Senior Report 8.22

seniorreport

Case Discussion by Eric Malone, MD

Visual Stimulus Case:

A 26 year old male with a past medical history of schizophrenia presents after jumping out of a second story window in a possible suicide attempt. He was brought to the emergency department on petition and was originally taken to the crisis center, where, in addition to intramuscular haloperidol and lorazepam, he also received a foot X-ray, which is provided below.

He has no other injuries and complains only of right foot pain. Examination shows deformity of the dorsal aspect of the right foot with tenderness and soft tissue edema over the midfoot. Range of motion in the right ankle is intact, as are peripheral pulses and neurologic function.

8.2228.22

 

Questions:

  1. Based on the above X-ray, which of the following is the most appropriate course of management:

A. Order more haloperidol and lorazepam because the patient is clearly malingering and there is nothing wrong with his foot.

B. Posterior mold right leg splint (with stirrups), non-weight bearing on the right leg, crutches, adequate analgesia and rapid orthopedic outpatient follow up (following completion of psychiatric evaluation)

C. Pain control, preoperative laboratory studies, and emergency department orthopedic consultation

D. Post-op shoe, pain control, PRN orthopedic or podiatric follow up.

 

  1. In addition to the findings that you identified on the above x-ray, which of the following other injuries is also likely present:

A. Occult talar dome fracture

B. Disruption of the ligamentous structure of the midfoot at the tarsometatarsal joint

C. Disruption of the vascular supply of the fifth metatarsal head

D. Calcaneal tendon rupture

 

  1. Failure to diagnose and appropriately manage this injury pattern is most commonly associated with which of the following:

A. Midfoot instability and collapse, severe arthritis

B. Avascular necrosis of the fifth metatarsal head

C. Atrophic degeneration of musculature of the dorsal foot including extensor digitorum brevis

D. Fracture non-union

 

Answers:

  1. C
  2. B
  3. A

Discussion:

The radiographs demonstrate a fracture through the base of the second metatarsal. In addition, there is widening of the joint space between the base of the first and second metatarsals and inferolateral subluxation of the first and second metatarsals relative to their respective cuneiforms. As with seemingly all orthopedic injuries, this pattern has an eponymous description. This injury pattern is known as a Lisfranc injury.

Lisfranc injuries refer more generally to a pattern of injury that involves disruption of the Lisfranc joint. As shown below, the Lisfranc joint is described anatomically as the articulation between the bases of the metatarsals and cuneiform bones.

This joint extends across the midfoot. Any disruption with or without fracture can be described as a Lisfranc injury. Notably, not all such injuries involve obvious metatarsal fractures; some are subtle and involve only ligamentous injury. Note that in the normal anatomical relationships of the midfoot, the proximal metatarsal articulates with the tarsal bones such that the borders of each are aligned, as shown below. The medial border of the second metatarsal aligns with the medial border of the middle cuneiform on the AP view. Presence of an avulsion fragment within the joint space between the first and second metatarsals is known as a Fleck sign (because you can never have enough eponymous ortho descriptors).

Mechanistically, Lisfranc injuries occur as a result of either direct (i.e. blunt) or indirect trauma. With an indirect traumatic injury, the Lisfranc joint undergoes excessive pronation or supination in an already plantar flexed foot, resulting in ligamentous injury. Examination will show midfoot tenderness, soft tissue swelling, potential ecchymosis, and difficulty or inability to bear weight. Plantar ecchymosis is an exam finding specific for Lisfranc injury.

Radiographic evaluation for Lisfranc injuries should focus on the relationships of the midfoot structures described above. In reviewing the x-rays in this case, note the abnormal relationship of the base of the second metatarsal to the cuneiform (red), the widening of the space between the first and second metatarsals (yellow), and the Fleck sign (blue).

Some Lisfranc injuries can be subtle. If history and exam is suggestive of more severe injury than demonstrated by x-ray, weight bearing radiographs or CT should be considered. Failure to diagnose and obtain appropriate early fixation is associated with increased complication rates.

All suspected Lisfranc injuries warrant ermegency department orthopedic consultation, and most will undergo operative fixation and extensive casting as an outpatient. Even when appropriately diagnosed and managed, there is a high degree of post-operative complications, primarily residual pain.

References:

Ross G,Cronin R,Hauzenblas J,Juliano P. Plantar ecchymosis sign: a clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. J Orthop Trauma 1996;10(2):119–22.

Rosen’s Emergency Medicine: Concepts And Clinical Practice. Marx J, Hockberger R, Walls RM, Adams J, Rosen P. Philadelphia. Mosby

M.J. Welck et al. / Injury, Int. J. Care Injured 46 (2015) 536–541

Hatem SF. Imaging of Lisfranc injury and midfoot sprain. Radiol Clin North Am 2008;46(6):1045–60.

DeOrio M, Erickson M, Usuelli FG, Easley M. Lisfranc injuries in sport. Foot Ankle Clin 2009;14(2):169–86.vier, 2010

Intern Report 7.9

Case Presentation by Dr. David Viau, MD

CC: Motor Vehicle Crash

HPI:
A 27 y.o. hispanic female is brought into Marquette, MI ED (a rural emergency department) by EMS as a trauma code on a backboard with a c-collar. The patient was driving on US41 (a small two lane highway) during a blizzard at 60mph when she all of a sudden she lost control of her car. The vehicle was found in the ditch with the front end smashed in by a large tree. Airbags were deployed. The patient was found by EMS standing next to the SUV, leaning on it for support, barely able to hold herself up. She does not remember what happened or if she was wearing a seat belt. She is currently complaining of feeling cold, neck pain and interscapular pain.

