Trauma II Board ReviewTrauma II Board Review

Tiffany Truong, MD, MPHTiffany Truong, MD, MPH

Mount Sinai School of MedicineMount Sinai School of Medicine

December 5, 2007December 5, 2007

A 50 yo M presents after a MVA with bruising over his A 50 yo M presents after a MVA with bruising over his sternum. He states that he hit his chest against the sternum. He states that he hit his chest against the steering wheel. His VS are unremarkable, and he is steering wheel. His VS are unremarkable, and he is asymptomatic except for anterior chest wall tenderness asymptomatic except for anterior chest wall tenderness at the site of bruising. The init CXR and sternal view at the site of bruising. The init CXR and sternal view reveal a sternal fx but are otherwise nl. There are no reveal a sternal fx but are otherwise nl. There are no other assoc injuries. EKG is nl. Which of the following other assoc injuries. EKG is nl. Which of the following is the MOST appropriate management plan for this pt?is the MOST appropriate management plan for this pt?

A.A. Admit for 24 hr telemetry monitoring.Admit for 24 hr telemetry monitoring.B.B. Perform 2 sets of CE and TPN tests, and dc if neg.Perform 2 sets of CE and TPN tests, and dc if neg.C.C. Perform echocardiogram in the ED, and dc if neg.Perform echocardiogram in the ED, and dc if neg.D.D. After a repeat EKG in 6 hrs, dc the pt with pain After a repeat EKG in 6 hrs, dc the pt with pain

medication, without any further testing.medication, without any further testing.

ANSWER: DANSWER: D

A.A. Admit for 24 hr telemetry monitoring. Admit for 24 hr telemetry monitoring. An isolated An isolated sternal fx is no longer considered an indicator of sternal fx is no longer considered an indicator of significant blunt myocardial injury and does not significant blunt myocardial injury and does not mandate a work up for BMI.mandate a work up for BMI.

B.B. Perform 2 sets of CE and TPN tests, and dc if neg. Perform 2 sets of CE and TPN tests, and dc if neg. CK lacks specificityCK lacks specificity. . Tpn may be elevated in pts Tpn may be elevated in pts with BMI, but their elevation doesn’t predict clinically with BMI, but their elevation doesn’t predict clinically significant complications, and they should not be significant complications, and they should not be used as screening tests in the ED.used as screening tests in the ED.

C.C. Perform echocardiogram in the ED, and dc if neg. Perform echocardiogram in the ED, and dc if neg. Echo is not useful as a screening test for detecting Echo is not useful as a screening test for detecting clinically significant BMI.clinically significant BMI.

D.D. After a repeat EKG in 6 hrs, dc the pt with pain After a repeat EKG in 6 hrs, dc the pt with pain medication, without any further testing.medication, without any further testing.

Blunt Myocardial Injury (aka Blunt Myocardial Injury (aka Myocardial Contusion)Myocardial Contusion)

Clinical features: pt in MVA > 35 MPH c/o chest painClinical features: pt in MVA > 35 MPH c/o chest painSignificant BMI unlikely, ~3% develop dysrythymia, 70% Significant BMI unlikely, ~3% develop dysrythymia, 70% have tachycardia out of proportion to blood loss, have tachycardia out of proportion to blood loss, conduction defectconduction defectCXR greatest value for finding assoc injuries: pulmonary CXR greatest value for finding assoc injuries: pulmonary contusion, rib fx. Sternal fx no longer considered impt.contusion, rib fx. Sternal fx no longer considered impt.Initial EKG predictive of subsequent clinically significant Initial EKG predictive of subsequent clinically significant EKG events – recommend initial EKG followed by repeat EKG events – recommend initial EKG followed by repeat EKG in 4-6 hrs.EKG in 4-6 hrs.Common ekg abnormalities are PVCs, 1st degree av Common ekg abnormalities are PVCs, 1st degree av block, RBBB (Right ventricle is closest to anterior chest block, RBBB (Right ventricle is closest to anterior chest wall)wall)

A 35 yo M presents with a single stab wound to R A 35 yo M presents with a single stab wound to R lateral chest. He has no other injuries. His VS are lateral chest. He has no other injuries. His VS are blood pressure 150/80 and HR 100. His breath blood pressure 150/80 and HR 100. His breath sounds are clear and equal b/l. Which of the sounds are clear and equal b/l. Which of the following is the BEST management plan for this following is the BEST management plan for this patient?patient?

A.A. Obtain a CXR, and discharge pt if negative.Obtain a CXR, and discharge pt if negative.B.B. Obtain a CXR on presentation, and perform a Obtain a CXR on presentation, and perform a

second one in 6 hrs. Discharge pt if both are second one in 6 hrs. Discharge pt if both are neg.neg.

C.C. Obtain a CXR on presentation, and perform a Obtain a CXR on presentation, and perform a second one in 12 hrs. Discharge pt if both are second one in 12 hrs. Discharge pt if both are neg. neg.

D.D. Discharge home, and instruct the pt to return if Discharge home, and instruct the pt to return if he develops shortness of breath.he develops shortness of breath.

