EMERGENCY MEDICINE

Dr. D. Cass, Dr. M. Thompson and Dr. J. Tyberg

Nadia Knarr, Daniel Penello and Aric Storck, chapter editors
Katherine Zukotynski, associate editor

INITIAL PATIENT ASSESSMENT ........... 2 APPROACH TO COMMON ER . . . . . . . . . . . . . . 25

AND MANAGEMENT PRESENTATIONS
Approach Abdominal pain
Prioritized Plan Alcoholic Emergencies
Rapid Primary Survey Anaphylaxis and Allergic Reactions
A. Airway Analgesia
B. Breathing Asthma
C. Circulation Chronic Obstructive Pulmonary Disease (COPD)
D. Disability Chest Pain
E. Exposure/Environment Headache
Resuscitation Hypertensive Emergencies
Detailed Secondary Survey Status Epilepticus
Definitive Care Syncope
Sexual Assault and Domestic Violence
PRE-HOSPITAL CARE . . . . . . . . . . . . . . . . . . . . . . 6 Violent Patient
Level of Providers
TOXICOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
APPROACH TO COMA . . . . . . . . . . . . . . . . . . . . 6 Approach to the Overdose Patient
Glasgow Coma Scale (GCS) ABCs of Toxicology
Management of the Comatose Patient D1 - Universal Antidotes
D2 - Draw Bloods
TRAUMATOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . 9 D3 - Decontamination
Epidemiology E - Examine the Patient
Considerations for Traumatic Injury Specific Toxidromes
Shock in the Trauma Patient G - Give Specific Antidotes and Treatment
Chest Trauma Specific Treatments
A. Immediately Life-Threatening Chest Injuries pH Alteration
B. Potentially Life-Threatening Chest Injuries Extra-Corporeal Drug Removal
Abdominal Trauma Disposition from the Emergency Department
Genitourinary (GU) Tract Injuries
Head Trauma REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Spine and Spinal Cord Trauma
Approach to Suspected C-Spine Injury
Orthopedic Injuries
A. Life and Limb Threatening Injuries
B. Upper Extremity Injuries
C. Lower Extremity Injuries
Soft Tissue Injuries
Environmental Injuries
Pediatric Trauma
Trauma in Pregnancy

MCCQE 2006 Review Notes Emergency Medicine – ER1

 INITIAL PATIENT ASSESSMENT AND MANAGEMENT
APPROACH
5 level triage (new Canadian Guidelines)
•I Resuscitation
• II Emergent
• III Urgent
• IV Less-urgent
•V Non-urgent
PRIORITIZED PLAN
1. Rapid Primary Survey (RPS)
2. Resuscitation (often occurs at same time as RPS)
3. Detailed Secondary Survey
4. Definitive Care
RAPID PRIMARY SURVEY (RPS)
Airway maintenance with C-spine control
B reathing and ventilation
Circulation (pulses, hemorrhage control)
Disability (neurologic status)
E xposure (complete) and E nvironment (temperature control)
restart sequence from beginning if patient deteriorates
A. AIRWAY
first priority is to secure airway
assume a cervical (C-spine) injury in every trauma patient ––> immobilize with collar and sand bags
Causes of Airway Obstruction
decreased level of consciousness (LOC)
airway lumen: foreign body (FB), vomit
airway wall: edema, fractures
external to wall: lax muscles (tongue), direct trauma, expanding hematoma
Airway Assessment
assess ability to breathe and speak
signs of obstruction
• noisy breathing is obstructed breathing until proven otherwise
• respiratory distress
• failure to speak, dysphonia
• adventitous sounds
• cyanosis
• agitation, confusion, “universal choking sign”
think about ability to maintain patency in future
can change rapidly, ALWAYS REASSESS
Airway Management
goals
• achieve a reliably patent airway
• permit adequate oxygenation and ventilation
• facilitate ongoing patient management
• give drugs via endotracheal tube (ETT) if IV not available
• NAVEL: Narcan, Atropine, Ventolin, Epinephrine, Lidocaine
start with basic management techniques then progress to advanced
1. Basic Management (Temporizing Measures)
protect the C-spine
chin lift or jaw thrust to open the airway
sweep and suction to clear mouth of foreign material
nasopharyngeal airway
oropharyngeal airway (not if gag present)
transtracheal jet ventilation (through cricothyroid membrane)
• used as last resort, if unable to ventilate after using above techniques
2. Definitive Airway
endotracheal intubation (ETT) (see Figure 1)
• orotracheal +/– Rapid Sequence Intubation (RSI)
• nasotracheal - may be better tolerated in conscious patient
• does not provide 100% protection against aspiration
indications for intubation
• unable to protect airway
• inadequate spontaneous ventilation
• O 2 saturation < 90% with 100% O 2
• profound shock
• GCS = 8
• anticipate in trauma, overdose, congestive heart failure (CHF), asthma,
and chronic obstructive pulmonary disease (COPD)
• anticipated transfer of critically ill patients
surgical airway (if unable to intubate using oral/nasal route)
• needed for chemical paralysis of agitated patients for investigations
• cricothyroidotomy
ER2 – Emergency Medicine MCCQE 2006 Review Notes
 INITIAL PATIENT ASSESSMENT AND MANAGEMENT
. . . CONT.

trauma requiring intubation

no immediate need immediate need

C-spine x-ray apneic breathing

positive negative* facial smash no facial smash

fiberoptic ETT oral ETT oral ETT oral ETT nasal ETT
or nasal ETT (no RSI) or RSI
or RSI

unable unable unable

cricothyroidotomy cricothyroidotomy cricothyroidotomy

* note: clearing the C-spine also requires clinical assessment (cannot rely on x-ray alone)
* ETT (endotracheal intubation), RSI (rapid sequence intubation)

Figure 1. Approach to Endotracheal Intubation in an Injured Patient

B. BREATHING
LOOK mental status (anxiety, agitation), colour, chest movement, respiratory rate/effort
FEEL flow of air, tracheal shift, chest wall for crepitus, flail segments
and sucking chest wounds, subcutaneous emphysema,
LISTEN sounds of obstruction (e.g. stridor) during exhalation, breath sounds
and symmetry of air entry, air escaping
Oxygenation and Ventilation
measurement of respiratory function: rate, pulse oximetry, ABG, A-a gradient, peak flow rate
treatment modalities
• nasal prongs ––> simple face mask ––> oxygen reservoir ––> CPAP/BiPAP
• Venturi mask: used to precisely control O 2 delivery
• Bag-Valve mask and CPAP: to supplement ventilation

C. CIRCULATION- see Shock section

Table 1. Estimation of Degree of Shock

Class I II III IV

Blood loss < 750 cc 750 - 1500 cc 1500 - 2000 cc > 2000 cc
(<15%) (15 - 30%) (30 - 40%) (> 40%)
Pulse < 100 > 100 > 120 > 140
Blood pressure (BP) Normal Normal Decreased Decreased
Respiratory Rate (RR) 20 30 35 > 45
Capillary refill Normal Decreased Decreased Decreased
Urinary output 30 cc/hr 20 cc/hr 10 cc/hr None
CNS status Anxious Mild Confused Lethargic
Fluid replacement Crystalloid Crystalloid Crystalloid + blood Crystalloid + blood

Table 2. Estimated Systolic Blood Pressure (SBP)

Based on Position of Palpable Pulse
Radial Femoral Carotid
sBP > 80 > 70 > 60
(mmHg)

MCCQE 2006 Review Notes Emergency Medicine – ER3

 INITIAL PATIENT ASSESSMENT AND MANAGEMENT
. . . CONT.

stop major external bleeding

• apply direct pressure
• elevate profusely bleeding extremities if no obvious unstable fracture
• consider pressure points (brachial, axillary, femoral)
• do not remove impaled objects as they tamponade bleeding
• use tourniquet as last resort
treatment
• 2 large bore peripheral IV’s for shock (14-16 gauge)
• bolus with Ringer’s lactate (RL) or normal saline (NS) (2 litres) and then blood as indicated
for hypovolemic shock
• inotropes for cardiogenic shock
• vasopressors for septic shock
D. DISABILITY
assess level of consciousness by AVPU method (quick, rudimentary assessment)
A - ALERT
V - responds to VERBAL stimuli
P - responds to P AINFUL stimuli
U - UNRESPONSIVE
size and reactivity of pupils
movement of upper and lower extremities (UE/LE)
E. EXPOSURE / ENVIRONMENT
undress patient completely
essential to assess all areas for possible injury
keep patient warm with a blanket +/– radiant heaters; avoid hypothermia
RESUSCITATION
restoration of ABCs
manage life-threatening problems as they are identified
often done simultaneously with primary survey
vital signs q 5-15 minutes
ECG, BP and O2 monitors
Foley catheter and nasogastric (NG) tube if indicated
• Foley contraindicated if blood from urethral meatus or other signs of urethral tear
(see Traumatology section)
• NG tube contraindicated if significant mid-face trauma or basal skull fracture
• may use orogastric tube
order appropriate tests and investigations: may include CBC, lytes, BUN, Cr, glucose, amylase,
INR/PTT, ß-HCG, tox screen, cross + type
DETAILED SECONDARY SURVEY
done after RPS problems have been corrected
designed to identify major injuries or areas of concern
head to toe physical exam and X-rays (C-spine, chest, pelvis - required in blunt trauma)
History
“AMPLE ”: Allergies, M edications, P ast medical history, Last meal, Events related to injury
Head and Neck
pupils
• assess equality, size, symmetry, reactivity to light
• inequality suggests local eye problem or lateralizing CNS lesion
• reactivity/level of consciousness (LOC)
• reactive pupils + decreased LOC ––> metabolic or structural cause
• non-reactive pupils + decreased LOC ––> structural cause
• extraocular movements (EOM’s) and nystagmus
• fundoscopy (papilledema, hemorrhages)
palpation of facial bones, scalp
tympanic membranes
Chest
flail segment, contusion
subcutaneous emphysema
auscultate lung fields
CXR
Abdomen
inspection, palpation, percussion, auscultation
immediate laparotomy if
• refractory shock with no other discernable cause
• obvious peritonitis
• increasingly distended abdomen
• positive diagnostic peritoneal lavage/CT scan
rectal exam for gastrointestinal (GI) bleed, high riding prostate and anal tone
bimanual exam in females

ER4 – Emergency Medicine MCCQE 2006 Review Notes

 INITIAL PATIENT ASSESSMENT AND MANAGEMENT
. . . CONT.

Musculoskeletal (MSK)
examine all extremities for swelling, deformity, contusion, tenderness
log rolled, palpate thoracic (T) and lumbar (L)-spines
pelvis: palpate iliac crests and pubic symphysis, pelvic stability (lateral, AP, vertical)
Neurological Examination (see Neurosurgery Chapter)
Glasgow Coma Scale (GCS)
alterations of rate and rhythm of breathing are signs of structural or metabolic abnormalities
progressive deterioration of breathing pattern implies a failing CNS
full cranial nerve exam
assessment of spinal cord integrity
• conscious patient: assess distal sensation and motor ability
• unconscious patient: response to painful or noxious stimulus applied to extremities
signs of increased intracranial pressure (ICP)
• deteriorating LOC (hallmark of increasing ICP)
• deteriorating respiratory pattern
• Cushing reflex (high BP, slow heart rate)
• lateralizing CNS signs (e.g. cranial nerve palsies, hemiparesis)
• seizures
• papilledema (occurs late)
DEFINITIVE CARE
1. continue therapy
2. continue patient evaluations (special investigations)
3. specialty consultations including O.R.
4. disposition: home, admission, or another setting
Ethical Considerations
Adults
Emergency Rule: consent not needed when patient is at imminent risk of suffering serious injury
(i.e., severe suffering, loss of limb, vital organ or life)
AND obtaining consent is either:
a) not possible (eg., patient is comatose), OR
b) would increase risk to the patient (e.g., time delay)
any CAPABLE and INFORMED patient can refuse any treatment or part of treatment, even if it is life-saving
in E.D. consider: is the patient truly capable? does pain, stress, psychological distress cloud their judgement?
the emergency rule assumes that most people would want to be saved in an emergency
EXCEPTIONS: Treatment can not be initiated if:
1. a competent patient has previously refused the same or similar treatment and there is no evidence to
suggest the patient's wishes have changed
2. an advance directive is available
3. a do not resucitate (DNR) order is available
4. refusal for help in a suicide situation is NOT an exception; care must be given
when in doubt, treat
Children
treat immediately if patient is at imminent risk
parents / guardians have right to make treatment decisions, however
if parents refuse treatment that is life-saving or will potentially alter the child's quality of life,
CAS is almost always contacted
MDs cannot then treat without consent of Child Services
Jehovah's Witnesses
refuse whole blood, packed red blood cells (PRBCs), platelets, plasma and WBCs even if life-saving
should be questioned directly about the use of albumin, immunoglobulins, hemophillic preparations
do not allow for autollogous transfusion unless there is uninterrupted extra corporeal circulation
ask for the highest possible quality of care without the use of the above interventions
(e.g., crystalloids for volume expansion, attempts at bloodless surgery)
may carry a signed, witnessed, dated Medical Alert card +/– bracelet specifically identifying their religious
affiliation and the procedures they will not consent to
will generally sign hospital forms releasing medical staff from liability
are consenting, capable adults and have the right to refuse medical treatment
most legal cases involve children of Jehovah's Witnesses
large centres may have policies surrounding care
if life-saving treatment is refused (e.g., blood transfusion) CAS is contacted

MCCQE 2006 Review Notes Emergency Medicine – ER5

 PRE-HOSPITAL CARE
LEVEL OF PROVIDERS
levels of providers not standard in every community
first responders usually non-medical (i.e. firefighters, police)
• administer CPR, O 2 , first aid, assist ventilation, automatic defibrillation (firefighters)
Level I Paramedic
• basic airway management (oropharyngeal airway and suction), O 2 by mask or cannula, CPR,
semi-automatic external defibrillation, basic trauma care
• blood sugar kit, administer some drugs (nitro, salbutamol, epinephrine, ASA, glucagon)
Level II Paramedic
• start IV, ventilation of intubated patients, interpret ECGs, manual defibrillation
Level III Paramedic
• advanced airway management (intubation), cardioversion and defibrillation,
emergency drugs (IV epinephrine, naloxone, dopamine), ACLS, needle thoracostomy
base hospital physicians
• provide medical control and verbal orders for Paramedics through line patch
• ultimately responsible for delegated medical act and pronouncement of death in the field

APPROACH TO COMA
Definitions
Coma - a sleep-like state, unarousable to consciousness
Stupor - unresponsiveness from which the patient can be aroused
Lethargy - state of decreased awareness and mental status (patient may appear wakeful)
GLASGOW COMA SCALE (GCS)
designed for use on trauma patients with decreased LOC; good indicator of severity of injury
often used for metabolic causes as well, but less meaningful
most useful if repeated
• changes in GCS with time is more relevant than the absolute number
• patient with deteriorating GCS needs immediate attention

Table 3. Glasgow Coma Scale

Eyes Open Best Verbal Response Best Motor Response

spontaneously 4 answers questions appropriately 5 obeys commands 6

to voice 3 confused, disoriented 4 localizes pain 5
to pain 2 inapproriate words 3 withdraws to pain 4
no response 1 incomprehensible sounds 2 decorticate (abnormal flexion) 3
no verbal response 1 decerebrate (abnormal extension) 2
no response 1

best reported as a 3 part score: Eyes + Verbal + Motor = total

provides indication of degree of injury
• 13-15 = mild injury
• 9-12 = moderate injury
• < 8 = severe injury
if patient intubated, GCS score reported out of 10 + T (T= tubed, i.e. no verbal component)