ROS:
Constitutional: Denies fevers
ENT: Denies epistaxis
Cardiovascular: Denies palpitation
Respiratory: Denies shortness of breath
Gastrointestional: Denies vomiting
Genitourinary: Denies hematuria
Musculoskeletal: Denies joint swelling
Integumentary: Denies rash
Neurological: Denies seizures
Psychiatric: Denies auditory or visual hallucinations

PMH: Histoplasmosis (from harvesting bat guano in Mexican caves), typhoid fever
PSH: 1 caesarian section for placenta previa
Social Hx: Patient denies smoking cigarettes and illicit drug use. She admits to EtOH consumption. Denies drink today. Last menstrual cycle 5 weeks ago.
Family HX: Hypertension, dyslipidemia, type 2 diabetes and obesity
Meds: prenatal vitamins
Allergies: Seasonal, Sulfa

Physical Exam:
Temperature: 34, HR 90s, BP 160/90, RR16, Sat 98% on RA
Constitutional: non-obese female immobilized on backboard w/c-collar.
Head and Neck: diffuse tenderness to palpation of the cervical spine.  There are no step-offs or deformities.  There are no raccoon eyes or battle signs present.
Eyes: Pupils are 3 mm round reactive to light bilaterally.  There is a good consensual reaction to light.  No sign of trauma to the eyes.
ENT: There is no hemotympanum present.  No rhinorrhea or bleeding from the naris.  The tongue is not swollen. Patient has a hoarse/raspy voice.
Cardiovascular: There is a normal S1 and S2 without murmur present.  The patient has 2+ pulses in the radial arteries bilaterally. There are 1+ pulses in the femoral arteries bilaterally.
Respiratory: Lung sounds are present bilaterally with appropriate air movement.  There is no wheezing appreciated.
Gastrointestional: Abdomen is soft, nondistended and nontender to palpation.  There is no guarding or rigidity.
Genitourinary: There is no signs of vaginal bleeding.
Musculoskeletal: No obvious deformity is noted in the extremities. Patient has 5/5 muscle strength to in arm flexion and extension, leg flexion and extenstion, dorsiflexion and plantar flexion bilaterally. She can touch thumb to each ringer and is able to resist separation of thumb from fingers appropriately .
Integument: Patient has a small haemostatic laceration on her left cheek. There is a seatbelt sign across the patient’s chest.
Neurological: GCS of 15, Patient is able to stick out tongue and move to both sides.  Uvula is not deviated. Smile and forehead wrinkling is symmetric.  Patient is able to shrug shoulders against resistance.  Patient has sensation in the V1, V2 and V3 distribution of the trigeminal nerve.  Extraocular eye movements are intact.  Patient has normal finger to nose test and normal heel-to-shin test.  There is a negative Babinski bilaterally.

Fast Exam: Did not reveal any intraperitoneal fluid or cardiac tamponade.

CXR: Did not show any acute cardiopulmonary process as per radiology intern.

Labs:
labs

QUESTIONS:

1.  What is the most sensitive diagnostic modality currently available given this patient’s scenario?
a) CT  Abdomen scan w/contrast
b) Chest x-ray
c) ED thoracotomy
d) Transesophageal echocardiogram
e) CT Chest w/contrast
f) CT head w/without contrast

2.  What is the best management for the patient with their suspected injury?
a) Nitroglycerin
b) Esmolol
c) Amlodipine
d) Dyazide

3. The patient complains of diffuse cervical spine tenderness to palpation. What is the most sensitive modality to detecting an injury?
a) Obtain a complete cervical spine x-ray series plus obliques.
b) CT c-spine
c) Able to use nexus criteria to clear c-spine without imaging.
d) Cervical spine sonography

Answers & Discussion:

1) e
2) b
3) b

1. The patient has an aortic tear secondary to a deceleration injury. Clues to this include the intrascapular pain, hoarse voice (compression of laryngeal nerve and slight compression of trachea, sometimes tracheal deviation will be observed) and decreased femoral pulses. Often the patients are hypertensive secondary to stretching the afferent sympathetic fibers at the isthmus of the aorta that may cause reflex hypertension(Rosen’s p. 452).

Initial diagnostic testing is as simple as a (b) chest x-ray. The big clue is widening of the superior mediastinum (50-90% sensitivity, 10% specificity). However mediastinum widening is not present in everyone with a blunt aortic injury, 7-44% of patients have no mediastinal widening. This implies mediastinal widening should increase our worry of a possible deceleration injury, but can neither confirm or rule out it’s existence. (a) CT scan w/contrast have nearly 100% sensitivity and specificity and are often thought of as better than historical gold standards of Aortogram. It is recommended that all patients with significant mechanism of injury under go a CT scan regardless of findings in the CXR. (d)Transesophageal echocardiogram (TEE) also provides great diagnostic power with a sensitivity of 87-100% (variability secondary to operator skill) and specificity of 98-100%.  Often surgical intervention will be started with TEE results alone.  (c) ED thoracotomy is not indicated here.

CORRECT ANSWER is (e), CT scanner is the most sensitive way to evaluate patients for aortic deceleration injuries..  

2. Management of the aortic rupture includes basic ABCs in the ED. Not all tears lead to immediate exsanguination. Other injuries such as intracranial injury or intra-abdominal hemorrhage may take priority. Strict blood pressure control should be maintained at all time with goal systolic blood pressures ranging from 100-120 mmHg. The goal with the decreased blood pressure is to decrease shearing forces exerted on the aorta. This is done by decreasing the number of pulsatile loads (heart rate) and managing the blood pressure.  (b) Beta blockers are the drugs of choice. Often a short acting titratable Esmolol is used, but lebatolol can be is used too.

Definitive management is surgical intervention either by open technique or utilizing endovascular technique. Patients should have prompt repair of the tear to decrease risk of rupture. However repair can often be delayed if more life threatening circumstances are present.

CORRECT ANSWER is (b) esmolol. (a,c,d) do not decrease heart rate, hence the shear force is not decreased. Rosen’s p.454

7.9

(google image)

flow across the vessel wall creates a Force perpendicular to the direction of flow. If the aorta intima has a tear it is liable to rupture through the adventitial layers and hemorrhage. Each pulsatile cycle increases risk.

3. (c)Complete cervical spine x-ray series plus oblique views are able to recognize spinal injuries with high accuracy as long as all seven cervical vertebrae are adequately visualized. They fail to recognize injury in 0.07% of patients with injuries and 0.008% of patients with unstable spinal injury. (Rosen’s p.403). That being said adequate visualization of all 7 cervical vertebrae is not obtainable on up to 25% of patients. Obesity is a risk factor for inadequate visualization of all 7 vertebrae.  The question needs rework.  I would get cross table lateral and transfer.