ANSWER: BANSWER: B

A.A. Obtain a CXR, and discharge pt if negative. Obtain a CXR, and discharge pt if negative. A A PTX may be delayed after a stab wound, 12% PTX may be delayed after a stab wound, 12% of pts will require chest tube for delayed of pts will require chest tube for delayed hemothorax or pneumothorax. hemothorax or pneumothorax.

B.B. Obtain a CXR on presentation, and perform a Obtain a CXR on presentation, and perform a second one in 6 hrs. Discharge pt if both are second one in 6 hrs. Discharge pt if both are neg.neg.

C.C. Obtain a CXR on presentation, and perform a Obtain a CXR on presentation, and perform a second one in 12 hrs. Discharge pt if both are second one in 12 hrs. Discharge pt if both are neg. neg. Most of PTX will be evident on CXR Most of PTX will be evident on CXR performed at 6 hours.performed at 6 hours.

D.D. Discharge home, and instruct the pt to return if Discharge home, and instruct the pt to return if he develops shortness of breath.he develops shortness of breath.

Which of the following statements regarding Which of the following statements regarding blunt thoracic aortic rupture is correct?blunt thoracic aortic rupture is correct?

A.A. External evidence of chest trauma is often External evidence of chest trauma is often lacking.lacking.

B.B. Fractures of the 1Fractures of the 1stst and 2 and 2ndnd ribs are highly ribs are highly suggestive of aortic injury.suggestive of aortic injury.

C.C. Most common symptom is dysphagia.Most common symptom is dysphagia.D.D. Most tears occur at the ascending aorta.Most tears occur at the ascending aorta.E.E. Obscuration of the aortic knob is the most Obscuration of the aortic knob is the most

sensitive sign on CXR.sensitive sign on CXR.

ANSWER: AANSWER: A

A.A. External evidence of chest trauma is often lacking. External evidence of chest trauma is often lacking. Fewer than 50% have external signs of trauma.Fewer than 50% have external signs of trauma.

B.B. Fractures of the 1Fractures of the 1stst and 2 and 2ndnd ribs are highly ribs are highly suggestive of aortic injury. suggestive of aortic injury. Not associated with Not associated with increased risk. increased risk.

C.C. Most common symptom is dysphagia. Most common symptom is dysphagia. Most Most common sx interscapular or retrosternal pain, common sx interscapular or retrosternal pain, absent in up to ¾ of pts.absent in up to ¾ of pts.

D.D. Most tears occur at the ascending aorta. Most tears occur at the ascending aorta. Descending aorta.Descending aorta.

E.E. Obscuration of the aortic knob is the most sensitive Obscuration of the aortic knob is the most sensitive sign on CXR. sign on CXR. Widening of mediastinum.Widening of mediastinum.

Thoracic Aortic DisruptionThoracic Aortic Disruption

Rapid deceleration injuries. Rapid deceleration injuries. Most common cause of death in blunt trauma, Most common cause of death in blunt trauma, 80% die at scene, 10-20% die w/in 180% die at scene, 10-20% die w/in 1stst hour. hour.Signs & sx: include chest pain, back pain, Signs & sx: include chest pain, back pain, dyspnea, intrascapular murmur, and extremity dyspnea, intrascapular murmur, and extremity pain caused by ischemia. pain caused by ischemia. CXR: widen mediastinum (8 cm) most common. CXR: widen mediastinum (8 cm) most common. Nl in 2–7% of patients with aortic injury. Nl in 2–7% of patients with aortic injury. Angiography gold standard, but now CT.Angiography gold standard, but now CT.Tx: BP management and surgical repair.Tx: BP management and surgical repair.

76 yo F unrestrained driver in MVA p/w respiratory 76 yo F unrestrained driver in MVA p/w respiratory distress on arrival and has paradoxical movement distress on arrival and has paradoxical movement of her R chest during labored respirations. BP of her R chest during labored respirations. BP 138/76, HR 118, RR 28, O2sat 88% RA. BS 138/76, HR 118, RR 28, O2sat 88% RA. BS auscultated on both sides of chest. ABG on high auscultated on both sides of chest. ABG on high flow O2: pH 7.37, Po2 78, HCO3 28. Which of the flow O2: pH 7.37, Po2 78, HCO3 28. Which of the following is correct?following is correct?

A.A. Can be treated with supplemental oxygen and Can be treated with supplemental oxygen and admission to stepdown unit.admission to stepdown unit.

B.B. Injury mandates early ventilatory support.Injury mandates early ventilatory support.C.C. Most likely cause of hypoxia is splinting fr painMost likely cause of hypoxia is splinting fr painD.D. R chest wall moves outward with inspiration and R chest wall moves outward with inspiration and

inward with expiration.inward with expiration.E.E. Tx involves analgesia and adhesive tap or rib Tx involves analgesia and adhesive tap or rib

belt to stabilize chest.belt to stabilize chest.

ANSWER: BANSWER: BA.A. Can be treated with supplemental oxygen Can be treated with supplemental oxygen

and admission to stepdown unit. and admission to stepdown unit. High High potential for deterioration. Early ventilatory potential for deterioration. Early ventilatory support and ICU.support and ICU.