Coma (GCS δ 8)
2/3 1/3

Toxic/Metabolic Primary CNS Disease/Trauma

M - Major organ failure

E - E lectrolyte/E ndocrine
T - T oxins/Temperature
A - Acid disorders Bilateral Cerebral Brainstem
B - Base disorders Hemispheres (affecting cognition) (affecting Recticular
O - decreased Oxygen level Activitating System (RAS))
L - Lactate
I - I nsulin (diabetes)/ Infection (sepsis) Diffuse lesion Diffuse trauma/ischemia Compression Direct
C - Cardiac/hyper Calcemia • supra/infratentorial • brainstem
tumour infarct
• sub/epidural • brainstem
Figure 2. Etiology of Coma hematoma hemorrhage
ER6 – Emergency Medicine MCCQE 2006 Review Notes
 APPROACH TO COMA. . . CONT.
MANAGEMENT OF THE COMATOSE PATIENT
ABC’s
airway management should take into account
• probability of C-spine injury, high if:
• major trauma
• head or face trauma
• history of fall or collapse
• likelihood of aspiration
• adequacy of ventilation
• correct hypoxia and hypercarbia
• reversibility of the cause of the coma
• hypoglycemia or narcotic overdose (OD) rapidly reversible therefore ETT may not be needed
(controversial)
• need for maximizing oxygenation
• carbon monoxide (CO) poisoning
• raised ICP (usually requires ETT)
Components of Resuscitation
IV access
rapid blood sugar, CBC, lytes, Cr and BUN, LFT’s, glucose, serum osmolality, ABG’s
ECG
universal antidotes
• thiamine 100 mg IM before glucose (if cachectic, alcoholic, malnourished)
• glucose: 50 cc of 50% (D50W) if glucose < 4 mmol/L (70 mg/dL) or
rapid measurement not available
• naloxone 0.4-2.0 mg IV if narcotic toxidrome present (risk of withdrawal
reaction in chronic opiate users, therefore use naloxone 0.4 mg in known users)
drug levels of specific toxins if indicated
rapid assessment and correction of abnormalities essential to prevent brain injury
Secondary Survey and Definitive Care
focused history (from family, friends, police, paramedics, old chart, etc.)
onset and progression
• abrupt onset suggests CNS hemorrhage/ischemia or cardiac cause
• progression over hours to days suggests progressive CNS lesion or toxic/metabolic cause
condition prior to coma
• confusional/delerious states suggest toxic/metabolic cause
• antecedent trauma, seizure activity, fever
• medications, alcohol, or drugs
past medical history (e.g. similar episode, depression)
physical examination
• vitals including temperature, cardiac, chest, abdominal exam and inspection for 5 N’s
selected laboratory and imaging studies (x-ray and CT)
Inspection - The Five N’s
Noggin – e.g. Raccoon eyes, Battle’s sign (appear ~8 hrs. after trauma)
Neck – C-spine, neurogenic shock, nuchal rigidity
e Nt – otorrhea, rhinorrhea, tongue biting, odour on breath, hemotympanum
Needles – track marks of IV drug abuse
Neurological – full examination essential but concentrate on
• GCS - follow over time
• respirations (rate and pattern)
• apneustic or ataxic (brainstem)
• Cheyne-Stokes (cortical, brainstem or toxic/metabolic)
• posture
• decorticate: severe bilateral damage above midbrain
• decerebrate: damage in midbrain, diencephalon
• movement
• spontaneity, symmetry and seizure activity
• pupils - reactivity and symmetry (CN II, III), papilledema (increased ICP)
• reflexes
• corneal reflex (CN V, VII)
• gag reflex (CN IX, X)
• oculocephalic reflex/doll’s eye reflex (after C-spine clearance): test for brainstem integrity
• oculovestibular reflex (rule out tympanic perforation and cerumen impaction first)
• deep tendon reflexes and tone
• plantar reflex
• caloric stimulation: normal response consists of ipsilateral slow gaze (brainstem mediated) and
contralateral saccadic correction (cortically mediated); cannot be voluntarily resisted
• lumbar puncture (LP) after normal CT to rule out meningitis, subarachnoid hemorrhage (SAH)
(increasing evidence that LP can be done as primary investigation if no evidence of increased ICP)
Diagnosis
findings suggesting a toxic-metabolic cause
• dysfunction at lower levels of the brainstem (e.g. caloric unresponsiveness)
• respiratory depression in association with an intact upper brainstem (e.g. reactive pupils)
• see Tables 4 and 5

MCCQE 2006 Review Notes Emergency Medicine – ER7

 APPROACH TO COMA. . . CONT.
Table 4. Structural vs. Metabolic Coma

Structural Toxic-Metabolic

Pupillary asymmetric pupils equal, round, regular

Reaction or absent reaction to light (see Table 5)

Extraocular asymmetric symmetric

movements or absent or absent

Motor asymmetric symmetric

Findings or absent or absent

Table 5. Toxic - Metabolic Causes of Fixed Pupils

Cause Pupils Characteristics Treatment

Anoxia dilated antecedent history of 100% O2 ,

shock, cardiac expectant management
or respiratory arrest, etc.

Anticholinergic dilated tachycardia physostigmine (for Atropine)

Agents warm, dry skin sodium bicarbonate (for TCA)
(e.g. atropine, TCA’s)

Cholinergic Agents small, barely diaphoresis, vomiting, atropine

(e.g. organo- perceptible reflex incontinence, increased
phosphates) secretions

Opiates pinpoint, barely needle marks naloxone

(e.g. heroin) perceptible reflex
(exception:
meperidine)

Hypothermia normal history of exposure warm patient

or dilated temperature < 35ºC (e.g. warm IV solutions, blankets)

Barbiturates midsized history of exposure ABC’

to dilated positive serum levels no
s specific antidote
confusion, drowsiness,
ataxia shallow respirations
and pulse

Methanol (rare) dilated optic neuritis ethanol ± dialysis

increased osmolal gap
metabolic acidosis

it is essential to re-examine comatose patients frequently - can change rapidly

diagnosis may only become apparent with the passage of time
• delayed deficit after head trauma suggestive of epidural hematoma
Disposition
readily reversible coma: discharge if adequate follow-up care available
enduring decreased LOC: admit to service based on tentative diagnosis
transfer patient if appropriate level of care not available

ER8 – Emergency Medicine MCCQE 2006 Review Notes

 TRAUMATOLOGY
EPIDEMIOLOGY
trauma is the leading cause of death in patients < 44 years
trimodal distribution of death
• minutes: lethal injuries; death usually at the scene
• early: this period includes the “golden hour” (death within 4-6 hours,
decreased mortality with trauma care)
• days-weeks: death from multiple organ dysfunction, sepsis, etc.
injuries generally fall into two categories
• blunt
• most common
• MVC, pedestrian-automobile impact, motorcycle collision, fall, assault, sports, etc.
• penetrating
• increasing in incidence
• gunshot wound, stabbing, impalement
CONSIDERATIONS FOR TRAUMATIC INJURY
important to know the mechanism of injury in order to anticipate/suspect traumatic injuries
always look for an underlying cause (alcohol, other drugs, seizure, suicide, medical problem)
always inquire about head injury, loss of consciousness, amnesia, vomiting, headache and seizure activity
Motor Vehicle Collisions (MVC)
weight and size of vehicle
• inversely proportional to severity of injury
speed of vehicle
location of patient in vehicle
type of crash and associated serious injuries:
• lateral/T-bone: head, cervical spine, thoracic and abdominal injury
• front end: head, cervical spine, thoracic, abdominal, pelvic and lower extremity
• rear end: over-extension of cervical spine (whiplash injury to neck)
• roll over: energy dissipated, less likely severe injury if victim restrained by seatbelt
• ejection of patient from vehicle/entrapment of patient under vehicle
degree of damage to vehicle, (especially if intrusion into passenger compartment)
broken windshield (head and cervical spine injury), condition of steering wheel (chest injury),
knees to dashboard (hip, femur injury)
use and type of seatbelt
• lap belt: spine and abdominal injury
• shoulder belt: look for major vessel injury
airbag deployment
death of same vehicle occupant
motorcycle collisions
• motorcycle speed
• site of anatomic impact
• use of helmet
Pedestrian-Automobile Crash
vehicle speed
site of impact on car
• children: tend to be run over
• adults: tend to be struck in lower legs, impact again on car and ejected to the ground
• look for triad of: 1. tibia-fibula or femur fracture, 2. truncal injury and 3. craniofacial injury
Falls
distance of fall: 50% mortality at 4 stories and 95% mortality at 7 stories (1 story = 12 feet)
position in which patient landed and type of surface
• look for shock, lower extremity, spine and pelvic fractures
Assault
weapon used
strangulation
sexual assault (see Common ER Presentations section)
Gunshot Wounds
type of gun
• handgun injuries: low or high velocity, extent of injury may be limited to a small area
• hunting and rifle injuries: high velocity, widespread injury
type of ammunition (e.g. hollow point bullets)
range of shot
• close range: massive tissue destruction at close range, deposition of wadding into wound
route of entry
Stab Wounds
route of entry, length of blade
type of penetration (stab, slash, impalement)
victim recollection and witness reports are often inaccurate and may not correlate with depth/severity
of wound
MCCQE 2006 Review Notes Emergency Medicine – ER9
 TRAUMATOLOGY. . . CONT.
SHOCK IN THE TRAUMA PATIENT (see Anesthesia Chapter)
inadequate organ and tissue perfusion (brain, kidney, extremities)
SHOCK IN THE TRAUMA PATIENT IS HEMORRHAGIC UNTIL PROVEN OTHERWISE
Classification
hemorrhagic shock (most common) - see Table 6
cardiogenic shock - e.g. blunt myocardial injury
obstructive shock - e.g. tension pneumothorax, cardiac tamponade, pulmonary embolism
distributive shock - e.g. spinal/neurogenic, septic and anaphylactic shock

Table 6. Classification of Hemorrhagic Shock (70kg male)

Class Blood loss (mL) BP Pulse Resp rate Urine output
I < 15% (< 750) normal <100 14-20 > 30 mL/hour
II 15-30% (750-1500) normal >100 20-30 0-30 mL/hour
II 30-40% (1500-2000) 9 >120 30-40 5-15 mL/hour
I 99
I >40% (>2000) >140 > 35 0 mL/hour
V

Clinical Evaluation
rapidly assess for other causes of traumatic shock
clinical features of acute hemorrhage
• early: tachypnea, tachycardia, narrow pulse pressure, reduced urine output (U/O),
reduced capillary refill, cool extremities and reduced central venous pressure (CVP)
• late: hypotension and altered mental status
Management of Hemorrhagic Shock
secure airway and supply O 2
control external bleeding (prompt surgical consultation for active internal bleeding)
infusion of 1-2 L of NS or RL as rapidly as possible
• replace lost blood volume at ratio of 3:1 (maintain intravascular volume)
if no response, consider ongoing blood loss (e.g. chest, abdomen, pelvis, extremities)
––> operative intervention required
blood transfusion
• indicated if:
1. severe hypotension on arrival, 2. shock persists following crystalloid infusion, 3. rapid bleeding
• packed RBC’s (PRBCs)
• cross-matched (ideal but takes time)
• type-specific (provided by most blood banks within 10 min.)
preferred to O-negative uncrossmatched blood if both available
• O-negative (children and women of child-bearing age)
• O-positive (everyone else) if no time for cross and match
• consider complications with massive transfusions
Unproven or Harmful Treatments
Trendelenberg position
steroids (used only in spinal cord injury)
MAST garments - non efficacious for treatment of shock; no longer used
vasopressors during hemorrhagic shock
CHEST TRAUMA
trauma to the chest accounts for, or contributes to 50% of trauma deaths
two types
• immediately life-threatening
• potentially life-threatening
A. IMMEDIATELY LIFE-THREATENING CHEST INJURIES
identified and managed during the primary survey
• airway obstruction
• tension pneumothorax
• open pneumothorax
• massive hemothorax
• flail chest
• cardiac tamponade
80% of all chest injuries can be managed non-surgically with simple measures such as intubation,
chest tubes, and pain control

ER10 – Emergency Medicine MCCQE 2006 Review Notes

 TRAUMATOLOGY. . . CONT.
Table 7. Immediately Life-Threatening Chest Injuries
Physical Exam Investigations Management

Airway Obstruction • anxiety, stridor, hoarseness, • do not wait for ABG’s to intubate • definitive airway management
altered mental status • intubate early
• apnea, cyanosis

Tension Pneumothorax • respiratory distress, tachycardia, • non-radiographic diagnosis • large bore IV needle, 2nd ICS
• a clinical diagnosis distended neck veins, cyanosis, mid clavicular line, followed by chest
• one-way valve causing asymmetry of chest wall motion tube in 5th ICS, anterior axillary line
accumulation of air in pleural • tracheal deviation away from pneumothorax
space • percussion hyperresonnance
• unilateral absence of breath sounds, • ICS = intercostal space
hypotension

Open Pneumothorax • gunshot or other wound (hole > 2/3 tracheal • ABG’s: decreased pO 2 • air-tight dressing sealed on 3 sides
• air entering chest from wound diameter) ± exit wound • chest tube
rather than trachea • unequal breathsounds • surgery

Massive Hemothorax • pallor, flat neck veins, shock • upright CXR: costophrenic blunting • restore blood volume
• > 1500 cc blood loss • unilateral dullness • chest tube
in chest cavity • absent breath sounds, hypotension • may receive thoracotomy:
> 1500 cc total blood volume
ε 200 cc/hr continued drainage

Flail Chest • paradoxical movement of flail segment • ABGs: decreased pO 2 , increased pCO 2 • O2 + fluid therapy + pain control
• free-floating segment of • palpable crepitus of ribs • CXR: rib fractures, lung contusion • judicious fluid therapy in absence of
chest wall due to > 4 rib • decreased air entry on affected side systemic hypotension
fractures, each at 2 sites • positive pressure ventilation
• underlying lung contusion • +/– intubation and ventilation
(cause of morbidity and
mortality)

Cardiac Tamponade • penetrating wound (usually) • ECHO • IV fluids

• Beck’s triad (hypotension, distended neck • pericardiocentesis
veins, muffled heart sounds) • open thoracotomy
• pulsus paradoxus
• Kussmaul’s sign