Often EM physicians lean on the (b) CT cervical scan too much to clear a c-spine, especially if the patients body habitus lends to easy x-ray visualization of all cervical vertebrae. That being said CT scans are superior to x-rays in the 25% of patients that we are unable to get adequate visualization of all cervical vertebrae. The sensitivity for CT to detect fractures varies according to studies, but generally has a sensitivity around 99.3-100%.

Other considerations are cost CT $4386 verses x-rays $513 and radiation exposure CT 26 mSv verses 4 mSv.

(c) Not accurate. The patient has cervical tenderness. Nexus criteria can be employed only if patient is non-tender. (d) this answer makes no sense, ultrasound is not used to detect injuries to the cervical spine.

Correct answer is (b). CT scan is the most sensitive way to detect c-spine injuries. That being said complete cervical spine X-ray series are appropriate and sufficient in many patients. X-rays have the advantage of being cheaper, less radiation and readily available. That being said there is 25% of the patient population who do not have adequate visualization of the cervical spine. These patients often being obese

References:
Rosen’s Emergency Medicine 8th edition.
Google image search for blood vessel image

Senior Report 6.20

Case Presentation by Dr. Jeanise Butterfield

Case:

An 18 year old girl was riding her horse when the horse stopped suddenly and put his head down.  She slid off the front of her horse landing on the posterior aspect of her left should and neck, rolling onto her back (think somersault).  She complains of severe back pain.  There is tenderness of the thoracic and lumbar spine diffusely with no neurologic deficits. CT of the cervical spine was within normal limits.  Radiographs of the thoracic and lumbar spine are shown below.

6.19-1j        6.19-2j    6.19-3j                           6.19-4j

Questions: 

 1) By mechanism of her injury, which type of spinal column injury do you suspect?

a) Flexion

b) Extension

c) Compression

2) Is there deformity visible on radiograph?

a) Yes

b) No

c) More information required

 3) Which of the following is a stable spinal fracture?

a) Flexion teardrop fracture

b) Unilateral facet dislocation

c) Hangman’s fracture

d) Jefferson fracture

4) If this patient was uncooperative and combative, the following treatment would be appropriate?

a) Have an individual hold patient’s head in alignment with spine

b) Sedation

c) Drug induced paralysis

d) All of the above

 

Answers and Discussion:

1.  a

2.  a

3.  b

4.  d

 

 

6.19-mri

Spinal column injuries are classified according to the mechanism of trauma: flexion, flexion-rotation, extension and vertical compression.  When assessing stability of a spinal injury (meaning the spinal cord is protected) it is helpful to view the spine as an anterior and a posterior column.  The anterior column consists of alternating vertebral bodies, intervertebral disks, anterior and posterior longitudinal ligaments.  The posterior column contains the spinal canal, pedicles, transverse processes, articulating facets, laminae and spinal processes with nuchal ligament complex, capsular ligaments and ligamentum flavum.  In a very basic sense you can imagine that if both columns are disrupted, the spine will move as two separate entities whereas if only one column is disrupted the other will resist movement.  This can only be applied to injuries below C2.

Unstable flexion injuries

–        Flexion teardrop fracture: avulsion of anteroinferior corner of a vertebral body by anterior longitudinal ligament causing anterior displacement of a wedge shaped fragment resembling a teardrop.  It commonly involves ligamentous disruption and is often associated with neurologic injury.  Of note, this can also occur with extension injury (see below).

–        Bilateral facet dislocation: Forces of flexion cause disruption anterior to the annulus fibrosis and anterior longitudinal ligament.  This causes anterior displacement of the spine above the level of injury as the upper vertebra passes over superior facets of the lower vertebra

–        Alanto-occipital dislocation: This occurs more often in children, partly due to larger relative head size and ligamentous laxity, can also occur non-traumatically in Down syndrome and rheumatoid arthritis.

–        Odontoid fracture with lateral displacement: need I say more?

–        Subluxation is also potentially unstable

Unstable flexion-rotation injuries

–        Rotary atlantoaxial dislocation: In trauma, may occur with forced rotation of the neck with some element of lateral tilt.  There are several ways this can occur with respect to placement of atlas on axis including rotation on odontoid or on one of the lateral articular process

Unstable extension injury

–        Hangman’s fracture: traumatic spondylolysis of C2.  Fracture-dislocation of atlas and axis, specifically of pars interarticularis of C2 and disruption of C2-3 junction.

–        Extension teardrop fracture: Same as above flexion teardrop fracture, usually occurs in lower cervical vertebra from diving accidents.

–        Posterior atlantoaxial dislocation

–        Posterior neural arch fracture (C1): results from compression of the posterior elements between occiput and spinous process of the axis during forced extension.  This is unstable primarily due to location.

Unstable vertical compression

–        Jefferson fracture: Axial loading results in shattering of the ring of the atlas, associated with disruption of transverse ligament.

Always think of spinal injury in patients presenting with trauma, especially motor vehicle collisions, falls from heights and sports related injuries.  Obtain radiographs in patients with suspected injury but don’t let distracting injury prevent you from performing complete physical exam and maintain spinal immobilization until spinal injury has been excluded.

Senior Report 6.14

Case Presentation by Dr. Cameron Kyle-Sidell

photo

photo

photo

Questions:

1) The injuries shown above are most consistent with which of the following clinical presentations:

a)  A furnace mechanic who suffered a flash burn

b)  A golf caddy struck by lightning

c)  A maintenance man who mishandles an overhead power line

d)  A lawyer working on a home improvement project gone wrong

2) The patient above complains of significant neck pain upon presentation.  Which of the following diagnostic modalities should be most considered:

a) CT of the neck with contrast to evaluate for underlying muscle necrosis

b)  Local surgical exploration at site of pain

c)  CT of the neck without contrast to evaluate for underlying bony injury

d)  Neck fasciotomy to relieve compartmental pressure

3)  The following patient can be safely discharged from the emergency department:

a)  A woman at 24 weeks gestation who suffers an electrical injury when plugging in a hair dryer, landing on her back, who has no loss of consciousness and a normal EKG.

b)  A 35 year old male who suffers electrical injury while plugging in the microwave, with a normal EKG and no loss of consciousness and a small cutaneous burn on his forearm.

c)  A 25-year-old male who is electrocuted by a power line at work, with an EKG demonstrating T wave inversions in the lateral leads, and no loss of consciousness.

d)  An 8-year-old male who suffers an oral burn after biting an electric extension cord with swelling of the tongue and the floor of the mouth with no active bleeding.

