EM Prework Cases

You're leading a canoe trip for a group on the Rio Grande River in Big Bend National Park in Texas. It's been a hot trip, with temperatures well over 90°F day after day. Today, the group started off with a long morning hike up a side canyon, and now you've been paddling for several hours, floating lazily along, watching birds swoop around the limestone cliffs. Suddenly, your observations are interrupted by yells for help downstream. You paddle quickly to a beached canoe and several people on shore. One of your participants is shouting something about a seizure. Another participant is lying on their back in the sand. Their legs are quivering, but their arms seem to be moving normally. The other participant insists this is a seizure—you're not so sure. You sweep the scene for safety and assess that no one is in the water and there are no obvious hazards. There is only one participant who is obviously in pain (43YOM with report of spasms to his legs). You do an initial assessment. Airway, breathing, and circulation are good. There is no bleeding, spine injury mechanism or apparent injuries. He is lying on his back, crying out in pain with obvious spasms to his legs. The patient says these spasms began a few minutes before, as they were kneeling in the canoe. The patient is alert and oriented to person, place, time, and situation) and denies losing responsiveness or being submerged in the river. The head-to-toe exam does not reveal any obvious sign of injury. Symptoms Patient complains of dizziness, nausea, and painful leg cramps. Allergies None Medications Denies over the counter, herbal, or recreational medication. Takes high blood pressure medication and is on their normal dosing schedule. Pertinent Hx Mild hypertension. Patient states they have "a cold and an upset stomach." Last in/out Patient's hydration status is unclear. They state they drank 3 liters of water each, today and yesterday. Did not eat today. No BM today. Urinated twice today. Urine color unknown. Events Paddling and hiking in hot, windy weather the past three days. 1. What is your most likely diagnosis? 2. Are there any diagnostic exams you would like to order? 3. How will you manage this case?

1. Heat exhaustion 2. Check renal function, cpk and Electrolytes --> this will guide your fluid replacement hypernatremic (primary water loss) - water depletion heat exhaustion --> lacks appropriate hydration hyponatremic (primary sodium loss) - salt depletion heat exhaustion --> drinking large amts of hypotonic solution

A 38-year-old woman presents with reports of feeling poorly, low grade temps, and severe muscle spasms. She states it feels like there are severe muscle knots in her legs, which feel like "golf balls" moving from one spot to another. She states all her muscles feel stiff, even her jaw, stating "it's hard to even chew." She denies dyspnea but states she can't take a "deep enough breath." She reports being seen at an outside clinic for the same and was given steroids for suspected inflammatory arthralgias, but she continued to feel poorly, and this prompted her visit to the emergency department. On review of her PMH she admits to stepping on a nail, which penetrated her shoe while jogging on a local outdoor trail 10 days ago but states her tetanus booster was up to date (8yrs ago). She states she pulled the nail out and cleaned it with soap and water. She denies receiving any medical attention. On exam, her temp is 100.1°F, BP 158/80, pulse 106bpm, rr 18, O2 98% on RA and she appears a bit diaphoretic. Lungs are CTA, heart sounds are tachy but regular without murmur, abdomen is soft and non-tender, there is full AROM throughout, deep tendon reflexes are increased, and the puncture wound to her left foot is healing without erythema, warmth or drainage. 1. What is your most likely diagnosis? 2. Are there any diagnostic exams you would like to order? 3. Identify your problems. Now, how will you manage this case?

Laboratory data (CBC, CMP, UA, PTT, and INR) were within normal limits. X-ray of the chest and left foot were normal. ECG was normal. Strychnine levels (which arrived after her discharge) were undetectable. Vital capacity measurements were within normal limits. Ms. D was diagnosed with *tetanus.* Once the diagnosis is made, treatment includes management of pulmonary and cardiovascular systems in a quiet environment, neutralization of the toxin, and removal of the organism. Tetanus immune globulin helps neutralize the circulating unbound tetanus. If surgical debridement of the wound is necessary, immune globulin must be administered prior to surgical intervention. A quiet environment along with benzodiazepines helps reduce spasms. *Metronidazole*(Flagyl) is the antibiotic of choice to reduce toxin-forming tetanus. If spasms cannot be controlled, sedation with ventilator support and paralytics may be required. For sympathetic instability, beta-blockers (i.e., esmolol or propranalol) or magnesium sulfate may be used to reduce catecholamine release. Dantrolene (Dantrium) is a direct skeletal relaxant and may also be considered useful for management of muscle spasticity and rigidity.

What is the most common displacement associated with supracondylar fractures?

Supracondylar Fracture with Posteromedial Displacement

which nerve has motor functions for *foot dorsiflexion, toe extension*?

deep peroneal nerve

Why is the common peroneal nerve prone to injury?

it runs along the lateral aspect of the knee right on the fibular head loss of - foot eversion (superficial) - foot dorsiflexion (deep) - toe extension (deep) foot drop (toes do not clear ground during swing phase)

which nerve has motor functions for *foot eversion*?

superficial peroneal nerve

posterior MEDIAL displacement indicates what kind of nerve injury?

radial nerve injury

inability to extend wrist or digits

radial nerve neurapraxia

which nerve innervates these areas: - first web space on dorsum side - volar pinky - volar index

- first web space on dorsum side: radial - volar pinky: ulnar - volar index: medial

What would be the clinical signs of an AIN lesion?