B. POTENTIALLY LIFE-THREATENING CHEST INJURIES

identified in secondary survey (CXR)
C - Contusion: pulmonary, myocardial
H - Hernia: traumatic diaphragmatic
ES - ESophageal perforation
T - Tracheobronchial disruption/ Traumatic aortic injury
need to have high index of suspicion, usually dependent on mechanism of injury
Pulmonary Contusion
history: blunt trauma to chest
interstitial edema impairs compliance and gas exchange
CXR: areas of opacification of lung within 6 hours of trauma
management
• maintain adequate ventilation
• monitor with ABG, pulse oximeter and ECG
• chest physiotherapy
• positive pressure ventilation if severe
Blunt Myocardial Injury (Rare)
history: blunt trauma to chest (usually in setting of multi-systemtrauma and therefore difficult to diagnose)
physical examination: overlying injury, i.e. fractures, chest wall contusion
investigations
• ECG: arrhythmias, ST changes
• patients with a normal ECG and normal hemodynamics never get dysrhythmias
management
•O2
• antiarrhythmic agents
• analgesia
Ruptured Diaphragm
difficult to diagnose (often missed)
more often diagnosed on left side since liver conceals defect on right
history: blunt trauma to chest or abdomen (e.g. high lap belt in MVC)
investigations
• CXR - abnormality of diaphragm/lower lung fields/NG tube placement
• CT scan and endoscopy - sometimes helpful for diagnosis
management
• laparotomy for diaphragm repair and because of associated intra-abdominal injuries
MCCQE 2006 Review Notes Emergency Medicine – ER11
 TRAUMATOLOGY. . . CONT.
Esophageal Injury
history: usually penetrating trauma (pain out of proportion to degree of injury)
investigations
• CXR: mediastinal air (not always)
• esophagram (Gastrograffin)
• flexible esophagoscopy
management
• early repair (within 24 hrs.) improves outcome but all require repair
Penetrating Neck Trauma
includes all penetrating trauma to the three zones of the neck (see Otolaryngology Chapter)
• zone 1: below cricoid cartilage, extending to thoracic inlet
• zone 2: between angle of mandible and cricoid cartilage
• zone 3: area of neck above mandible
management
• injuries require further evaluation if deep to platysma (should not be explored in E.D.)
• zone 1 and 3 injuries ––> angiography
• zone 2 injuries ––> O.R. for exploration
DON’T:
• clamp structures (can damage nerves)
• probe
• insert NG tube (leads to bleeding)
• remove weapon/impaled object
Airway Injuries
always maintain a high index of suspicion
larynx
• history: strangulation, clothes line, direct blow, blunt trauma, any penetrating injury involving platysma
• triad of:
1. hoarseness
2. subcutaneous emphysema
3. palpable fracture, crepitus
• other symptoms: hemoptysis, dyspnea
• investigations
• CXR
• CT scan
• arteriography (if penetrating)
• management
• airway - manage early because of edema
• C-spine: may also be injured, consider mechanism of injury
• surgical: tracheotomy vs. repair
trachea/bronchus
• frequently missed
• history: deceleration, penetration, increased intra-thoracic pressure
• complaints of dyspnea, hemoptysis
• examination: subcutaneous air, Hamman’s sign (crunching sound synchronous with heart beat)
• CXR: mediastinal air, persistent pneumothorax or persistent air leak after chest tube inserted
for pneumothorax
• management
• surgical repair if > 1/3 circumference
Aortic Tear
90% tear at subclavian (near ligamentum arteriosum), most die at scene
salvageable if diagnosis made rapidly in E.D.
history
• sudden high speed deceleration (e.g. MVC, fall, airplane crash)
• complaints of chest pain, dyspnea, hoarseness (frequently absent)
physical examination: decreased femoral pulses, differential arm BP (arch tear)
investigations: CXR, CT scan, transesophageal echo (TEE), aortography (gold standard)
x-ray features
• wide mediastinum (most consistent)
• pleural cap
• massive left hemothorax
• indistinct aortic knuckle
• tracheal deviation to right side
• depressed left mainstem bronchus
• esophagus (NG tube) deviated to right side
management
• thoracotomy (may treat other severe injuries first)
Late Causes of Death in Chest Trauma
respiratory failure
sepsis (adult respiratory distress syndrome (ARDS))

ER12 – Emergency Medicine MCCQE 2006 Review Notes

 TRAUMATOLOGY. . . CONT.
ABDOMINAL TRAUMA
two mechanisms
• blunt trauma - usually causes solid organ injury
• penetrating trauma - usually causes hollow organ injury
Blunt Trauma
two types of hemorrhage
• intra-abdominal bleed
• retroperitoneal bleed
high clinical suspicion in multi-system trauma
physical exam unreliable in multi-system trauma
• slow blood loss not immediately apparent
• other injuries may mask symptoms
• serial examinations are required
inspection: contusions, abrasions, distension, guarding
palpation: tenderness, rebound tenderness, rigidity
diagnostic tests are indicated in patients with
• unexplained shock
• equivocal signs of abdominal injury
• unreliable physical exam (paraplegia, head injury, substance use)
• high likelihood of injury (pelvic/lumbar fracture, etc.)
• impending periods of non-observation (e.g. surgery)
diagnostic tests include
• CXR
• free air under diaphragm (if patient not supine)
• diaphragmatic herniation
• ultrasound: FAST (focused abdominal sonogram for trauma)
• to identify presence/absence of free fluid in the peritoneal cavity
• NOT used to identify specific organ injuries
• CT scan: best investigation if patient stable enough
• IVP
• diagnostic peritoneal lavage (DPL)
• tests for intra-peritoneal bleed
• cannot test for
• retroperitoneal bleed
• discerning lethal from trivial bleed
• diaphragmatic rupture
• criteria for positive lavage:
• > 10 cc gross blood
• bile, bacteria, foreign material
• RBC count > 100,000 x 106 /L,
WBC > 500 x 10 6 /L, amylase > 175 IU
management
• general: fluid resuscitation and stabilization
• surgical: watchful wait vs. laparotomy
• solid organ injuries: decision based on hemodynamic stability, not the specific injuries
• hemodynamically unstable or persistently high tranfusion requirements ––> laparotomy
• all hollow organ injuries ––> laparotomy
note: seatbelt injuries may have
• retroperitoneal duodenal trauma
• intraperitoneal bowel transection
• mesenteric injury
• L-spine injury
Penetrating Trauma
high risk of gastrointestinal (GI) perforation and sepsis
history: size of blade, calibre/distance from gun, route of entry
local wound exploration with the following exceptions:
• thoracoabdominal region (may cause pneumothorax)
• back or flanks (muscles too thick)
management
• gunshot wounds ––> always require laparotomy
• stab wounds - “Rule of Thirds”
• 1/3 do not penetrate peritoneal cavity
• 1/3 penetrate but are harmless
• 1/3 cause injury requiring surgery
• mandatory laparotomy if
• shock
• peritonitis
• evisceration
• free air in abdomen
• blood in NG tube, Foley catheter or on rectal exam
MCCQE 2006 Review Notes Emergency Medicine – ER13
 TRAUMATOLOGY. . . CONT.
GENITOURINARY TRACT (GU) INJURIES
diagnosis based on mechanism of injury, hematuria (gross or microscopic),
and appropriate radiological studies
Renal
etiology
• blunt trauma
• contusions (parenchymal ecchymosis with intact renal capsule)
• parenchymal tears
• non-communicating (hematoma)
• communicating (urine extravasation, hematuria)
• penetrating injuries
• renal pedicle injury due to acceleration/deceleration
history: mechanism of injury, hematuria, flank pain
physical exam: costovertebral angle (CVA) tenderness, upper quadrant mass, shock
investigations
• CT scan (study of choice if hemodynamically stable)
• intravenous pyelogram (IVP) (during laparotomy)
• renal arteriography (if renal artery injury suspected)
management
• 90% conservative (bedrest, analgesia, antibiotics)
• 10% surgical for
• hemodynamically unstable or continuing to bleed > 48 hours
• major urine extravasation
• renal pedicle injury
• all penetrating wounds
• major lacerations
• renal artery thrombosis
• infection
Ureter
etiology
• iatrogenic (most common)
• blunt (rare) at uretero-pelvic junction
• penetrating (rare)
history: mechanism of injury, hematuria
physical exam: findings related to intra-abdominal injuries
investigations: retrograde ureterogram
management: uretero-uretostomy
Bladder
etiology
• blunt trauma
• extraperitoneal rupture from pelvic fracture fragments
• intraperitoneal rupture from trauma + full bladder
• penetrating trauma
history: gross hematuria, dysuria, urinary retention, abdominal pain
physical exam
• extraperitoneal rupture: pelvic instability, suprapubic tenderness from mass of urine
or extravasated blood
• intraperitoneal rupture: acute abdomen
investigations: urinalysis, CT scan, urethrogram, +/– retrograde cystography
management
• extraperitoneal: minor rupture ––> Foley drainage, major rupture ––> surgical repair
• intraperitoneal: drain abdomen and surgical repair
Urethral
etiology
• usually blunt trauma in men
• anterior (bulbous) urethra damage with straddle injuries
• posterior (bulbo-membranous) urethra with pelvic fractures
history/physical
• anterior: blood at meatus, perineal/scrotal hematoma, blood and urine extending from
penile shaft and perineum to abdominal wall
• posterior: inability to void, blood at meatus, suprapubic tenderness, pelvic instability,
superior displacement of prostate, pelvic hematoma on rectal exam
investigation: retrograde urethrography
management
• anterior: if Foley does not pass, requires suprapubic drain
• posterior: suprapubic drainage, avoid catheterization
Contraindications to Foley Catheterization
1. blood at the urethral meatus
2. ecchymosis of the scrotum
3. “high riding” prostate on DRE of male patients
if any of the above, digital rectal exam (DRE), a retrograde cystouretharogram indicated to rule out
urethral tear or ruptured bladder
ER14 – Emergency Medicine MCCQE 2006 Review Notes
 TRAUMATOLOGY. . . CONT.
HEAD TRAUMA(see Neurosurgery Chapter)
60% of trauma admissions have head injuries
60% of MVC-related deaths are due to head injury
first physician who sees patient has greatest impact on the outcome
alteration of consciousness is the hallmark of brain injury
Assessment of Brain Injury
history
• pre-hospital state, mechanism of injury
vital signs
• shock (not present in isolated brain injury, except in infants)
• Cushing’s response to increasing ICP (bradycardia with hypertension)
• hyperthermia
level of consciousness
• Glasgow Coma Scale (GCS)
pupils: pathology = anisocoria > 1 mm (in patient with altered LOC)
neurological exam: lateralizing signs - motor/sensory
Severe Head Injury
GCS = 8
deteriorating GCS
unequal pupils
lateralizing signs
Investigations
CT scan
skull x-rays
• little value in the early management of obvious blunt head injury
• for diagnosis of calvarium fractures (not brain injury)
• may help localize foreign body after penetrating head injury
Specific Injuries
skull fractures (diagnosed by CT of head)
• linear, non-depressed
• most common
• typically occur over temporal bone, in area of middle meningeal artery
(commonest cause of epidural hematoma)
• depressed
• open (associated overlying scalp laceration)
• closed
• basal skull
• typically occur through floor of anterior cranial fossa
(longitudinal more common than transverse)
• clinical diagnosis superior (Battle’s sign, racoon eyes, CSF otorrhea/rhinorrhea, hemotympanum)
facial fractures (see Plastic Surgery Chapter)
diffuse brain injury
diffuse axonal injury
concussion (brief LOC then normal)
focal injuries
• contusions
• intracranial hemorrhage (epidural, acute subdural, intracerebral)
Management
general
• ABC’s
• treat other injuries e.g. shock, hypoxia
early neurosurgical consultation to direct acute and subsequent patient management
medical
• seizure treatment/prophylaxis
• steroids are of NO proven value
• diazepam, phenytoin, phenobarbital
• treat suspected raised ICP
• 100% O2
• intubate and hyperventilate to a pCO 2 of 30-35 mmHg
• mannitol 1 g/kg infused as rapidly as possible (reserved for head-injured
patients who are showing evidence of increased ICP)
• raise head of stretcher 20 degrees if patient hemodynamically stable
• consider paralyzing meds if agitated/high airway pressures
surgical
Disposition
neurosurgical ICU admission for severely head-injured patients
in hemodynamically unstable patient with other injuries, prioritize most life threatening injury

MCCQE 2006 Review Notes Emergency Medicine – ER15

 TRAUMATOLOGY. . . CONT.
SPINE AND SPINAL CORD TRAUMA
spinal immobilization (cervical collar, spine board) must be maintained until spinal injury has been ruled out
vertebral injuries may be present without spinal cord injury, therefore normal neurologic exam
does not exclude spinal injury
if a fracture is found, be suspicious, look for another fracture
spine may be unstable despite normal C-spine x-ray
collar everyone except those that meet ALL the following criteria
• no pain
• no tenderness
• no neurological symptoms or findings
• no significant distracting injuries
• no head injury
• no intoxication
note: patients with penetrating trauma (especially gunshot and knife wounds) can also have spinal cord injury
X-Rays
full spine series for trauma
• AP, lateral, odontoid
lateral C-Spine
• must be obtained on all blunt trauma patients (except those meeting above criteria)
• must visualize C7-T1 junction (Swimmer’s view or CT scan often required)
thoracolumbar
• AP and lateral views
• indicated in
• patients with C-spine injury
• unconscious patients
• patients with symptoms or neurological findings
• patients with deformities that are palpable when patient log-rolled
Management of Cord Injury
immobilize the entire spine with the patient in the supine position (collar, sand bags, padded board, straps)
if patient must be moved, use a “log roll” technique with assistance
if cervical cord lesion, watch for respiratory insufficiency
• low cervical transection (C5-T1) produces abdominal breathing (phrenic innervation of
diaphragm still intact)
• high cervical cord injury ––> no breathing ––> intubation
hypotension (neurogenic shock)
• treatment: warm blanket, Trendelenberg position (occasionally), volume infusion,
consider vasopressors

APPROACH TO SUSPECTED C-SPINE INJURY

Clearing the C-Spine
cervical collar must stay on at all times until C-spine is cleared (see Figure 3)

ER16 – Emergency Medicine MCCQE 2006 Review Notes

 TRAUMATOLOGY. . . CONT.

Suspected C-spine Injury

* based on mechanism of injury (e.g. MVC, fall, sports)

History: midline neck pain, numbness or parasthesia, presence of distracting pain, patient head-injured,
patient intoxicated, loss of consciousness or past history of spinal mobility disorder

Physical exam: posterior neck spasm, tenderness or crepitus, any neurologic deficit or autonomic
dysfunction, altered mental state
NO YES

C-spine cleared 1. Plain x-rays, 3 views

2. CT scan if:
• inadequate plain film survey
• suspicious plain film findings
C-spine cleared • to better delineate injuries seen on plain films
• any clinical suspicion of atlanto-axial dislocation
• high clinical suspicion of injury despite normal x-ray
Normal • to include C1-C3 when head CT is indicated in head
trauma cases
Flexion/
extension Neck pain
films
Normal films Abnormal films
Abnormal
Abnormal
Remain immobilized, neurological
consult spine service exam Remain immobilized, consult spine service
Abnormal
MRI

C-spine cleared Normal

Figure 3. Approach to C-spine Clearing

C-Spine X-Rays
3-view C-spine series is the screening modality of choice
• AP
• lateral C1-T1 (± swimmer’s view) - T2 not involved with neck movements
• odontoid (open mouth or oblique submental view)
Odontoid View (see Figure 5)
examine the dens for fractures
• beware of artifact (horizontal or vertical) caused by the radiologic shadow of the teeth overlying
the dens. Repeat view if unable to rule out fracture. If still unable to rule out fracture consider CT or
plain film tomography.
examine lateral aspects of C1
• odontoid should be centred between C1 lateral masses
• lateral masses of C1 and C2 should be perfectly aligned laterally. If not, suspect a fracture of C1
• lateral masses should be symmetrical (equal size)
Anteroposterior View
alignment of spinous processes in the midline
spacing of spinous processes should be equal
check vertebral bodies

Supine Oblique Views

detects some injuries not visible on the usual three views
better visualization of posterior element fractures (lamina, pedicle, facet joint)
can be used to visualize the cervicothoracic junction

MCCQE 2006 Review Notes Emergency Medicine – ER17

 TRAUMATOLOGY. . . CONT.