 

Answers:

1)  C.

The injuries pictured above are most consistent with a high voltage electrical burn.  When a patient presents with an electrical burn, it is important to establish the source of injury.  Electrical burns are typically divided into high voltage and low voltage injuries.  High voltage injury is defined as exposure to more than 1000V.  The patient pictured presented after grabbing a fallen overhead power line exceeding 10,000 V with his right hand.  High voltage injuries present as painless, depressed, yellow-gray charred craters with central necrosis. In general, high voltage injuries may largely spare the skin surface but cause extensive injury to underlying soft tissue and bone.  High voltage electrical injury can however lead to a “kissing burn” as seen running down the patient’s midline, a cutaneous burn which occurs along flexor creases when an electrical current arcs across both flexor surfaces.  These burns are important to recognize as they are often associated with significant underlying injury.  This kind of “hidden” damage is rare in low voltage injuries.

A golf caddy struck by lightning is unlikely to present with the findings in the picture. Lightning strikes act as an instantaneous current, and while its voltage can exceed 1 million volts, it rarely causes significant cutaneous burns or soft tissue damage because of its brief duration. Lightning is more likely to cause cardiac and respiratory arrest, neurologic sequelae, and autonomic instability.  There are four main types of burns that can be seen with lightning strikes: linear burns, punctate burns, feathering burns, and thermal burns. Linear burns occur where sweat or moisture has accumulated on the body, such as down a person’s chest or in the axilla.  Punctate burns resemble cigarette burns. Feathering burns show no damage to the skin itself and make a fern like pattern on the skin secondary to electron showers induced by lightning. They do not require therapy. Thermal burns occur if a person’s clothing catches on fire or if they have metal on their body that is heated by the flash.  Many people who have experienced lightening strikes will present with a combination of these types of burns.

A lawyer working on a home improvement project likely sustained a low voltage injury which creates smaller, well-demarcated contact burns at the sites of skin entry and exit than is indicated in the picture. A furnace mechanic who suffered a flash burn will normally present as a superficial partial thickness burn which more closely resembles a traditional burn as seen in victims of fires.

2)  C. 

Secondary trauma must be considered in all high-voltage exposures, especially in those involving direct current electricity.  Just as the voltage potential of electrical injuries is important to distinguish, it is important to determine if the patient was exposed to alternating current (AC) or direct current (DC).  A direct current is more often used in automobiles, batteries, and high-voltage power lines.  An alternating current is more common in homes and offices.  Exposure to each leads to muscle contractions. Direct current causes a single muscle contraction that often throws the patient away from the source while an alternating current leads to tetanic muscle contractions which can often bring the patient in closer proximity to the source.  Most electrical exposures occur to the upper extremity, and because the flexors of the upper extremity are typically stronger than the extensors, the tetanic contractions in AC exposure often cause the arm to flex and bring the source closer to the body.  While both AC and DC can lead to significant morbidity (and mortality), a direct current exposure suggests a much higher risk of secondary trauma.  Given our patient’s high voltage, direct current exposure, we should have a high degree of suspicion for secondary traumatic injury.  Our patient in fact had a loss of consciousness and sustained a contusion to the back of his head from being thrown backward during the incident.  A CT of the neck without contrast is warranted to rule out a cervical fracture from the fall.  It is not uncommon for patients to present with fractures and joint dislocations, including posterior shoulder dislocations, due to falls and forceful muscle contractions after direct current exposure.

Surgical exploration of the neck and fasciotomy are not indicated at this time.  While significant underlying muscle necrosis and edema can occur leading to increased compartmental pressures, this is far more common in the extremities.  In the absence of hard signs such as progressive neurologic dysfunction and vascular compromise, early surgical intervention is generally not indicated.  While careful monitoring for increased compartmental pressures is required, unnecessary surgical intervention including fasciotomy can lead to a prolonged hospital course including multiple ensuring surgeries and significant rehabilitation time.  A CT with contrast is not the diagnostic modality of choice to evaluate for cervical fractures or compartment pressures.

3)  B.

A 35 year old male who suffers electrical injury while plugging in the microwave with a normal EKG and no loss of consciousness and a small cutaneous burn on his forearm can be safely discharged. Current recommendations suggest that all patients who present to the emergency department after suffering an electrical injury to a low or high voltage source should have an EKG  performed to evaluate for arrhythmias and cardiac injury.  Patients who experience low-voltage injury with no EKG abnormalities, no loss of consciousness, or other significant injury can be safely discharged home with appropriate wound care.

A pregnant patient with a viable fetus requires fetal heart monitoring due to the potential for placental abruption. Ultrasound may also be indicated if the patient experiences symptoms such as vaginal bleeding, decreased fetal movement, or persistent abdominal pain to assess for fetal viability. Electric burns can increase uterine activity and affect uteroplacental circulation, which can require aggressive resuscitation in the hospital. Fetal complications as a result of electrical trauma include IUGR, spontaneous abortion, oligohydraminos, and cessation of fetal movement.

The child with an oral burn and tongue swelling has evidence of possible airway compromise.  He should be closely observed to monitor for further swelling.  If this patient had no intraoral swelling, he could be discharged home.  One of the most common injuries seen in children is an oral arc burn which occurs with biting of an electrical cord.  These patients can have delayed bleeding up to 2 weeks after the incident from the labial artery when the initial eschar separates, however observation to monitor for this delayed bleeding is unnecessary.  Parents should be properly educated on the chance for rebleeding and instructed to return should such bleeding occur.

Any patient with a high voltage injury with or without EKG abnormalities requires admission to a burn center due to the possible for significant hidden underlying injury.

References

Emergency Medicine Practice.  Electrical Injuries:  A review for the emergency clinician.  October 2009, Volume 11, Number 10. Ebmedicine.net

Intern Report 6.13

Case Presentation by Dr. Sarah Michael

CC: I can’t breathe!

