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SAEM Trauma
An 18 year old hockey player is hit in the mouth with a puck, fracturing a maxillary canine tooth. He brings the severed piece of tooth with him. On physical exam, the tooth is fractured halfway between the tip and the gumline. The root of the tooth is still firmly intact. The exposed fracture site has a yellowish tinge without blood. Of the following choices, which is the most appropriate management for this patient? A. Application of calcium hydroxide, placement of aluminum foil, and dental follow- up B. Placement of tooth fragment in saline gauze, outpatient dental follow-up C. No specific treatment required D. Immediate dental consult to avoid abscess formation E. Replace fractured piece and place acrylic splint - correct answer The answer is D. Ellis II dental fracture involves enamel and dentin. The fracture site typically has a yellowish tinge. Ellis III dental fractures are characterized by exposure of pinkish pulp and often blood. These fractures require immediate dental consultation to prevent abscess formation. A 22 year old man is punched in the nose during a fight. He presents to the emergency department with obvious nasal bone deformity. Pressure controls the bleeding. Physical exam reveals no maxillary bone or orbital rim tenderness, intact vision and extraocular movement. The oropharynx and mandible are unremarkable. Nasal inspection reveals a swollen, ecchymotic, tender nasal septum. Which of the following is the most appropriate initial step? A. Incision and drainage of the septal hematoma followed by nasal packing B. Needle aspiration of the septal hematoma C. Plastic surgery consult for immediate reduction of nasal fracture D. Facial CT scan to rule out more serious facial fractures E. Outpatient follow-up with an ENT specialist to surgically correct a deviated septum - correct answer A. Incision and drainage of the septal hematoma followed by nasal packing
A 24 year old woman is playing racquetball and sustains a direct blow from the ball to the right eye. She presents to the emergency department complaining of eye pain and double vision. On exam, her right eye does not track properly with upward gaze. This finding suggests which of the following injuries? A. Zygomatic arch fracture B. Ethmoid fracture C. Inferior orbital wall fracture D. Inferior orbital rim fracture E. Superior orbital rim fracture - correct answer C. The patient most likely has an orbital floor fracture with entrapment. A 32 year old man is struck several times in the head with a baseball bat. Upon emergency medical service arrival, he is mildly confused, vomits once, and complains of a severe headache. The emergency medical technicians establish two large-bore IVs. Prior to arrival at the emergency department, he loses consciousness and begins to seize. He is actively seizing when he is brought into the trauma bay. What should be the first step in the management of this patient? A. Administration of mannitol 50 g IV B. Emergency craniotomy C. Rapid sequence intubation using paralytic agent D. Administration of 2 liters NS bolus - correct answer C. Rapid sequence intubation using paralytic agent The airway should be managed as the first priority in this patient. The other maneuvers may be helpful but are secondary to securing an airway and providing oxygenation/ventilation. Airway comes first! A 46 year old man is brought in by EMS after a motor vehicle collision in which he was an unrestrained driver. Although he has no obvious injury to his head or neck, he complains of chest pain and appears very short of breath. His vital signs are: T 99.2 F, BP 85/57, HR 123, RR 36, SpO2 95% on non-rebreather. The CXR demonstrates a tension pneumothorax. Of the following, which is the most appropriate next step in this man's care? A. Performance of a chest CT scan to further delineate the pathology
The Ottawa ankle rules are a validated (for adults) set of physical exam findings to determine if an ankle X-ray is needed after an injury. If any of the first 4 answers is present or if there is tenderness over the navicular or base of the 5th metatarsal, an X-ray should be obtained. If the correct answer to all questions is no, then an X-ray is not needed. Choose the INCORRECT statement regarding thoracentesis from the anterior approach (needle decompression): A. The recommended insertion site is the second intercostal space, midaxillary line. B. An upright chest X-ray should always be performed following a thoracentesis to confirm the successful relief of a tension pneumothorax and the absence of hemothorax or other complications. C. If a tension pneumothorax is confirmed via needle decompression, then a thoracostomy tube should be placed as soon as possible. D. A 14- to 20-gauge needle is inserted perpendicularly over the superior edge