1. Dens
2 2 2. C1 Lateral Mass
1
3. C2
1. anterior vertebral line
2. posterior vertebral line
(anterior margin of spinal canal)
3. posterior border of facets
4. laminar fusion line
3
(posterior margin of spinal canal)
5. posterior spinous line
(along tips of spinous processes)
5 To clear the x-ray ensure that:
43 A) the dens is centred between the lateral massess of C1
2 1 B) C1 and C2 are aligned laterally
C) the lateral masses of C1 are symmetrical in size
Figure 4. Lines of Contour on a
Lateral C-Spine X-Ray Figure 5. Odontoid of C-Spine X-Ray
Illustrated by Kim Auchinachie Illustrated by Eddy Xuan

Lateral View: The ABCS

A - Alignment and Adequacy
must see C1 to C7-T1 junction - if not - downward traction of shoulders, swimmer’s view, bilateral supine
obliques, or CT scan
lines of contour (see Figure 4) (in children < 8 years of age: physiologic subluxation of C2 on C3, and C3
on C4, but the spinolaminal line is maintained)
widening of interspinous space (fanning of spinous processes) suggests posterior ligamentous disruption
widening of facet joints
check atlanto-occipital joint:
• line extended inferiorly from clivus should transect odontoid
atlanto-axial articulation - widening of predental space (> 3 mm in adults, > 5 mm in children)
indicates injury of C1 or C2
B - Bones
height, width and shape of each vertebral body
pedicles, facets, and laminae should appear as one - doubling suggests rotation
C - Cartilages
intervetebral disc spaces - widening anteriorly or posteriorly suggests vertebral compression
S - Soft Tissues
widening of retropharyngeal (> 7 mm at C1-4, may be wide in children less than 2 yrs. on expiration)
or retrotracheal spaces (> 22 mm at C6-T1, > 14 mm in children < 15 years of age)
prevertebral soft tissue swelling: only 49% sensitive for injury
Management Considerations
immobilize C-spine with collar and sand bags (collar alone is not enough)
injuries above C4 may need ventilation
continually reassess high cord injuries - edema can travel up cord
beware of neurogenic shock
administer methylprednisolone within 8 hours of C-spine injury
before O.R. ensure thoracic and lumbar x-rays are normal, since 20% of patients with C-spine fractures have
other spinal fractures
early referral to spine service
Sequelae of C-spine Fracture
decreased descending sympathetic tone (neurogenic / spinal shock) responsible for most sequelae
cardiac
• no autoregulation, falling BP, decreasing HR, vasodilation
• GIVE IV FLUIDS ± pressors
respiratory
• no cough reflex (risk of aspiration pneumonia)
• no intercostal muscles +/– diaphragm
• intubate and maintain vital capacity
gastrointestinal
• ileus, vasodilation, bile and pancreatic secretion continues (> 1L/day), risk of aspiration, GI stress ulcers
• NG tube may be required for suctioning, feeding, etc.
renal
• hypoperfusion ––> IV fluids
• kidney still producing urine (bladder can rupture if patient not urinating)
• Foley catheter may be required (measure urine output)
ER18 – Emergency Medicine MCCQE 2006 Review Notes
 TRAUMATOLOGY. . . CONT.
skin
• vasodilation, heat loss, no thermoregulation, atrophy (risk of skin ulcers)
muscle
• flaccidity, atrophy, decreased venous return
penis
• priapism

ORTHOPEDIC INJURIES (see Orthopedics Chapter)

role of E.D.: identify injuries, restore anatomy (reduce and immobilize), administer antibiotics and
tetanus prophylaxis
Physical Exam
look: deformity, swelling, bleeding, bruising, spasm, colour
feel: pulse, warmth, tenderness, crepitation, sensation, capillary refill
move: range of motion (ROM) assessed actively (beware passive ROM testing)
Describing Orthopedic Injuries
open vs. closed
neurovascular status
location of fracture
type of fracture
alignment: displacement, angulation
General Approach
fractures
• immobilize/traction/ice/analgesia
open wounds
• remove gross contamination, irrigate
• cover with sterile dressing
• definitive care within 6-8 hours
• control bleeding with pressure (no clamping)
• splint fracture
• antibiotics - cefazolin (+/– gentamycin, metronidazole/penicillin in dirty injury)
• tetanus prophylaxis (if none in last 10 yrs)
joint injuries
• orthopedic consultation
• reduce dislocations after x-ray
• immobilize
A. LIFE AND LIMB THREATENING INJURIES
usually because of blood loss
• pelvic fractures (up to 3.0L blood loss)
• femur fractures (up to 1.5L blood loss per femur)
• open fractures (double blood loss of a closed fracture)
neurovascular compromise
open fractures
extensive soft tissue injuries
amputations
compartment syndrome
Life Threatening Injuries
major pelvic fractures
traumatic amputations
massive long bone injuries
vascular injuries proximal to knee/elbow
Limb Threatening Injuries
fracture/dislocaton of ankle
crush injuries
compartment syndrome
dislocations of knee/hip
fractures with vascular/nerve injuries
open fractures
fractures above the knee or elbow
Assessment of Neurovascular Injury
assess pulses before and after reduction
diminished pulses should not be attributed to “spasm”
angiography is definitive if diagnosis in doubt
Vascular Injuries Suggested by 6 P’s
P ulse discrepancies
P allor
P aresthesia/hypoesthesia
P aresis
P ain (especially when refractory to usual doses of analgesics)
P olar (cold)
MCCQE 2006 Review Notes Emergency Medicine – ER19
 TRAUMATOLOGY. . . CONT.
Treatment of Vascular Compromise
realign limb/apply traction
recheck pulses (Dopplers)
surgical consult
consider measuring compartment pressures
angiography
Compartment Syndrome (see Orthopedics Chapter)
rise in interstitial pressure above that of capillary bed (30-40 mmHg)
usually in leg or forearm
often associated with crush injuries (extensive soft tissue damage)
clinical diagnosis
suspect when you find
• excessive pain; worse with passive stretching of involved muscles
• decreased sensation of nerves in that compartment
• tense swelling
• weakness, paralysis
• pulse may still be present until very late
hallmark: pain refractory to treatment with “usual” dose of analgesic agent
management
• compartment syndrome
• remove constrictive dressings/casts
• prompt fasciotomy

B. UPPER EXTREMITY INJURIES

anterior shoulder dislocation
• axillary nerve at risk
• shown on lateral view: humeral head anterior to glenoid
• reduce, immobilize, re-X ray, out-patient appointment with ortho
Colle’s fracture
• from fall on the outstretched hand (FOOSH)
• AP film: shortening, radial deviation, radial displacement
• lateral film: dorsal displacement, volar angulation
• reduce, immoblize with volar slab, out-patient with ortho (consider presentation)
• if involvement of articular surface, emergent ortho referral
scaphoid fracture
• tender in snuff box, pain on scaphoid tubercle and pain on pressure on thumb (axial loading)
• negative X -ray: thumb spica splint, re-X-ray in 1 week +/– bone scan
• positive x-ray: thumb spica splint x 6-8 weeks
• risk of avascular necrosis (AVN) of scaphoid if not immobilized

C. LOWER EXTREMITY INJURIES

ankle and foot fractures
• see Ottawa ankle rules (Figure 6)
knee injuries
• see Ottawa knee rules (Figure 7)
avulsion of the base of 5th metatarsal
• occurs with inversion injury
• supportive tensor, below knee walking cast for 3 weeks
calcaneal fracture
• associated with fall from height
• associated injuries may involve ankles, knees, hips, pelvis, lumbar spine

An ankle radiographic series is only required if

there is any pain in malleolar zone and any of these findings:
1. bone tenderness at A
or
2. bone tenderness at B
or
3. inability to bear weight both
immediately and in emergency department

A foot radiographic series is only required if

there is any pain in midfoot zone and any of these findings:
1. bone tenderness at C
or
2. bone tenderness at D
or
3. inability to bear weight both
Figure 6. Ottawa Ankle Rules immediately and in emergency department

Reprinted with permission from Stiell et. al. JAMA 271:827-832,1994.

ER20 – Emergency Medicine MCCQE 2006 Review Notes

 TRAUMATOLOGY. . . CONT.

A knee x-ray examination is only required for acute injury patients with one or more of:
• age 55 years or older
• tenderness at head of fibula
• isolated tenderness of patella*
• inability to flex to 90º
• inability to bear weight both immediately and in the emergency department (four steps)**
*no bone tenderness of knee other than patella
**unable to transfer weight twice onto each lower limb regardless of limping
Figure 7. Ottawa Knee Rules
Reprinted with permission from Stiell et. al. JAMA 271:8, 611-615, 1995.

SOFT TISSUE INJURIES

Bruises
tender swelling (hematoma) following blunt trauma
is patient on anticoagulants? coagulopathy?
acute treatment: “ RICE”
Rest
I ce
Compression
E levation
Tetanus Prophylaxis
the following table provides guidance for tetanus prophylaxis in the E.D.
Table 8. Tetanus Prophylaxis
Immunization History Non Tetanus Prone Wounds Tetanus Prone Wounds 1
Td 2 TIG3 Td TIG
Uncertain or < 3 doses Yes No Yes Yes
3 or more, none for > 10 years Yes No Yes No
3 or more, > 5 but < 10 years ago No No Yes No
3 or more, < 4 years ago No No No No
1 wounds > 6 hours old, > 1 cm deep, puncture wounds, avulsions, wounds resulting from missiles, crush wounds, burns, frostbite, wounds
contaminated with dirt, feces, soil or saliva
2 3
tetanus and diptheria toxoids (Td), absorbed tetanus immune globulin (TIG) - 250 units
Source: MMWr 2001; 50(20); 418, 427. MMWr 1991; 40(RR12); 1-52.

Abrasions
partial to full thickness break in skin
management
• clean thoroughly (under local anesthetic if necessary) with brush to prevent foreign body impregnation
(tattooing)
• antiseptic ointment (Polysporin) or Vaseline for 7 days for facial and complex abrasions
• tetanus prophylaxis are per above table
Lacerations
always consider every structure deep to a laceration severed until proven otherwise
in hand injury patient, include following in history: handedness, occupation, mechanism of injury, previous
history of injury
physical exam
• think about underlying anatomy
• examine tendon function and neurovascular status distally
• x-ray wounds if a foreign body is suspected (e.g. shattered glass) and not found when exploring wound
• clean and explore under local anesthetic
management
• irrigate copiously with normal saline
• evacuate hematomas, debride non-viable tissue, and remove foreign bodies
• secure hemostasis
• suture (Steristrip, glue, or staple for selected wounds) unless delayed presentation, a puncture wound,
or animal bite
• in general, facial sutures are removed in 5 days, those over joints in 10 days, and everywhere else in
7 days; removal is delayed in patients on steroid therapy
• in children, topical anesthetics such as LET (Lidocaine, Epinephrine and Tetracain) and in selected
cases a short-acting benzodiazepine (midazolam) for sedation and amnesia are useful
• DO NOT use local anesthetic with epinephrine on fingers, toes, penis, ears, nose
• maximum dose of lidocaine
• 7 mg/kg with epinephrine
• 5 mg/kg without epinephrine
MCCQE 2006 Review Notes Emergency Medicine – ER21
 TRAUMATOLOGY. . . CONT.
Mammalian Bites
important points on history
• time and circumstances of bite • allergies
• symptoms • tetanus immunization status
• comorbid conditions • rabies risks
on examination
• assess type of wound: abrasion, laceration, puncture, crush injury
• assess for direct tissue damage - skin, bone, tendon, neurovascular
x-rays
• if bony injury or infection suspected check for gas in tissue
• ALWAYS get skull films in children with scalp bite wounds, +/– CT to rule out cranial perforation
treatment
• wound cleansing and copious irrigation as soon as possible
• irrigate/debride puncture wounds if feasible, but not if sealed or very small openings -
avoid hydrodissection along tissue planes
• debridement is important in crush injuries to reduce infection and optimize cosmetic
and functional repair
• culture wound if signs of infection (erythema, necrosis or pus) - anaerobic cultures if foul smelling,
necrotizing, or abscess
• notify lab that sample is from bite wound
most common complication of mammalian bites is infection (2 to 50%)
• types of infections resulting from bites: cellulitis, lymphangitis, abscesses, tenosynovitis, osteomyelitis,
septic arthritis, sepsis, endocarditis, meningitis
• early wound irrigation and debridement are the most important factors in decreasing infection
rabies (see Infectious Diseases Chapter)
• virus is transmitted via animal bites
• reservoirs: warm-blooded animals except rodents, lagomorphs (e.g. rabbits)
• post-exposure vaccine is effective; treatment depends on local prevalence (contact public health)
to suture or not to suture?
• the risk of wound infection is related to vascularity of tissue
• vascular structures (i.e. face and scalp) are less likely to get infected, therefore suture
• avascular structures (i.e. pretibial regions, hands and feet) by secondary intention
high risk factors for infection
• puncture wounds
• crush injuries
• wounds greater than 12 hours old
• hand or foot wounds, wounds near joints
• immunocompromised patient
• patient age greater than 50 years
• prosthetic joints or valves
Prophylactic Antibiotics
widely recommended for all bite wounds to the hand
should be strongly considered for all other high-risk bite wounds
3-5 days is usually recommended for prophylactic therapy
dog and cat bites (pathogens: Pasteurella multocide, S. aureus, S. viridans )
80% of cat bites, 5% of dog bites become infected (NEJM 1999, AnEm1994)
• 1st line: amoxicillin + clavulinic acid
• 2nd line: tetracycline or doxycycline
• 3rd line: erythromycin, clarithromycin, azithromycin
human bites (pathogens: Eikenella carrodens, S. aureus, S. viridans , oral anaerobes)
• 1st line: amoxicillin + clavulinic acid
• 2nd line: erythromycin, clarithromycin, azithromycin
• 3rd line: clindamycin
althoug antibiotic prophylaxis is frequently given following any mamallian bite Cochrane Review (2000) only
shows decreased rate of infection following human bites; not cat or do
ENVIRONMENTAL INJURIES
Burns (see Plastic Surgery Chapter)
immediate management
• remove noxious agent
• resuscitation
• 2nd and 3rd degree burns: Parkland Formula: Ringer's lactate 4cc/kg/%BSA burned
(not including 1st degree); give 1/2 in first 8 hours, 1/2 in second 16 hours
• at 8 hours: FFP or 5% albumin: if > 25% BSA give 3-4 U/day for 48 hours
• second 8 hours: 2/3-1/3 at 2cc/kg/%BSA
• urine output should be 40-50 cc/hr or 0.5 cc/kg/hr
• avoid diuretics
• continuous morphine infusion at 2 mg/hr with breakthrough bolus
• burn wound care - prevent infection, cover gently with sterile dressings
• escharotomy or fasciotomy for circumferential burns (chest, extremities)
• systemic antibiotics infrequently indicated
• topical - silver sulfadiazene; face - polysporin; ears - sulfomyalon
ER22 – Emergency Medicine MCCQE 2006 Review Notes
 TRAUMATOLOGY. . . CONT.
guidelines for hospitalization
• 10-50 years old with 2nd degree burns to > 15% TBSA or 3rd degree to greater than 5% TBSA
• less than 10 years old or > 50 years old with 2nd degree to > 10% TBSA or 3rd degree to > 3% TBSA
• 2nd or 3rd degree on face, hands, feet, perineum or across major joints
• electrical or chemical burns
• burns with inhalation injury
• burn victims with underlying medical problems or immunosuppressed patients
(e.g. DM, cancer, AIDS, alcoholism)
Inhalation Injury
carbon monoxide (CO) poisoning - see Toxicology section
• closed environment
• cherry red skin/blood (usually a post-mortem finding, generally unreliable)
• headache, nausea, confusion
• pO 2 normal but O 2 sat low
• true O 2 sat must be measured (not value from pulse oximeter nor calculated value based
on a blood gas)
• measure carboxyhemoglobin levels
• treatment: 100% O 2 +/– hyperbaric O 2
thermal airway injury
• etiology: injury to endothelial cells and bronchial cilia due to fire in enclosed space
• symptoms and signs: facial burns, intraoral burns, singed nasal hairs, soot in mouth/nose,
hoarseness, carbonaceous sputum, wheezing
• investigations: CXR +/– bronchoscopy
• treatment: humidified oxygen, early intubation, pulmonary toilet, bronchodilators
Hypothermia
predisposing factors: old age, lack of housing, drug overdose, EtOH ingestion, trauma (incapacitating),
cold water immersion, outdoor sports
diagnosis: mental confusion, impaired gait, lethargy, combativeness, shivering
treatment on scene
• remove wet clothing; blankets + hot water bottles; heated O 2 ; warmed IV fluids
• no EtOH due to peripheral vasodilating effect
• vitals (take for > 1 minute)
• cardiac monitoring; no chest compressions until certain patient pulseless > 1 minute,
since can precipitate ventricular fibrillation
• NS IV since patient is hypovolemic and dehydrated secondary to cold water diuresis and fluid shifts
• note: if body temperature < 32.2ºC, you may see decreased heart rate, respiratory rate, and muscle
tone, dilated + fixed pupils (i.e. patient appears “dead”)
• due to decreased O 2 demands, patient may recover without sequelae
treatment in hospital
• patient hypovolemic and acidotic
• rewarm slowly with warm top + bottom blankets (risk of “afterdrop” if cold acidotic blood of periphery
recirculated into core)
• at body temperature < 30ºC risk of ventricular fibrillation therefore warm via peritoneal/hemodialysis or
cardiopulmonary bypass
PATIENT IS NOT DEAD UNTIL THEY ARE WARM AND DEAD!