B.B. Injury mandates early ventilatory support.Injury mandates early ventilatory support.C.C. Most likely cause of hypoxia is splinting from Most likely cause of hypoxia is splinting from

pain. pain. Pulmonary contusion.Pulmonary contusion.D.D. R chest wall moves outward with inspiration R chest wall moves outward with inspiration

and inward with expiration. and inward with expiration. Inward with Inward with inspiration and outward with expiration.inspiration and outward with expiration.

E.E. Tx involves analgesia and adhesive tap or Tx involves analgesia and adhesive tap or rib belt to stabilize chest. rib belt to stabilize chest. Inhibit expansion Inhibit expansion of chest and aggravate atelectasis, of chest and aggravate atelectasis, worsening gas exchange.worsening gas exchange.

Flail ChestFlail Chest

Segmental fractures in 2 or more locations on the same ribSegmental fractures in 2 or more locations on the same ribParadoxical inward movement of the chest wall during inspiration Paradoxical inward movement of the chest wall during inspiration and outward movement during expiration and outward movement during expiration Significant blunt trauma (MVA, fall from height)Significant blunt trauma (MVA, fall from height)Initially compensate for reduce TV by hyperventilate, when fatigue Initially compensate for reduce TV by hyperventilate, when fatigue or underlying pulmonary injury develops -> respiratory failure.or underlying pulmonary injury develops -> respiratory failure.Tx: Supplemental oxygen is the first-line treatment. Pain control with Tx: Supplemental oxygen is the first-line treatment. Pain control with analgesia to allow pt to fully expand lungs and improve ventilation. analgesia to allow pt to fully expand lungs and improve ventilation. Early intubation considered. Early intubation considered. External chest wall support reduce VC, worsen respiratory function, External chest wall support reduce VC, worsen respiratory function, no indicated.no indicated.Indications for early vent support: shock, three or more associated Indications for early vent support: shock, three or more associated injuries, severe head injury, comorbid pulmonary disease, fracture injuries, severe head injury, comorbid pulmonary disease, fracture of eight or more ribs, or age greater than 65 years of eight or more ribs, or age greater than 65 years

Which of the following is the BEST method for Which of the following is the BEST method for diagnosing a diaphragmatic injury in a patient diagnosing a diaphragmatic injury in a patient with a stab wound to the left upper quadrant?with a stab wound to the left upper quadrant?

A.A. Computed tomography.Computed tomography.B.B. Diagnostic peritoneal lavage.Diagnostic peritoneal lavage.C.C. Upper gastrointestinal series.Upper gastrointestinal series.D.D. Laparoscopy.Laparoscopy.

ANSWER: DANSWER: DA.A. CT. CT. CT may miss small diaphragmatic injuries CT may miss small diaphragmatic injuries

from penetrating trauma.from penetrating trauma.B.B. DPL. DPL. The threshold RBC count for a positive The threshold RBC count for a positive

lavage should be lowered since diaphagmatic lavage should be lowered since diaphagmatic injury does not result in as much bleeding as injury does not result in as much bleeding as with solid organ injury.with solid organ injury.

C.C. Upper GI series. Upper GI series. Upper GI series may Upper GI series may demonstrate displacement of viscera into demonstrate displacement of viscera into chest after blunt diaphragmatic injury, but this chest after blunt diaphragmatic injury, but this does not occur acutely after penetrating does not occur acutely after penetrating trauma due to the small size of the hole.trauma due to the small size of the hole.

D.D. Laparoscopy. With penetrating trauma, the Laparoscopy. With penetrating trauma, the diagnosis of diaphragmatic injury is difficult diagnosis of diaphragmatic injury is difficult and may only be made with laparotomy or and may only be made with laparotomy or laparoscopy. laparoscopy.

Diaphragmatic InjuriesDiaphragmatic Injuries

Majority caused by penetrating trauma.Majority caused by penetrating trauma.Occur predominately on L side b/c liver protects right Occur predominately on L side b/c liver protects right side. Most likely sight of injury posterio-lateral portion of side. Most likely sight of injury posterio-lateral portion of L diaphragmL diaphragmOften difficult to visualize on initial chest x-ray Often difficult to visualize on initial chest x-ray (nasogastric tube may enhance diagnosis). Abdominal (nasogastric tube may enhance diagnosis). Abdominal viscera or NG tube seen in thoracic cavity viscera or NG tube seen in thoracic cavity CT scan or laparoscopy more sensitive, although CT scan or laparoscopy more sensitive, although diaphragmatic ruptures can be missed even on initial CT. diaphragmatic ruptures can be missed even on initial CT. Delays in diagnosis lead to increased morbidity and Delays in diagnosis lead to increased morbidity and mortality. mortality.

A 27 yo M p/w a single stab wound to A 27 yo M p/w a single stab wound to L flank. VS are BP 110/80, HR 90. L flank. VS are BP 110/80, HR 90. Which of the following is the most Which of the following is the most appropriate next step in appropriate next step in management?management?