- inability to flex at interphalangeal joint of thumb - inability to flex at distal interphalangeal joints of digits 2 +3

You are moonlighting in a rural emergency room when a father rushes his 3-year-old daughter into the waiting area. You quickly determine that he and the child have been at a relative's farm where they were spraying for bugs in an old barn. The child had been fine, but while at the farm developed abdominal cramping, cough, drooling, and tearing. While in route the child seems to be having increased respiratory difficulty, and the dad notes she soiled and urinated upon herself. 1. Identify the toxidrome. 2. What are your clues? 3. What would you like to order and why? 4. How will you manage this patient?

*1. Identify the toxidrome.* Clues: spraying for bugs (pesticides)- organophosphate poisoning --> *cholinergic toxidrome*. --> enhanced parasympathetic activation (acetylcholine) Try to memorize anticholinergic and know it well and then know that this is the complete opposite --> Agitated, anxious, pinpoint pupils (miosis), initial nicotinic receptor stimulation may give you tachycardia, tachypnea, but then the muscarinic receptors are stimulated, and you are bradycardic (too brady think ventricular dysarrhytmia), bradypnea. --> *This is a WET toxidrome*--> salivation, hyperperistalsis, urinary and fecal incontinences, diarrhea, emesis, diaphoresis, lacrimation, GI cramps (hyperperistalsis) --> Bronchoconstriction/ bronchospasm (?albuterol), muscle fasciculations and weakness or seizures. --> Anticholinergic Opposite: Agitated/ delirium, mydriasis, hyperthermia, tachycardia, tachypnea, hypertension, dry flushed skin, dry mucous membranes, decreased bowel sounds, urinary retention *2. What are your clues?* Exposure to pesticide, abdominal cramping, cough, drooling, tearing, urinary incontinence *3. What would you like to order and why?* High index of suspicion so therapy is not delayed; confirmation via decreased serum pseudocholinesterase and erythrocyte cholinesterase levels. (low levels of the enzymes that break down Ach) cbc for leukocytosis with left shift BG-hyperglycemia is common with secondary release of catecholamines Check electrolytes Lactate--> high levels is a poor clearance/ worse prognosis LFTs- AST may be elevated LDH -= high levels may be associated with oxidative tissue damage Trop if indication for MI CXR to evaluate respiratory symptoms Place on telemetry, EKG if needed (any indication of myocardial damage) *4. How will you manage this patient?* *Remove clothing, wipe skin down The patient is drooling, this may be from laryngeal spasm which will lead to a compromised airway. Very minimum, place her on *oxygen* *If unable to tolerate oral secretions intubate*--> *do not use succinylcholine* Organophosphates are irreversibly bound to cholinesterase causing deactivation of acetylcholinesterase. Caution: *avoid succinylcholine* for endotracheal intubation, because it is metabolized by plasma acetylcholinesterase, resulting in prolonged paralysis -if they are having bronchospasm what should you give--> *albuterol, epinephrine* -acetylcholine is binding to *muscarinic* receptors --> block this with *atropine* -alternative pralidoxime- reverses cholinergic excess at both *muscarinic and nicotinic receptors* do not give to patients with *myasthenia gravis*, may cause myastenic crisis

A 55-year-old man with a history of atrial fibrillation develops a sudden sharp pain in his right leg. He presents to the emergency department, where he is found to have a cold right foot and calf, as well as nonpalpable pulses below the knee. The patient is taken to the operating room approximately 8 hours after the onset of the pain. He undergoes an embolectomy of a popliteal artery clot without complication. In the recovery room, however, he begins complaining of intense right foot and calf pain that continues to escalate, despite copious analgesia. When you evaluate the patient, he complains of 10/10 pain in his foot and calf that is constant, sharp, and without relief. On physical exam, his right lower leg is pale and firm to touch. Palpable posterior tibial and dorsalis pedis pulses are present bilaterally. He experiences excruciating pain with passive dorsiflexion flexion of the right foot. 1. What is the most likely diagnosis? 2. How do you confirm the diagnosis? 3. What is the appropriate treatment? 4. What are the major complications associated with this condition?

1. *Compartment Syndrome* can be clinically diagnosed or with measurement of the compartment pressure. 2. *5 Ps*: Five signs and symptoms classically found in patients with compartment syndrome, including: pain out of proportion to exam, paralysis, paresthesias, pallor, pulselessness, poikilocytosis (coolness) --> Patient is having pain out of proportion (despite copious analgesia), +pallor --> Compartment is firm 3. intracompartmental pressure (ICP) > 30 mmHg can be used as a threshold to aid in diagnosis --> perform fasciotomy 4. Neurovascular compression can occur --> paralysis (nerve), thrombosis, ischemia --> rhabdomyolysis (ARF, hyperkalemia), diminished limb function, muscle contractures, gangrene, amputation, sepsis, death

A 19-year-old college student is brought into the emergency department via ambulance after her friends found her confused and she appears intoxicated. Her friend tells you that the patient was in a fight with her girlfriend and that she was really upset. She is uncertain about her medications but thinks that she takes something for her "mood". She did not find any open pill bottles. Her vital signs are: BP = 110/80, P = 140, RR = 38, T = 98.7F, O2 sat = 98% on room air. Though she initially appeared intoxicated, she deteriorates during her observation period in the ED. You find her in the hallway unresponsive to painful stimuli. You immediately proceeded to control her airway, confirm tube placement, and re-examine her. Her pupils are 5mm and reactive (2-4avg). Her skin is not flushed. She is tachycardic with regular beats, and the rest of her exam is relatively unremarkable. There are no signs of trauma. She does not appear to have a clear toxidrome. Her EKG shows a sinus tachycardia with normal intervals. You send a full set of labs including an ABG, CBC, CMP, and a tox screen including ethanol level, acetaminophen level and salicylate. You also remembered to check her pregnancy status. Her labs return with an ABG as follows: pH = 7.1, pCO2 = 25 (35-45), pAO2 = 400 1. Why is her pCO2 low? 2. Interpret the ABG:

1. Could be caused by her initial increased RR of 38 so she was initially blowing off her CO2 through hyperventilation. side note: After a few hours after ingestion there is a transient excitation that leads to CNS depression. After 4-12 hours have passed, the pt developed severe metabolic acidosis from the accumulation of acid metabolites and lactate. 2. metabolic acidosis (pH down, pCO2 down)

A 70-year-old woman was found unconscious in her unheated home with overnight temperatures of 30.2⁰F. On arrival to ED her core rectal temperature was 69.8⁰F, blood pressure 90/50 and pulse was 28 beats per minute. EKG demonstrated slow atrial fibrillation (see attachment) Laboratory values included a serum potassium of 1.1 (3.5-4.5) mEq/L, phosphorous <1 (2.5-4.5mg/dl), pH 6.95, lactate 8.5 mmol/L, glucose 522 (70-110mg/dl) and her renal function was normal. Abnormal EKG findings: slow atrial fibrillation + Osborne (J waves) 1. What is your most likely diagnosis: 2. Interpret the EKG findings (does it provide any clues for this case): slow atrial fibrillation + 3. What would you like to do next and why?

1. Diagnosis a. Systemic hypothermia with atrial fibrillation b. Severe hypokalemia (initially hypothermia results in an intracellular shift of potassium leading to hypokalemiaà this occurs because of the beta-adrenergic surge that is occurring in the body which causes skeletal muscle to uptake K+ (NaK-ATPase) because we need those skeletal muscles to produce shivering so the body can produce heat) c. Severe hyperglycemia (hypothermia causes a decrease in insulin sensitivity and insulin secretion, which can lead to hyperglycemia ) d. Metabolic acidosis/ lactic acidosis. 2. +J waves which are indicative of hypothermia 3. Warm patientà there is no risk of refreezing so active warming à repeat EKG and labs after rewarming

A 22-year-old man presents with severe right middle finger pain and swelling x 2 days. He states the pain is constant, aggravated with movement and mildly relieved with naproxen. The patient states the only thing he can recall is a small cut to the affected area which occurred while picking up broken glass 1 week ago. He states the cut which has since healed was barely noticeable and he washed it immediately. PMFSH: pt states he has been otherwise healthy, immunizations are up to date (last tetanus booster age 12), denies tobacco, EtOH, or illicit drug use. Physical Examination Vitals: normal, General: patient appears well developed, well nourished Right middle finger: The finger is erythematous and warm with significant swelling a 1mm scab over previously lacerated area (per pt). There is diffuse tenderness with palpation of volar aspect from distal palmar crease to the distal interphalangeal joint. Pain with passive extension. 1. What is your most likely diagnosis? 2. What pertinent positive findings support this diagnosis? 3. How will you manage this case? If you choose an antibiotic, be able to explain what you are covering?

1. Flexor Tenosynovitis 2. Tender over flexor tendon, pain with passive exertion, circumferential swelling (sausage digit) --> Kanavel Cardinal Signs of tendon sheath infection 3. Most commonly isolated organism is Staph aureus, more often MRSA than MSSA --> Vancomycin and Zosyn would be a good choice for coverage with 53% of cases having MRSA (see antibiotic coverage slide next to review). IV antibiotics and surgery for I&D

A 5-year-old boy (weight: 20kg) was helping his father do some minor repairs and maintenance on the family car. The boy drank from what he thought was a cordial container, inadvertently ingesting up to 50 mL of a radiator coolant containing 95% ethylene glycol. The boy is taken to the local health center, which is 3 hours by aeromedical retrieval from a major hospital. 1. What type of clinical findings and laboratory changes might you expect to see? 2. How will you manage this patient?

1. Hypotension, tachycardiac, tachypnea, fixed dilated pupils, seizures *AG metabolic acidosis*, high osmolality, low ethanol level in intoxicated patient, hypocalcemia with prolonged QT, and later findings would indicate brain hemorrhage (bilateral basal ganglia) 2. airway - DSI w/ ketamine, correct pH with bicarb call poison control consider *fomepizole* or ethanol replenish cofactors consider dialysis

A 46-year-old man presents with left elbow and wrist pain after a mechanical fall on to an outstretched hand just prior to arrival. On exam, the patient appears in pain and is guarding his arm by holding it flexed at 90°. The elbow is swollen and tender to palpation along lateral aspect of the humerus and radius. AROM is limited and pronation of the extremity elicits increased pain. Sensation is decreased to the volar aspect of his thumb, index finger, middle finger, and the lateral aspect of his ring finger. 1. What is your most likely diagnosis (at this point)? 2. If your suspicions were correct which motor deficit may you see on physical exam? a.Inability to abduct all fingers b.Inability to extend wrist and fingers c.Inability to oppose thumb and pinky 3. What is your next step of management and if your suspicions are correct how will you treat it?

1. Median Nerve Injury with suspicion for elbow injury 2. C. Inability to oppose thumb and pinky 3. Order X-ray, analgesics

A 38-year-old man with a history of non-insulin dependent diabetes and heroin abuse presents with swelling, redness and warmth to his right foot x 1 day. The patient denies injury but admits his work boots are a bit tight and have been rubbing on his foot. Vitals are normal and you prescribe clindamycin to treat his cellulitis, strict glycemic control, and plan to return in two days for re-evaluation. The next morning the patient notices the swelling is worse and decides to go to the emergency department after lunch because he knows they might want to keep him overnight. You remove his sock and find the following (missing a toe) 1. What is your most likely diagnosis? 2. Why did the patient's findings progress despite treatment with clindamycin?