Frostbite
ice crystals form between cells
classified according to depth - similar to burns (1st to 3rd degree)
1st degree
• symptoms: initial paresthesia, pruritus
• signs: erythema, edema, hyperemia, NO blisters
2nd degree
• symptoms: numbness
• signs: blistering, erythema, edema
3rd degree
• symptoms: pain, burning, throbbing (on thawing)
• signs: hemorrhagic blisters, skin necrosis, edema,decreased range of motion
management
• remove wet and constrictive clothing
• immerse in 40-42ºC water for 10-30 minutes
• leave injured region open to air
• leave blisters intact
• debride skin gently with daily whirlpool immersion (topic ointments not required)
• surgical intervention may be required to release restrictive escars
• never allow a thawed area to re-freeze

MCCQE 2006 Review Notes Emergency Medicine – ER23

 TRAUMATOLOGY. . . CONT.
PEDIATRIC TRAUMA
priorities remain the same
Airway
“sniffing position”
short trachea (5 cm in infants, 7.5 cm at 18 months)
orotracheal tube diameter = age/4 + 4
uncuffed ETT under age 8
surgical cricothyroidotomy NOT indicated
needle cricothyroidectomy with jet ventilation if unable to intubate
Breathing
stethoscope not as useful for diagnosing problems - noting tachypnea is important
Circulation
normal blood volume = 80 ml/kg
fluid resuscitation
• bolus crystalloid 20 ml/kg
• repeat x 1 if necessary
• blood replacement if no response to 2nd bolus of crystalloid
venous access
• intraosseous infusion if unable to establish IV access in < 30 seconds
• venous cutdown (medial cephalic, external jugular, great saphenous)
Thermoregulation
children prone to hypothermia
blankets/external warming/cover scalp

Table 9. Normal Vitals in Pediatric Patients

HR sBP RR
Infant < 160 80 40
Preschool < 140 90 30
Adolescent < 120 100 20

TRAUMA IN PREGNANCY
treatment priorities the same
the best treatment for the fetus is to treat the mother
Hemodynamic Considerations
near term, inferior vena caval compression in the supine position can decrease cardiac output by 30-40%
• use left lateral decubitus (LLD) positioning to alleviate compression and increase blood return
BP drops 5-15 mmHg systolic in 2nd trimester, increases to normal by term
HR increases 15-20 beats by 3rd trimester
Blood Considerations
physiologic macrocytic anemia of pregnancy (Hb 100-120)
WBC increases to high of 20,000
Shock
pregnant patients may lose 35% of blood volume without usual signs of shock (tachycardia, hypotension)
however, the fetus may be in “shock” due to contraction of the uteroplacental circulation
Management Differences
place bolster under right hip to stop inferior vena cava compression
fetal monitoring (Doppler)
early obstetrical involvement
x-rays as needed (C-spine, CXR, pelvis)
consider need for RhoGAM if mother Rh–

ER24 – Emergency Medicine MCCQE 2006 Review Notes

 APPROACH TO COMMON ER PRESENTATION
ABDOMINAL PAIN
Origins of Abdominal Pain
1. GI: appendicitis, diverticulitits, bowel obstruction, perforation, hepatitis, cholecystitis, organ lasceration
2. Urinary: cystitis, pyelonephritis, ureteral calculi
3. Genital
Female: ectopic pregnancy, pelvic inflammatory disease (PID), endometriosis,
salpingitis / tubo-ovarian abscess, ovarian torsion / cyst
Male: referred from testicles
4. Vascular: AAA, bowel or splenic infact (be aware of sickle cell status)
5. Other: diabetic ketoacidosis (DKA), Herpes Zoster Virus (HZV), intra-abdominal abscess, MI, pneumonia,
lead poisoning, glaucoma
Life-Threatening Causes
ectopic pregnancy
ischemic bowel, aortic rupture/dissection (pain >> findings)
hepatic/splenic injury
perforated viscus
myocardial infarction (MI)
History
pain: onset, location, character, severity, aggravating and alleviating factors,
associated symptoms (nausea, vomiting, diarrhea, vaginal bleeding)
past medial/surgical/gynecological history, drugs, travel history
Physical Exam
general appearance (diaphoretic, jaundiced, lying very still vs. writhing in pain),
vital signs (including posturals)
inspection: distention, scars, ecchymoses
auscultation: bowel sounds, bruits
palpation: peritoneal signs (shake, cough, rebound tenderness and guarding),
organomegaly, hernias, pelvic and testicular exams
Tests
DO NOT DELAY CONSULTATION if patient unstable
CBC, U/A, amylase, ß-HCG, LFTs, renal function, lytes
AXR: calcifications, free air, gas pattern
U/S: biliary tract, ectopic pregnancy, AAA (abdominal aortic aneurysm)
CT: trauma, AAA, pancreatitis but UNSTABLE PATIENTS SHOULD NOT BE SENT FOR IMAGING
Management
NPO, IV, NG tube, analgesics (communicate with consultants in advance)
growing evidence that SMALL amounts of narcotic analgesics
improve diagnostic accuracy of physical exam of surgical abdomen
consults: general surgery, vascular, gyne as necessary
ALCOHOLIC EMERGENCIES(see Psychiatry Chapter)
EtOH LEVELS CORRELATE POORLY WITH INTOXICATION

Acute Intoxication
may invalidate informed consent
slurred speech, CNS depression, disinhibition, incoordination
nystagmus, diplopia, dysarthria, ataxia ––> coma
frank hypotension (peripheral vasodilation)
obtundation - must rule out
• head trauma + intracranial hemorrhage
• associated depressant/street drugs
• synergistic ––> respiratory/cardiac depression
• hypoglycemia: must screen with bedside glucometer
• hepatic encephalopathy
• precipitating factors: GI bleed, infection, sedation, electrolyte abnormalities, protein meal
• Wernicke’s encephalopathy (“ WACO”)
Ataxia
Coma
Ocular findings: nystagmus, CN VI paresis ocular findings (may be absent at time of presentation)
• give thiamine 100mg IV
• post-ictal state, basilar stroke
Seizures
associated with ingestion and withdrawal
withdrawal seizures
• occur 8-48 hr. after last drink
• typically brief generalized tonic-clonic seizures
• if >48 hr., think of delerium tremens (DT) (see Table 10)

MCCQE 2006 Review Notes Emergency Medicine – ER25

 APPROACH TO COMMON ER PRESENTATIONS. . . CONT.
Treatment
diazepam 10mg PO q1h until calm
thiamine 100mg IM then 50-100mg/day
admit patients with DT
withdrawal signs – see Table 9
Table 10. Alcohol Withdrawal Signs

Time since last drink Syndrome Description

6-8 hr. Mild withdrawal - generalized tremor, anxiety, agitation but no delerium
- autonomic hyperactivity, insomnia, nausea, vomiting

1-2 days Alcoholic hallucinations - visual and auditory hallucinations

- vitals often normal
8 hr. - 2 days Withdrawal seizures - see above

3-5 days Delirium Tremens - 5% of untreated withdrawal patients

- severe confusional state
- agitation, insomnia, hallucinations/delusions, tremor
- tachycardia, hyperpyrexia, diaphoresis

Cardiovascular Diseases (see Cardiology Chapter)

hypertension (HTN)
cardiomyopathy: shortness of breath (SOB), edema
arrhythmias (“holiday heart”)
• atrial fibrillation, atrial flutter, premature ventricular contraction (PVC),
premature atrial contraction (PAC), supraventricular tachycardia (SVT), ventricular tachycardia (VT)
Metabolic Abnormalities
alcoholic ketoacidosis
• history of chronic alcohol intake with abrupt decrease in intake
• malnourished, abdominal pain with nausea and vomiting (N/V)
• anion gap (AG) metabolic acidosis, urine ketones, low glucose and normal osmolality EtOH level zero
• treatment: dextrose, thiamine and NS; resolves in 12-24 hr
abnormal alcohols (see also Toxicology section)
• ethylene glycol ––> CNS, CVS, renal findings
• methanol
• early: lethargy, confusion
• late: headache, visual changes, N/V, abdominal pain, tachypnea
• both produce severe metabolic acidosis with AG and osmolal gap
• EtOH co-ingestion is protective
• treatment
• IV 10% EtOH bolus and drip to achieve blood level of 20 mmol/L
• alcohol loading may be done PO
• fomepizole (4-mp) if available
• urgent hemodialysis required
other abnormalities
• hypomagnesemia
• hypophosphatemia
• hypocalcemia
• hypoglycemia
Gastrointestional (GI) Abnormalities
gastritis
• common cause of abdominal pain and GI bleed in chronic alcohol users
pancreatitis
• serum amylase very unreliable in patients with chronic pancreatitis
• hemorrhagic form (15%) associated with increased mortality
hepatitis
• AST/ALT ratio > 2 suggests alcohol as the cause as well as elevated GGT with acute ingestion
peritonitis
• occasionally accompanies cirrhosis
• leukocytosis, fever, generalized abdominal pain
• paracentesis for diagnosis
GI bleeds
• most commonly gastritis or ulcers, even if patient known to have varices
• must consider Mallory-Weiss tear
• often complicated by underlying hematologic abnormalities
• cirrhosis

ER26 – Emergency Medicine MCCQE 2006 Review Notes

 APPROACH TO COMMON ER PRESENTATIONS. . . CONT.
Miscellaneous Problems
rhabdomyolysis
• presents as acute weakness associated with muscle tenderness
• usually occurs after prolonged immobilization
• increased creatinine kinase (CK), hyperkalemia
• myoglobinuria - may lead to acute renal failure
• treatment: IV fluids, forced diuresis (mannitol)
increased infections - due to host defences, immunity, poor living conditions
• atypical pneumonias (Gram negatives, anaerobes, TB)
• meningitis
• peritonitis with ascites - E.coli, Klebsiella , Strep
• bacteremia - after urinary tract infection (UTI), soft tissue infections
• usually require admission and IV antibiotics
ANAPHYLAXIS AND ALLERGIC REACTIONS
Etiology
requires: 1. exposure 2. latent period 3. re-exposure
exaggerated immune response to antigens
mediated by IgE, released histamine, bradykinins, leukotrienes
most common: penicillin, stings, nuts, shellfish
anaphylactoid: non-IgE mediated, direct trigger, may occur with first exposure (e.g. radiocontrast dyes),
treatment similar to anaphylaxis
Symptoms and Signs
cardiovascular collapse (shock), arrhythmia, MI
marked anxiety and apprehension
skin - generalized urticaria, edema, erythema, pruritus
respiratory compromise, choking sensation, cough, bronchospasm or laryngeal edema, wheezes and stridor
allergies and prior episodes important
patients on ß-blockers and H2 blockers may develop more severe reactions and be
refractory to standard therapies
Treatment
stop the cause, ABC’s
on scene - ‘epi-pen’ (injectable epinephrine) if available
MODERATE signs and symptoms (minimal airway edema, mild bronchospasm, cutaneous reactions)
• adult: 0.3 -0.5 ml of 1:1000 solution IM or SC epinephrine
• child: 0.01 ml/kg/dose up to 0.4 mL/dose 1:10 000 epinephrine
SEVERE signs and symptoms (laryngeal edema, severe bronchospasm and shock)
• epinephrine via IV or ETT starting at 1 ml of 1:10 000
• cardiac monitoring, ECG
diphenhydramine 50 mg IM or IV(Benadryl) q 4-6h
methylprednisolone 50-100 mg IV dose depending on severity
salbutamol via nebulizer if bronchospasm present
• glucagon (for those on ß-blockers) 5-15 µg q 1min IV
Angioedema / Urticaria (see Dermatology Chapter)
cutaneous IgE-mediated reaction
more severe form: erythema multiforme (EM)
Treatment: epinephrine, antihistamines, steroids
ANALGESIA
Table 11. Summary of Analgesics

Drug Dose Indications Side Effects

Aspirin 300-900 mg PO q 4-6h headache, MSK, dysmenorrhea interaction with warfarin, exacerbate asthma

Acetaminophen 0.5-1g PO q 4-6h similar to aspirin liver and renal damage

± codeine codeine: constipation, respiratory depression

NSAIDS
• Ibuprofen • 0.4-0.6 g PO q 3-4h MSK pain gastric irritation, GI bleed, interaction with
• Diclofenac • 75 mg IM injection diuretics, warfarin and lithium

OPIOIDS
• Morphine • 2-10 mg IV titrate up trauma, pulmonary edema in nausea and vomiting (give with Gravol)
• Demerol • 12.5-25 mg IV, titrate up left ventricular failure (LVF),
severe pain