A.A. DPLDPLB.B. Wound exploration with a cotton Wound exploration with a cotton

swab.swab.C.C. CT with IV contrast.CT with IV contrast.D.D. CT with oral, rectal, and IV CT with oral, rectal, and IV

contrast.contrast.

ANSWER: DANSWER: D

A.A. DPL. DPL. In a pt who is hemodynamically stable In a pt who is hemodynamically stable after penetrating flank trauma, DPL would be after penetrating flank trauma, DPL would be helpful for intraperitoneal injury but does not helpful for intraperitoneal injury but does not sample the retroperitoneal injury (kidney).sample the retroperitoneal injury (kidney).

B.B. Wound exploration with a cotton swab. Wound exploration with a cotton swab. Difficult Difficult and limited, esp with deeper wounds that and limited, esp with deeper wounds that extends to muscle layer.extends to muscle layer.

C.C. CT with IV contrast. CT with IV contrast. D.D. CT with oral, rectal, and IV contrast. Triple CT with oral, rectal, and IV contrast. Triple

contrast should be used to identify rectal and contrast should be used to identify rectal and sigmoid injury. Oral contrast may not extend sigmoid injury. Oral contrast may not extend down to these areas. Accuracy of CT for flank down to these areas. Accuracy of CT for flank stab wounds approaches 98%.stab wounds approaches 98%.

Flank or Back WoundFlank or Back Wound

Associated with to retroperitoneal injuries such Associated with to retroperitoneal injuries such as the colon, kidney, ureters and major vascular as the colon, kidney, ureters and major vascular structures structures Colon is the injury most often missed. If colon Colon is the injury most often missed. If colon injury is suspected, serial physical examination injury is suspected, serial physical examination is extended to 72 hours, watching for fever or a is extended to 72 hours, watching for fever or a rise in WBCrise in WBCAn alternative is to perform a triple-contrast CT An alternative is to perform a triple-contrast CT scan. Where the wound track extends up to the scan. Where the wound track extends up to the colon, or there is evidence of abnormal bowel colon, or there is evidence of abnormal bowel wall thickening, laparotomy is indicated.wall thickening, laparotomy is indicated.

An 8 yo M hit a car door while riding his bike. Upon An 8 yo M hit a car door while riding his bike. Upon presentation, he is crying and c/o abdominal pain. His presentation, he is crying and c/o abdominal pain. His PE reveals age-appropriate vital signs, an abrasion PE reveals age-appropriate vital signs, an abrasion across his epigastrium, and diffuse tenderness w/o across his epigastrium, and diffuse tenderness w/o rebound or guarding. Labs are notable for amylase 220 rebound or guarding. Labs are notable for amylase 220 Iu. UA reveals 2-5 RBCs per Iu. UA reveals 2-5 RBCs per HPFHPF. Which of the . Which of the following is correct?following is correct?

A.A. Despite a nl abd CT, the child could have pancreatic Despite a nl abd CT, the child could have pancreatic injury and should be admitted for observation.injury and should be admitted for observation.

B.B. An IV pyelogram should be performed for evaluation An IV pyelogram should be performed for evaluation of hematuria.of hematuria.

C.C. The bowel is the most commonly injured organ The bowel is the most commonly injured organ following this mechanism.following this mechanism.

D.D. Duodenal hematoma is unlikely if a repeat exam Duodenal hematoma is unlikely if a repeat exam reveals no abdominal tenderness.reveals no abdominal tenderness.

ANSWER: AANSWER: A

A.A. Despite a nl abd CT, the child could have pancreatic Despite a nl abd CT, the child could have pancreatic injury and should be admitted for observation.injury and should be admitted for observation.

B.B. An IV pyelogram should be performed for evaluation An IV pyelogram should be performed for evaluation of hematuria. of hematuria. In pts with nl VS and microscopic In pts with nl VS and microscopic hematuria, no further wu is indicated as long as pt is hematuria, no further wu is indicated as long as pt is asymptomatic.asymptomatic.

C.C. The bowel is the most commonly injured organ The bowel is the most commonly injured organ following this mechanism. following this mechanism. Spleen, followed by liver, Spleen, followed by liver, are most commonly injured organs, with bowel are most commonly injured organs, with bowel injury occuring < 5% of pts with blunt abd trauma.injury occuring < 5% of pts with blunt abd trauma.

D.D. Duodenal hematoma is unlikely if a repeat exam Duodenal hematoma is unlikely if a repeat exam reveals no abdominal tenderness. reveals no abdominal tenderness. Duodenal Duodenal hematomas can be missed by both PE and CT. A hematomas can be missed by both PE and CT. A contrast-CT can aid in diagnosis, but if this injury is contrast-CT can aid in diagnosis, but if this injury is suspected based on mechanism of injury, the child suspected based on mechanism of injury, the child should be admitted for further eval and observation.should be admitted for further eval and observation.

