Dr. Satyanarayana
Dr. Satyanarayana
Christine Crain (She/Her), CC3
Dalhousie Medicine MD Candidate, Class of 2022
Reviewed by Dr. Mark McGraw
Copedited by Dr. Mandy Peach
Relevant Cases:
First, 7-year-old male presents to the ED by EMS having heard a “pop” in his neck followed by extreme pain in his neck and shooting pain down his left arm while playing with his father. He was feeling much better on arrival but was put on C-spine precautions.
Second, 76-year-old male presents via ambulance after being found down with an unwitnessed fall in a parking lot. He had obvious head trauma with a large supraorbital hematoma and arrived in a C-collar.
Third, 52-year-old gentleman with a history of partial C-spine transection arrives via EMS after being found down and inebriated by his PSW after attempting to transfer himself from his chair to his bed. Patient states he suspects he was down for about hours and that his previously strong leg now feels heavier and weaker.
Problem:
The Canadian C-spine Rules have excellent sensitivity (90% to 100%)1 but have only been validated for those between the ages of 16-65. As well, any red flag symptoms, such as paresthesias, a dangerous mechanism, or intoxication, then these rules are not validated
Figure 1: Canadian C-Spine Rules. Diagram has been re-designed by the BoringEM.org team for clarity.
So, what do you do instead? In the first case, there are NEXUS rules with a sensitivity of 100% and a negative predictive value also at 100%. These are the same rules used for the adult population, but, where being under age 16 is an exclusion criterion in the Canadian rules, the NEXUS rules have been validated in the paediatric population as well2.
Figure 2: NEXUS C-Spine Rules. Retrieved from MDCalc.
What about Geriatrics? They tend to be more on the fragile side due to conditions like osteopenia or osteoporosis and injuries or trauma may be further complicated by medications like blood thinners, because of this, these patients are considered high risk and should automatically receive imaging. Luckily, the NEXUS decision rule has also been validated in the geriatric population3. However, a caveat is required around what is meant by “altered level of consciousness”. This is something that can be hard to know in the Emergency Department without gaining collateral information. Altered Mentation is the hallmark of many degenerative brain diseases such as Alzheimer’s which may affect level of orientation. So, while the NEXUS criteria are validated in the Geriatric population, it’s important to gather collateral information on baseline mentation before performing imaging based only on altered level of consciousness.
Finally, in the situation where there is intoxication, the level of suspicion in these cases will be dictated more by mechanism and other associated injuries. The Canadian C-Spine rules can be used in patients who are intoxicated if the patients are alert and cooperative. However, in the situation with known vertebral disease, as in our third case, imaging will be done more based on new deficits, objective or subjective.
Case Resolutions:
In the first attached case, per the NEXUS rules, our patient didn’t need imaging. However, in the paediatric population the patient is not the only concern. The patient’s father was beside himself, thinking this was his fault as it happened while they were playing. Therapeutic radiography was used to put the father at ease. In this case, while there were no indications for imaging, there was an increased intervertebral space anteriorly at C7-8, which may have been consistent with an Anterior ligament rupture. More imaging was scheduled for the next day, and the patient was sent home with a collar on until he could be cleared via MRI.
For our second patient, he was altered on arrival with a GCS of 13, with deterioration on route reported by EMS. Additionally, he was on a blood thinner, so there was an increased risk for an intracranial bleed. He was sent for emergent CT, which showed a Type 2 Odontoid fracture. He was admitted to Neurosurgery.
Figure 3: Case courtesy of Dr Mohammad Taghi Niknejad, Radiopaedia.org, rID: 21310
In our final C-spine case, due to the subjective new deficit in the patient’s left leg, C-spine CT and thoracolumbar radiography were used to compare to previous imaging, many of which were available due to the recency of his injury. There was no evidence of any new injury on imaging, so the patient was observed doing a gentle range of his neck which produced no pain or other symptoms. His C-collar was removed, and he was discharged home to the care of his PSW.
Conclusion
It’s important to remember the limitations of tools we use regularly. The excellent sensitivity of the Canadian C-Spine rules makes it a very appealing tool to rely on; however, it’s important to remember how limited the population that the tool applies to. While other tools may help to fill the gaps, as the NEXUS rules do, sometimes these tools are hard to remember when you use them less often.
Hopefully by outlining and reminding you of the limitations, I will have helped you remember the other tools that are available to us in the Emergency Department in these situations.