MCCQE 2006 Review Notes Emergency Medicine – ER27

 APPROACH TO COMMON ER PRESENTATIONS. . . CONT.
ASTHMA (see Respirology Chapter)
Etiology
exposure to a “trigger”
bronchospasm
airway inflammation leading to airway edema
Differential Diagnosis
foreign body aspiration
bronchiolitis
pneumonia
cystic fibrosis (CF)
congestive heart failure (CHF)
History
onset, duration, severity
management prior to coming to hospital
past medical history
asthma, cystic fibrosis (CF)
previous visits to the E.D. and admissions for the same problem
associated symptoms
fever, productive cough, orthopnea, chest pain
Physical Exam
general appearance
• pale, cyanotic, diaphoretic, altered LOC, distressed, unable to speak in full sentences
inspection
• use of accessory muscles, tachypnea
auscultation of the chest
• Silent – Emergency!
• prolongued expiratory phase +/– wheezes
• crackles/ rhonchi/ rubs
• heart murmurs, S3 / S4
Investigations
• O 2 Sat
• peak clow meter
• routine blood work +/- ABG’s
• CXR

Table 12. Asthma Assessment and Treatment

Classification Assessment Treatment

Near Death - exhausted, confused, diaphoretic, cyanotic - 100% O 2 , cardiac monitor, IV access
- silent chest, ineffective respiratory effort - intubate
- decreased HR - ß-agonist: MDI 4-8 puffs q 20 min x 3 OR nebulizer 5 mg q 20 min x 3

- 2 sat <90% - anti-cholinergics: MDI 4-8 puffs q 20 min x 3 OR

O nebulizer 0.25 mg q 20 min x 3

- IV steroids: methylprednisolone 125 mg IV hydrocortisone 500 mg IV
- CXR, ABG

Severe Asthma - agitated, diaphoretic, laboured respirations - anticipate need for intubation
- difficulty speaking - similar to above management
- no relief from ß-agonist
- 2 sat <90%
-O 1 <40%
FEV
Moderate Asthma - SOB at rest, cough, congestion, chest tightness - 2
- nocturnal symptoms -Oß-agonist
- inadequate relief from ß-agonists - systemic steroids: prednisone 40-60 mg PO
- 1 40-60% - anticholinergics
FEV
Mild Asthma - exertional SOB/cough with some nocturnal symptoms - ß-agonist
- good response to ß-agonist - monitor FEV 1
- 1 > 60%
FEV
admit if FEV1 < 25% (pre-treatment) or FEV1 < 40% (post treatment)
discharge plans
• ß-agonist: x 2-3 days
• steroids x 1-2 weeks
• patient education on triggers, medication use, etc.

ER28 – Emergency Medicine MCCQE 2006 Review Notes

 APPROACH TO COMMON ER PRESENTATIONS. . . CONT.
COPD (see Respirology Chapter)
Etiology
emphysema: destruction of alveoli can lead to tachypnea and dyspnea
chronic bronchitis: chronic cough and sputum production
both usually co-exist
Exacerbations
worsening dyspnea or tachypnea
acute change in frequency, quantity and colour of sputum production
history
• premorbid health status
• trigger: pneumonia, urinary tract infection (URTI), pulmonary embolism (PE), CHF, drugs
tests
• CXR, ECG, ABG, FEV 1
treatment
• keep O 2 sat > 90% (BEWARE OF CO 2 RETAINERS)
• bronchodilators + anticholinergics
• steroids: IV methylprenisolone 125 mg or prednisone PO 40 mg (tapered over 3 weeks)
• antibiotics: Septra, cephalosporins, quinolones
• ventilation: chance of ventilation dependency
• admit if co-morbid illness
• discharge on antibiotics, bronchodilators and taper steroids
CHEST PAIN
Must Rule Out Life-Threatening Causes
unstable angina/acute MI
thoracic aortic dissection
pulmonary embolism (PE)
spontaneous pneumothorax/tension pneumothorax
esophageal rupture
pericarditis/cardiac tamponade
Additional Differential Diagnosis
stable angina
GI disorders: peptic ulcer disease (PUD), pancreatitis, cholecystitis, esophagitis, etc.
pneumonia
MSK
spontaneous pneumothorax (young, thin, tall)
psychogenic (diagnosis of exclusion)
Initial Resuscitation and Management
O2 , IV, cardiac monitoring, portable CXR
History
compare with previous episodes
pain characteristics
risk factors
• cardiac: hypertension, family history, smoking, cholesterol, DM
• pulmonary embolism: immobility, cancer, use of estrogen, family history
• aortic dissection: hypertension
classic presentations (but presentations seldom classic)
• aortic dissection - sudden severe tearing pain, often radiating to back
• pulmonary embolism (PE) - pleuritic chest pain (75%), dyspnea, anxiety, tachycardia
• pericarditis - anterior precordial pain, pleuritic, relieved by sitting up and leaning forward
• acute coronary artery disease (CAD) - retrosternal squeezing/pressure pain, radiation to arm/neck,
dyspnea, nausea/vomiting, syncope
• esophageal - frequent heartburn, acid reflux, dysphagia, relief with antacids
more likely to be atypical in females, and > 80 years
Physical Exam
vitals
• tachypnea (may be the only sign of PE)
• BP in BOTH arms: = 20 mm Hg difference suggests thoracic aortic dissection
palpate chest wall for tender points but not a good discriminator since 25% of patients with acute MI have
chest wall tenderness
• accept only if fully reproduces pain symptoms and more serious causes excluded
• may result from pleural inflammation
cardiac exam
• jugular venous pressure (JVP)
• heart sounds: friction rub, muffling
• new murmurs
• mitral regurgitation murmur in acute MI (papillary muscle dysfunction)
• aortic insufficiency murmur in aortic dissection
respiratory exam
• percuss and auscultate all the lung fields
peripheral vascular exam - abdomen, extremities
MCCQE 2006 Review Notes Emergency Medicine – ER29
 APPROACH TO COMMON ER PRESENTATIONS. . . CONT.
Investigations
ECG
• cardiac + non-cardiac causes
• PE, acute MI may have NORMAL ECG in up to 50% of cases
• always compare with previous
CXR
• pulmonary embolism (PE)
• 50% completely NORMAL
• atelectasis, elevated hemidiaphragm, pleural effusion
• Westermark’s sign, Hampton’s hump
• aortic dissection
• mediastinal widening, bulging aortic arch, separation of intimal
calcification from edge of aortic shadow, depressed left main bronchus
• change from previous CXR is the most accurate finding
• CXR is normal in 20% of thoracic dissection
• pneumothorax
• need inspiration and expiration views
ABGs - NORMAL in 20% of patients with PE
• serial cardiac enzymes (see Cardiology Chapter)
• normal CK does NOT rule out MI
• troponin I more sensitive (but positive later than CK-MB; can have false positives in renal failure)
V/Q scan and helical CT if PE suspected
HEADACHE(see Neurology Chapter)
key principles
• brain is anesthetic (most headaches arise from surrounding structures such as blood vessels,
periosteum, muscle)
• every headache is serious until proven otherwise
THE COMMON
• migraine (no aura)/classic migraine (involves aura)
• gradual onset, unilateral, throbbing
• nausea/vomiting, photophonophobia
• treatment : analgesics, neuroleptics, vasoactive meds
• tension /muscular headache
• never during sleep, gradual over 24 hours
• posterior/occipital
• increased with stressors
• treatment : modify stressor, local measures, NSAIDS
THE DEADLY
• subarachnoid hemorrhage (SAH)
• sudden onset, increased with exertion
• “worst” headache, nausea and vomiting
• diagnosis : CT, LP (5-15% of patients with negative CT have SAH)
• urgent neurosurgery consult
• increased ICP
• worst in morning, supine, or bending down
• physical exam: neurological deficits, cranial nerve palsies
• diagnosis : CT scan
• consult neurosurgery
• meningitis
• temporal arteritis (not immediately deadly but causes great morbidity)
HYPERTENSIVE EMERGENCIES
Varon J, Marik P. The Diagnosis and Management of Hypertensive Crises. Chest. 2000:118(1):214-227.

Hypertensive Emergencies (aka Hypertensive Crisis)

definition: acute elevation of systolic and diastolic BP associated with end-organ damage of the CNS,
the heart, or the kidneys
treatment: lower blood pressure to “normal” within 30-60 minutes
Hypertensive Urgencies
definition: severely elevated blood pressure (usually dBP > 115) with no evidence of end-organ damage
most commonly due to non-compliance with medications
treatment: gradually reduce pressure over 24-48 hours to a level appropriate for the patient
Pathophysiology
the majority of hypertensive emergencies occur in patients with preexisting chronic hypertension.
However, fewer than one percent of hypertensive patients will develop a hypertensive emergency
related to acute increase in systemic vascular resistance likely induced by humoral vasoconstrictors
endothelial injury and fibrinoid necrosis of the arterioles occurs following severe elevation of blood pressure
vascular damage induces platelet deposition and fibrin formation resulting in tissue ischemia and further
release of vasoactive substances
ER30 – Emergency Medicine MCCQE 2006 Review Notes
 APPROACH TO COMMON ER PRESENTATIONS. . . CONT.
Evaluation of Patient With Severe Hypertension
goal is to differentiate hypertensive emergencies from hypertensive urgencies
history
• prior hypertensive crises
• antihypertensive medications prescribed and BP control
• monoamine oxidase inhibitors (MAOIs)
• street drugs (cocaine, amphetamines, phencyclidine, etc.)
physical examination
• blood pressure measurement in all limbs
• fundoscopic exam (hemorrhages, papilledema, etc.)
lab
• CBC, electrolytes, BUN, creatinine, urinalysis
• peripheral blood smear – to detect microangiopathic hemolytic anemia
• CXR – if shortness of breath (SOB)
• ECG – if chest pain
• head CT – if neurological findings
Hypertensive Emergencies
Hypertensive Encephalopathy
• pathophysiology: cerebral hyperperfusion due to blood pressure in excess of the capacity
for cerebral autoregulation
• signs and symptoms: headache, nausea, vomiting, mental status changes (lethargy to coma),
fundoscopic changes (hemorrhage, exudates, cotton wool spots, papilledema, sausage linking)
• treatment: sodium nitroprusside or labetalol. Avoid clonidine and pure B blockers
• NB: with CNS manifestations of severe hypertension is often difficult to differentiate causal
relationships (ie: hypertension could be secondary to primary cerebral event [Cushing effect])
Pregnancy Induced Hypertension (PIH) (see Obstetrics Chapter)
Cardiovascular Emergencies
• left ventricular failure (LVF)
• pathophysiology: decreased LV function due to increased afterload, increased oxygen demand
and decreased coronary blood flow may cause angina, MI, or pulmonary edema
• signs and symptoms: chest pain, SOB
• treatment: goal is to decrease preload and afterload (iv nitroprusside and nitroglycerin)
• diuretics for volume overload
• avoid diazoxide, hydralazine, minoxidil as these drugs increase oxygen demand
• thoracic aortic dissection (see Cardiac and Vascular Surgery Chapter)
Hypertensive Renal Emergencies
• renal failure can be either the cause or effect of a hypertensive emergency
• hypertension associated with deteriorating renal function is considered an emergency
• hypertension in the setting of chronic renal failure is due to sodium and water retention by the
diseased kidney and increased activation of the renin-angiotensin system
• diagnosis: proteinuria, RBC and RBC casts in urine, elevated BUN and creatinine
• treatment: IV calcium channel blockers, +/- emergent ultrafiltration
Catecholamine Induced Hypertensive Emergencies
• etiology: discontinuation of short-acting sympathetic blocker (e.g. clonidine, propranolol)
• pheochromocytoma
• sympathomimetic drugs (cocaine, amphetamines, phencyclidine)
• MAOI in combination with sympathomimetics or tyramine containing foods (cheese, red wine)
• treatment: readminister sympathetic blocker if due to withdrawal (e.g. clonidine, propranolol)
• avoid use of pure beta-blockers as they inhibit beta mediated vasodilation and leave
alpha-adrenergic vasoconstriction unopposed
• best agents are nicardipine, verapamil, fenoldopam. Phentolamine and nitroprusside are
possible alternatives
STATUS EPILEPTICUS (see Neurology Chapter)
a single seizure/series of seizures that lasts > 30 min
• generalized: tonic-clonic, tonic, clonic, myoclonic, absence
• partial: simple, complex
etiology
• drugs (anticonvulsant withdrawal, EtOH withdrawal),metabolic disorders, cerebrovascular disorders,
infection, idiopathic
investigations
• CBC, lytes, BUN, Cr, glucose, anticonvulsant levels, tox screen, prolactin (8), CT +/– MRI, EEG
treatment
• diazepam 5-20 mg IV
• Dilantin 15 mg/kg, given over 30 mins
• phenobarbital 15 mg/kg IV
• if above fail, Lidocaine 1.5 mg/kg IV; Pentothal 3 mg/kg IV OR midazolam and intubate
• emergency EEG if no response after 15-20 minutes

MCCQE 2006 Review Notes Emergency Medicine – ER31

 APPROACH TO COMMON ER PRESENTATIONS. . . CONT.
SYNCOPE
sudden, transient loss of consciousness and postural tone with spontaneous recovery
Etiology
usually caused by generalized cerebral hypoperfusion
cardiogenic: arrhythmia, outflow obstruction, MI
• non-cardiogenic: peripheral vascular (hypovolemia), vaso-vagal, cerebrovascular disorders,
seizure disorders
History
gather details from witnesses
distinguish between syncope and seizure (see Neurology Chapter)
• signs and symptoms of precyncope, syncope and postsyncope
• past medical history, drugs
Physical
BP and pulses in both arms, posturals
cardiovascular exam and neuro exam
Investigations
ECG
CBC, lytes, BUN, creatinine, glucose, ABG’s, Troponin, CKMB, Mg, Ca
Disposition
cardiogenic syncope: admit to medicine/cardiology
non-cardiogenic syncope: discharge with follow-up of Holter or echo study

