Author: Zack (Page 7 of 9)

Constipation

Common Causes of Constipation

  • Lifestyle
    • Low fiber diet
    • Minimal water intake
    • Poor exercise
  • Medications
    • Especially opiates
  • Endocrine/electrolytes
    • Hypothyroidism
    • Hypercalcemia
  • Bowel obstruction
    • Delayed colonoscopy
    • Unintentional weight loss
    • Previous abdominal surgeries
  • Rectal problems
    • Anal fissures
    • Fecal impaction
    • Masses

How to Treat Constipation

  • Fiber (ex. Metamucil, Citrucel)
    • Adds structure to the stool
  • Water (polyethylene glycol/miralax)
    • Hydrates the stool
  • Fat (colace)
    • Softens the stool
  • Stimulants (Senna)
    • Increases intestinal activity
    • Decreases transit time
  • Suppositories (Glycerine, Dulcolax, Fleet)
    • Stimulate rectum and cause reflexive bowel movements

Additional Reading

Diabetic Ketoacidosis (DKA)

The blood sugar is NOT the emergency- Acidosis, Hypokalemia, and Dehydration are!!!

Signs and Symptoms

  • Vomiting
  • Abdominal pain
  • Polydipsia
  • Polyuria

Step 1: Test for DIABETIC-KETO-ACIDOSIS

  • Diabetes
    • Blood sugar
      • Typically notably elevated (>250 mg/dL)
      • Can be normal in certain circumstances
  • Ketones
    • Easiest test is a urinalysis
    • Serum ketones also can be obtained
  • Acidosis
    • Blood gas (arterial or venous)
      • pH <7.3

Step 2: Check Potassium Level

  • Patients frequently depleted of whole body potassium
  • Insulin administration will causes further drops in serum potassium level

Step 3: Replace Potassium

  • If potassium <3.3, do not give insulin
    • Replace potassium prior to insulin
  • If potassium >3.3 but <5.5
    • Consider supplementing potassium at this point
    • May continue insulin

Step 4: Give Fluids

  • Adult patients are frequently 3-6 LITERS depleted
  • 20 ml/kg NS during first hour

Step 5: Start an Insulin Drip

  • This accomplishes 2 things…
    • It decreases blood sugar
    • It also decreases acid production

Additional Reading

Laceration Repair

Step 1: Pain Control

  • Local anesthesia
    • Most common agent is lidocaine (frequently already in laceration repair kits)
    • Inject through wound edges (not through epidermis)
    • This decreases pain
  • Alternative is digital/regional nerve block

Step 2: Irrigation

  • Laceration repair is not a sterile procedure
  • Copious irrigation is the best method to decrease chance of wound infection
    • Faucet/sink vs saline

Step 3: Alternative Wound Closure Techniques

  • Dermabond/Tissue Adhesive
    • Works best on easily approximated wound edges and little tension
    • Commonly used in pediatrics and geriatrics
  • Staples
    • Sometimes leaves a poor cosmetic outcome
    • Commonly used for scalp wounds
    • Rapidly stops bleeding
    • Quickest and easiest closure method to perform

Step 4: Choose a Suture Type

  • Absorbable (Gut, Monocryl)
    • Pros: Patient doesn’t need to return for removal
    • Cons: Loses tensile strength
  • Non-Absorbable (Prolene)
    • Pros: Good cosmetic outcomes, easy to see (bright blue)
    • Cons: Patient must have them removed

Step 5: Repair the Wound

  • Gently approximate wound edges
    • You are not trying to “seal” the wound closed
    • Primary goal is to improve cosmetic outcome
  • Keep it simple
    • Simple interrupted sutures
    • Instrument tie

Additional Reading

Laceration Evaluation

Lacerations are the single best opportunity to demonstrate your procedural skills during your clerkship!!!

To Close or Not To Close?

  • Closing a wound with sutures, etc = Healing by “primary intention”
    • INCREASES risk of infection but DECREASES scar
  • Leaving a wound open = Healing by “secondary intention”
    • DECREASES risk of infection but INCREASES scar

Step 1: History

  • Does patient have comorbidities that increase risk of infection/poor healing?
    • Diabetes
    • Renal Failure
    • Obesity
    • Smoking
    • Immunosuppression
  • How long since injury happened?
  • Any concern for foreign body?