References
Dr. Luke Edgar PGY1 FMEM, Dr. Dan Hines
Dalhousie University Department of Emergency Medicine
Thoracic Surgeon, Dalhousie University, Saint John
PGY1 iFMEM Program, Dalhousie University, Saint John
Big thanks to Dr. Joanna Middleton for leading discussions this month.
All cases are theoretical, but highlight important discussion points.
Authored and Edited by Dr. Mandy Peach
Case
A 46 yo male is transported to the ED via EMS after sustaining multiple injuries in a motorcycle accident. He was helmeted and driving on a community street, he estimates at 70km/hr, when he hit a patch of water and hydroplaned off the road into a ditch. He was not ambulatory on scene and a bystander called EMS. On arrival in the trauma bay his vitals are: BP 100/62 HR 115 Sat 100% on NRB, T 37.2
You begin your primary survey. His airway is patent and he is speaking full sentences. He complains primarily of chest pain with breathing and pain in his hips and legs. His helmet was removed on scene by EMS and is in good condition. He was collared as a precaution. He has obvious bruising over the anterior chest, you suspect from hitting the handlebars, but normal chest rise bilaterally with breathing. He has decreased air entry bilaterally to the bases, PoCUS reveals normal lung slide. You move on to circulation. There is no sign of arterial bleeding. FAST exam shows negative RUQ and LUQ views, however it is indeterminate as the patient was placed in a pelvic binder on scene and you can’t visualize the pelvic views.
Do you remove the pelvic binder to access for pelvic injuries?
No – pelvic ring injuries can result in massive venous hemorrhage. This patient is hypotensive and tachycardic, given the mechanism a pelvic injury is quite likely – therefore removing the binder could stop any tamponade of vessels, leading to move blood loss and an unstable patient.
If a patient is externally hemorrhaging from a source thought to be under the binder than the binder can be transiently removed to control the bleeding1 .
You decide to leave the binder in place and get portable XRs as you work through your trauma survey. XR’s confirm a pelvic ring fracture – you suspect open book that has been ‘closed’ with the binder.
This patient has a pelvic injury, other than hemorrhage what other injuries/complications is this patient at risk of 2,7,8?
Intraabdominal: 16%
Rectal injury – considered open fracture
High risk of infection/sepsis if missed
Urologic injury: <5%
More common in men (10X more likely)
Consider in anterior pelvic fractures
Gynecologic injury (if patient were female): 2-4%
Vaginal injury – considered open fracture
Neurological: 10-15%
Sacral plexus injury
The worsening instability of fracture = higher neurological risk
Cauda equina
Thoracic aortic rupture: 1.4% in pelvic fracture compared to 0.3% in blunt trauma without pelvic fracture
Imagine this patient was dropped off at the door by his friends who lifted him in, instead of being assessed by EMS – what injuries on visual exam would be concerning for pelvic injury3?
Perineal/scrotal bruising or hematomas
Blood at the urinary meatus or vaginal introitus or rectum
Malrotation of the lower limbs
Is a DRE warranted in this patient? In every trauma patient 4?
Rectal exam changes the management in 1.2% of trauma cases.
3 situations where a rectal exam is warranted
Spinal cord injury to access for sacral sparing
Pelvic fracture to determine if fracture is open
Penetrating abdominal trauma to assess for gross blood.
*Consider vaginal exam if consider genital injury as well.
What would be a contraindication to foley insertion?
Concern for genitourinary injury5
– Blood at the urethral meatus
– Penile/scrotal ecchymosis
– Gross hematuria or
– Patient unable to urinate
If possible, insert foley before application of pelvic binder if no contraindications. But in the field foley insertion does not delay the application of a pelvic binder.
If you were concerned about pelvic injury do you want to confirm with XR before placing a binder4?
No – if any concern for pelvic injury bind immediately.
Consider foregoing the pelvic exam and just place the binder on spec if mechanism of injury is concerning for pelvic injury.
If I do examine the pelvis – what is the best approach 4?
Do not place outward pressure or assess for vertical instability
Do not rock the pelvis.
Apply an inward pressure of the iliac wings once to assess for any movement.
Movement felt? Hold that inward pressure and immediately apply a pelvic binder.
How do you place a binder6?
This video reviews both the use of a commercial binder and using a bedsheet if you’re in a ‘bind’.
