EM Clerkship

We order lots of imaging in emergency medicine, and during your clerkship, you may be expected to interpret any of these images for yourself. Obviously, you may not be able to perfectly interpret everything, and that’s OK. However, you absolutely HAVE to know how to interpret a chest X-ray. It is very high yield for your SLOE. In this episode I give you a basic approach using an ABCDEFG mnemonic.

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 * Trauma Basics (EM Clerkship)* Trauma in Pregnancy (AAFP)

For our last trauma episode, we will be covering the basic approach to injuries in pregnant women. These can be very stressful cases, but the good news is that the approach is very straight forward. It’s just 5 extra interventions you have to perform in addition to your normal trauma resuscitation.

Happy Thanksgiving everybody! No episode this weekend. I just want you all to know that I’m so grateful for you. You have been some of the most positive, supportive listeners I could have ever hoped for. Thank you so much for downloading. See ya next weekend!

L→ Episode Summary

Leg injury is one of the most common types of trauma we see in Emergency Medicine. The most important thing to remember about these types of injuries are the Ottawa rules. These are very VERY high yield. Learn them now and you will be well prepared for your rotation.

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 * The Importance of the RUG (Taming the SRU)* Genitourinary Trauma (emDOCs)

Genitourinary injuries are an often neglected aspect of trauma, but they are very important because they lead to long term morbidity if missed. In this episode we will cover a general approach to GU trauma as well as the 4 main injuries types you will encounter.

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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 * Trauma Basics (EM Clerkship)* FAST Examination (SAEM)

Abdominal trauma is probably the most difficult and most subjective type of trauma that you can evaluate. There is no perfect decision criteria that you can use. There is no perfect test. It all comes down to some magical combination of clinical gestalt and objective findings. Sure, we can usually tell when the patient needs to go straight to the OR, and we do have some great tools such as bedside ultrasound. However, none of these work 100% of the time. That is why I always consider three things when thinking through these cases. Mechanism, Exam, and Imaging.

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 * Blunt Cardiac Injury (American Association for the Surgery of Trauma)* FAST Exam (SAEM)

This week we are continuing our trauma series and talking about cardiac injury. There are 3 big diagnoses in this section that we will cover: cardiac tamponade, aortic dissection, and blunt cardiac injury. All 3 can kill your patient, and all 3 are easy to evaluate for if you know what to look for. We will cover all of these as well as several common pimp questions in this episode.

We’re having a short episode this week. ACEP 16 just wrapped up, and it was AWESOME! In this episode we’re gonna discuss a little bit about the conference itself as well as share a few quick pearls that I learned. We will also answer a user email from Andre asking about tips for interview season.

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 * Round 12 – Difficulty Breathing (EM Clerkship)* Chest Tube Thoracotomy Demonstration (YouTube)