1. Necrotizing fasciitis 2. Clinda does not cover gram negatives/ pseudomonas (see antibiotic coverage slide next) Diabetic risk factor→ clindamycin doesn't cover pseudomonas or overall a broad enough spectrum.

A 65-year-old man with a history of peripheral vascular disease, congestive heart failure, and atrial fibrillation on coumadin presents to the emergency department by ambulance after being hit by a car while crossing the street. The patient reports pain to the lateral aspect of his right leg from the hip to the ankle. He reports impact with the lateral aspect of his leg causing him to fall but denies head injury or any associated loss of consciousness. Physical Exam General. The patient is screaming in pain. Right Knee: There is a notable anterior translocation of proximal tibia at about 15° with diffuse swelling and ecchymosis along the lateral aspect. The affected area is TTP, AROM is limited, and he is unable to bear weight. Right lower leg: compartments are soft and non-tender. Right ankle/foot: no swelling or ecchymosis, no focal areas of tenderness to palpation. Skin: 3cm laceration to lateral aspect of knee Vascular: Rt DP pulse is 1+ (cap refill 4 secs), Lt DP is 2+ (cap refill 2 secs) Neuro: Sensation is decreased to the web space between 1st and 2nd toe. The patient is unable to dorsiflex. 1. What is your most likely diagnosis? (at this point) 2. Which physical exam finding would you suspect to also find? a.Difficulty ambulating on toes b.Difficulty ambulating on heels c.Difficulty squatting d.Difficulty with straight leg raise 3. What is the next most important step? a.Order diagnostic imaging b.Measure ankle-brachial index c.Measure anterior compartment pressure d.Order IV analgesic 4. The ankle-brachial index and anterior compartment pressure were both evaluated and deemed to be within normal limits. This patient's current physical exam findings indicate which acute findings as of this point? a.There is no definitive diagnosis at this point b.There is nerve, vascular, and bony injury c.There is nerve and ligamentous injury d.There is nerve injury

1. Peroneal Nerve Injury (dec sensation to webspace, unable to dorsiflex (foot drop)) with suspected Knee fx or dislocation, possible arterial injury with note of asymmetric pulses. ?PVD or acute arterial injury 2. B 3. B (anytime there is a possible knee dislocation you are at risk of damaging popliteal artery) ABI first Same time you are ordering analgesics and placing your x-ray order because it will take x-ray a minute to come, you should be done with ABI by then. 4. C- the joint is not aligned we know at least the ligament is injured at very minimum We've established that the peroneal nerve has been injured (drop foot, web space) And we've established that there is no arterial injury (+pulse, ABI okay)

A 74-year-old man is found in his small apartment after having a seizure on a hot summer afternoon. The EMS providers state that they found him in a poorly ventilated apartment without any air conditioning. They established an IV of normal saline prior to arrival and obtained a finger stick glucose of 146 mg/dL. Because he was postictal during transport, they were unable to obtain any other history. On arrival in the emergency department, his temperature is 106°F, blood pressure is 157/92 mm Hg, heart rate is 156 beats per minute, and respiratory rate is 28 breaths per minute. He is extremely warm to touch. He is combative, moaning, and flailing his arms and legs at staff. His pupils are midrange and reactive to light. His mucous membranes are dry. His neck is supple. His skin is flushed, hot, and dry. 1. What is the most likely diagnosis? 2. What is the best initial treatment?

1. Seizure secondary to heat stroke; temp 106F, CNS change 2. Management of the ABCs and rapid cooling --> water immersion Other: CNS dysfunction extreme hyperthermia >104F multiorgan failure flushed hot dry skin + dehydration

A 22-year-old man with a history of polysubstance abuse is brought to the emergency department after his parents found him somnolent in his bedroom lying in bed. Several unidentified pills were lying on his nightstand. On arrival, his blood pressure is 120/70 mmHg, the temperature is 98.6 F, respiratory rate is 14/min, his pulse is 70/min, and pulse oximetry is 98% on room air. He is very difficult to arouse. 1. Overdose of which of the following medications is most likely to have caused this patient's presentation? 2. Which toxidrome does this case fall under? 3. How will you manage this case?

1. benzodiazepines 2. sedative-hypnotic toxidrome - *decreased DTRs in this and opioids* 3. Flumazenil, supportive benzos, barbituates, sleeping aid, alcohol, ambian, soma (muscle relaxer)

A 16-year-old female presents to the emergency department complaining of local pain to the right ankle surrounding a small, punctate lesion. She also reports abdominal pain and right lower extremity cramping. The patient notes she left her campground this morning and reported to the emergency department as her cramping symptoms worsened during her drive home. On exam, the lesion and surrounding area appear clean. The lower extremity compartments are soft, and her toes exhibit a capillary refill time less than two seconds. 1. What is your most likely diagnosis? 2. What pertinent positive findings support this diagnosis? 3. Are there any complications you should look for and document are or aren't present? 4. How will you manage this case?

1. black widow spider bite 2. 1.lower extremity and abdominal cramping 3. look for necrosis, systemic findings 4. Clean the affected area, opioid administration, Latrodectus antivenom brown recluse--> necrotic eschar (thick scab), red white blue, hemorrhagic blister This patient was most likely bitten by a black widow spider. Her symptoms are consistent with a black widow spider bite: abdominal cramping, a bite mark on the skin, and muscle cramping, and pain. Black widow spiders are found especially in wooded areas, and activities such as camping, hiking, and gathering wood put patients at an increased risk of encountering a black widow spider. Given the specific skin findings on the patient's ankle, water, and food consumption are an unlikely cause of her symptoms.