Traumatic PancreatitisTraumatic Pancreatitis

Clinical: mild epigastric tenderness, resolve in Clinical: mild epigastric tenderness, resolve in early stages of injury, then increased severity w/I early stages of injury, then increased severity w/I 6 hrs when pancreatic enzymes begin irritating 6 hrs when pancreatic enzymes begin irritating the peritoneum, which may become the peritoneum, which may become superinfected and produce retroperitoneal superinfected and produce retroperitoneal abscess. abscess. CT scan can’t exclude blunt pancreatic, CT scan can’t exclude blunt pancreatic, diaphragmatic, or bowel injury.diaphragmatic, or bowel injury.Serum amylase is normal in up to 37% of pts Serum amylase is normal in up to 37% of pts with pancreatic injurywith pancreatic injuryRapid deceleration or severe crush injury Rapid deceleration or severe crush injury

A 52 yo back seat passenger presents after A 52 yo back seat passenger presents after being involved in a high speed MVA. Inspection being involved in a high speed MVA. Inspection of the abdomen reveals the findings c/w lap belt of the abdomen reveals the findings c/w lap belt injury. Compared to other patients with blunt injury. Compared to other patients with blunt abdominal trauma, this patient is at increased abdominal trauma, this patient is at increased risk for injury to which of the following organs?risk for injury to which of the following organs?

A.A. intestineintestine

B.B. kidneykidney

C.C. liverliver

D.D. pancreaspancreas

E.E. spleenspleen

ANSWER: AANSWER: A

A.A. intestine. When lap belt bruises are present, intestine. When lap belt bruises are present, there is a higher incidence of intestinal injury. there is a higher incidence of intestinal injury. Although seat belt sign is seen in only 1/3 of Although seat belt sign is seen in only 1/3 of cases, its presence is highly correlated with cases, its presence is highly correlated with injury. Diaphragmatic injury can been seen injury. Diaphragmatic injury can been seen secondary to compressive forces.secondary to compressive forces.

B.B. kidneykidney

C.C. liverliver

D.D. pancreaspancreas

E.E. spleenspleen

Seat Belt SignSeat Belt SignLow-lying transverse abdominal ecchymosis has Low-lying transverse abdominal ecchymosis has a strong association with hollow viscus injury a strong association with hollow viscus injury and mesenteric tears . and mesenteric tears . Hollow viscus injury often does not produce any Hollow viscus injury often does not produce any pain or tenderness until 6-8 hours following the pain or tenderness until 6-8 hours following the traumatic event. traumatic event. At minimum, patients with lap-belt contusions At minimum, patients with lap-belt contusions should undergo serial abdominal examinations.should undergo serial abdominal examinations.Findings of abdominal tenderness should prompt Findings of abdominal tenderness should prompt diagnostic study (e.g., abdominal CT and/or diagnostic study (e.g., abdominal CT and/or DPL) or laparotomy. DPL) or laparotomy.

Which of the following statements Which of the following statements regarding lightening injuries is correct? regarding lightening injuries is correct?

A.A. Aggressive fluid loading is indicated.Aggressive fluid loading is indicated.

B.B. Fetal death is common in pregnant Fetal death is common in pregnant victims.victims.

C.C. Lower extremity paralysis is rare.Lower extremity paralysis is rare.

D.D. Rhabdomyolysis is a frequent Rhabdomyolysis is a frequent complication.complication.

E.E. Tympanic membranes usually are Tympanic membranes usually are normal.normal.

ANSWER: BANSWER: BA.A. Aggressive fluid loading is indicated. Aggressive fluid loading is indicated. Overly Overly

aggressive fluid admin may worsen cerebral aggressive fluid admin may worsen cerebral edema.edema.

B.B. Fetal death is common in pregnant victims. Fetal death is common in pregnant victims. (50% fetal mortality rate).(50% fetal mortality rate).

C.C. Lower extremity paralysis is rare. Lower extremity paralysis is rare. 2/3 p/w LE 2/3 p/w LE paralysis and 1/3 with UE paralysis.paralysis and 1/3 with UE paralysis.

D.D. Rhabdomyolysis is a frequent complication. Rhabdomyolysis is a frequent complication. Rhabdomyolysis occurs in only 6% of pts.Rhabdomyolysis occurs in only 6% of pts.

E.E. Tympanic membranes usually are normal. Tympanic membranes usually are normal. More than 50% of lightening injury victims More than 50% of lightening injury victims have perforated TMs.have perforated TMs.

LighteningLighteningElectrical and most lightning burns have an Electrical and most lightning burns have an entrance and exit point entrance and exit point Death usually secondary to cardiac arrest, Death usually secondary to cardiac arrest, lightening causes massive countershock and lightening causes massive countershock and produces asystole. produces asystole. Burns are superficial, deep muscle damage rare.Burns are superficial, deep muscle damage rare.Cataracts are common and may occur Cataracts are common and may occur immediately or develop up to 2 yrs after incident.immediately or develop up to 2 yrs after incident.Secondary injuries: ruptured TMs, spinal Secondary injuries: ruptured TMs, spinal fractures at multiple levels, bilateral scapular fractures at multiple levels, bilateral scapular fractures, internal organ injuries, long-bone fractures, internal organ injuries, long-bone fractures, intracranial bleeding, seizures, cardiac fractures, intracranial bleeding, seizures, cardiac arrhythmias, and cardiac arrest.arrhythmias, and cardiac arrest.