Remember that the binder goes over the greater trochanters (even though it is called a ‘pelvic’ binder). You can also internally rotate the legs and tape them together at the ankles to decreased anatomic bleed space4
Now imagine you are working a peripheral ED and the patient can’t be transported immediately due to mass casualty event at the nearest trauma center. The patient has been stabilized and will likely be in your department for hours.
Other than vitals, monitoring of symptoms and PoCUS assessment, what else should be part of your reassessment for a patient in a pelvic binder?
“Circumferential compression provided by pelvic binders should be released every 12 hours to check skin integrity and provide wound care as required1”
The patient had pulmonary contusions and other superficial injuries on exam in additional to an unstable pelvic fracture. He went on to have a successful OR and recovery.
References & further reading:
Pelvic image from: Govaert, Geertje & Siriwardhane, Mehan & Hatzifotis, Michael & Malisano, Lawrence & Schuetz, Michael. (2012). Prevention of pelvic sepsis in major open pelviperineal injury. Injury. 43. 533-6. 10.1016/j.injury.2011.12.002.
Reviewed and Edited by Dr. David Lewis
All case histories are illustrative and not based on any individual
You are a third year clinical clerk asked to go see a patient and assess their injuries. A 28 year old female, who is sitting upright in bed and texting her friends, came into the Emergency department via ambulance with a laceration over her right forearm and wrist. EMT vital signs are as follows: BP 128/84, HR 106, RR 18, Temp 37.2, O2 Sats 99% on RA, GCS 15, and Blood glucose 6.4 mmol/L. She weighs 60 kg. The paramedics had wrapped her arm with gauze, which has a blood tinged color to it.
What is your approach?
Mechanism and timing of injury: The patient was carrying towels down the stairs to her pool, tripped and fell down 5 steps, landing on her right side and breaking through a glass panel on her deck. This occurred 45 minutes ago.
Potential for concurrent injuries based on mechanism: The patient denies any loss of consciousness or head trauma. Denies any pain besides the laceration and does not feel like she has broken any bones.
Functional status prior to injury: She had full range of movement and full sensation in her right arm, wrist, and hand prior to the injury.
Medical History: Patient denies any allergies, diabetes, renal disease, cardiac and vascular diseases, and no bleeding disorder. She is a healthy non-smoker, and her only medication is an OCP.
Tetanus Status: She is up-to-date with her immunizations and her last tetanus shot was 2 years ago.
Patient is a well-looking 28 year old female with no signs of distress. She is alert and oriented to person, place, and time. She has a bandage on her right forearm that has dried blood on it. She denies any numbness or tingling in her hand. There is no obvious deformity of the arm.
Remove bandage and assess wound: Patient has a 6 cm rounded laceration with the wound extending from the mid-wrist on the volar side to Lister’s tubercle on the dorsal side. It looks like you can see some tendons and muscle at the wound base, but they do not look injured. There is no sign of glass or other foreign bodies, no dead tissue, and the wound bed appears bloody. It has a slow stream of blood running out of it. The surround skin is pink and appears undamaged.
Assess for neurovascular compromise 3,4 : The wrist anatomy is complex and it is important to consider the underlying anatomy when deciding on how to test for injury. Also compare to the patients “normal” other side.
Test for motor function: patient is able to fully extend, flex, and deviate the wrist to both ulnar and radial sides. She is able to flex, extend, abduct, and adduct her thumb, and has no trouble with opposition. She has flexion at the PIP and DIP joints from D2 to D5. She is able to fully extend her fingers and perform abduction as well. Her strength is 5/5 for these movements as well.
Test for sensation: Patient has sensation to light-touch and pin-prick over her thenar eminence, distal aspect and dorsal aspect (proximal to PIP) of D2, D3, and radial half of D3 (testing for intact median nerve). As well as sensation over the radial aspect of the dorsal hand (Radial Nerve). With this injury you should not expect the ulnar nerve to be damaged, but you’re a studious clerk and testing reveals intact sensation.
Test for vascular compromise: You do not notice any pulsatile aspect to the bleeding, her skin is pink, warm, and has <3 seconds of capillary refill. You palpate strong radial pulses and are reassured that she has not injured this artery.
With this examination you are reassured that she has not injured any underlying structures (tendons, nerves, muscles, and vasculature). You tell the patient that despite a large cut, she is lucky that no serious damage was done.