A 21-year-old female is transported to the emergency department after an apparent domestic dispute. On arrival, it is apparent that she has multiple stab wounds to her chest and abdomen. She is alert and oriented but in acute distress. Her blood pressure is 98/64, pulse 112, respirations 32 and oxygen saturation 94% on nonrebreather mask. There is no jugular venous distension. You can appreciate a small degree of tracheal deviation. An eFAST is performed which includes the following findings.

6.13-1

6.13-2

6.13-3

1. The most appropriate next step in the management of this patient is:

A: Needle decompression of the right hemithorax

B: Left-sided chest tube

C: CT of the chest, abdomen and pelvis

D: Emergent transport to OR

2. The patient’s clinical status remains unchanged.  A repeat U/S shows the following:

6.13-4j

Now the most appropriate next step is:

A: Chest tube placement

B: Intubation

C: Finger thoracostomy

D: Chest x-ray

3. Which of the following is true regarding the patient’s belongings?

A: They should be placed in a plastic bag and remain with her.

B: They should be placed in paper bags and offered to the police.

C: If ED staff handles them they lose their forensic value.

D: Blood-soaked items should be placed in biohazard waste.

Answers & Discussion:

1. The answer is A, needle decompression.

The patient in the vignette is in shock and her physical exam is concerning for a  tension pneumothorax with respiratory distress and hypotension. Notably, JVD may be absent in the hypotensive patient. In order to correctly answer the question, you need to be able to interpret the eFAST findings.

An eFAST (extended FAST) exam includes the normal FAST structures as well as the lung at the 3-4 intercostal space on the anterior chest wall. This is the most superior aspect of the chest in a supine patient and the location where you would expect air to accumulate.  You’re given 3 images to interpret.

The first image is of Morrison’s pouch, the most sensitive FAST view for intraperitoneal free fluid. This patient has a renal fat pad that could be mistaken for free fluid. You should be able to appreciate that the structure is lenticular with internal echoes and bounded by the hyperechoic line of the renal capsule.  This is known as the double line sign and is a frequent cause of a false positive FAST examination. Therefore, it is not a reason to rush the patient to the OR. If it’s helpful, think about it as a renal corollary of the pericardial fat pad that can sometimes mimic pericardial effusion.

6.13 ans -1j

The second image shows you a normal M-mode ultrasound of the right lung. You can see the “seashore sign” with an abrupt transition between the chest wall and lung parenchyma at the pleura. It would be imprudent to place a chest tube on the unaffected side.  

6.13 ans-2

The third image shows you the lung point of the left lung, indicating the presence of a pneumothorax. This is the place on the chest wall where the lung transitions from pneumothorax to being against the chest wall. In M-mode, you’d be able to see both the “seashore” and “barcode” signs vary with respiration.  In a setting concerning for tension, needle decompression is the way to go.  Intubating the patient before decompression risks further destabilization.   Fixing a tension pneumothorax may also prevent the need for intubation.

6.13 ans-4

2: The correct answer is A, chest tube placement.

In the trauma patient with persistent respiratory distress and decreased breath sounds after needle decompression, you should consider chest tube placement for presumptive hemothorax per ATLS guidelines. Chest tube placement is certainly indicated given the ultrasound image, which demonstrates a massive hemothorax. There is near complete consolidation of the lung as it floats in a sea of fluid. The M-mode graphic shows the movement of the lung edge with respiratory variation.

6.13-ans 3

The patient may need intubation for respiratory failure (and definitely for her trip to the OR). But intubation before tension is resolved would likely worsen the tension and could be disastrous.  Similarly, tension pneumo- or hemo-thorax is a clinical diagnosis and treatment should not be delayed by imaging.

Thoracotomy in the OR is indicated for patients who have a chest tube output of 1500 cc or greater of blood during the first hour. Given the appearance on ultrasound, more than 1500 cc would be expected. However, the tension should be relieved at once and not delayed by transportation to the OR.

Finger thoracotomy should be considered and is an option if you are uncertain of the diagnosis of hemothorax. In this case the diagnosis is not in doubt and chest tube is required.  A chest tube is also indicated once a decompressive needle thoracostomy is performed.  Furthermore, a hemothorax this large will likely re-accumulate very quickly.

3. The correct answer is B.

The patient is a victim of a violent crime and her clothing, through which she was stabbed, likely contains valuable forensic evidence. Caring for the patient obviously takes priority over the preservation of such evidence, but steps can be taken to maintain evidence integrity so long as they do not delay care. When removing a patient’s clothing, try to avoid cutting through stab or bullet holes and always wear gloves. In some cases, the frequent changing of gloves can help to keep from cross-contaminating evidence.  Even if evidence is collected or handled suboptimally in the provision of care for the patient, it is not worthless and should still be made available to investigators.

After being removed from the patient, clothing should be placed in separate paper bags and given to law enforcement. The paper bags will allow the blood to dry in a way that does not promote the formation of mildew, which can destroy the evidence. Blood soaked items should be placed in separate plastic bags followed by separate paper bags. Law enforcement should be informed that the items are soaked so they can be dried appropriately.

If law enforcement declines the evidence, it should be returned to the patient.

Riviello, edited by Ralph J. (2010). Manual of forensic emergency medicine : a guide for clinicians. Sudbury, Mass.: Jones and Bartlett Publishers. ISBN 978-0-7637-4462-5.

Senior Report 5.23

 

Case Presentation by Dr. Brandon Cheppa

Chief Complaint: “My foot hurts”

History of Present Illness:  This is a 40 year old male with a one day history of sudden right foot pain.  He states that last night he jumped over a fence and upon landing he had sudden onset of pain in his foot.  He states that he has barely been able to put weight on his foot and that walking is difficult.  The pain is constant, worsening, and he has never had pain in his foot like this before.  He denies any knee, hip, or back pain.  He denies any history of pain in any of his other joints.  He denies any head trauma, loss of consciousness, or numbness in any of his extremities.  He has not tried any medications and nothing seems to make it better or worse.

Review of Systems:  As per HPI

Past Medical, Family, and (or) social history:

Past Medical History:  Negative for Hypertension, Negative for diabetes

Past Surgical History: Denies any surgeries

Medications: None

Allergies: No known drug allergies

Social History:  Smokes cigarettes, denies alcohol, drugs, or intravenous drug use.