Step 2: Identify Tetanus Status

  • Has patient EVER been immunized against tetanus?
  • Has it been >5 years since last tetanus shot?

Step 3: Tetanus Prophylaxis

  • Give tetanus booster (Tdap) if >5 years since last tetanus shot
  • Give tetanus immunoglobulin (IG) if patient has never had tetanus immunization

Step 4: Give Specific, Objective Description of Laceration

  • EXACT length
    • Must use a ruler
    • Most important BILLING categories
      • 2.5 cm or less
      • 2.6 cm to 7.5 cm
      • 7.6 cm to 12.5 cm
  • Description
    • Shape
      • Linear
      • Stellate
      • Flap
    • Depth
      • Superficial
      • Muscle
      • Bone
  • Neurovascular exam
    • Sensation
    • Motor
    • Cap refill

Step 5: Rule Out Foreign Body

  • Consider X-Ray
    • Not all foreign bodies will show up on x-ray
      • Especially organic material, clothing, etc
  • Consider bedside ultrasound
    • (You are not expected to know how to do this, only to consider this)

Additional Reading

Sore Throat

You must know the FOUR emergent causes of sore throat!

Step 1: Apply the Centor Criteria

  • Determines if patients is at risk for Group A strep (“strep throat”)
  • 4 Criteria
    • Fever
    • No cough
    • Tonsiller exudates
    • Lymphadenopathy
  • Interpretation
    • If patient has ALL of the criteria
      • Treat for strep throat
    • If patient has NONE of the criteria
      • Don’t even test for strep throat
    • If patient has SOME of the criteria
      • Consider testing for strep throat

Step 2: Prescribe Antibiotics

  • B-lactams work best
    • Penicillin
    • Amoxicillin
  • If patient has allergy, consider alternative agent
    • Azithromycin
    • Clindamycin

Step 3: Pain Control

  • NSAIDS
  • Steroids

Step 4: Consider EBV (Epstein-Barr Virus)

  • Consider in patients not getting better on antibiotics
  • Examine for splenomegaly
    • If present, no contact sports

Step 5: Consider the FOUR Emergent Causes of Sore Throat

  • Ludwigs angina
    • Airway emergency
    • Infection UNDER the tongue
  • Peritonsillar abscess (PTA)
    • Complication of bacterial pharyngitis
    • Causes “trismus” (difficulty opening mouth)
    • Frequently need to be drained
  • Retropharyngeal abscess
    • Airway emergency
    • Difficult to diagnose by exam alone
      • Infection is BEHIND airway
      • Seen on lateral neck xray
  • Epiglottitis
    • Airway Emergency
    • “The Triad”
      • Drooling
      • Dysphagia
      • Distress (respiratory)
    • Lateral neck xray shows “thumbprint sign”

Additional Reading

  • Peds O- Oxygen, Airway, and Respiratory Disorders (EM Clerkship)
  • Airway Infectious Disease Emergencies (UNM)

Procedural Sedation

Procedural sedation is one of the core procedures in Emergency Medicine. You WILL see this during your clerkship