A 6-year-old girl is brought to the emergency department by her parents. She is comatose, tachypneic (25 breaths per minute), and tachycardic (150 bpm), but she appears flushed, and fingertip pulse oximetry is normal (97%) breathing room air. Questioning of her parents reveals that they are homeless and have been living in their car. The nights have been cold, and they have used a small charcoal burner to keep warm inside the vehicle. 1. What is the most likely diagnosis? 2. What treatment should be instituted immediately?

1. carbon monoxide poisoning 2. supplemental oxygen --> *hyperbaric oxygen* if she doesn't improve (repeat carboxyhemoglobin levels) Other examples Heater recently installed or being worked on in the home Water heater as well Sleeping on a boat while running Here they used a small charcoal burner but just having the car running as well. What are they at risk for long term? Despite hyperbaric therapy, up to 40% of the patients can still develop chronic, neurocognitive impairment and hense, patients should be scheduled for neuro psychological evaluation approximately 1-2 months after recovery.

A 25-year-old woman is brought to the emergency department by police after attempting to break into a grocery store. When they apprehended her, they noted her pupils were large and that she seemed "high." The patient states that she has been "smoking" for the past year. She notes that without her "smokes," she craves the drug, becomes very sleepy, depressed, and has a huge appetite. In the ED, she complains of chest pain. The patient has a temperature of 100.4°F, heart rate of 120 beats per minute, and blood pressure of 160/90 mm Hg. Her pupils are both 6 mm and reactive. Her thyroid is normal to palpation. The heart and lung examinations reveal tachycardia but are otherwise normal. Neurologic examination is unremarkable. 1. What is the most likely diagnosis? 2. Which toxidrome does this case fall under? 3. How will you manage this case?

1. cocaine intoxication 3. sympathomimetic toxicity 3. benzos if HR above 160: *do not give BB (unopposed alpha stimulation)* if chest pain--> nitro, troponin, EKG

A 27-year-old healthy man presents to the emergency department 30 hours after injuring his right thumb while at work. The patient states he works as an industrial painter at new local construction sites. He states he was loading his paint gum with latex based paint when the device malfunctioned and sprayed his thumb. His employer sent him to the local urgent care where he was evaluated and discharged on a 7-day prescription of Keflex with instruction to follow up with occupational health in 1 week. The patient reports progressively worsening swelling and pain to his thumb with the inability to flex it which prompted his visit to the emergency room. Physical Exam Thumb: There is a 1mm wound (see image). The thumb pad is tense, swollen, and tender to palpation. However, the remainder of the thumb including the volar aspect proximal to the pad is non-tender and there is no circumferential swelling. Sensation is diminished to the volar aspect of the thumb pad, but otherwise intact to soft and sharp. The patient is unable to flex at the IP joint, but can flex at the MCP joint and he is able to extend, abduct and adduct without difficulty. There is no pain with passive extension. Hand/Wrist: There is no erythema, warmth, swelling or tenderness to palpation. There is full AROM. Sensation is intact. Radial pulse is 2+ and capillary refill is < 2 seconds except for thumb which was deferred from testing. 1. What is your most likely diagnosis? 2. Was Keflex an appropriate choice of antibiotics? Why/ Why not? 3. If left untreated what is the patient at risk for? 4. What is the next step in management?

1. high pressure injection injury 2. Keflex covers gram +, most gram -, but not pseudomonas or anerobes - The majority of these infections are caused by Staphylococcus aureus (A+), beta-hemolytic streptococci (A+) and Clostridium spp (Anerobe +) 3. Flexor tenosynovitis, septic joint, osteomyelitis, sepsis, amputation 4. X-ray, basic labs for surgery. IV abx and surgical debridement

An 18-year-old man presents to the emergency department agitated, confused and hallucinating. The patient's friends state that the group was walking around in the woods looking for some "weeds to smoke" in order to get "high." The patient was first to smoke one of the weeds and subsequently became agitated. His friends decided to bring him to the ED for evaluation. On arrival to the ED, the patient's vital signs are blood pressure 180/100 mm Hg, heart rate 120 beats per minute, respiratory rate 18 breaths per minute, temperature 101°F, and pulse oximetry 98% on room air. On physical examination, his pupils are 6 mm, skin is erythematous and warm to the touch, axillae are dry, abdomen has decreased bowel sounds, and the patient is grabbing at things that are not there. 1. What is the most likely diagnosis? 2. Which toxidrome does this case fall under? 3. How will you manage this case?

1. likely Jimson weed intoxication which essentially mimics atropine 2. anticholinergic toxicity (dilated pupils, dry, hyperthermia, decreased GI bowel sounds (hypoperstalsis), high HR, tachy, AMS 3. Physostigmine, charcoal, neostigmine for ileus if needed, benzodiazepines for symptomatic management as needed Neostigmine - if they have hyperperistalsis TCA--> amitryptaline --> *DO NOT give phystigmine for pts taking TCAs*

An 18-year-old man is brought into the emergency department after being found on the street unresponsive. He is lethargic and does not answer questions. He has been given 1 ampule of Dextrose intravenously without result. On examination, his heart rate is 60 beats per minute, and respiratory rate is 8 per minute and shallow. His pupils are pinpoint and not reactive. There are multiple intravenous track marks on his arms bilaterally. 1. Identify the toxidrome? 2. What are your clues? 3. What would you like to order and why? 4. How will you manage this patient?