Family History: Unknown

Examination of organ system and body areas:

Vital signs: BP: 136/97, HR: 88, RR: 18, Temp 36.7 orally

Constitutional:  Patient appears comfortable, sitting in a wheelchair

HEENT:  Head is normocephalic, atraumatic, no tenderness to palpation, PERRLA, EOMI,

Neck:  Soft, supple, no masses, no cervical midlinetenderness

Cardiovascular:  Normal heart sounds

Respiratory:  Normal breathsounds

Gastrointestinal:  Soft, non-tender, non-distended, no palpable masses

Skin: No lacerations, no open lesions, no rashes seen

Neurological:  Patient is AOx3, acting appropriately, No sensory deficits,  grossly moving all extremities well, normal facial symmetry.  He has a hobbling gait favoring his left side and is unable to put weight on his right leg.

Back: No midline tenderness of entire spine

Skin:  No ecchymosis or breaks in skin seen

Musculoskeletal:  Upper extremities and Left lower extremities have full range of motion at all joints with 5/5 strength to flexion and extension and have no swelling or deformities to palpation.  Focused exam of left lower extremity:  Full range of motion of hip and knee with 5/5 strength to flexion and extension.  Patient has no calf tenderness, no Achilles tendon tenderness.  Right ankle has no malleolar tenderness.  He has tenderness of his midfoot, it is red, swollen with no crepetus or fluctuence.  He has good symmetrical pules of both feet with good capillary refill and he is neurovascularly intact.

Labs: None

Images: Complete x-ray of the foot was obtained

Questions:

1) The x-ray obtained is concerning for which type of fracture?

A. Boxer’s fracture

B. Jones’ fracture

C. Lisfranc’s fracture

D. Maisonneuve fracture

E. Salter-Harris type IV fracture

2) What is the appropriate disposition for the patient?

A.  Ace wrap, crutches, non-weight baring, follow-up with orthopedic clinic in 1 week

B.  Ace wrap, “ortho shoe”, weight bare as tolerated, follow-up with orthopedic clinic in 1 week

C.  Immediate orthopedic consultation in the emergency department

D.  Posterior mold splint, crutches, non-weight baring, follow-up with orthopedic clinic the next day

3) What is the most common complication this patient will experience if this injury is not appropriately treated?

A.  Compartment syndrome

B.  Deep Venous Thrombosis

C.  Degenerative Arthritis

D.  Osteomyelitis

E.   Regional Pain Syndrome

Answers:

1)    C

2)    C

3)    C

Discussion:

A Lisfranc fracture is one part of the collective term Lisfranc Injury.  A Lisfranc injury can very in radiographic presentations, but are all centered around any injury to the tarsometatarsal joints, also known as Lisfranc’s joint.

The Lisfranc’s Joint is made up of the five metatarsals and their articulations with the three cuneiforms, the navicular bone, and the cuboid bone.  The biomechanical structure of the foot allows for passage of neurovascular bundles and connective tissues through the foot without being crushed by a person’s weight.  The metatarsal bones have a trapezoid shape and are arranged in an arch configuration using the second metatarsal as the “keystone”.  Under normal physiologic conditions the second metatarsal has very little motion compared to the other four metatarsal bones.

The Lisfranc ligament is the strongest of the tarsometarsal ligaments and connects the lateral surface of the medial cuneiform to the medial base of the fifth metatarsal.  There are no proximal ligaments between the bases of the first and second metatarsals, most likely due to the evolution of the foot from a primitive hand structure where the first metatarsal evolved from a primitive thumb.  There are ligamentous connections between the second through fifth metatarsal bones and all five have distal ligamentous connections.  One to two mm of dorsolateral displacement of the affected base of the second metatarsal can lead to 13-25% reduction of contact at the joint.  The dorsalis pedis artery and deep peroneal nerve can be compromised with this injury due to their locations in the foot.

Patients can injure this structure by many mechanisms and it usually results in a closed fracture.  Motor vehicle collisions, falls, and even pedestrians tripping on curbs can produce this injury.  It stems from forceful abduction of the forefoot of a plantar-flexed foot.  Windsurfers, motorcyclists, and people who get thrown off horses have been historically at risk for this injury.  Patients typically will present with pain, swelling to the midfoot, and difficulty placing weight on the injured extremity.  They may present with ecchymosis to the plantar surface of the midfoot, although not specific, it is suggestive of an injury.  A detailed history and physical exam with attention to other associated injuries such as at the knees, hips, and lower back will guide your work-up.

Complete x-rays of the foot will pick up a Lisfranc injury 90% of the time.  With high clinical suspicion, and a presumptive negative x-ray, you can elect to get “stress” views of the foot which requires the patient to place weight on the injured foot.  Often times this is difficult to accomplish due to significant pain, or lack of ability to interpret a “stressed-view” of a foot x-ray, therefore a CT scan will aid in diagnosis.

With the knowledge of the anatomy combined with the mechanism of force, on radiograph, a fracture at the base of the second metatarsal is pathognomonic of a disruption of the Lisfranc ligamentous complex.  The diagnosis is made radiographically on the anteriorposterior view when there is a gap greater than 1 mm between the bases of the first and second metatarsals.  Other radiographic findings may be present or can lend to the diagnosis such as loss of alignment of the medial edge of the base of the second metatarsal with the medial edge of the middle cuneiform; loss of alignment of the lateral border of the third metatarsal shift with the lateral border of the lateral cuneiform; or loss of alignment of the medial border of the fourth metatarsal with the medial border of the cuboid.  If radiographs are unequivocal, and suspicion is still high, there is a chance of a spontaneously reduced dislocation.

Patient who sustain a Lisfranc injury require an emergency room orthopedic consultation and are to be made non-weight baring until their evaluation.  This is due to the large degree of instability of the joint that could lead to significant disability, and the potential for compartment syndrome and/or neurovascular injury.  Patients typically need to go to the operating room and undergo open or closed reduction with application of hardware.  Patients who have a Lisfranc sprain, will require below-knee casting, crutches, “RICE” therapy, and close orthopedic follow-up due to their potential for operative fixation.