Common Scenarios

  • Cardioversion
  • Orthopedic reductions
  • Painful procedures

Three Step Approach to Procedural Sedation

  • Step 1: Risk stratify the patient
    • Mallampati score (aka “How visible is the uvula?”)
      • Level 1: Can visualize THE WHOLE uvula
      • Level 2: Can visualize MOST of the uvula
      • Level 3: Can visualize SOME of the uvula
      • Level 4: Can NOT visualize the uvula
    • ASA (aka “How healthy are they?”)
      • Level 1: Healthy
      • Level 2: Mild illness
        • Hypertension
        • Hyperlipidemia
        • Anemia
      • Level 3: Major illness
        • Diabetes
        • Coronary disease
        • COPD
        • Chronic renal disease
      • Level 4: Extremely unhealthy
        • Dialysis patient
        • Severe heart failure
        • Chronically debilitated
      • Level 5: Dying
        • Patient needs operation to live
          • Intracranial hemorrhage with midline shift
          • Ruptured aortic aneurysm
          • Ruptured papillary muscle with cariogenic shock
          • Dissecting aortic aneurysm
  • Step 2: Informed consent
    • Patients sign a GENERAL CONSENT to treat when registering to the department
    • Many emergency scenarios require physician to operate with IMPLIED CONSENT
    • Many patients have an ADVANCED DIRECTIVE
    • In stable patients and higher risk procedures, separate WRITTEN CONSENT is often required
      • Varies by hospital
      • Typically required for procedural sedation in stable patients
  • Step 3: Gather supplies
    • Nurse and nursing supplies
      • IV
      • Cardiac monitor
    • Respiratory therapy and respiratory supplies
      • Capnography
      • Bag-valve mask
      • Airway box

Top 5 Procedural Sedation Medications

  • Midazolam (“Versed”) – 0.02 mg/kg IV
    • Reduces anxiety prior to procedure
    • Provides no analgesia
  • Fentanyl – 1 mcg/kg IV
    • Reduces pain
    • Useful for painful procedures
      • Incision and drainage
      • Simple reductions
  • Propofol – 0.5-1mg/kg IV
    • General anesthetic
    • Best given “low and slow”
    • Short acting
    • Causes respiratory depression and hypotension
  • Etomidate – 0.15 mg/kg IV
    • General anesthetic
    • Less hypotension than propofol
    • Can cause myoclonus
  • Ketamine – 1-2mg/kg IV
    • “Dissociative”
    • Provides both amnesia AND analgesia
    • Can cause emergence reactions
    • Can cause laryngospasm and secretions

Additional Reading

Back Pain

Step 1: Identify Classic Red Flags for Can’t Miss Diagnoses

  • Aortic Dissection and Abdominal Aortic Aneurysm (AAA)
    • Age >50
    • Hypertension
    • “Ripping” or “Tearing” pain
    • Absent pulses in lower extremities
  • Spinal Infections
    • Fever
    • Immunocompromized
      • HIV
      • Diabetes mellitus
      • Transplant patients
  • Spinal cord compression (especially cauda equina)
    • Urinary retention
      • Consider obtaining post-void residual
    • Saddle anesthesia
    • Fecal incontinence/decreased rectal tone
  • Fracture
    • Recent trauma
    • Advanced age
  • Cancer
    • History of cancer
    • Night sweats
    • Weight loss

Step 2: Testing Plan (If Patient Has Red Flags)

  • X-ray or CT scan if concerned for fracture
  • MRI if concerned for infection, cord compression, or cancer

Step 3: Symptom Management

  • NSAIDS
    • Naproxen
    • Ibuprofen
  • “Muscle relaxants”
    • Cyclobenzaprine
  • Other agents
    • Opiates
    • Topical therapy
    • Lidocaine patches

Step 4: Counseling

  • Remain active
  • Avoid heavy lifting
  • Red flags = immediate return to ED

Additional Reading

Dental Pain

Minor complaint. Huge SLOE points!

Step 1: Identify Which Tooth is Causing Pain

  • Bonus points if you number teeth correctly!
    • Number 1-32
      • Tooth #1 is top right
      • Tooth #32 is bottom right
    • Refer to dental chart for reference

Step 2: Correct Terminology When Making Diagnosis

  • Pulpitis
    • Pain in the tooth itself
    • Reversible
      • Triggered by hot/cold etc (then goes away)
    • Irreversible
      • Does not resolve
  • Gingivitis
    • Pain of the gingiva around the tooth
  • Periapical abscess
    • Pain with percussion of tooth

Step 3: Give Pain Medicine

  • NSAIDS have been shown to work best
    • Naproxen
    • Ibuprofen
  • Opiates for breakthrough pain
    • Hydrocodone-acetaminophen (Norco)
    • Oxycodone-acetaminophen (Percocet)

Step 4: Consider Antibiotics

  • Pulpitis does not require antibiotics
  • Gingivitis/Periapical abscess frequently improve on antibiotics
    • Penicillin VK

Step 5: Inferior Alveolar Nerve Block

Additional Reading

  • Inferior Alveolar Nerve Block (YouTube)
  • Common Dental Emergencies (AFP)

Vertigo

Does the patient have CENTRAL vertigo (bad) or PERIPHERAL vertigo?