In approximately what percentage of In approximately what percentage of patients is laparotomy required for an patients is laparotomy required for an anterior abdominal wall stab wound?anterior abdominal wall stab wound?

A.A. 10%. 10%.

B.B. 30%. 30%.

C.C. 50%. 50%.

D.D. 70%.70%.

E.E. 90%90%

ANSWER: BANSWER: BA.A. 10%. 10%.

B.B. 30%. 30%.

C.C. 50%. 50%.

D.D. 70%.70%.

E.E. 90%90%

Anterior Abdominal Stab WoundsAnterior Abdominal Stab Wounds2/3 pts have peritoneal violation, of these ½ 2/3 pts have peritoneal violation, of these ½ (30% of those injured) will require laparatomy. (30% of those injured) will require laparatomy. General rule of thumb: 1/3 don’t penetrate General rule of thumb: 1/3 don’t penetrate peritoneum, 1/3 penetrate but don’t require peritoneum, 1/3 penetrate but don’t require laparotomy, 1/3 require laparotomy. laparotomy, 1/3 require laparotomy. Local wound exploration followed byLocal wound exploration followed by Discharge home if no violation anterior fasciaDischarge home if no violation anterior fascia Admission for observation/serial PE/DPL if superficial Admission for observation/serial PE/DPL if superficial

muscle fascia violated.muscle fascia violated. Indications for exploration: progressive abdominal Indications for exploration: progressive abdominal

tenderness, increasing leukocytosis, fever, abdominal tenderness, increasing leukocytosis, fever, abdominal distension, etc. distension, etc.

75 yo F slips and falls in her bathtub and 75 yo F slips and falls in her bathtub and injures her L hip. She is helped out of the injures her L hip. She is helped out of the bathrub by her daughter but is unable to bathrub by her daughter but is unable to ambulate secondary to pain. In the ED, initial ambulate secondary to pain. In the ED, initial hip and pelvis xrays are neg. The pt continues hip and pelvis xrays are neg. The pt continues to have pain in her L leg when she attempts to to have pain in her L leg when she attempts to ambulate. What is the next most appropriate ambulate. What is the next most appropriate management?management?

A.A. Admit to a rehab facility for physical therapyAdmit to a rehab facility for physical therapyB.B. Order inlet and outlet views of the pelvisOrder inlet and outlet views of the pelvisC.C. Order MRI of the left hipOrder MRI of the left hipD.D. Order nuclear bone scanOrder nuclear bone scanE.E. Prescribe narcotic pain meds and a walker and Prescribe narcotic pain meds and a walker and

arrange for outpatient orthopedic evaluation.arrange for outpatient orthopedic evaluation.

ANSWER: CANSWER: CA.A. Admit to a rehab facility for physical therapy. Admit to a rehab facility for physical therapy.

Underlying occult fx would be worsen with Underlying occult fx would be worsen with early mobilization.early mobilization.

B.B. Order inlet and outlet views of the pelvis. Order inlet and outlet views of the pelvis. Unlikely to diag occult fem neck fx.Unlikely to diag occult fem neck fx.

C.C. Order MRI of the left hipOrder MRI of the left hipD.D. Order nuclear bone scan. Order nuclear bone scan. Useful but more Useful but more

sensitive after 72 hours.sensitive after 72 hours.E.E. Prescribe narcotic pain meds and a walker Prescribe narcotic pain meds and a walker

and arrange for outpatient orthopedic and arrange for outpatient orthopedic evaluation. evaluation. Underlying occult fx would be Underlying occult fx would be worsen with early mobilization.worsen with early mobilization.

Occult Femoral Neck FractureOccult Femoral Neck FractureSuspect in elderly pt when hip pain Suspect in elderly pt when hip pain prevents ambulation but plain films don’t prevents ambulation but plain films don’t reveal a fracture. reveal a fracture.

MRI within 24 hours on injury often reveals MRI within 24 hours on injury often reveals a fx that was imperceptible at time of a fx that was imperceptible at time of injury.injury.

Senile osteoporosis leading cause of Senile osteoporosis leading cause of femoral neck fx with minor trauma.femoral neck fx with minor trauma.

Which of the following statements regarding Which of the following statements regarding blunt traumatic placental abruption is correct?blunt traumatic placental abruption is correct?

A.A. In pregnant women with blunt trauma, less In pregnant women with blunt trauma, less than 40% of fetal losses result from than 40% of fetal losses result from placental abruption.placental abruption.

B.B. More than ½ of women with placental More than ½ of women with placental abruption can present with no vaginal abruption can present with no vaginal bleeding.bleeding.

C.C. Position of the placenta affects the incidence Position of the placenta affects the incidence of traumatic placental abruption.of traumatic placental abruption.

D.D. Ultrasonography is the best method for Ultrasonography is the best method for identifying placental abruption.identifying placental abruption.

E.E. Women with traumatic placental abruption Women with traumatic placental abruption are less likely to have coagulopathy than are are less likely to have coagulopathy than are those w/o traumatic placental abruption.those w/o traumatic placental abruption.

