dose of lidocaine

7 mg/kg with epinephrine

5 mg/kg without epinephrine

• in children, topical anestheticssuch asLET (lidocaine, epinephrine, and tetracaine),distraction

provided by Child Life Specialist or parent; and in selected cases a short-acting benzodiazepine

(midazolam or other agents) for sedation and amnesia are useful

• secure hemostasis

• evacuate hematomas, debride non-viable tissue, remove hair and foreign bodies

• ± prophylactic antibiotics(consider for animal/human bites, intra-oral lesion,or puncture wounds to

the foot)

suture unless:delayed presentation (>24 h), puncture wound, mammalian bite,crush injury,or

retained foreign body

• take into account patient and wound factors when considering suturing

• advise patient when to have sutures removed

• cellulitis and necrotizing fasciitis (see Plastic Suruerv, El.16)

40 7

fray!)

N.B.Patientson steroid therapy may need

sutures for longer periods of lime

Early wound irrigation and debridement

are the most importantfactors in

decreasing infection risk

Alternatives

Q

toSutures

• Tissue glue

, Steristrips-

• Staples

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ER18 Emergency Medicine Toronto Notes 2023

Approach to Common ED Presentations

Abdominal Pain

Table 12. Selected Differential Diagnosis of Abdominal Pain

Emergent Usually Less Emergent

Perforated viscus, bowel obstruction, ischaemic bowel,appendicitis. Diverticulitis, gastroenteritis, GERD,esophagitis,

strangulated hernia,I8D flare, esophageal rupture, peptic ulcer disease gastritis, IBS

Hepatobiliary Hepatic/splenic injury.pancreatitis, cholangitis,spontaneous bacterial Biliary colic,cholecystitis, hepatitis

peritonitis

Genital Female:Ovarian torsion, ectopic pregnancy,tubo ovarian abscess

Male:Testicular torsion

Urinary Pyelonephritis

Ml,aortic dissection,AAA

Respirology PE. empyema

Metabolic OKA.sickle cell crisis, toiin.Addisonian crisis

Gl

Female: PIO, ovarian cysl.salpingitis, endometriosis

Male: epididymitis, prostatitis, orchitis

Renal colic, cystitis

Pericarditis

Pneumonia

Tonic ingestions(e.g. acetaminophen, Iron.HSAIDs,

etc.), lead poisoning, porphyria

Abdominal wall injuty.herpcs roster, psychiatric,

abscess, hernia,mesenteric adenitis

CVS

Other Significant trauma,acute angle closure glaucoma

• differential can be focused anatomically by location of pain:right upper quadrant, left upper

quadrant, right lower quadrant, left lower quadrant, epigastric, periumbilical, diffuse

History

. pain:OPQRST

• review symptomsfrom genitourinary, gynecological,gastrointestinal, respiratory, and cardiovascular

systems

• abdominal trauma/surgeries,most recent colonoscopy, most recent endoscopy,last FOBT/F1T test

Physical Exam

• vitals, abdominal (including DRE, CVA tenderness), pelvic/genital, respiratory, and cardiac exams as

indicated by history

Investigations

• ABCs, do not delay management and consultation if patient unstable

• labs:CBC, electrolytes, glucose, BUN/Cr, U/A tliver enzymes, Ll Ts, lipase,

fi-hCG, ECG, troponins, ±

VBCi/lactate

• AXR:if suspicious of foreign body or SBO (small bowel obstruction) in low resource setting. Can also

use if frequent SBOs and usual conservative management

• CXR upright:look for pneumoperitoneum (free air under diaphragm), lung disease

• U/S:all gynaecologic structure, testicles, biliary'tract, ectopic pregnancy, appendicitis in children and

young adults, nephro-urolithiasis in young patients, AAA, free fluid:in select cases, can proceed to CT

if U/S if non-diagnostic but there is high clinical suspicion

• CT:SBO, trauma, AAA, pancreatitis, nephro-/urolitniasis, appendicitis, and diverticulitis

Management

• NPO, IV, NG tube (if SBO), analgesics, consider antibiotics and anti-emetics

• growing evidence thatsmall amounts of opioid analgesics improve diagnostic accuracy of physical

exam ofsurgical abdomen

• consult as necessary: internal medicine, general surgery, vascular surgery, gynecology, etc.

