(Answered 2023) Emergency Medicine Trauma Exam
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- A 16-year-old girl presents with right thumb pain after a fall while skiing.
Physical examination reveals pain and swelling of the right thumb. X-ray of the thumb is negative. Valgus stress at the metacarpophalangeal joint results in increased pain and deviation of 40 degrees. What treatment is indicated?
CT scan of the thumb Sugar tong splint and urgent referral for surgical management Thumb spica and urgent referral for surgical management Thumb spica for 4 weeks and primary care follow up
Answer: ( C )
Explanation:
The patient presents with rupture of the ulnar collateral ligament (UCL) and requires immobilization and urgent surgical management. Injury to the UCL was initially described in Scottish gamekeepers (hence Gamekeeper's thumb).The injury was developed through the repetitive motion of twisting the necks of rabbits.Today, the injury is most commonly seen in skiers who receive the injury during a fall while holding a ski pole. The mechanism of injury is forced abduction of the thumb resulting in a tear of the UCL near its insertion at the proximal phalanx.Physical examination reveals swelling and tenderness along the ulnar surface of the thumb and difficulty with making a pinching motion. Valgus stress of the UCL can differentiate a partial tear from a complete rupture of the ligament.Stress should be applied to the metacarpophalangeal (MCP) joint in full extension and at 30 degrees of flexion. If there is more than 35 degrees of joint laxity or 15 degrees of laxity beyond the unaffected thumb, a complete UCL rupture should be suspected. Both partial tears and complete ruptures should be placed in a thumb spica splint. Partial tears typically will recover completely with immobilization whereas complete ruptures invariably need surgical repair. 1 / 4
A CT scan of the thumb (A) is not necessary for the diagnosis of a UCL rupture. Sugar tong splinting (B) does not immobilize the first MCP or first IP joints. A thumb spica and follow up with primary care (D) is appropriate for a partial tear but not for a complete rupture.
- One Step Further
Question: What is Stener's lesion?
Answer: Soft tissue interposition from the adductor aponeurosis associated with
a ulnar collateral ligament rupture.
- A 13-year-old boy with no past medical history presents to urgent care with
a headache three days after a closed head injury. The patient states that he stood up from kneeling and hit the top of his head on a wood cabinet. There was no loss of consciousness or seizure activity. In addition to the headache, he complains of difficulty concentrating at school and dizziness. His physical examination is unremarkable. What management is indicated?
CT scan of the head with contrast CT scan of the head without contrast MRI of the brain Referral to primary care physician
Answer: ( D )
Explanation:
The patient presents with minor head trauma and complaints consistent with a concussion and should have follow-up arranged with their primary care provider or concussion specialist. A concussion is a minor traumatic brain injury (TBI) that is often seen in MVCs and collision sports (football, hockey). It is typically caused by a rotational injury or an acceleration- deceleration injury. Patients will present with a number of non-specific symptoms including headaches, dizziness, confusion, amnesia, difficulty concentrating, and blurry vision but do 2 / 4
not have focal neurologic findings. Despite the absence of severe intracranial injury, patients can have chronic and debilitating symptoms from concussions.Neurology referral is recommended, as patients should have functional testing and tracking of their symptoms for resolution. It is vital to council patients to avoid contact sports or activities that increase the risk of recurrent injury as these patients are at risk for more severe injury with a second impact.
In the absence of focal neurologic findings, absence of antiplatelet or anticoagulant use, and minor trauma, imaging is not needed (A, B, C).
- One Step Further
Question: What imaging modality can show abnormalities in patients with
concussion in the acute setting?
Answer: Positron emission tomography (PET) scan.
- A 55-year-old construction worker presents to the ED after a fall from 20
feet while at work. Per EMS, the patient was confused when they found him with a large hematoma over the right temporal area, swelling of the right maxilla, and deformities to the right shoulder and knee. Appropriate spinal precautions were initiated prehospital. On arrival at the ED, his GCS score is eight with a blood pressure of 162/96, heart rate of 72, and oxygen saturation of 100% on a non-rebreather mask. Which of the following statements is correct regarding the management of this patient's airway?
Attempt rapid sequence intubation with etomidate and succinylcholine Cervical spine radiographs should be obtained prior to establishing a defin-itive airway since the patient's oxygen saturation is 100% Continue oxygenation via non-rebreather face mask and immediately obtain a CT scan of the brain followed by neurosurgical consultation Lidocaine administration is contraindicated due to a paradoxical elevation in intracranial pressure Nasotracheal intubation is an appropriate alternative to orotracheal airway-
Answer: ( A )
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Explanation:
Trauma patients with a GCS score less than or equal to eight require immediate airway management. It is suspected that even a single episode of hypoxia in the patient with severe head trauma leads to a poorer prognosis.This patient should be endotracheally intubated using etomidate and succinylcholine. Etomidate is an ideal induction agent in the head-trauma patient. Etomidate has been shown to decrease cerebral oxygen consumption, cerebral blood flow, and intracranial pressure but appears to have minimal effects on cerebral perfusion pressure.Airway management takes priority in this scenario. Given the patient's GCS score of eight in the setting of polytrauma, it is recommended to establish a definitive airway. During endotracheal intubation, the patient's cervical spine should be immobilized to prevent any further injury to the spinal cord. As long as proper cervical spine precautions are taken, cervical radiographs (B) can be obtained after the patient is stabilized. Achieving this, however, can occur with in-line traction and does not require immobilization using a hard collar.Although epidural hematoma is a strong consideration, it is unsafe to take the patient to head CT (C) without first securing the airway. Consulting neurosurgery for patients with severe head trauma is prudent and can occur prior to the return of CT scan results. But the initial priority in such patients is establishment of a definitive airway. There is a reflexive response to laryngoscopy and intubation that increases intracranial pressure, although the precise mechanism is poorly understood. Intravenous lidocaine (D) is thought to reduce intracranial pressure and blunt the response to laryngoscopy and intuba- tion. Although recent reports have questioned the clinical benefit, administration of lidocaine during the pretreatment phase of rapid sequence induction for head injury patients remains a component of current ATLS guidelines. The nasotracheal airway (E) should not be attempted in patients with midface trauma or potential basilar skull fracture because the tube may inadvertently penetrate the intracranial space.
- One Step Further
Question: How much does succinylcholine elevate serum potassium con-
centration?
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