Luckily, you just finished your plastic surgery rotation and had plenty of experience drawing up local anesthetic. You also learned how to inject a wound while trying to minimize the patients pain. You were told to ALWAYS USE EPI and ALWAYS USE BICARB in your anesthetic solution.5 You draw up one 10 ml solutions (or 100mg) of Lidocaine 1% with epinephrine 1:100,000 buffered with 1 ml bicarbonate (1:10 ratio of bicarb to lidocaine). Maximum dose being 7mg/kg or 420 mg for this patient. You’re wondering if you might need more and realize that you could be getting close to the patient maximum dose; however, you remembered you could always dilute your solutions to double the amount of syringes and still have effective analgesia.5,6 You use a smaller gauge needle (27 or 30 gauge) as this helps to reduce the pain experienced by the patient.5 You let the patient sit for a while so the analgesia will be effective.
You irrigation the wound with copious amounts of tap water (or saline). Again, you notice no foreign bodies or signs of infection. You position the patient lying down in bed and cleanse the skin around the wound with chlorhexidine swabs to prep the surface for wound closure.1,3,7,8
Note: Debridement of jagged, dead, or highly contaminated tissue may be necessary in order to promote wound healing and provide an optimal surface for closure and cosmetic effect.3
When you were gathering your supplies you realized there were many options for sutures, so you decided to ask your attending. They recommended a non-absorbable either 4-0 or 5-0 Nylon suture and to use a simple interrupted technique. You closed the wound and the edges approximated well. You, your patient, attending are all happy with the result. The patient is discharged with follow-up for suture removal in 7 days.
Wound Closure Resources
Useful Patient Information Reference from the ACS
Typical emergency department suture choice is a monofilament non-absorbable suture, this is due to ease of handling, knot security (does not easily break), and emergency texts report a lower rate of infections.1,2,3 There is also the need for suture removal, which requires follow-up and a second look at how the wound is healing. Absorbable sutures are usually harder to handle and tying knots can be tricky due to ease of breaking, especially with smaller sized sutures. Much of the emergency texts cite an increase in rates of infection with absorbable sutures as a reason not to choose them. However, evidence suggests that there is no significant difference in rates of infections or clinical outcome.9-12 Literature does point towards higher rates of tissue reactivity (inflammation associated with placing of suture) with absorbable sutures.12 Really selection of sutures comes down to wound factors (location and tension requirements), patient factors (need for follow-up, compliance, etc.), as well as physician preference. See tables for types and recommended use.
Edited by Dr David Lewis
Measles has for many years been an infrequent diagnosis in our population. However falling herd immunity is resulting in cases presenting to Canadian ED’s.
Measles signs and symptoms appear around 10 to 14 days after exposure to the virus.
Measles causes a red, blotchy (erythematous maculopapular) rash that usually appears first on the face and behind the ears, then spreads downward to the chest and back and finally to the feet. Koplick’s spots can appear 1-2 days before the rash. The rash appearance can be variable, discrete maculopapular or merging erythematous.
Note that it is possible to be influenced by past experience with mimics, resulting in falsely diagnosing a mimic in the presence of a stroke.
Stroke chameleons are disorders that look like other disorders but are actually stroke syndromes
A very useful BMJ review article on Posterior Stroke can be accessed here.
Be cautious of migraine diagnosis with history that is different to typical migraine presentation. Multiple visits should raise concerns. Importance of thorough neuro exam to find possible deficits that would raise suspicion for more serious pathology. In posterior stroke, special attention should be given to examining the visual fields.
See Rounds Presentation by Dr. Dylan Blacquiere (Neurologist)
After meeting with Dr. Blacquiere and the ER Department regarding stroke management and SAH management, I’m recommending the following based on new literature and evolving management in “high risk” patients.
1) High risk TIA patients, such as those who had a profound motor / speech deficit that is resolving should have a CTA carotid / COW as well as their standard CT head.
2) SAH patients should have CT done prior to LP due to false positive LP rates. If there is any question about vascular malformation / aneurysm, follow with a CTA. The CTA isn’t necessary for every headache patient, etc, just those with a positive bleed on the unenhanced CT.
The evidence is summarised in this recent paper – Imaging Recommendations for Acute Stroke and Transient Ischemic Attack Patients: A Joint Statement by the American Society of Neuroradiology, the American College of Radiology and the Society of NeuroInterventional Surgery
Standard ATLS teaching, but this error still occurs……
Ensure a complete secondary survey is completed in all patients presenting with history of trauma.
Read the StatPearl Article and then do the MCQ test here