1. opioid intoxication 2. Lethargic, pinpoint pupils, IV track marks 3. Its still a suspicion, remember when someone is down for an unknown amt of time you want to know how much has been affected. Were their organs hypoperfused. Is there renal damage, hyperkalemia from cell death --> EKG as well, check LFTs for liver damage. Is there more than one thing on board --> alcohol, UDS +++LACTATE 4. -establish IV access -respiratory rate is 8rpmà I would want to know o2 saturation, let's say its 70% --> what can we do? -give Narcan --> if it works your good, just add oxygen --> If not then intubate as the patient can not maintain airway pt can maintain airway??? - hold position for head while giving narcan

Her electrolyte panel and tox screen show: Na = 138, K = 5.8 , Cl = 100, HCO3 = 9 Acetaminophen = 0.0, Salicylates = 0.0 Ethanol = 186, TCAs = negative 3. Why is the potassium so high? 4. Is there an anion gap? 5. What do you suspect is causing this patient's signs and symptoms?

3. acidosis causes potassium to move from cells to extracellular fluid (plasma) in exchange for hydrogen ions 4. 138 (Na ) - 100+9 (Cl + HCO3) = 29 (16 normal) 5. Alcohol ketoacidosis, salicylate poisoning --> This patient was actually binging on vodka and redbull. Alcoholic ketoacidosis is a specific group of symptoms and metabolic state related to alcohol use. Symptoms often include abdominal pain, vomiting, agitation, a fast-respiratory rate, and a specific "fruity" smell. Consciousness is generally normal. Complications may include sudden death. Ethanol is a toxin, the majority of which is oxidized in the liver to acetaldehyde. Normally the liver will break down this toxin, but a damaged liver results in decreased gluconeogenesis and lactate production. Characteristic history Chronic alcohol abuse, plus recent binge Binge terminated by severe nausea, vomiting, and abdominal pain Tx: IV fluids (5% dextrose) and thiamine wintergreen essential oil: salicyclate poisoning

An 18-year-old woman is brought by a friend to the emergency department about 30 minutes after she took "a bunch" of Tylenol. The patient states she was upset with her parents, who grounded her after she came home late from a party. She swallowed half a bottle of extra-strength Tylenol in order to "make them feel sorry." She is tearful, says she was "stupid," and denies any true desire to hurt herself or anyone else. She has no other complaints and denies any past attempts to hurt herself. On examination, her blood pressure is 105/60 mm Hg, heart rate is 100 beats per minute, and respiratory rate is 24 breaths per minute (crying). Her pupils are equal and reactive bilaterally. Her sclerae are clear, and her mucous membranes are moist. The lungs are clear, and heart sounds are regular. The abdominal examination is benign with normal bowel sounds. She is awake and alert without any focal neurologic deficits. 1. What is the most appropriate next step? 2. What are the potential complications of this ingestion? 3. What is the mechanism of acetaminophen toxicity?

Acetaminophen Toxicity + Suicide Attemptà She's sorry, she doesn't intend to harm herself, Do we place a 72hr hold (EDO) Notice that her physical exam is essentially unremarkable. The first 24hrs there are often minimal and nonspecific symptoms including anorexia, nausea, vomiting, malaise 1.What is the most appropriate next step? Obtain IV access; send appropriate laboratory studies; administer activated charcoal; evaluate need for N-acetylcysteine (NAC). 2. What are the potential complications of this ingestion? Hypoglycemia, metabolic acidosis, hepatic failure, and renal failure. 3. What is the mechanism of acetaminophen toxicity? Production of toxic metabolite, N-acetyl-p-benzoquinoneimine (NAPQI).

Thompson Test

Achilles tendon rupture

*For the 65 YO patient in the previous scenario:* You must stabilize this injury to prevent any further damage. Which treatment option is indicated for this injury? a.No intervention is indicated in ER, admit and call ortho b.Knee immobilizer c.Call vascular surgeon for immediate revascularization d.Long leg posterior post mold •Will you need to update tetanus, if so, what will you give? •Does this patient need prophylactic antibiotic coverage? •If so, what will you prescribe?

D Td or Tdap if they've never had it 3cm laceration to lateral aspect of knee --> open fracture --> needs coverage - In ED we often give Ancef (cefazolin- 1st generation covers gram + and most gram -), you need to broad-spectrum antibiotics (gram + and gram - coverage) 3rd generation cephalosporin You will need to irrigate this wound well, give antibiotics, stabilize the leg and get ortho involved for surgery

A 44-year-old homeless man is found on a park bench in the middle of the winter. He is cold and covered in snow. A concerned citizen calls 911, and EMS transports the patient to the Emergency Department. The patient is minimally responsive. A pack of cigarettes and a small bottle of whiskey are found in his jacket pocket. On examination, he is thin and disheveled. His extremities are pale and cold with clear fluid-filled blisters on his hands and several of his fingers. His blood pressure is 110/70 mm Hg, heart rate is 90 beats per minute and irregular, respiratory rate is 18 breaths per minute, and his rectal temperature is 86°F. He is not shivering. 1. What is your most likely diagnosis? 2. What are your recommendations?

Frostbite No chance of refreezing, passive initially while preparing water bath, no rubbing. Warm bath immersion temp should be 98.6 to 102.2F. Warm to touch/ not hot. Rewarm until a red-purple color appears and skin become pliable.

Salicylate Poisoning Clues on presentation.