SEXUAL ASSAULT AND DOMESTIC VIOLENCE

involve local/regional sexual assault team
1 in 4 women and 1 in 10 men will be sexually assaulted in their lifetime
General Management Principles
ABC’s
ensure patient is not left alone and ongoing emotional support provided
set aside adequate time for exam (usually 1 1/2 hours)
obtain consent for medical exam and treatment, collection of evidence,
disclosure to police (notify police as soon as consent obtained)
Sexual Assault Kit (document injuries, collect evidence)
samples ––> labeled immediately ––> passed directly to police
offer community crisis resources (e.g. shelter, hotline)
do not report unless victim requests (legally required if <16 years)
History
who? how many? when? where did penetration occur? what happened ? any weapons or physical assault?
post-assault activities (urination, defecation, change of clothes, shower, douche, etc.)
gynecologic history
• gravity, parity, last menstrual period (LMP)
• contraception
• last voluntary intercourse (sperm motile 6-12 hours in vagina, 5 days in cervix)
Physical Exam
evidence collection is always secondary to treatment of serious injuries
never retraumatize a patient with the examination
general examination
• mental status
• sexual maturity
• patient should remove clothes and place in paper bag
• document abrasions, bruises, lacerations, torn frenulum/broken teeth (indicates oral penetration)
pelvic exam and specimen collection
• ideally before urination or defecation
• examine for seminal stains, hymen, signs of trauma
• collect moistened swabs of dried seminal stains
• pubic hair combings and cuttings
• speculum exam
• lubricate with water only
• vaginal lacerations, foreign bodies
• Pap smear
• oral/cervical/rectal culture for gonorrhea and chlamydia
• posterior fornix secretions if present or aspiration of saline irrigation
• immediate wet smear for motile sperm
• air-dried slides for immotile sperm, acid phosphatase, ABO group
others
• fingernail scrapings
• saliva sample from victim
• VDRL - repeat in 3 months if negative
• serum ß-HCG
• blood for ABO group, Rh type, baseline serology (e.g. hepatitis, HIV)
ER32 – Emergency Medicine MCCQE 2006 Review Notes
 APPROACH TO COMMON ER PRESENTATIONS. . . CONT.
Treatment
medical
• suture lacerations
• tetanus prophylaxis
• gynecology consult for foreign body, complex lacerations
• assumed positive for gonorrhea and chlamydia
• azithromycin 1g PO x 1 dose or cefixime 400 mg PO x 1 dose +
doxycycline 100 mg BID PO x 7 days
• may start prophylaxis for hepatitis B and HIV
• pre and post counselling for HIV testing
• pregnancy prophylaxis offered
• Ovral 2 tabs STAT and 2 tabs in 12 hrs (within 72 hrs post-coital) with Gravol 50mg
psychological
• high incidence of psychological sequelae
• have victim change and shower after exam completed
• follow-up with MD in rape crisis centre within 24 hours
• best if patient does not leave E.D. alone
Domestic Violence
IDENTIFY THE PROBLEM (need high index of suspicion)
• suggestive injuries
• somatic symptoms (chronic and vague complaints)
• psychosocial symptoms
if disclosed, be supportive and assess danger
management
• treat injuries
• ask about sexual assault and children at home
• document findings
• plan safety
FOLLOW-UP: family doctor/social worker
VIOLENT PATIENT
SAFETY FIRST - yourself, patient, staff, other patients
always consider and rule out organic causes (as they can be fatal)
leading organic causes are EtOH, drugs, and head injuries
Differential Diagnosis
organic
• drugs/toxins/withdrawal
• metabolic (electrolyte abnormalities, hypoglycemia, hypoxia)
• infections (sepsis, encephalitis, brain abscess, etc.)
• endocrine (Cushing’s, thyrotoxicosis)
• CNS (head injuries, tumour, seizure, delirium and dementia)
functional/psychiatric
• situational crisis
• schizophrenia, bipolar disorder (manic), personality disorder
Prevention
be aware and look for prodromal signs of violence
• prior history of violence or criminal behaviour
• anxiety, restlessness, defensiveness, verbal attacks
try to de-escalate the situation early
• address the patient’s anger
• empathize
Restraints
physical
• present option to patient in firm but non-hostile manner
• demonstrate sufficient people to carry it out
• restrain supine or on side
• suction and airway support available in case of vomiting
pharmacologic
• often necessary - may mask clinical findings and impair exam
• Haldol 5-10 mg IM (be prepared for dystonic reactions, especially with multiple doses of neuroleptics
over a short period) + lorazepam 2 mg IM/IV
• look for signs of anticholinergic OD first (see Toxicology section)
once restrained, search person/clothing for drugs and weapons
History
antecedent and precipitating events and locale
drugs: prescription, over the counter (OTC) (antihistamines, anticholinergics, stimulants),
recreation/abuse/steroids, withdrawal reaction
past medical history (especially DM)
past psychiatric history and past legal history
patient’s insight
speak to family/friends

MCCQE 2006 Review Notes Emergency Medicine – ER33

 APPROACH TO COMMON ER PRESENTATIONS. . . CONT.
Physical Exam
vitals
• temperature often increased in delirium or toxic psychosis
• hypothermia may have altered mental status
signs of trauma - especially head and neck
neurologic exam, including brief mental status
signs of drug toxicity and needle marks
signs of hypoglycemia
Investigations
screening bloodwork: CBC, lytes, glucose, creatinine, BUN, osmolality
selective drug and toxin screen (see Toxicology section)
CT head if necessary

TOXICOLOGY
APPROACH TO THE OVERDOSE PATIENT
History Taking
1. How much? How long ago? What method? (ingestion, inhalation, dermal, occular, environmental, IV ?)
2. accidental vs non-accidental exposure
Physical Exam
1. focus on: BP, HR, pupils, LOC, airway
Principles of Toxicology
“All substances are poisons ... The right dose separates a poison from a remedy”
5 principles to consider with all ingestions
1. resuscitation (ABCs)
2. screening (toxidrome? clinical clues?)
3. decrease absorption of drug
4. increase elimination of drug
5. is an antidote available?
suspect overdose when:
• altered level of consciousness/coma
• young patient with life-threatening arrhythmia
• trauma patient
• bizarre or puzzling clinical presentation

ABCs OF TOXICOLOGY
basic axiom of care is symptomatic and supportive treatment
can only address underlying problem once patient is stable
A Airway (consider stabilizing the C-spine)
B Breathing
C Circulation
D1 Drugs
• ACLS as necessary to resuscitate the patient
• universal antidotes
D2 Draw bloods
D3 Decontamination (decreased absorption, increased elimination)
E E xpose (look for specific toxidromes)/ Examine the Patient
F F ull vitals, ECG monitor, Foley, x-rays, etc.
G Give specific antidotes, treatments
Go back and reassess.
CALL POISON CONTROL CENTRE
OBTAIN CORROBORATIVE HISTORY FROM FAMILY/FRIENDS IF PRESENT

D1 - UNIVERSAL ANTIDOTES
treatments which will never hurt any patient and which may be essential
Oxygen
do not deprive a hypoxic patient of oxygen no matter what the
antecedent medical history (i.e. even COPD and CO 2 retention)
if depression of hypoxic drive, intubate and ventilate
only exception: paraquat or diquat (herbicides) inhalation or ingestion

ER34 – Emergency Medicine MCCQE 2006 Review Notes

 TOXICOLOGY. . . CONT.
Thiamine (Vitamin B 1 )
100 mg IV/IM to all patients prior to IV/PO glucose
a necessary cofactor for glucose metabolism, but do not delay glucose if thiamine unavailable
to prevent Wernicke-Korsakoff syndrome WACO
• Wernicke’s encephalopathy - Ataxia, Confusion, Ophthalmoplegia)
• untreated, may progress to Korsakoff’s psychosis (disorder in learning and
processing of new information)
• treatment: high dose thiamine (1000 mg/day x 3 days)
• most features usually irreversible
populations at risk for thiamine deficiency
• alcoholics
• anorexics
• hyperemesis of pregnancy
• malnutrition states
in E.D., must assume all undifferentiated comatose patients are at risk
Glucose
give to any patient presenting with altered LOC
do dextrostix prior to glucose administration
adults: 0.5-1.0 g/kg (1-2 mL/kg) IV of D50W
children: 0.25 g/kg (2 mL/kg) IV of D25W

Naloxone
antidote for opioids: diagnostic and therapeutic (1 min onset of action)
used in the setting of the undifferentiated comatose patient
loading dose
• adults
• 2 mg initial bolus IV/IM/SL/SC or via ETT
• if no response after 2-3 minutes, progressively double dose until a response or
total dose of 10 mg given
• known chronic user, suspicious history, or evidence of tracks 0.01 mg/kg
(to prevent acute withdrawal)
• child
• 0.01 mg/kg initial bolus IV/IO/ETT
• 0.1 mg/kg if no response and narcotic suspected
maintenance dose
• may be required because half-life of naloxone much shorter
than many narcotics (half-life of naloxone is 30-80 minutes)
• hourly infusion rate at 2/3 of initial dose that produced patient arousal

D2 - DRAW BLOODS
essential bloods
• CBC, electrolytes, urea, creatinine
• glucose (and dextrostix), INR, PTT
• ABGs, measured O2 sat
• osmolality
• acetylsalicylic acid (ASA), acetaminophen alcohol levels
potentially useful bloods
• drug levels
• Ca 2+ , Mg2+ , PO43–
• protein, albumin, lactate, ketones and liver tests
Serum Drug Levels
treat the patient, not the drug level
negative toxicology screen only signifies that the specific drugs tested were not detectable in the particular
specimen at the time it was obtained (i.e. does not rule out a toxic ingestion)
generally available on serum screens (differs by institution)
(screen is different from drug levels - screen is very limited)
• acetaminophen*
• ASA*
• barbituates and other sedative/hypnotics
• benzodiazepines (qualitative only)
• ethanol
• ethylene glycol*
• methanol*
• tricyclic antidepressant (TCA) (qualitative only)
* significant if in "toxic" range
urine screens also available (qualitative only)
MCCQE 2006 Review Notes Emergency Medicine – ER35
 TOXICOLOGY. . . CONT.
Toxic Gaps (see Nephrology Chapter)

Anion gap (AG) = Na + – (Cl– + HCO3– ) Plasma osmolal gap (POG) = (measured - calculated) osmoles
• normally POG < 10 mOsm/L
• normal range 10-14 mmol/L
• unmeasured cations: Mg 2+ , Ca2+ • calculated osmolality = 2 Na+ + BUN + blood glucose (mmol/L)
• unmeasured anions: proteins, organic acids, PO 43– , sulfate

Metabolic acidosis Plasma Osmolal Gaps

Increased AG: differential of causes (*toxic) Increased osmolal gap: “MAE DIE”
“MUDPILES CAT" Methanol
Methanol* Acetone
Uremia Ethanol
D iabetic ketoacidosis/Alcoholic ketoacidosis
Diuretics (glycerol, mannitol, sorbitol)
P henformin*/Paraldehyde*
Isoniazid*/Iron* Isopropanol
Lactate (anything that causes seizures or shock) Ethylene glycol
Ethylene glycol*
Salicylates* Oxygen saturation gap: (measured – calculated) O 2 saturation

(1) measured by absorption spectrophotometry (pulse oximetry)

Cyanide* (2) calculated from Hb/O2 saturation curve
Arsenic*
Toluene* Increased O 2 saturation gap
(3) carboxyhemoglobin
Decreased AG
1. error (4) methemoglobin
2. electrolyte imbalance (increased Na + /K+ /Mg2+ ) (5) sulfhemoglobin
3. hypoalbuminemia (50% fall in albumin
~ 5.5 mmol/L decrease in the AG)
4. Li, Br elevation
5. paraproteins (multiple myeloma)

Normal AG
(1)K+ : pyelonephritis, obstructive nephropathy, renal tubular acidosi (RTA), IV, TPN
(2)K+ : small bowel losses, acetazolamide, RTA I, II

Table 13. Use of the Clinical Laboratory in the Initial Diagnosis of Poisoning

T EST FINDING SELECTED CAUSES

ABGs • hypoventilation ( 8 Pco2 ) • CNS depressants (opioids, sedative-hypnotic

agents, phenothiazines, and EtOH)
• hyperventilation • salicylates, CO, other asphyxiants

Electrolytes • anion-gap metabolic acidosis • “MUDPILES CAT”

• hyperkalemia • digitalis glycosides, fluoride, K+
• hypokalemia • theophylline, caffeine, ß-adrenergic agents,
soluble barium salts, diuretics

Glucose • hypoglycemia • oral hypoglycemic agents, insulin, EtOH

Osmolality • elevated osmolar gap • “MAE DIE”

and Methanol, Acetone, Ethanol, Diuretics,
Osmolar Gap Isopyropyl alcohol, Ethylene glycol

ECG • wide QRS complex • TCAs, quinidine, other class Ia and Ic

antiarrhythmic agents
• prolongation of QT interval • quinidine and related antiarrhythmics,
terfenadine, astemizole
• atrioventricular block • Ca2+ antagonists, digitalis glycosides,
phenylpropanolamine

Abdominal • radiopaque pills or objects • “CHIPES”

x-ray Calcium, Chloral hydrate, CCl4 , Heavy metals,
Iron, P otassium, Enteric coated Salicylates,
and some foreign bodies

Serum • elevated level (> 140 mg/l • acetaminophen (may be the only clue to a recent
Acetaminophen 4 hours after ingestion) ingestion)

ER36 – Emergency Medicine MCCQE 2006 Review Notes

 TOXICOLOGY. . . CONT.
D3 - DECONTAMINATION
PROTECT YOURSELF FIRST
CALL POISON CONTROL CENTRE IF ANY UNCERTAINTY

Ocular Decontamination
saline irrigation to neutral pH
alkali exposure requires ophthalmology consult
Dermal Decontamination (wear protective gear)
remove clothing
brush off toxic agents
irrigate all external surfaces
Gastrointestinal Decontamination
activated charcoal (AC)
• indications
• single dose will prevent significant absorption of many drugs and toxins
• contraindications
• acids, alkalis, cyanides, alcohols, Fe, Li
• dose = 1 g/kg body weight or 10 g/g drug ingested
• odourless, tasteless, prepared as slurry with H 2 O
• cathartics rarely used (risk electrolyte imbalance)
multi-dose activated charcoal (MDAC)
• absorption of drug/toxin to charcoal prevents availability and promotes fecal elimination
• without charcoal, gut continuously absorbs toxins; MDAC (multidose activated charcoal) interrupts the
enterohepatic circulation of some toxins and binds toxin diffusing back into enteral membrane from the
circulation
• MDAC can increase drug elimination (potentially useful for phenobarbitol, carbamazepine,
theophylline, digitoxin, others)
• dose
• various regimes
• continue until nontoxic or charcoal stool
whole bowel irrigation
• flushes out bowel
• 500 mL (child) to 2000 mL (adult) of balanced electrolyte solution/hour by mouth until clear
effluent per rectum
• indications
• awake, alert patient who can be nursed upright
• delayed release product
• drug/toxin not bound to charcoal
• drug packages - if any evidence of breakage ––> emergency surgery
• recent toxin ingestion (up to 4-6 hours)
• contraindications
• evidence of ileus, perforation, or obstruction
surgical removal
• indicated for drugs
• that are toxic
• that form concretions
• that are not removed by conventional means

E - EXAMINE THE PATIENT

vital signs (including temperature), skin (needle tracks, colour), mucous membranes, odours and CNS
head-to-toe survey
• C-spine
• signs of trauma
• signs of seizures (incontinence, “tongue biting”, etc.)
• signs of infection (meningismus)
• signs of chronic alcohol abuse
• signs of drug abuse (track marks, nasal septum erosion)
• mental status

SPECIFIC TOXIDROMES
Narcotics, Sedatives/Hypnotics, Alcohol Overdose
signs and symptoms
• hypothermia
• bradycardia
• hypotension
• respiratory depression
• dilated/constricted pupils
• CNS depression

MCCQE 2006 Review Notes Emergency Medicine – ER37

 TOXICOLOGY. . . CONT.
Drug / Substance Withdrawal
withdrawal state generally opposite to the physiological effect of the drug
signs and symptoms of sedative withdrawal
• increased temperature • agitation
• tachycardia • tremor
• hypertension • hallucinations
• dilated pupils • seizures
• diaphoresis
drugs
• alcohol
• benzodiazepines
• barbituates
• antihypertensives
• opioids

