Category: Trauma and Environmental

Rabies Prophylaxis

Introduction

  • What is rabies?
    • A very rare and aggressive encephalitis
    • Global impact with exception of UK/Australia
  • Animals whose bites/scratches may require prophylaxis
    • Bats
    • Dogs, Cats, Ferrits
    • Other carnivorous animals
    • Foxes, Coyotes, Skunks, Raccoons
  • Post exposure prophylaxis
    • Both Rabies vaccine and immunoglobulin

When Do You Give Rabies Prophylaxis?

  • Step 1: Bitten or scratched by domesticated pet?
    • Immunization status of pet does not matter
    • Animal must be monitored
    • Give prophylaxis if animal develops encephalitis
  • Step 2: Bitten or scratched by wild animal?
    • If animal is captured it can be sacrificed and tested
    • Give prophylaxis the animal is not captured and is a potential carrier
  • Step 3: Possible bat scratch/bite?
    • Give prophylaxis if the patient (or baby) cannot confidently say “NO, I DID NOT GET BITTEN OR SCRATCHED BY THE BAT”
  • Step 4: Do NOT give prophylaxis if the animal is not a carrier of rabies (check local guidance)
    • Reptiles
    • Birds
    • Small rodents
    • Rabbits/Hares
    • Livestock
  • Step 5: How to give prophylaxis
    • Only contraindication is severe egg allergy
    • Can be given to babies/pregnant women/etc
    • Rabies immunoglobulin
      • Give ONCE in the department
      • Inject as much as possible around wound
    • Rabies vaccine
      • Give first day
      • Have patient come back for more doses on day 3, 7, 14 (and SOMETIMES 28)

Pearls

  • It doesn’t matter if the bite/scratch was provoked or unprovoked
  • It doesn’t matter where on the body the patient received the bite/scratch
  • It’s a universally fatal disease
  • No rabies in small rodents, reptiles, birds, squirrels, hamsters, rats, or rabits
  • The NNT is >300,000 (but we still do it)

Additional Reading

Occupational Exposures

The only chief complaint that you are guaranteed to eventually have to manage in a colleague

Respiratory Exposures

  • Meningococcus​ (meningococcemia, meningitis, etc)
    • Give prophylaxis (ceftriaxone) if…
      • Intubated a pt without a mask
      • Suctioned a pt without a mask
      • Performed mouth to mouth resuscitation
  • Tuberculosis​ 
    • CDC recommends testing if exposed
      • Treat if positive
    • CDC recommends prophylaxis in..
      • Little children, HIV positive, immunosuppressed

Cutaneous Exposures (Broken Skin, Mucous Membranes, Needle Stick)

  • Hepatitis B​
    • Test source patient
      • If positive, 1-30% risk of transmission with needle stick exposure
        • (Mucous membrane/broken skin exposures are much lower risk)
    • Test exposed colleague for anti-HepB surface antibody level
    • If source patient is positive and coworker is not fully immunized…
      • Treatment
        • Hep B Vaccine
        • Hep B Immunoglobulin
  • Hepatitis C​
    • Test source patient
      • If positive, 2% risk of transmission with needle stick exposure
        • (Mucous membrane/broken skin exposures are much lower risk)
    • Get baseline hepatic function labs (LFTs) in coworker
    • Follow-up on outpatient basis, no prophylaxis available
  • HIV​
    • Test source patient with rapid HIV test
      • If positive, 1/300 risk of transmission with needle stick exposure
        • Transmission risk increases if: bloody exposure, large needle bore
        • (Mucous membrane/broken skin exposures are much lower risk)
    • Generally recommend prophylaxis if source is positive
      • Prophylaxis is potentially curative if given at exposure
      • Counsel on safe sex practices
      • Counsel on common treatment side effects
        • GI symptoms, headaches, fatigue

Additional Reading HIV Occupational Exposure Guidelines (US Public Health Service)

Gunshot Wounds (Arms and Legs)

Evaluate 5 important structures when evaluating gunshot wounds in an extremity.

Blood Vessel Injuries

  • 3 Categories
    • Hard-Signers
      • Mnemonic: HARD Bruit
        • Hypotension
        • Arterial/pulsatile bleeding
        • Rapidly expanding hematoma
        • Deficits (pulse)
        • Audible BRUIT/thrill
      • These patients likely need OR
    • Soft-Signers
      • Significant vascular oozing/bleeding
      • Large hematoma
        • These patients need to be screened with ABI (ankle brachial index)
          • ABI <0.9 or asymmetry between extremities is concerning for vascular injury
        • If abnormal, obtain a CTA
    • No-Signers
      • No additional management for vascular injury required

Nerve Injuries

  • Relatively rare
  • Document neuro exam in the extremity
  • Consult if abnormal

Bone Injuries

  • Relatively common
  • Diagnosed by x-ray
  • Consult orthopedics for fracture

Soft Tissue Injury

  • Be sure to count/document number of holes
  • Typically do not need laceration repair unless cosmetic area
  • Don’t miss compartment syndrome
    • Mnemonic: “P’s”
      • Pain out of Proportion
      • Pain with Passive range of motion
      • Paresthesias
      • Pallor
      • Paralysis
      • Poikilothermia

The Bullet: What To Do With It?

  • The bullet is almost never removed, unless…
    • Very superficial/cosmetic and easy to remove
    • In a joint

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

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)

ATLS

Airway/C-spine. Breathing. Circulation. Disability. Exposure. Secondary Survey.

Airway and C-Spine

  • General airway principles
    • “If they can’t speak, they can’t control their airway”
    • “If GCS is <8, intubate”
      • In the real world, it’s a clinical judgement call
  • General c-spine principles
    • Clear c-spine with NEXUS/Canadian rules
    • Otherwise stabilize spine and place in cervical collar

Breathing

  • If patient has tachypnea, hypoxemia, or respiratory distress
    • Give O2
    • Examine for tension pneumothorax
      • Deviated trachea
      • Asymmetric breath sounds
        • If concerned perform needle decompression
        • THEN
        • Tube thoracostomy

Circulation

  • If patient has tachycardia, hypotension, or obvious blood loss
  • Stop the bleed
  • Emergent transfusion
  • Consider early OR if unstable
    • In the real world, CT is frequently obtained pre-op regardless of stability

Disability

  • Pupils
  • GCS
  • If concerned for head injury
    • Obtain CT head without contrast

Exposure

  • Fully undress the patient
  • Warm blankets

Secondary Survey

  • Visualize everything
  • Palpate everything
  • Bedside chest/pelvic x-ray and FAST scan

Common Labs

  • Type and screen
  • CBC
  • Electrolytes
  • Urinalysis
  • EKG
  • Blood alcohol level
  • Lactic acid (if concerned for shock)

Common Imaging

  • CT head without contrast
  • CT maxillofacial without contrast
  • CT cervical spine without contrast
  • CTA neck
  • CT abdomen/pelvis WITH contrast
  • Retrograde urethrogram
  • Additional x-rays

Common Treatments

  • Blood products
  • Tetanus immunization
  • Analgesics

Additional Reading

© 2020 EM Clerkship

Theme by Anders NorenUp ↑