Step 1: How Does Patient Describe the Vertigo?

  • Asking the patient to describe their dizziness has since been disproven… (However, the classic teaching is)
  • Central vertigo
    • Mild
    • Vague
  • Peripheral vertigo
    • Severe
    • Sudden

Step 2: What Are the Associated Symptoms?

  • Central vertigo frequently associated with “The Dangerous D’s”
    • Diplopia (double vision)
    • Dysphagia (difficulty swallowing)
    • Dysmetria (uncoordinated movement)
    • Dysarthria (difficulty speaking)

Step 3: Does this Patient Have Risk Factors for Central Vertigo?

  • History of stroke
  • Atrial fibrillation
  • Diabetes
  • Recent trauma

Step 4: Do a Neuro Exam

  • Important exam findings for central vertigo
    • Abnormal gait
    • Abnormal finger-to-nose
    • Nystagmus
  • Important exam findings for peripheral vertigo
    • Dix-Hallpike

Step 5: Plan

  • If concerned for CENTAL vertigo
    • MRI head/neck
  • If concerned for PERIPHERAL vertigo
    • Treat with meclizine

Additional Reading

  • Posterior Circulation Strokes and Dizziness (emDOCs)

Hyperkalemia

Hyperkalemia = EKG… EKG changes = Calcium…

Step 1: Recheck the Potassium

  • Most common cause of hyperkalemia is PSEUDOhyperkalemia
    • Caused by too aggressive/fast of a blood draw
      • Causes RBCs to break open and falsely increase serum potassium

Step 2: Get an EKG

  • Earliest EKG change
    • Peaked T waves
  • Late EKG changes
    • Flattened P wave
    • Prolonged QRS
  • Critical/Emergent EKG changes
    • Sine wave

Step 3: Protect the Heart

  • EKG Changes = Give Calcium
    • Calcium gluconate (can be given IV)
    • Stabilizes the myocardium against dysrhythmia

Step 4: Shift Potassium Into Cells

  • Insulin (plus D50)
  • Albuterol

Step 5: Remove Potassium from Body

  • Kayexalate
    • Notorious for causing intestinal necrosis
    • Falling out of favor
  • Furosemide

Additional Reading

How to Interpret a Chest X-Ray

A-B-C-D-E-F-G

Two Types of X-Rays

  • Anterior-Posterior (“AP”)
    • Classic “portable” xray
      • The beam shoots from in front of the patient (anterior)
      • TO
      • The plate sitting behind the patient (posterior)
  • Posterior-Anterior (“PA”)
    • Requires trip to radiology
    • Results in a better picture
      • The beam shoots from behind the patient (posterior)
      • TO
      • The plate sitting in front of the patient (anterior)

Three Indicators of a High Quality Chest X-Ray

  • Well inflated lungs
  • Visualize spine through cardiac silhouette
  • Medial aspect of both clavicles lined up
    • Evaluates for rotation

Chest X-Ray Interpretation Mnemonic

  • A-B-C-D-E-F-G
  • A = Airway
    • Trachea midline (rule out tension pneumothorax)
  • B = Bones
    • Rib/Clavicle/Shoulder fractures
  • C = Cardiac silhouette
    • Should be no bigger than 50% of distance from chest wall to chest wall
      • Larger than this may represent cardiomyopathy
  • D = Diaphragm
    • Costophrenic angles should be sharp
      • Blunted in pleural effusion
  • E = Equipment
    • Central lines
    • Endotracheal tubes
    • Chest tubes
  • F = Lung Fields
    • The most important step
    • Look at lung markings/tissue to evaluate for…
      • Pneumothorax
      • Consolidation
      • Nodules
      • Pulmonary Edema
  • G = Great vessels
    • Look for mediastinal widening (> 8cm)
      • Can be a sign of aortic injury
      • Looks falsely widened on AP/portable chest x-ray

Additional Reading

Trauma in Pregnancy

Mom is Scared. You are Scared. Don’t Be Scared.