of the rib. E. After the needle is inserted into the pleural space, a rush of air confirms the presence of a tension pneumothorax. - correct answer A. The recommended insertion site is the second intercostal space, midaxillary line. The recommended insertion site for needle decompression of tension pneumothoraces is the second intercostal space along the midclavicular line. If a lateral approach is needed, the recommended insertion site is the fourth or fifth intercostal space in the midaxillary line. The lateral approach poses a greater risk of parenchymal injury. The needle should always be inserted over the superior edge of the rib as the neurovascular bundle runs along the inferior margin (answer B). The remaining answers are all correct statements regarding thoracentesis (answers C, D, E). In a patient with a suspected ruptured globe from penetrating trauma to the eye, all of the following should be performed EXCEPT: A. ophthalmology consultation B. visual acuity assessment C. administration of broad spectrum antibiotic therapy D. ascertainment of intraocular pressure via tonometry
E. ascertainment of tetanus status - correct answer D. ascertainment of intraocular pressure via tonometry Tonometry should not be performed in patients with suspected ruptured globe, as application of the Tono-Pen pressure to the eye may cause the vitreous humor to exude from the eye, thereby complicating the injury. Tetanus status is important to check, as ocular injuries, like skin injuries, may be a portal for tetanus exposure. Broad-spectrum antibiotic therapy is indicated. Anti-emetic therapy may be helpful in preventing the elevations in intraocular pressure associated with vomiting. Visual acuity assessment is important and ophthalmology consultation is critical. Following a motor vehicle crash, a 25 year old man presents complaining of a painful right eye. Visual acuity is 20/200 in the right eye and 20/25 in the left eye. The right eye protrudes from the orbit and the patient has right eye pain with extraocular movement. What is the most likely cause of his symptoms? A. ruptured globe B. retrobulbar hematoma C. chemosis D. hyphema E. orbital blow-out fracture - correct answer B. retrobulbar hematoma Traumatic proptosis with impaired extraocular movements is classic for retrobulbar hematoma. Sequelae include optic nerve ischemia and secondary visual impairment. A ruptured globe presents with enophthalmos, not proptosis, as vitreous humor leaks out of the eye. Neither hyphema nor chemosis causes proptosis. Orbital blowout fractures can cause inferior rectus muscle entrapment and secondary pain with impairment of extraocular movement. Yet, they do not present with proptosis - unless complicated by retrobulbar pathology. Following a brawl at a local bar, a gentleman presents with an impressive right- sided periorbital ecchymosis. All of the following physical examination findings would suggest an orbital blowout fracture EXCEPT: A. right-sided epistaxis B. proptosis C. right-sided infraorbital subcutaneous emphysema D. anesthesia of the right infraorbital region E. diplopia with upward gaze - correct answer B. proptosis Orbital blowout fractures classically involve the maxillary or ethmoid sinus and consequently often cause either epistaxis (through the connection of the maxillary
C. Mother with gunshot wound to abdomen, blood pressure 96/42; fetal heart tones undetectable D. Mother with abdominal pain, blood pressure of 80/40; fetal heart tones 100 beats per minute E. Mother with vaginal bleeding, blood pressure 118/78; fetal heart tones 80 beats per minute - correct answer B. Mother pulseless and apneic for 2 minutes' duration and still in arrest; fetal heart tones of 100 beats per minute Though emergency C-section after maternal death is a rarely indicated procedure, rapid intervention (within minutes) of maternal demise has resulted in viable births. A 76 year old restrained driver is involved in a head-on collision at about 35 mph. He arrives at the emergency department in a cervical collar and on a backboard. His only complaint is neck pain, and he has mild posterior neck tenderness. A CT scan of the neck shows no fracture and only degenerative arthritis. Upon re-evaluation you note the patient has difficulty raising his arms against gravity and there is decreased grip strength bilaterally. The remainder of his neurological exam is normal. What is the most appropriate management for this patient? A. Administration of IV steroids and ordering of cervical MRI B. Reassurance and discharge with NSAIDs given the non-anatomical distribution of weakness C. Immediate neurosurgical decompression D. Flexion and extention radiographs to rule out ligamentous injury E. Discharge home with a hard cervical collar with neurosurgical follow-up - correct answer A. Administration of IV steroids and