Salicylate poisoning is easy to miss because early in the illness course it can present in a fairly benign manner. Without a clear history of ingestion, salicylate poisoning may be initially misdiagnosed as pneumonia, sepsis or DKA because of the overlapping features. While the seldom seen classic triad is *hyperventilation, tinnitus and GI upset*, salicylate poisoning clinical features also include nausea, vomiting, abdominal pain, deafness, flushed skin, sweating, hyperthermia, altered level of awareness, pulmonary edema and cardiovascular instability. Often the key clue is an *elevated respiratory rate without an obvious primary respiratory cause and a normal oxygen saturation*; a result of the patient's effort to *blow off CO2.* Symptom onset is *3-8hrs;* Salicylate levels greater than 100 mg/dL are considered severe toxicity and occur 12 to 24 hours after ingestion. Damage to the basement membranes will cause *cerebral and pulmonary edema.* Patients may become obtunded and develop seizures. Hypoventilation may replace hyperventilation, which is concerning for impending respiratory failure. D5 with 3 amps of sodium bicarbonate ECG clues. ECG clues of salicylate poisoning include a widened QRS and AV block that can lead to ventricular dysrhythmias.

A 53-year-old man who has otherwise been healthy and in his normal state of health presents with report of numbness and tingling to his right upper extremity and inability to extend his hand. The patient denies injury and states he woke up this way. He states the night prior he spent the evening drinking beer with friends while watching a game of football. He states the night overall was quite uneventful, "he believes," as he fell asleep on a high back bar stool which is where he woke up this morning. He states his arm was hanging over the back of the stool and it felt like it was asleep initially, so he didn't think too much of it but states his symptoms have persisted for 2 hours now and this prompted his visit to the ED. The patient denies neck pain or history of intermittent neck pain. He denies any previously similar episodes and denies history of EtOH dependence. He states the last time he's had that much beer was when the Bears won the Superbowl. There is no swelling, erythema, warmth, or areas of ecchymosis. Extremity is non-tender to palpation, compartments are soft. The patient has full AROM of the shoulder and elbow. but there is flaccid weakness to wrist and finger extensors. Sensation is decreased to the lateral aspect of the upper arm just inferior to the deltoid, middle portion of the posterior forearm and dorsum of the lateral half of the hand including web space between thumb and index finger (1st webspace). 1. What is your most likely diagnosis? 2. Why did this occur? 3. How will you manage it?

Saturday night palsy or radial nerve injury Compression of the nerve in the axilla by the chair Splint and follow up, may take a few days

A neurologic injury is a RED FLAG that there is also what other type of injury present?

arterial injury

If pt has posterior LATERAL displacement + these findings, what nerve is injured? - Thumb and index finger opposition deficit (OK sign)

anterior interosseous nerve

What nerve controls flexion at the distal interphalangeal joint of the index finger and interphalangeal joint of the thumb? - Flexor pollicis longus of thumb - Flexor digitorum profundus of index finger

anterior interosseous nerve

An 18-year-old woman is brought in by EMS after an unknown suicidal ingestion. She is confused, her pupils are dilated, and she is tachycardic. She has no tremors or rigidity. She has no history of chronic substance abuse or withdrawal. 1. How can you distinguish an anticholinergic vs sympathomimetic toxidrome?

anticholinergic → dry skin and decreased bowel sounds sympathomimetic → sweating, increased bowel sounds

An arterial injury places the patient at risk for what other injury?

brachial artery injury - dissection or thrombosis

Which of the following interpretations is most accurate? a. Fracture coronoid process with associated elbow effusion b. Raised fat pads and supracondylar fracture c. Elbow effusion but, no fracture demonstrated d. No abnormality

c. Elbow effusion but, no fracture demonstrated see slide 29 on tuesday ppt

A 48-year-old woman presented to a homeless shelter health clinic with painful feet. She was unemployed and had lost the support of her family and had been evicted from her mother's house due to marijuana and heroin abuse. She had been staying at the shelter since that time. She was caught in a freezing rain and her socks and fur lined boots became wet. Lacking a change of footwear, she had been wearing the wet socks and boots for three days at the time she presented to the clinic. PMH- no known chronic illness Substance use-reports occasional marijuana, heroin, and alcohol use. 40 pack-year smoke history. Denies binge drinking, blackouts, or hangovers. Physical Exam Vitals: Temp 96.2°F, BP 127/76, 95bpm, 18rpm. General: The patient is alert and oriented x4, calm and cooperative with exam. Feet: full AROM Skin: The soles are severely macerated (see image) but there are no blisters, and the skin is otherwise intact. Vascular: Feet are cool to the touch. Posterior tibialis 2+ bilaterally. Nailbeds are blanched with sluggish capillary refill. Neuro: The client had no sensation to light touch by monofilament test in both feet. She described her feet as numb but experienced a prickly pain when she walked. 1. What is your most likely diagnosis? 2. How will you manage this case?

immersion syndrome Trench foot Immediate treatment consists of protecting the extremities from trauma and secondary infection. Rewarm the injured areas gradually by exposing them to air. Do not soak or massage the skin. The patient should avoid any pressure to region until all ulcers have healed. Keep the affected area elevated to aid in removal of edema fluid, and protect pressure sites (eg, heels) with pillows or booties lined with cotton batting. Antimicrobials are only necessary if infection occurs. Hospitalize all patients with immersion syndrome.