Drug Class Overdose Signs and Symptoms Examples of Drugs

Anticholinergics • hyperthermia “Hot as a Hare” Anticholinergic drugs

• dilated pupils "Blind as a Bat” antidepressants
• dry skin “Dry as a Bone” Flexeril
• vasodilatation “Red as a Beet” Tegretol
• agitation/hallucinations “Mad as a Hatter” antihistamines (e.g. Gravol, diphenhydramine)
• ileus “The bowel and bladder antiparkinsonians
• urinary retention lose their tone and the antipsychotics
• tachycardia heart goes on alone” antispasmotics
belladonna alkaloids (e.g. atropine, scopolamine)

Cholinergics “DUMBELS” cholinergics

Diaphoresis, Diarrhea, D ecreased blood pressure (nicotine, mushrooms)
Urination anticholinesterases
Miosis (physostigmine, organophosphate insecticides)
Bronchorrhea, B ronchospasm, Bradycardia
EEmesis, E xcitation of skeletal muscle
Lacrimation
S alivation, S eizures

Extrapyramidal dysphonia major tranquilizers

rigidity and tremor
dysphagia
torticollis
laryngospasm
trismus (deviation of eyes in all directions)
oculogyric crisis

Hemoglobin Derangements increased respiratory rate carbon monoxide poisoning (carboxyhemoglobin)

decreased level of consciousness
seizures
cyanosis (unresponsive to O2 ) drug ingestion (methemoglobin, sulfhemoglobin)
lactic acidosis

Metal Fume Fever abrupt onset of fever, chills, myalgias fumes from heavy metals (welding, brazing, etc.)
metallic taste in mouth amphetamines
nausea and vomiting • caffeine
headache • cocaine
fatigue (delayed respiratory distress) • ephedrine (and other decongestants)
• LSD

Sympathomimetics increased temperature • PCP

CNS excitation (including seizures) • theophylline
tachycardia
nausea and vomiting • thyroid hormone
hypertension •ASA toxicity looks like sympathomimetic
diaphoresis overdose
dilated pupils • sedative/hypnotic withdrawal
(including alcohol) also similar

ER38 – Emergency Medicine MCCQE 2006 Review Notes

 TOXICOLOGY. . . CONT.
G - GIVE SPECIFIC ANTIDOTES AND TREATMENTS
note: hemodialysis can be considered for all drugs

Table 14. Toxins and Antidotes

Toxin Antidote/Treatment
Acetaminophen N-acetylcysteine (Mucomyst)
Anticholinergics *Physostigmine
Benzodiazepines flumazenil (Romazicon/Anexate)
ß-blockers atropine, isoprotenerol, glucagon
Calcium channel blockers calcium chloride or gluconate
Carbon Monoxide 100% oxygen, hyperbaric O2
Cyanide Lilly kit (amyl nitrite, then sodium nitrite): Na thiosulfate
Digoxin stop dig, use FAB fragments (Digibind), restore K+
Heparin protamine sulfate
Insulin glucose/glucagon
Iron deferoxamine
Methanol/Ethylene glycol ethanol or fomepizole, leucovorin (for methanol), thiamine and pyrudoxine for EG
Nitrites methylene blue
Opioids naloxone (Narcan)
Organophosphates atropine, pralidoxime
Salicylates alkalinize urine, restore K+
TCA’s sodium bicarbonate bolus
Warfarin vitamin K; (FFP if necessary)
* available through special access programme only

SPECIFIC TREATMENTS
Acetaminophen Overdose
acetaminophen = paracetamol = APAP
acute acetaminophen OD ––> metabolized by Cytochrome P450 ––> saturation of pathway ––>
toxic metabolite (NAPQI) scavenged by glutathione (an antioxidant) (in non-overdose situations)
• in OD: exhaustion of glutathione stores ––> NAPQI accumulates ––>
binds hepatocytes and hepatic necrosis
toxic dose of acetaminophen > 150 mg/kg (~7.0 g)
increased risk of toxicity if chronic EtOH and/or anti-convulsant drugs
clinical: no symptoms
• serum acetaminophen level
• evidence of liver/renal damage (delayed > 24 hours)
• increased AST, INR
• decreased glucose, metabolic acidosis, encephalopathy (indicate poor prognosis)
management
• decontamination
• serum acetaminophen level 4 hours post ingestion
• measure liver enzymes and INR, PTT
• use the Rumack-Matthew Nomogram for acetaminophen hepatotoxicity
• N-acetylcysteine (Mucomyst)
• substitutes for glutathione as anti-oxidant to prevent liver damage
• use according to dosing nomogram
• best effect if started within 8 hrs post-ingestion, but therapy should be initiated regardless
ASA Overdose
acute and chronic (elderly with renal insufficiency)
clinical
• hyperventilation (central stimulation of respiratory drive)
• increased AG metabolic acidosis (increased lactate)
• tinnitus, confusion, lethargy
• coma, seizures, hyperthermia, non-cardiogenic pulmonary edema, circulatory collapse
ABG’s possible: 1. respiratory alkalosis
2. metabolic acidosis
3. respiratory acidosis
management
• decontamination
• 10:1 charcoal:drug ratio
• whole bowel irrigation (useful if enteric-coated ASA)
• close observation of serum level, serum pH
• alkalinization of urine as in Table 14 to enhance elimination and to protect the brain
(want serum pH 7.45-7.55)
• may require K + supplements for adequate alkalinization
• consider hemodialysis when
• severe metabolic acidosis (intractable)
• increased levels
• end organ damage (unable to diurese)
MCCQE 2006 Review Notes Emergency Medicine – ER39
 TOXICOLOGY. . . CONT.
Table 15. Urine Alkalinization in ASA Overdose
Plasma pH Urine pH Treatment
alkaline alkaline D5W with 20 mEq KCl/L +
2 amps HCO3 /L at 2-3 cc/kg/hr
alkaline acid D5W with 40 mEq KCl/L +
3 amps HCO3 /L at 2-3 cc/kg/hr
acid acid 3 /L
D5W with 40 mEq KCl/L + 4 amps HCO

Anticholinergic Overdose (e.g. antihistamines)

physostigmine salicylate: reversible acetylcholinesterase inhibitor
supportive therapy
Benzodiazepine (BZ) Overdose
flumazenil (Anexate): specific benzodiazepine antagonist
indications
• iatrogenic BZ oversedation
• to reverse BZ anesthesia
contraindications
• known seizure disorder
• mixed OD (especially if tricyclic antidepressant (TCA) suspected)
• BZ dependence or chronic use
dose
• adult: 0.3 mg IV (q5mins to maximum 1.0 g)
• child: 10 µg/kg (as above, maximum 0.3 mg)
CAUTION - most BZ have prolonged half life compared to flumazenil
• if re-sedation occurs, repeat doses or IV infusion may be indicated
Beta Blockers
symptoms within 2 hours of ingestion
atropine or isoprotenerol if severe
glucagon
• works as non-ß-adrenergic receptor agonist to increase production of cAMP, thereby
increasing contractility
glucagon 50-100 µg/kg (5-10 mg for adults) slow IV push, then IV at 70 µg/kg/hour
Calcium Channel Blockers
order ECG, lytes (Ca2+ , Na+ , Mg2+ , K+ especially)
calcium chloride 1-4 g of 10% solution IV if hypotension
atropine or isoprotenerol if severe
glucagon
inotrope/aggressive supportive therapy
CO Poisoning
100% O2 therapy by face mask critical for CO poisoning
hyperbaric O 2 disputed benefits; no evidence for therapy in mild-moderate
cerebral dysfunction (may prevent neurological sequelae)
coma is an undisputed indication for hyperbaric O 2 therapy (still the standard of care)
hyperbaric O 2 (efficacy unclear) suggested for pregnant patients
Digoxin Overdose
Digibind = digoxin-specific antibody fragments (Fab)
use in combination with activated charcoal
indications
• life threatening arrhythmias unresponsive to conventional therapy (ventricular fibrillation,
ventricular tachycardia, conduction block)
• 6 hr serum digoxin >19 nmol/L (> 15 ng/mL)
• initial serum K + > 5 mmol/L
• history of ingestion > 10 mg for adult, > 4 mg for child
dose
• 1 vial = 40 mg Digibind neutralizes 0.6 mg digoxin
• cost of one vial = $200
• empirically: 20 vials if acute ingestion 5-10 vials if chronic ingestion (90-95% of cases)
• onset of action 20-90 minutes
• renal elimination half life 20-30 hours
Acute Dystonic Reaction
benztropine (Cogentin), antihistamines, benzodiazepines effective
benztropine has euphoric effect and potential for abuse
for acute dystonic reaction
• 1-2 mg IM/IV benztropine then 2mg PO bid x 3 days
OR
diphenhydramine 1-2 mg/kg IM/IV then 25 mg PO qid x 3 days
ER40 – Emergency Medicine MCCQE 2006 Review Notes
 TOXICOLOGY. . . CONT.
Hydrogen Fluoride Burns
Ca2+ gluconate gel topical or intradermal or both
intravenous calcium chloride for systemic hypocalcemia, hyperkalemia
Insulin/Oral Hypoglycemic Overdose
glucose can be given IV, PO or via NG
glucagon (if no access to glucose)
• 1-2 mg IM
Ethanol Overdose
very common in children
mouthwash > 70% EtOH, perfumes/colognes 40 – 60% EtOH
dehydrogenase pathway is less active in children
presentation: flushed face, dilated pupils, sweating, GI distress, hypothermia, hypoventilation, hypotension
order: serum EtOH level, glucose
manage: airway, circulation, glucose levels
folate up to 50 mg q4h IV
gastric decontamination if ingestion < 1hr ago
hemodialysis if serum EtOH > 500 mg/dL
Methanol or Ethylene Glycol Overdose
ethanol PO/IV used to block metabolism of methanol and ethylene glycol preventing toxicity
Fomepizole (4-methylpyrazole) 15 mg/kg initial dose, a competitive inhibitor of alcohol dehydrogenase,
available for ethylene glycol intoxication (~$2000 a day); recent evidence for use in methanol intoxication
folic acid (Leucovorin) 50 mg IV q4h for several days to potentiate folate-dependent metabolism of formic
acid in methanol poisoning
dialysis if ethanol treatment unsuccessful, visual impairment (MetOH), renal failure (ethylene glycol)
or uncorrectable metabolic acidosis
thiamine 100 mg IV q6h plus pyridoxine 100 mg IV q6h to enhance alternative metabolism to
non-toxic products in ethylene glycol poisoning
Organophosphates/Cholinergic Overdose
atropine
• anticholinergic / antimuscarinic
• for anticholinesterase poisonings and cholinergic poisonings with muscarinic symptoms
• 0.03 mg/kg to max 2 mg/dose (may repeat q 10-15 min until secretions dry)
(may need hundreds of milligrams)
pralidoxime (Protopam, 2-PAM)
• reactivates acetylcholinesterase, reverses nicotinic effects
• organophosphate poisonings only
• most beneficial if given within 24-36 hours
• 25-50 mg/kg over 5 min IV q6h, up to 1-2 g for adults
Tricyclic Antidepressants (TCAs) Overdose
cardiac monitoring mandatory because of cardiac toxicity
QRS complex width predicts outcome
• > 100 ms: increased risk of seizures
• > 160 ms: increased risk of arrythmias
evidence unavailable regarding when to give bicarbonate (HCO 3– )
dose: 1-2 mEq/kg q 10-15 min bolus (2-4 amps)
Warfarin/Rat Poison Overdose
Vitamin K (see Table 16)

Table 16. Protocol for Warfarin Overdose

INR Management

< 5.0 • reduce maintenance dose +/– hold dose x 1

5.0-9.0 • if no risk factors for bleeding, hold Coumadin x 1-2 days and reduce maintenance dose
OR
• if rapid reversal required, Vit K 2-4 mg PO, repeat INR in 24 h
• additional Vit K 1-2mg PO if INR still high (onset 4-6 h)

9.0-20.0 • Vit K 3-5 mg PO, INR in 24h and additional Vit K if necessary

> 20.0 • fresh frozen plasma (FFP) 10-20 mL/kg

• Vit K 10 mg IV over 10 min (IV Vit K only if life-threatening hemorrhage); onset ~ 2 h
• increased Vit K dosing (q4h)
• phenobarbital (little evidence)

MCCQE 2006 Review Notes Emergency Medicine – ER41

 TOXICOLOGY. . . CONT.
pH ALTERATION – see Table 14
if toxin has potential for ion-trapping at physiologically achievable pH
urine alkalinization
• urine pH 7.5-8.0
• potentially useful for salicylates, phenobarbital
• evidence for phenobarbital is equivocal
EXTRA-CORPOREAL DRUG REMOVAL (ECDR)
Criteria for Hemodialysis
toxins that have
• water solubility
• low protein binding
• low molecular weight
• adequate concentration gradient
• small volume of distribution (Vd) or rapid plasma equilibration
removal of toxin will cause clinical improvement
advantage is shown over other modes of therapy
greater morbidity from prolonged supportive care
predicted that drug or metabolite will have toxic effects
impairment of normal routes of elimination (cardiac, renal, or hepatic)
clinical deterioration despite maximal medical support
useful for toxins at the following blood levels:
• alcohols
• methanol: > 15.6 mmol/L (> 25-50 mg/dL)
• ethylene glycol: > 8 mmol/L (> 50 mg/dL)
• salicylates
• acute (within 6 h): > 7.2-8.7 mmol/L (> 100 mg/dL)
• chronic: > 4.3-4.8 mmol/L (> 60 mg/dL)
• lithium
• acute (within 6 h): > 4.0 mmol/L
• chronic: > 2.5-4.0 mmol/L
• bromine: > 15 mmol/L
• phenobarbital: 430-650 mmol/L
• chloral hydrate (––> trichloroethanol): > 200 mg/kg
Criteria for Hemoperfusion
as for hemodialysis
absorbent has greater drug binding capacity than protein or tissue
useful for
• theophylline: > 330 mmol/L (chronic), > 550 mmol/L (acute)
• short acting barbiturates (secobarbital)
• non-barbiturate sedative-hypnotics
• (phenytoin, carbemazepine, disopyramide, paraquat, methotrexate, Amanita phalloides)
DISPOSITION FROM THE EMERGENCY DEPARTMENT (E.D.)
discharge home vs. prolonged E.D. observation vs. admission
methanol, ethylene glycol
• delayed onset
• admit and watch clinical and biochemical markers
TCA’s
• prolonged/delayed cardiotoxicity warrants admission to monitored (ICU) bed
• if asymptomatic and no clinical signs of intoxication: 6 hour E.D. observation
adequate with proper decontamination
• sinus tachycardia alone (most common finding) with history of OD warrants observation in E.D.
hydrocarbons/smoke inhalation
• pneumonitis may lag 6-8 hours
• consider observation for repeated clinical and radiographic examination
ASA, acetaminophen
• if borderline level, get second level 2-4 hours after first
oral hypoglycemics
• admit all patients for minimum 24 hours if hypoglycemic
Psychiatric Consultation (see Psychiatry Chapter)
once patient medically cleared, arrange psychiatric intervention if required
beware - suicidal ideation may not be expressed

REFERENCES
Roberts JR and Hedges JR. (ed). 1998.Clinical procedures in emergency medicine. 3rd ed . WB Saunders Co.

Tintinalli JE and Kelen GE. (ed). 1999.Emergency medicine: A comprehensive study guide. 5th ed . McGraw-Hill Professional Publishing.
ER42 – Emergency Medicine MCCQE 2006 Review Notes