ordering of cervical MRI Central cord syndrome results from a hyperextension injury, typically in elderly patients with significant degenerative joint disease. The ligamentum flavum buckles into the cord, resulting in a contusion of the cord's central portion. A 46 year old construction worker falls 6 feet off a ladder onto a concrete surface and has sudden and severe low back pain. The pain radiates down his right leg and he develops numbness over the anterior shin and dorsum of the foot. On physical exam he has decreased sensation to pinprick over the dorsum of the right foot (medially) and some weakness in right foot dorsiflexion. At which level is a protruding intervertebral disc most likely? A. L1-L B. L2-L C. L3-L
D. L4-L
E. L5-S1 - correct answer D. L4-L Sensation of the dorsal aspect of the foot and dorsiflexion of the foot are functions of the L5 nerve root. Herniation of the L4-5 disc would result in compression of L5. hich of the following cervical spine fractures is considered stable? A. Jefferson fracture of C B. Hangman's fracture of C C. Flexion teardrop fracture D. Bilateral facet dislocation E. Transverse process fracture - correct answer E. Transverse process fracture A transverse process fracture involves only one of the supporting spinal columns (the posterior column) and is therefore stable A 23 year old man is stabbed in the anterior neck with a 3-inch knife during a street fight. At the scene, there is some bleeding, which is controlled with direct pressure. He presents to the emergency department breathing comfortably and in no distress. His pulse is 88, blood pressure 126/76, and oxygen saturation 99% on room air. There is a 1cm laceration 2cm above the right sternoclavicular junction, lateral to the trachea. There is mild oozing and no obvious underlying hematoma. There is no obvious subcutaneous air, and he has clear lung sounds. What is the most appropriate management for this patient? A. Angiography, esophogram, and admission for observation B. Local wound exploration and discharge home after 6-hour observation period C. CT scan of the neck and discharge home after 6 hours of observation D. Immediate operative exploration E. Local wound exploration and discharge home if no significant injury identified - correct answer A. Angiography, esophogram, and admission for observation one I penetrating neck injuries are located between the sternal notch and the cricoid cartilage. A major concern is injury to non-compressible vascular structures such as common carotid, vertebral, subclavian, aortic arch. Other structures in this area include trachea, esophagus, and lung apices. Physical exam is often unreliable and angiography, esophogram, and observation are warranted.
the peritoneal cavity, and CT scan is the test of choice for diagnosing solid organ injury. A 36 year old man is a restrained driver involved in a high speed MVA where his car is struck on the driver's side door with significant intrusion. His physical exam is significant for a large contusion on his left flank. His abdominal exam is benign and rectal exam reveals a normal prostate. A Foley catheter is placed with return of gross hematuria. Which test is indicated to evaluate for the presence of urologic injury? A. CT abdomen / pelvis with IV contrast alone B. CT abdomen / pelvis without contrast C. Ultrasound of the kidneys D. CT abdomen / pelvis with IV and transurethral contrast E. Ultrasound of the bladder D - correct answer D. CT abdomen / pelvis with IV and transurethral contrast In which of these patients is emergency department thoracotomy indicated? A. Patient with stab wound to the anterior chest who is dyspneic with an oxygen saturation of 80% and a blood pressure of 168/ B. All of the above should undergo emergency department thoracotomy. C. Unbelted driver in a high-speed motor vehicle crash who loses his pulse while being extricated, and arrives at the E.D. after a 45-minute transport D. Patient with a gunshot wound to the chest who upon arrival is unconscious and pulseless, with a systolic blood pressure of 60 E. Pedestrian struck with massive pelvic fractures who loses pulses and blood pressure at the scene - correct answer D. Patient with a gunshot wound to the chest who upon arrival is unconscious and pulseless, with a systolic blood pressure of 60 Emergency Department thoracotomy is a controversial procedure. When chosen carefully, successful resuscitation can occur. Cardiac arrest due to blunt trauma has a dismal success rate and is generally not considered an indication for ED thoracotomy. Thoracotomy for penetrating chest wounds has the best success rate. An awake patient with a relatively normal blood pressure does not need one performed in the Emergency Department. An unconscious and pulseless patient with a detectable blood pressure has the best chance for survival.