ANSWER: ANSWER: A.A. In pregnant women with blunt trauma, less than In pregnant women with blunt trauma, less than

40% of fetal losses result from placental abruption. 40% of fetal losses result from placental abruption. Leading cause of fetal loss aside from maternal Leading cause of fetal loss aside from maternal death in TPA.death in TPA.

B.B. More than ½ of women with placental abruption can More than ½ of women with placental abruption can present with no vaginal bleeding.present with no vaginal bleeding.

C.C. Position of the placenta affects the incidence of Position of the placenta affects the incidence of traumatic placental abruption. traumatic placental abruption. Does not affect.Does not affect.

D.D. Ultrasonography is the best method for identifying Ultrasonography is the best method for identifying placental abruption. placental abruption. Fetal distress most sensitive for Fetal distress most sensitive for TPA, measured by cardiotocographic monitoring. TPA, measured by cardiotocographic monitoring.

E.E. Women with traumatic placental abruption are less Women with traumatic placental abruption are less likely to have coagulopathy than are those w/o likely to have coagulopathy than are those w/o traumatic placental abruption. traumatic placental abruption. Women w/ TPA 54 x Women w/ TPA 54 x more likely to have DIC. more likely to have DIC.

Traumatic Placental AbruptionTraumatic Placental AbruptionIn blunt trauma, shearing and deceleration In blunt trauma, shearing and deceleration forces separate placenta from uterine wall. forces separate placenta from uterine wall. Disrupts gas exchange b/ fetus and Disrupts gas exchange b/ fetus and mother -> hypoxia -> fetal distress.mother -> hypoxia -> fetal distress.In blunt trauma, 50-70% fetal loss result fr In blunt trauma, 50-70% fetal loss result fr placental abuption.placental abuption.Classic: vaginal bleeding, abd pain, Classic: vaginal bleeding, abd pain, amniotic fluid leaking, fetal distress; 63% amniotic fluid leaking, fetal distress; 63% women may not have vaginal bleeding.women may not have vaginal bleeding.Diag: Cardiotoco monitoring.Diag: Cardiotoco monitoring.

A 20 yo F presents for evaluation of a sprained A 20 yo F presents for evaluation of a sprained ankle. She sustained the injury while running, ankle. She sustained the injury while running, despite pain, she was able to talk for a short despite pain, she was able to talk for a short distance and is able to walk 4 steps in the ED. distance and is able to walk 4 steps in the ED. Radiographs are not indicated if the exam also Radiographs are not indicated if the exam also reveals absence of bony tenderness: reveals absence of bony tenderness:

A.A. About the anterior talotibial jointAbout the anterior talotibial jointB.B. Along the posterior edge of the distal 3cm Along the posterior edge of the distal 3cm

and the tips of both malloeli and tibial and the tips of both malloeli and tibial plafond.plafond.

C.C. Along the posterior edge of the distal 6 cm Along the posterior edge of the distal 6 cm and of the tips of both malleoliand of the tips of both malleoli

D.D. Over the deltoid and anterior talofibular Over the deltoid and anterior talofibular ligamentsligaments

E.E. Over the distal tibia laterally & prox fibula.Over the distal tibia laterally & prox fibula.

ANSWER: CANSWER: CA.A. About the anterior talotibial jointAbout the anterior talotibial jointB.B. Along the posterior edge of the distal Along the posterior edge of the distal

3cm and the tips of both malloeli and 3cm and the tips of both malloeli and and tibial plafond.and tibial plafond.

C.C. Along the posterior edge of the distal 6 Along the posterior edge of the distal 6 cm and of the tips of both malleolicm and of the tips of both malleoli

D.D. Over the deltoid and anterior talofibular Over the deltoid and anterior talofibular ligamentsligaments

E.E. Over the distal tibia laterally & prox Over the distal tibia laterally & prox fibula.fibula.

Ottowa Ankle Rules:Ottowa Ankle Rules:

Ankle radiographs are required if either of the Ankle radiographs are required if either of the following is present:following is present: Patient is unable to bear weight and walk 4 steps Patient is unable to bear weight and walk 4 steps

immediately after the injury and at the time of immediately after the injury and at the time of evaluation.evaluation.

Or there is tenderness along the posterior edge of the Or there is tenderness along the posterior edge of the distal 6 cm of the tips of either malleolus. distal 6 cm of the tips of either malleolus.

If patient does not meet either of these criteria, If patient does not meet either of these criteria, radiographs are not necessary.radiographs are not necessary.

Rules does not apply to subacute/chronic injuries or Rules does not apply to subacute/chronic injuries or patients with multiple injuries, intoxication, or altered patients with multiple injuries, intoxication, or altered sensation, neurologic injuries, or head injuries.sensation, neurologic injuries, or head injuries.

Which of the following is the most common Which of the following is the most common mechanism of injury associated with isolated mechanism of injury associated with isolated blunt pancreatic injury in children?blunt pancreatic injury in children?

A.A. Direct blow to the abdomen from a pitched Direct blow to the abdomen from a pitched baseball.baseball.