Disposition

• admission:surgical abdomen,workup ofsignificant abnormal findings, need for IV antibiotics or pain

control

• discharge: patients with a negative lab and imaging workup who improve clinically during theirstay;

instruct the patient to return ifsevere pain,fever, or persistent vomiting develops

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ER19 Emergency Medicine Toronto Notes 2023

Acute Pelvic Pain

Etiology

• gynecological

ovaries: ruptured ovarian cysts (most common cause of pelvic pain), ovarian abscess, ovarian

torsion (rare,50% will have ovarian mass)

fallopian tubes:salpingitis, tubal abscess, hydrosalpinx

uterus:leiomyomas (uterine fibroids)

- especially with torsion of a pedunculated fibroid or in a

pregnant patient (degeneration), P1D

other: ectopic pregnancy (ruptured/expanding/leaking),spontaneous abortion (threatened or

incomplete),endometriosis and dysmenorrhea,sexual or physical abuse

• non-gynecological (see causes of lower abdominal pain above)

History and Physical Exam

• pain:OPQRST

• associated symptoms: vaginal bleeding, discharge, dyspareunia, bowel and/or bladder symptoms

• pregnancy and sexual history, including oligo/amenorrhea, menorrhagia, and fibroids

• vitals

• gynecological exam:assess for cervical motion tenderness/

“chandeliersign" (suggests P1D)

• abdominal exam

Investigations

• (J-hCG for all women of childbearing age

• CBC and differential, electrolytes, glucose, creatinine,BUN, culture and sensitivity, PTl'

/lNR

• U/A to rule out urologic causes

• vaginal and cervical swabs for culture and sensitivity if performing a pelvic exam or urine NAAT for

ST1 testing if no pelvic exam is performed

• pelvic and abdominal U/S:evaluate adnexa, thickness of endometrium, pregnancy,free fluid or

masses in the pelvis

• Doppler llow studies for ovarian torsion

Gynaecological Causes of Pelvic Pain

• Ovarian cyst

• Dysmenorrhea

• Mittclschmorz

• Endometriosis

. Ovarian torsion

. Uterine fibroids/neoplasm

• Adnexal neoplasm

. P1D*cervicitis

Management

• general: analgesia, determine if admission and consults are needed

• specific:

• ovarian cysts

unruptured or ruptured, and hemodynamically stable:analgesia and follow-up

ruptured with significant hemoperitoneum:may require surgery

ovarian torsion:surgical detorsion or removal of ovary

uncomplicated leiomyomas, endometriosis, and secondary dysmenorrhea can usually be treated

on an outpatient basis,discharge with gynecology follow-up

P1D: broad spectrum antibiotics, recommend low threshold to treat empirically

U/Sisthe preferred imaging modality in

the assessment of acute pelvic pain

Possible Causes of Coma

AEIOU TIPS

Acidosis/Alcohol

Epilepsy

Infection

Oxygen (hypoxiaf/Opiates

Uremia

Temperature/Trauma (especially head)

Insulin (too little or too much)

Psychogenic/Poisoning

Structural or space-occupying lesion

Disposition

• referral: gynecological or obstetrical causes requiring surgical intervention, requiring admission, or

oncological in nature

• admission: patients requiring surgery, IV antibiotics/pain management

• discharge: negative workup and resolving symptoms; give clear instructionsfor appropriate follow-up

Altered Level of Consciousness

Definitions

• altered mental status: collective, non-specific term referring to change in cognitive function,

behaviour, or attentiveness,including:

delirium (see Psychiatry, PS23)

dementia (see Psychiatry, PS24 )

lethargy:state of decreased awareness and alertness (patient may appear wakeful)

stupor: unresponsiveness but rousable

coma: a sleep-like state, not rousable to consciousness

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F.R20 Emergency Medicine Toronto Notes 2023

Coma (GCS <8)

(Majority)

1

(Minority)

A 1

^