A 32 year old female is shot with a 38-caliber pistol at close range in the right anterior chest. She presents to the emergency department intoxicated and yelling. Her vitals include a pulse of 92, blood pressure of 134/84, and oxygen saturation of 97%. She has clear breath sounds bilaterally. The entrance wound is just above the right breast and an exit wound is noted in the right axilla. What is the most appropriate management of this patient? A. IV access, endotracheal intubation, CT scan of chest to look for pneumo- or hemothorax, or injuries to the heart or great vessels B. IV access, endotracheal intubation, emergency department thoracotomy to search for cardiac or pulmonary vascular injury C. IV access, endotracheal intubation and simultaneous placement of a right chest tube, bedside ultrasound, portable chest X-ray, and admission to the ICU if stable D. IV access, portable chest X-ray, tube thoracostomy, and exploratory thoracotomy in the OR to search for cardiac or pulmonary vascular injury E. IV access, portable chest X-ray, right chest tube placement if X-ray shows a pneumo- or hemothorax, admission to the ICU for observation - correct answer C. IV access, endotracheal intubation and simultaneous placement of a right chest tube, bedside ultrasound, portable chest X-ray, and admission to the ICU if stable During a bar fight, a 42 year old man is stabbed in the left side with an unknown weapon. He presents to the emergency department with dyspnea, pulse of 108, blood pressure of 138/92, and oxygen saturation of 94% on room air. He has absent breath sounds on the left side; you note a small puncture wound in the midaxillary line at the level of the 10th rib. His abdominal exam is normal. Two large-bore IVs are established. What is the appropriate management of this patient? A. Left-sided chest tube, portable chest x-ray, diagnostic peritoneal lavage, and admission B. Left-sided chest tube, portable chest x-ray, and abdominal CT scan C. Endotracheal intubation, portable chest x-ray, exploratory laparotomy in the OR, and admission D. Endotracheal intubation, left-sided chest tube, portable chest x-ray, and admission E. Left-sided chest tube, portable chest x-ray, and admission - correct answer B. Left-sided chest tube, portable chest x-ray, and abdominal CT scan Which is the most common associated neurological finding with a distal radius fracture? A. Decreased sensation over the hypothenar eminance
A knee dislocation frequently injures the popliteal artery, threatening the survival of the limb. Immediate reduction for the dislocation is warranted to attempt to restore flow through the artery, and should be attempted by the ED physician without waiting for orthopedics. Transport to the OR is an unnecessary delay, and while arteriography will be indicated, the most urgent priority is restoring blood flow. A patient falls onto his face, and has a CT scan of the face as shown in the Figure. Which indirect finding suggestive of possible facial fracture is present on the CT? [image] A. Nasal fracture B. Extra-sinus air C. Exopthalmos D. Fluid (blood) in the sinuses - correct answer D. Fluid (blood) in the sinuses Blood in the sinuses can be a useful indirect indicator of facial fracture. A 41 year old man is seen in the emergency department after a street fight where he punched another man in the mouth. He has a small, jagged laceration over the dorsum of the metacarpophalangeal joint of his right hand. The wound is irrigated copiously, tetanus is given, and the wound is left open to heal by secondary intention because of the infection risk. In addition to treating Streptococcus and Staphylococcus species, antibiotics must also treat which other bacterial species? A. Escherichia. coli B. Eikenella corrodens C. Pasteurella multocida D. Actinomyces israelii - correct answer B. Eikenella corrodens There are many species of bacteria in the human mouth, and Eikenella corrodens is an aggressive one, frequently causing infection in the first 24 hours after injury. A young male patient presented to the emergency department with a history of single gunshot wound from unknown source and caliber. He was hemodynamically stable and had little pain in the right lower quadrant of the abdomen, which was the site of two wounds about 6 inches apart (see Figure). No other wounds were identified during physical examination. Which of the following statements regarding this case is true? [image]