General Principles

  • Evaluate for intimate partner violence in all poorly explained traumas during pregnancy
  • Get the scans you would order in a non-pregnant patient, even CTs!
    • Shield the uterus if necessary

Basic Approach to Trauma in Pregnancy

  • Step 1: Place mother in left lateral decubitus position
    • This removes the weight of the uterus OFF the inferior vena cava (IVC)
      • Can significantly improve patient’s hemodynamics
  • Step 2: Palpate the fundus
    • If fundus is palpable at umbilicus, fetus is approximately 20 weeks
    • Add 1 week of pregnancy for every 1cm above umbilicus
  • Step 3: Pelvic ultrasound
    • Primary utility is to reassure mother that baby is OK
      • Calculate fetal heart rate
    • Also identifies SOME placental abruptions and pelvic free fluid
  • Step 4: Obtain type and screen
    • If mother is Rh NEGATIVE…
      • Give RhoGAM
      • Prevents Rh isoimmunization in mothers with Rh positive babies
  • Step 5: Consult OBGYN for fetal heart monitoring (tocodynamometry)
    • Best test to rule out placental abruption and uterine irritability
    • Only necessary if patient is >20 weeks gestational age

Additional Reading

Genitourinary Trauma

Four important injuries. Four different imaging studies to obtain.

Step 1: Obtain Pelvic X-Ray

  • Commonly performed at bedside as part of initial trauma evaluation
  • A pelvic injury significantly increases risk of GU injury

Step 2: Examine the Perineum

  • Common signs of GU injury
    • Blood at urethral meatus
    • Bruising of the perineum

Step 3: Obtain Urinalysis

  • Gross hematuria is the red flag
    • Can be identified at bedside
  • Importance of microscopic hematuria uncertain
    • If you decided to send a formal urinalysis…
    • Patient needs follow up on the hematuria until resolved

Step 4: Consider the FOUR Genitourinary Injuries

  • Kidney injury
    • Evaluate with CT scan abdomen/pelvis with IV contrast
    • Occur in approximately 10% abdominal trauma
      • Flank pain
      • Lower rib trauma
  • Ureteral injury
    • Evaluate with delayed CT scan abdomen/pelvis with IV contrast
      • Call radiology to help choose right imaging protocol
    • RARE injury
      • Sometimes seen with penetrating trauma or surgical injury
    • Frequently needs surgical repair
  • Bladder injury
    • Evaluate with retrograde cystogram
    • Occurs when patient with distended bladder has direct impact to low abdomen
  • Urethral injury
    • Evaluate with retrograde urethrogram (RUG)
    • TWO subtypes
      • Posterior injury
        • Occur with pelvic fractures
      • Anterior injury
        • Occur with straddle-type injuries

Additional Reading

Abdominal Trauma

Step 1: Does This Patient Need Surgery NOW?

  • Obvious penetrating injury to abdomen
  • Peritonitis
  • Hypotensive

Step 2: FAST Scan

  • Performed with bedside ultrasound machine
  • Blood/intra-peritoneal fluid is hypoechoic (black) in appearance
  • Four views required
    • Right upper quadrant
      • Probe marker points towards patient’s head
      • “Morrisons Pouch”
        • Potential space between liver and right kidney
    • Left upper quadrant
      • Probe marker towards patient’s head
      • Most difficult view to obtain
      • Potential space around spleen and between spleen and left kidney
    • Suprapubic
      • Probe marker towards patient’s head
      • Looking for thin rim of fluid between bladder wall and bowel wall
    • Subxiphoid
      • Hold probe flat and aim through liver towards heart
      • Looking for fluid around heart and evidence of cardiac tamponade

Step 3: Consider the Mechanism

  • Low risk
    • Low speed MVAs
    • Falling down only a few steps
  • High risk
    • Falling off ladder/roof
    • High velocity MVA/impact

Step 4: Perform Careful Abdominal Exam

  • Pain
  • Bruising/Seatbelt sign
  • Distension
  • Peritonitis
    • Rigidity
    • Rebound
    • Guarding

Step 5: Obtain Imaging if High Risk Mechanism or Abnormal Exam

  • CT Abdomen/Pelvis with IV contrast
  • If normal CT scan but you still have clinical concern- ADMIT
    • Serial abdominal exams
    • CT notorious for missing small bowel and diaphragmatic injuries

Additional Reading

Cardiac Trauma

Cardiac tamponade. Aortic Dissection. Blunt cardiac injury.