What nerve serves the volar aspect of the upper extremity and thus ....flexion?

median nerve

Which nerve? - palpate webbing space btwn thumb and index finger, including PALMAR surface of hand

median nerve

which nerve? - ability to bring thumb and little finger together so they are touching

median nerve

Which nerve innervates the Volar aspect of thumb, index finger, middle finger and half of the ring finger?

median nerve - think hunger games

If pt has posterior LATERAL displacement + these findings, what nerve is injured? - Thumb and pinky finger opposition deficit - Hand of benediction: unable to flex or extend 2nd/ 3rd digits - Decrease/ loss of sensation to thumb, index, middle and radial aspect of ring finger.

median nerve injury

A 44-year-old homeless man is found on a park bench in the middle of winter. He is cold and wet from the falling snow. A concerned citizen called EMS to transport the patient to the Emergency Department. The patient is minimally arousable and his clothes are soaked from the waist down. A pack of cigarettes and a small bottle of whiskey are found in his jacket pocket. On examination, he is thin, disheveled, malodorous, and his extremities are pale and cold. His blood pressure is 110/70 mm Hg, heart rate is 90 beats per minute and irregular, respiratory rate is 18 breaths per minute, and his rectal temperature is 86°F. There is no evidence of trauma, and the patient is not shivering.

moderate hypothermia (risk factors, homelessness, alcohol, smoking)

which nerve is affected with Supracondylar Fracture with Posteromedial Displacement?

radial nerve - can't give a thumbs up - sensation diminished on dorsum side

What will a vascular exam of an UE show?

presence of pulse, warmth, capillary refill, and color of hand vascular status in 3 categories - hand well-perfused (warm and red), radial pulse present - hand well-perfused, radial pulse absent - hand poorly perfuse (cool and blue or blanched), radial pulse absent

Which nerve innervates the same aspect of the dorsum of the hand?

radial nerve

Which nerve? - palpate webbing space btwn thumb and index finger, including DORSAL surface of hand

radial nerve

which nerve? - ability to extend wrist and fingers at knuckle joint - if cast is over hand only assess extension of fingers

radial nerve

A 30-year-old man presents to the emergency department by ambulance with report of bilateral lower extremity pain. The patient states he woke up this morning to the sound of the fire-alarm and when he went to open his bedroom door the handle was too hot to touch, and smoke was beginning to pour in from beneath the door. He reports having no other way out to escape as the fire began to burn through the door, so he jumped from his secondary story window. He denies head injury or loss of consciousness and has no other complaints. On exam there is diffuse swelling and ecchymosis to both feet and ankles with tenderness throughout. AROM is severely limited with inability to dorsiflex bilaterally; Thompson test is positive bilaterally. There is decreased sensation to pinprick along the right posterolateral foot. Posterior tibial pulses and dorsalis pedis pulses are 2+ bilaterally; capillary refill < 2 seconds bilaterally. 1. What is your most likely diagnosis(at this point)? 2. What is your next step? Be specific. 3. Which immobilization technique would be indicated for these injuries? a.Admission, no immobilization as this may worsen neurovascular injury b.Bilateral long leg post molds in resting equinus position (partial plantar flexion) to allow the injured area to heal without tension c.Bilateral long leg post molds with 90° dorsiflexion to promote healing with proper alignment 5. Do you need anything else to complete the management of this patient?

sural nerve injury (formed by terminal branches of tibial and common peroneal nerves that join together in the superficial aspect of the distal third of the leg). Note that the sural nerve is sensory only which represents the decreased sensation to the lateral aspect of the foot. This patient's inability to dorsiflex is likely related to pain from the fracture and Achilles's tendon injury as this is innervated by the sciatic Nerve, Common Peroneal Nerve, Deep Peroneal Nerve 4. B 5. analgesics, stabilize with post molds, update tetanus as needed, broad spectrum antibiotics for open fracture on the right, call ortho and admit to prepare for surgery

Which nerve? palpate btwn little finger and distal ring finger on palmar and dorsal surface of hand

ulnar nerve

which nerve? - ability to abduct all fingers

ulnar nerve

Flexor pollicis brevis muscle receives most of its innervation from what nerve?

ulnar nerve --> flex thumb at MCP joint

inability to abduct or adduct fingers

ulnar nerve neurapraxia

The mother of a 16-year-old girl calls you when you are on call on a Saturday afternoon. The mother states that her daughter was stung by a wasp about 2 hours ago on her left arm. The patient has no known his- tory of previous allergic reactions to insect bites or stings. She is having no difficulty breathing or swallowing, nor has she been dizzy or light- headed. The mother's primary concern is that the area of the sting is red and swollen. The daughter says that it hurts and itches. She says that the site of the injury was the midpoint of the forearm and there is now red- ness and swelling extending in a circular pattern that is about 3 in across. The red area is hot to the touch, so the mother is concerned that it is infected. She gave her daughter some ibuprofen for the pain and would like you to phone in some antibiotic and something to prevent the reaction from spreading. 1. Which antibiotic should you prescribe to treat this condition? 2. What other treatments might be beneficial at this point?

wasp sting 1. none, infection takes time to develop. You have to explain to her that this is a local inflammatory reaction 2. Remove the stinger immediately --> #1 and wash site (decontamination) Other therapy that may be beneficial: Local applications of ice, nons- teroidal anti-inflammatory drug (NSAID) or acetaminophen for pain, and antihistamine for itching. What if the patient is wheezing? What if they say my throat is tight? ?Hypotensive Do we need to monitor the patient? Most reactions develop in the first 15 mins nearly all occur within the first 6hrs In general the shorter the interval between sting and onset of symptoms the more severe the reaction. Fatalities tend to occur within first hour.

Arterial injury

•Risk of *brachial artery injury* -dissection or thrombosis •Document radial pulse •Document capillary refill •If the extremity is disfigured, reduce to anatomical alignment immediately. •Always document pulse and refill before and after post mold placement and teach patient how to check capillary refill in case swelling worsens and vascular supply becomes compromised.