EM Clerkship

Injuries to the chest are one of the most common, most life-threatening, and most important injuries that occur during severe trauma. In this episode we will cover injuries to the lungs with a specific focus on the 3 life threatening diagnoses that must be considered during every case: tension pneumothorax, open pneumothorax, and hemothorax.

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 * Neck Trauma: A Practice Update (emDOCs)

Today we will be covering neck injury. Specifically, we will cover soft tissue injury of the neck. It can be divided into blunt and penetrating trauma. And because this is where the blood vessels are located, the test of choice for these injuries will be a CT angiogram. We’ll discuss the indications for CTA, when to go straight to the OR, as well as a few other pearls during this week’s episode.

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)

This episode will overview cervical spine injuries in trauma. First you put the collar on, then you take it off. The tricky part is learning WHEN to take the collar off. You have two options. Option 1 is to use a decision rule called the NEXUS criteria. Option 2 is to get a CT of the cervical spine and then “clear the collar” when the picture returns. Otherwise, the collar stays on until the patient can get follow up with a spine specialist.

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 * Trauma Basics (EM Clerkship)* CORE EM: Facial Fractures (emDOCs)

We are continuing our trauma series this week and will be discussing facial trauma. Severe injuries to the face sound complicated, but I promise you they’re not. In this episode we will cover the basic management of all facial trauma as well as the 6 major injuries you might see during your rotation.

C→ Episode Summary

Congratulations on getting those applications submitted! Today, we’re trying a different format. This is an interview with Dr. Mark Reiter, program director at the University of Tennessee – Nashville, about application day and ERAS. When I was a medical student, I had absolutely no idea what went through a program director’s mind on application day. But this week, I finally had a chance to get my questions answered. Please send me some constructive feedback about this episode so I can continue to provide quality content. Good luck with your interviews, and as always, be sure to enjoy your shift!

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)

Over the next several weeks we are going to be doing a series of episodes on trauma. Starting today with head trauma. There are lots of critical diagnoses that you cannot miss with head injuries, and you need to order a CT head without contrast if you suspect any of them. One way to help you decided whether to order a CT is by using the Canadian Head CT Rule. We will cover all of this and more in today’s episode.

W→ Episode Summary

We’re taking a mental break this week and talking about Step 3. I took the test last month and found out a few weeks ago that I passed! And so in this episode we’ll be breaking down the details of test day, study strategy, and my overall thoughts about how it went. Step 3 is definitely not a test you want to blow off, but it’s also fairly easy to pass as long as you prepare appropriately.

Elderly people die from abdominal pain Step 1: Risk Stratify * Certain patient groups have VERY high mortality when having abdominal pain* Geriatrics* Immunocompromised* Diabetics Step 2: Consider Genitourinary Causes * Be especially cautious with lower abdominal/flank pain* Mention that you performed or considered performing GU exam during presentation!* Common GU causes of abdominal pain* Testicular/ovarian torsion* Prostatitis/pelvic inflammatory disease* Ectopic pregnancy Step 3: High-Yield Tests to Consider * CBC and Electrolytes* EKG and Troponin* Liver Panel and Lipase* Urinalysis and Urine pregnancy Step 4: Order Appropriate Imaging * CT scan is most useful test with abdominal pain in adults* Need to give IV contrast if concerned for vascular pathology* Usually performs just as well as ultrasound (even in cases where ultrasound is the classic, initial test)* 3 “exceptions” to the CT first rule* If concerned for biliary pathology* RUQ ultrasound* If concerned for genitourinary pathology* Testicular/Pelvic ultrasound* Renal ultrasound (kidney stone)* If concerned for Abdominal Aortic Aneurysm* Bedside Aorta ultrasound Step 5: Disposition * Classic teaching is that patients discharged with undifferentiated abdominal pain need follow up in 12-24 hours* It’s ok to have them come back to the ED if necessary Additional Reading * Abdominal Pain History (EM Clerkship)* Abdominal Pain Exam, Plan, and Disposition (EM Clerkship)

The most common chief complaint in Emergency Medicine is abdominal pain. Most students already have an understanding of the basic approach to this problem. We know to ask about fevers, palpate the abdomen, and give something for nausea. In this episode we will be discussing an additional 5 steps that tend to be overlooked with this chief complaint as well as some can’t miss items on your differential diagnosis.