Cardiac Tamponade

  • Blood fills pericardial sac
    • Increasing pressure on myocardium -> Decreased preload
    • Decreased preload -> Hypotension -> Death
  • Clinical exam shows Beck’s Triad
    • Hypotension
    • Muffled heart sounds
    • Jugular venous distension (JVD)
  • Diagnosed during FAST exam (subxiphoid view)
  • Treat with pericardiocentesis
    • Bedside thoracotomy if patient loses pulse

Aortic Dissection/Rupture/Tear

  • Common with rapid deceleration injuries
  • Most commonly occurs at ligamentum arteriosum
    • Small ligament that attaches arch of aorta to pulmonary artery
    • Remnant of the ductus arteriosus
  • Obtain CTA of the chest if…
    • Widened mediastinum on chest x-ray
    • Unequal pulses
    • Concerning mechanism of injury
  • Requires emergent repair

Blunt Cardiac Injury

  • Contusion to the myocardium can cause arrhythmia/death
    • Place patient on cardiac monitor
    • Consider EKG/troponin
  • Commotio Cordis
    • Blunt impact to chest resulting in ventricular fibrillation

Additional Reading

Thoracic Trauma

Step 1: Perform ATLS Primary Survey (B- Breathing)

  • Signs of respiratory distress/injury
    • Shortness of breath
    • Hypoxemia
    • Tracheal deviation
    • Diminished breath sounds

Step 2: Consider Performing Bedside Tube Thoracostomy

  • Insert at 5th intercostal space just anterior to mid-axillary line

Step 3: Imaging

  • Start with portable bedside chest x-ray
  • Pneumothorax can also be diagnosed by thoracic ultrasound

Step 4: Consider the 3 Critical Diagnoses

  • Tension pneumothorax
    • Pressure builds up between chest wall and lung
    • Eventually decreases cardiac preload -> Hypotension/Death
    • Treatment
      • Needle decompression
      • Tube thoracostomy
  • Open pneumothorax
    • Lung unable to expand during inspiration
    • Treatment
      • 3-sided occlusive dressing over open (“sucking”) chest wound
      • Tube thoracostomy
  • Hemothorax
    • Chest cavity fills with blood
    • Eventual decreases cardiac preload -> Hypotension/Death
    • Treat with tube thoracostomy

Step 5: Consider the 3 Other Common Diagnoses

  • Rib fractures
    • Diagnose with chest x-ray
    • Treatment
      • Pain control
      • Incentive spirometry
  • Small pneumothorax
    • Worsens with positive pressure ventilation (intubation, BiPAP)
    • Treatment
      • Supplemental oxygen
      • Supportive care
  • Pulmonary contusion
    • Supportive care

Additional Reading

Neck Trauma

The hardest question… Should you get a CTA?

Blunt Trauma of Neck

  • Obtain CTA if…
    • Patient has neurologic deficit
      • Numbness
      • Weakness
      • Visual changes
    • Patient sustained forceful impact to the neck
    • Patient has fracture
      • Basilar skull
      • Facial bones
      • Cervical spine

Penetrating Trauma of the Neck

  • Go to OR if patient is unstable
  • Go to OR if patient has HARD signs
    • HARD Bruit Mnemonic
      • Hemoptysis/Hematemesis/Hypotension
      • Arterial bleeding
      • Rapidly expanding hematoma
      • Deficit (neurologic/pulse)
      • Bruit
  • Otherwise obtain CTA of the neck

Additional Reading

C-Spine Trauma

Step 1: Protect the Spine

  • Apply cervical collar

Step 2: Apply NEXUS Criteria

  • Use the “SPINE” mnemonic
    • Spinal midline tenderness
    • Painful distracting injury
    • Intoxication
    • Neurologic deficit
    • Encephalopathy

Step 3: If Patient Has None of the NEXUS Criteria… You Are Done!