B.B. Fall from a 2Fall from a 2ndnd-story window onto a hard -story window onto a hard surfacesurface

C.C. Handlebar injury during neighborhood Handlebar injury during neighborhood bicycle accidentbicycle accident

D.D. Lap-belt injury during a high-speed motor Lap-belt injury during a high-speed motor vehicle crashvehicle crash

E.E. Straddle injury from a fall onto a rigid Straddle injury from a fall onto a rigid horizontal pole.horizontal pole.

ANSWER: CANSWER: CA.A. Direct blow to the abdomen from a pitched Direct blow to the abdomen from a pitched

baseball. baseball. Commotio cordis.Commotio cordis.B.B. Fall from a 2Fall from a 2ndnd-story window onto a hard -story window onto a hard

surface. surface. Other solid organs more likely from Other solid organs more likely from wide distribution of forces.wide distribution of forces.

C.C. Handlebar injury during neighborhood Handlebar injury during neighborhood bicycle accidentbicycle accident

D.D. Lap-belt injury during a high-speed motor Lap-belt injury during a high-speed motor vehicle crash. vehicle crash. Bowel injury and lumbar spine Bowel injury and lumbar spine injury.injury.

E.E. Straddle injury from a fall onto a rigid Straddle injury from a fall onto a rigid horizontal pole. horizontal pole. Genitourinary injuries.Genitourinary injuries.

Commotio CordisCommotio CordisSudden cardiac death or near sudden cardiac Sudden cardiac death or near sudden cardiac death after blunt, low-impact chest wall trauma death after blunt, low-impact chest wall trauma in the absence of structural cardiac abnormality in the absence of structural cardiac abnormality

Ventricular fibrillation is the most commonly Ventricular fibrillation is the most commonly reported arrhythmia induced reported arrhythmia induced

Young male athletes aged 5–18 years Young male athletes aged 5–18 years

Blows to the chest from baseballs, softballs, Blows to the chest from baseballs, softballs, hockey pucks, and other objects. hockey pucks, and other objects.

Death is usually instantaneous, and successful Death is usually instantaneous, and successful resuscitation is uncommon. resuscitation is uncommon.

A 62 yo M presents after being struck in the head with A 62 yo M presents after being struck in the head with a piece of lumbar 2 hours earlier. His wife says that he a piece of lumbar 2 hours earlier. His wife says that he was “dazed” immediately after the accident but did not was “dazed” immediately after the accident but did not lose conciousness. He says he has a headache. GCS lose conciousness. He says he has a headache. GCS 15. PE is normal except for 3 cm scalp hematoma. The 15. PE is normal except for 3 cm scalp hematoma. The next appropriate next step in management is:next appropriate next step in management is:

A.A. Admit to ED observation unit for serial neurologic Admit to ED observation unit for serial neurologic exam.exam.

B.B. Discharge with head injury instructions.Discharge with head injury instructions.C.C. Obtain a noncontrast CT head and neurosurgery Obtain a noncontrast CT head and neurosurgery

consult.consult.D.D. Obtain a noncontrast CT head and if negative, Obtain a noncontrast CT head and if negative,

discharge. discharge. E.E. Obtain skull x-rays to screen for more severe Obtain skull x-rays to screen for more severe

intracranial injury.intracranial injury.

ANSWER: DANSWER: D

A.A. Admit to ED observation unit for serial Admit to ED observation unit for serial neurologic exam.neurologic exam.

B.B. Discharge with head injury instructions.Discharge with head injury instructions.

C.C. Obtain a noncontrast CT head and Obtain a noncontrast CT head and neurosurgery consult.neurosurgery consult.

D.D. Obtain a noncontrast CT head and if Obtain a noncontrast CT head and if negative, discharge.negative, discharge.

E.E. Obtain skull x-rays to screen for more Obtain skull x-rays to screen for more severe intracranial injury.severe intracranial injury.

ACEP Clinical Policy for mild TBIACEP Clinical Policy for mild TBIDefinition: At least one met:

1) Any of loss of consciousness (LOC) of less than 30 minutes and GCS score of 13 to 15 after this period of LOC; (2) any loss of memory of the event immediately before or after the accident, with posttraumatic amnesia of less than 24 hours; (3) any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented, orconfused).

““Is there role for plain film skull xrays in assessment of Is there role for plain film skull xrays in assessment of acute mild TBI in the ED?”acute mild TBI in the ED?”No, the literature does not support the use of skull xrays No, the literature does not support the use of skull xrays in the ED. (level B recommendation)in the ED. (level B recommendation)

ACEP Clinical Policy for mild TBIACEP Clinical Policy for mild TBI

“Which patients with acute MTBI should have a noncontrast head CT scan in the ED?”

A head CT scan is not indicated in those patients with MTBI unless one of the following is present: headache, vomiting, age greater than 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicle, or seizure. (level A)

ACEP Clinical Policy for mild TBIACEP Clinical Policy for mild TBI

“Can a patient with mild TBI be safely discharge from the ED if the head CT shows no acute injury?”

Pt can be discharged under the following conditions: (level C)

Pt presents at least 6 hrs after injury

Clinical exam is normal

Head CT shows no acute abnormality

Pt under supervision of a responsible 3rd party can be discharged sooner than 6 hrs

The End!The End!