A. The superior-medial wound (at the top right of the Figure) is likely the entrance wound, and the inferior-lateral wound is likely the exit wound, of a single missile B. The two wounds are more likely than not the result of two separate missiles C. If it is suspected that the two wounds are from the same missile, the emergency department physician's documentation should note which wound is the entrance, and which is the exit D. Wound description is essential for the emergency medicine specialist. However, description of a wound as to entrance or exit is best left to forensic examination. - correct answer D. Wound description is essential for the emergency medicine specialist. However, description of a wound as to entrance or exit is best left to forensic examination. The overall evidence points to a superior-medial to inferior-lateral wound trajectory, with subcutaneous ecchymosis indicating the missile track and the more ragged wound at the inferior-lateral (groin) region most likely an exit wound. However, though wound description is very important for the emergency physician (both as a guide to injury evaluation and also as an early characterization of wounds, before interventions such as wound exploration obscure physical findings), speculation as to whether wounds are entrance or exit wounds are best left off of the E.D. record. Clinicians tend to oversimplify and/or misinterpret physical wound characteristics. Thus, the best course is a meticulous description (or photograph) of the wound, noting items such as tattooing (i.e. of gunpowder) or stellate tissue destruction (which can be due to expansion of gun barrel gases in a contact wound) but leaving interpretation of the physical evidence to forensics experts. The wound characteristics are not consistent with self-inflicted injury, though the ED physician should have a low index of suspicion for psychiatric consultation when there is doubt on this subject. A patient presents to the ED after a fall with chest pain. A chest xray shows a rib fracture but no pneumothorax, and a chest CT is ordered. What is the most appropriate treatment for a small pneumothorax, detected only on chest CT, in a hemodynamically stable trauma patient? A. Chest tube placement B. Heliox by face mask C. Immediate needle decompression D. 100% oxygen - correct answer D. 100% oxygen An occult pneumothorax may resorb with only oxygen administration, not requiring invasive management. Needle decompression is used for tension pneumothorax, and heliox may be used for reactive airway disease to reduce resistance to flow.
A. Persistent pneumothorax B. Aortic rupture leading to a right hemothorax C. Pericardial tamponade - correct answer A. Persistent pneumothorax The chest CT shows a chest tube in place on the right, with incomplete reinflation of the lung. The left hemithorax is grossly normal, but there is a large right pulmonary contusion, as well as pneumothorax and small hemothorax on the right. The aorta appears intact (aortic injuries usually leak into the left hemithorax, not the right). In differentiating high voltage electrical injury from lightning injury, which of the following is your best discriminator? A. Fractures or dislocations B. Deep burns C. Loss of consciousness D. Cardiac arrest - correct answer B. Deep burns Patients with high voltage injury commonly present with devastating burns. The burns are most severe at the source and ground contact points. The most common sites of contact with the source include the hands and the skull. The most common areas of ground contact are the heels. Deep burns occur in less than 5% of lightning injuries. Electrical injuries may cause four types of superficial burns or skin changes: linear burns, punctate burns, feathering, or thermal burns. Loss of consciousness, cardiac arrest and orthopedic injuries can be seen in both high voltage electrical injury and lightning injury. Electrolyte abnormalities are not common in either injury. Using the rule of 9s, what is the approximate burn surface area of a victim who has sustained second-degree burns to the anterior chest and anterior area of both arms? A. 20% B. 25% C. 30% D. 35% - correct answer B. 25% A right-handed patient sustains a circumferential burn (see figure) to the distal right forearm and hand, which is cool despite warm ambient temperature. Regarding the initial assessment and management of the patient, which of the following is correct?
[image] A. As shown in the Figure, the burn represents about 10% of total body surface area B. The involved areas of this 3rd-degree burn would be expected to be mostly insensate C. Prophylactic penicillin should be given to any patient with a significant burn D. Pain medication should be withheld pending obtaining operative consent for emergency burn debridement - correct answer B. The involved areas of this 3rd- degree burn would be expected to be mostly insensate The answer is D. 3rd-degree burns are often insensate; withholding pain medication is not necessary; one hand is about 2-3% TBSA, and prophylactic antibiotics are not recommended