Step 4: If Patient Has Positive NEXUS Criteria…

  • Obtain CT scan of the cervical scan without contrast

Step 5: Clear the C-Spine

  • If CT scan negative -> Have patient turn head 45 degrees to right and left
    • If patient has no limitation and no paresthesias or neurologic deficit…
      • Remove collar
    • If still concerned for spinal injury despite normal CT
      • Keep collar on and have patient follow up in clinic for reexam

Unstable Cervical Spine Fractures

  • Mnemonic: Jefferson Bit Off a Hangmans Tit
    • Jefferson fracture
    • Bilateral facet dislocation
    • Odontoid fracture
    • Atlantooccipital dislocation
    • Hangman’s fracture
    • Teardrop fracture

Additional Reading

  • NEXUS Criterial for C-Spine Imaging (MDCalc)
  • Unstable Spine Fractures (WikEM)

Facial Trauma

There are 6 major areas/injuries to the face.

Basic Approach to Facial Injury

  • Step 1: Airway
    • Indications for intubation after trauma
      • Burns to the airway
      • Rapidly expanding hematoma
      • GCS <8
  • Step 2: CT Maxillofacial Without Contrast
  • Step 3: Supportive Care
    • Stop bleeding
      • Apply pressure
      • Control epistaxis
        • Caution advised with packing if patient has basilar skull fracture
    • Ice
    • Analgesics
  • Step 4: Antibiotics
    • Common indications
      • Fractures of a sinus
      • Open fractures
  • Step 5: Consider Consulting the Appropriate Specialist
    • Eye trauma -> Ophthalmology
    • ENT trauma -> ENT
    • Oral/Dental trauma -> Oral/maxillofacial surgery or dentistry

Six Key Facial Injuries

  • Frontal bone
    • Fractures of the INTERNAL frontal sinus wall = BAD
  • Eyes and orbits
    • “Blowout” fractures with entrapment of the extra-occular muscles = BAD
  • Nose
    • Septal hematoma = BAD
  • Zygoma (Cheekbone)
    • Zygomaticomaxillary complex fracture (aka Tripod fracture) = BAD
  • Maxilla (Upper jaw)
    • Le Fort fractures = BAD
  • Mandible (Lower jaw)
    • Open fractures (intraoral laceration) = BAD

Additional Reading

Head Trauma

CT scan without contrast is your test of choice.

Step 1: Consider Your Differential Diagnoses

  • Five high-yield head trauma diagnoses
    • Skull fracture
      • External skull fracture
      • Basilar skull fracture
    • Epidural hematoma
    • Subdural hematoma
    • Traumatic subarachnoid hemorrhage (SAH)
    • Concussion

Step 2: Important Add-ons When Taking History

  • Specific mechanism of injury
  • Loss of consciousness
  • Blood thinners/antiplatelet agents

Step 3: Important Add-ons To Your Physical Exam

  • GCS Score (MDCalc)
  • Pupils
  • Basilar Skull Findings
    • Raccoon eyes
    • Battle sign
    • CSF rhinorrhea
    • Hemotympanum

Step 4: Calculate Canadian Head CT Rule

  • Only apply to patients with…
    • Loss of consciousness
    • Amnesia to event
    • Witnessed disorientation
  • Exclude patients with
    • Blood thinners
    • Seizure(s)
    • Age <16
  • High risk criteria
    • GCS <15 2 hours post injury
    • Suspected open/depressed skull fracture
    • Signs of basilar skull fracture
    • 2 or more episodes of vomiting
    • Age >65
  • “Moderate” risk criteria
    • Retrograde amnesia >30 minutes
    • Dangerous mechanism
      • Fall >3 ft
      • Motor vs pedestrian
      • Ejected from MVA

Additional Reading

  • Canadian CT Head Injury/Trauma Rule (MDCalc)
  • Evaluation and Management of Concussion in Sports (AAN)
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