The most common complication of an untreated Lisfranc injury is degenerative arthritis in the form of posttraumatic arthrosis.  Other less common complications include: compartment syndrome in the acute injury setting, deep venous thrombosis due to the amount of immobility, regional pain syndrome.

With early diagnosis and proper orthopedic intervention, 95% of patients at 3.5 years will have an excellent outcome.

The case revisited:

This gentlemen raised our suspicion for a midfoot injury based on his mechanism and physical exam.  We obtained foot radiographs and it showed a fracture of the base of the second metatarsal (circled in green), widening between the bases of the first and second metatarsal (measurement in blue), and a “fleck sign” (circled in red) which is a ligamentous disruption from the base of the second metatarsal.  This radiograph raised our suspicion for a Lisfranc injury and the orthopedic service was consulted.

They requested a CT scan due to the high potential for other associated fractures and it also showed a comminuted fracture of the medial cuneiform bone.

 

They opted to not take him for emergent surgery due to him having an ongoing underlying infection which was unknown during the initial patient encounter.  On reassessment, the patient had been experiencing painless, white discharge from his penis for the last two months.  The orthopedic service felt his infection could complicate his healing due to the chance that hardware will need to be applied during surgery.  They placed him in a cast, made him non-weight baring, and wanted him to follow-up in their clinic when his infection had resolved.  He was swabbed for Gonorrhea and Chlamydia, and treated for both of those infections including Trichomonas.  The results of his cultures were negative making Trichomonas the most likely cause of his infection.  At a follow-up visit in the orthopedic clinic, they felt there was not significant boney displacement and took him to the operating room to achieve “stressed” views of the foot under anesthesia.  They were satisfied with the stability of the joint and did not undergo any surgical intervention.  He was placed him in a non-weight baring cast and will continue to follow-up in the orthopedic clinic.

References:

Rosen’s, 7th edition, pp 681-695

Tintinalli’s, 6th edition, pp 1742-1746

Browner: Skeletal Trauma, 4th edition, 2008, Foot Trauma chapter

Ouzounian T.J., Shereff M.J.: In vitro determination of midfoot motion.  Foot Ankle  1989; 10:140-146.

Lu J., Ebraheim N.A., Skie M., et al: Radiographic and computed tomographic evaluation of Lisfranc dislocation: A cadaver study.  Foot Ankle Int  1997; 18:351-355.

Intern Report 5.20

Case Presentation by Dr. Jessica Ruffino

HPI: 25y/o female at 36 weeks GA presents to ED via EMS as a trauma code after MVA.  Patient was a restrained driver, airbags were deployed.  Patient states she was rear-ended while stopped at a traffic signal and hit the car in front of her.  Other vehicle was driving about 25mph.  Patient complains of abdominal pain mostly across lower abdomen.  Patient thinks she is having contractions, unsure of frequency.  Denies loss of fluid.  Last felt fetal movement prior to accident.  Patient denies chest pain, SOB, N/V.  Patient states her pregnancy has been uncomplicated, denies high blood pressure or diabetes.  Patient did not lose consciousness, was ambulating at scene per EMS.

ROS:  Negative except for stated in HPI

PMH:  G1P0.  Denies asthma, diabetes, hypertension

PSH:  None

Medications: Prenatal vitamins

Allergies: NKDA

SH:  Denies alcohol, tobacco, drug use.

Physical Examination:

Vital signs: BP 100/75, HR 100, RR 16, Temp. 36.9°, Pulse ox. 98% on RA

Constitutional: Patient is well nourished, gravid uterus.  No respiratory distress.  Appears anxious.

Head:  Normocephalic, atraumatic.  No tenderness to palpation.

Eyes:  Pupils 3mm bilaterally, round and reactive to light.  EOMI.  No conjunctival pallor.  No scleral icterus.

ENMT:  No hemotypmanum bilaterally.  No rhinorrhea or epistaxis.  Mucous membranes are moist.  No erythema or exudates in throat.

Neck:  In cervical collar.  No c-spine tenderness to palpation, no palpable deformities. Cardiovascular:  S1, S2.  Slightly tachycardic.  Regular rhythm.  No murmurs, rubs or gallops.

Respiratory:  Lungs CTAB.  No wheezes, rhonci or rales.  No tenderness over chest wall.  No palpable crepitus over chest wall or neck.

Gastrointestinal:  Gravid uterus.  Uterus is firm.  Fundus palpable about 15cm above umbilicus.  Tenderness to palpation in lower quadrants bilaterally.  Positive seatbelt sign across abdomen.

Genitourinary:  Sterile speculum exam showed small amount of bright red blood in vaginal canal.  Cervix is closed.

Musculoskeletal:  No TTP or deformities palpated along entire spine.  No obvious deformities.  No swelling.  No dependent edema.  2+ DP pulses bilaterally.

Skin:  No lacerations or rashes.  Positive seatbelt sign across abdomen.

Neuro:  Awake, alert and oriented x 3.  Normal speech.  Strength is 5/5 proximally and distally and bilateral upper and lower extremities.  Sensation to light touch intact throughout.  DTR’s 2+ bilaterally.

A FAST exam was performed and was negative.  Transabdominal ultrasound findings shown below.  FHTs in 140s-160s.

Questions:

1.  What is the most sensitive indicator of placental abruption?

a)  Ultrasound findings

b)  Fetal distress

c)  Vaginal bleeding

d)  Uterine tenderness

2.  Which of the following is true of resuscitation of a pregnant patient with uterus palpable at or above umbilicus who is in cardiopulmonary arrest?

a)  No modifications to resuscitative efforts should be made

b)  Chest compressions should be performed higher on sternum

c)  Manual displacement of uterus to the left should be attempted

d)  Defibrillation is contraindicated

3.  A pregnant patient may lose how much circulating blood volume before manifesting hypotension or clinical signs of shock?

a)  30-35%

b)  10-15%

c)  20-25%

d)  40-45%

 

Correct Answers:

  1. B
  2. C
  3. A

 

Discussion:

Trauma occurs in 6 to 7% of all pregnancies.  It is the leading cause of maternal death due to nonobstetric causes, accounting for close to 50% of fatalities in pregnant women.  The most common causes of injury in pregnancy, in order of frequency, that result in emergency department (ED) visits are motor vehicle crashes (MVCs), interpersonal violence, and falls.  Counseling on proper seatbelt and alcohol use and screening for interpersonal violence may help to reduce the morbidity and mortality rates for pregnant patients.  Although the essential principles of trauma management remain unchanged in the pregnant patient, a number of special points need to be considered.  Pregnancy causes alterations in physiology and anatomy that affect multiple organ systems. Although there are two lives involved, maternal life takes priority.

