Category: Trauma and Environmental

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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

• Rabies Guidelines (CDC)

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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)

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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

• NBME Shelf Review Part 2- Trauma (EM Clerkship)

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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 (EM Clerkship)
• Wound Closure for the Emergency Practitioner (LacerationRepair)

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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

• Laceration Repair (EM Clerkship)
• Wound Closure for the Emergency Practitioner (LacerationRepair)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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CT scan without contrast is your test of choice.

Step 1: Consider Your Differential Diagnoses

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

Step 2: Important Add-ons When Taking History

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

Step 3: Important Add-ons To Your Physical Exam

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

Step 4: Calculate Canadian Head CT Rule

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

Additional Reading

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

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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

• Advanced Trauma Life Support (Wikipedia)
• Round 5 – Geriatric Fall (EM Clerkship)