In blunt trauma, 50 to 70% of all fetal losses result from placental abruption.  Placental separation results when the inelastic placenta shears away from the elastic uterus during sudden deformation of the uterus. Because deceleration forces can be as damaging to the placenta as direct uterine trauma, abruption can occur with little or no external sign of injury to the abdominal wall.  Because all gas exchange between the mother and fetus occurs across the placenta, abruption inhibits the flow of oxygen to the fetus and causes in utero CO2 accumulation. Such hypoxia and acidosis can lead to fetal distress.  Sustained uterine contractions induced by intrauterine hemorrhage also inhibit uterine blood flow, further contributing to fetal hypoxia.

 

 

The diagnosis of abruption is a clinical one, and ultrasonography and the Kleihauer-Betke test are of limited value.  Classical clinical findings of abruption may include vaginal bleeding, abdominal cramps, uterine tenderness, maternal hypovolemia (up to 2 L of blood can accumulate in the gravid uterus), or a change in the fetal heart rate. However, in some trauma studies, as many as 63% of cases showed no evidence of vaginal bleeding.

The most sensitive indicator of placental abruption is fetal distress. Hence, prompt fetal monitoring is a very important assessment technique in trauma during pregnancy. There is also a close linkage of abruption to uterine activity. One study reported that if 12 or more contractions occurred in any hour of a 4-hour cardiotocographic monitoring period, the risk of abruption was 14%; abruption did not occur in this study if contractions occurred less than once every 10 minutes.  Ultrasound (US) is less than 50% accurate as a first-line test in detecting placental abruption.  If the abruption bleeds externally, not enough blood collects to be seen sonographically. Even with significant intrauterine blood accumulation, accurate US diagnosis may be difficult because of placental position (i.e., posterior) and confounding uterine or placental structural conditions.

 

Hemodynamic Changes of Pregnancy (Mean Values)

PARAMETER NONPREGNANT TRIMESTER 1 TRIMESTER 2 TRIMESTER 3
Heart rate (beats/min) 70 78 82 85
Systolic blood pressure (mm Hg) 115 112 112 114
Diastolic blood pressure (mm Hg) 70 60 63 70
Cardiac output (L/min) 4.5 4.5 6 6
Central venous pressure (mm Hg) 9.0 7.5 4.0 3.8
Blood volume (mL) 4000 4200 5000 5600
Hematocrit without iron (%) 40 36 33 34
Hematocrit with iron (%) 40 36 34 36
White blood cell (cell/mm3) 7200 9100 9700 9800

 

The relative hypervolemic state can mislead the clinician during maternal resuscitation after trauma and make clinical findings difficult to interpret.  A pregnant patient may lose 30% to 35% of circulating blood volume before manifesting hypotension or clinical signs of shock.  Uterine arteries constrict, which results in diminished fetal blood flow and tissue oxygenation before significant evidence of maternal hypovolemia appears.

Cardiopulmonary arrest in a pregnant patient must be considered under two scenarios: before fetal viability and after fetal viability. The accepted age of fetal viability varies among institutions, but 22 to 26 weeks is generally considered potentially viable. The uterine fundus is palpable at the umbilicus at 20 weeks. After 20 weeks, the gestational age of the fetus can be estimated by measuring the fundus from the pubic symphysis to the top of the fundus. The fundal height in centimeters corresponds roughly to the gestational age in weeks. Before approximately 22 to 24 weeks’ gestation, all efforts should focus on the mother, with no modifications to CPR.  Beyond 22 weeks or if the gravid uterus can be palpated above the umbilicus, several modifications of CPR should be instituted: (1) the patient should be positioned to minimize aortocaval compression, and (2) appropriate preparations for a potential cesarean section and care of a viable fetus should be made.

Limitation of aortocaval compression is achieved by (1) having someone manually displace the uterus to the left, (2) tilting the patient 15 to 30 degrees on a tiltable table, or (3) placement of a roll or a Cardiff wedge, if available, under the patient’s right hip and flank. The Cardiff wedge provides a tilt of 27%, allowing 80% of the compressive force, compared with CPR in the supine position, which maintains 30% or less of normal cardiac output in nonpregnant adults.  The “human wedge” has been advocated for bystander CPR. In this technique, the patient lies across the thighs of the rescuer, who is in a kneeling position. Despite relatively clear current recommendations regarding resuscitation in pregnancy, there is little research in this area.

 

Massive fetomaternal transplacental hemorrhage causes alloimunization in Rh incompatibility but also endangers the fetus by severe fetal anemia and resulting fetal distress and possible exsanguination. ABO incompatibility causes less severe disease.

The Kleihauer-Betke test identifies fetal cells in a maternal blood sample. Most laboratories screen for FMH of 5 mL or more. Unfortunately, the amount of FMH sufficient to sensitize most Rh-negative women is well below this 5-mL sensitivity level. Therefore, all Rh-negative mothers who have a history of abdominal trauma should receive one prophylactic dose of Rhesus immune globulin (RhIG). In the first trimester, one 50-g dose is used because total fetal blood volume is only 4.2 mL by 12 weeks’ gestation and a 50-g dose covers 5 mL of bleeding. During the second and third trimesters, a 300-?g dose of RhIG is given, which protects against 30 mL of FMH. Beyond 16 weeks’ gestation, the total fetal blood volume reaches 30 mL, so it is quite possible that massive FMH may exceed the efficacy of one 300-g dose of RhIG. Therefore, it is unlikely that a Kleihauer-Betke test is useful in the treatment of severely injured pregnant trauma patients.

 

References:

Rosen’s Emergency Medicine. 7th editon. Pages 252-261.

Tintinelli’s Emergency Medicine.  7th edition.