_OHFP.indb 433 _OHFP.indb 433 30/05/2014 16:18 30/05/2014 16:18 434 CHAPTER 15 Emergency department Trauma Worrying features shock, tachypnoea, dGCS, signifi cant mechanism.1 Think about emergency severe trauma (b p232); common head injury, neck injury, concealed bl eeding, fractures, dislocations, sprains, strains, bruises, incisional wounds, lacerations, abrasions, foreign bodies. Ask about location at time of injury, activity prior to injury, cause/mecha- nism/direction of injury, ability to walk/move immediately after and now, exa cerbating/relieving actions, pain, associated symptoms, time of last meal; PMH all medical problems, clotting abnormalities, kidney problems, GI problems, surgery, admissions, psychi atric problems; DH tetanus status, allergies; SH occupation, dominant hand, normal mobility , help at home. Important questions to help assess RTAs Collision speed (both vehicles combined)? Wearing s eatbelt? Airbags deployed? Position front/back)? Injuries/fatalities of other vehicle occup ants? Patient trapped in car? What stopped the car? Was the car written off ? in car (driver/passenger side, Obs HR, BP, RR, GCS, blood glucose, temp. Look for (see b pp146 \200\223152 for specifi c j oint examinations); resting position, bruising, swelling, deformity, skin changes, active r ange of movement, tenderness (bony vs. soft tissue), passive range of move- ment, stability of joint, ability to use joint eg walking, always check: \200 Joints directly above and below the site of injury \200 Distal sensation/circulation (pulse, capillary refi ll) of aff ected limbs. Investigations X-ray if fracture/dislocation is possible or to exclude ) a radio-opaque foreign body (eg some glass, metal). g y ( g g Consequences of trauma covered elsewhere b p440 b p460 b p436 b p438 Wounds Head injury Neck injury Epistaxis Treatment Analgesia (b p86) should be given prior to examination and investigation to allow time for the drugs to act. The following injuries need senior review or referral: \200 W ounds with involvement of deep structures, eg tendons \200 Wounds in cosmetically sensiti ve areas, eg face \200 Wounds in functionally sensitive areas, eg hands, genitals \200 Wounds with loss of skin tissue \200 Displaced fractures \200 Unstable fractures \200 Open fractures \200 Fractures with skin tenting or associated dislocation \200 Disloca tion of major joints (ie hip, knee, ankle, shoulder, elbow) \200 Injuries with neurovascu lar compromise. 1 eg fall from >1m or 5 stairs; axial load to head \200\223 eg diving; hig h-speed motor vehicle collision; rollover motor accident; ejection from a motor vehicle; accident involving motorized recrea tional vehicles; bicycle collision. OHFP.indb 434 OHFP.indb 434 30/05/2014 16:18 30/05/2014 16:18 435 TRAUMA Soft tissue injuries (sprains, strains) A sprain is minor damage to a ligament while a stra in is caused by minor damage to a muscle. Both are managed the same way: \200 Rest initia lly, but weight-bear or exercise as soon as symptoms allow \200 Ice to reduce swelling ov er the fi rst 48h; keep the ice away from the skin (eg use a tea towel) and apply for 10 \200\22315min at a time Elevation reduces both swelling and pain. Prescribe adequate analgesia (eg paracetamol 1g/6 h PO and ibuprofen 400mg/6h PO) and give reassurance. Compression is not routinely recommen ded as it can delay regaining full mobility. Natural history symptoms often worsen over 24 \200\22348h then start to improve; they may t ake up to 6wk to resolve completely. Most heal completely, otherwise physiotherapy strength ening exercises can help. Dislocations \200 Provide adequate analgesia \200 Document defi cits in distal circulat ion and sensation and at-risk nerves \200 X-ray before and after reduction (except ankle dislocation which should be reduced urgently, with senior supervision) Recheck and document any defi cits in distal circulation and sensation and at-risk nerves. Appropriately immobilize/strap. Discharge with analgesia and orthopedic follow-up if necessary. Natural history symptoms im prove dramatically with reduction though some discomfort may be present for days/weeks. Fur ther dislocation is common and may need physiotherapy or surgical treatment. Fractures Types hairline very small fracture, no bony displacement; simple 2 bone sections; comminuted \211 3 bone sections; open/compound break in skin overlying a fracture. You should suspect a fracture if there is a history of high forces, bony tenderness, swelli ng or reduced range of movement (ROM). Treatment \200 Analgesia only eg single rib or coccyx fractures, these do not need imaging unless a complication is suspected (eg pneumothorax) Immobilization (eg backslab, sling) analgesia, fracture clinic follow-up for fractures that do not need an urgent orthopedic review Orthopedic referral if unstable, compound (open) or neurovascular compromise. Natural history pain worst after the injury with little improvement by day 3 \200\2235. Sim ple fractures should heal over 6wk with minimal complications; serious fractures may reduce range of movement permanently. 3Open/compound fractures resuscitate (b p472). Seek immedia te senior help, especially if distal sensation/circulation impaired or coexisting dislocati on. Give analgesia (eg IV morphine), take a digital/polaroid photo, cover the wound with io dine/saline-soaked swabs, start IV antibiotics (eg co-amoxiclav 1.2g/8h IV), review tetanus status, X-ray; refer urgently to orthopedics. _OHFP.indb 435 _OHFP.indb 435 30/05/2014 16:18 30/05/2014 16:18 436 CHAPTER 15 Emergency department Wounds Ask about mechanism of injury, paying particular attention to bites (animal or human ), foreign bodies (eg metal/broken glass), contamination with soil or manure and when the w ound occurred. Always ask about and document tetanus status. Look for record the site, size (measure) and type of the wound (see Table 15.1), check distal sensation, pulse/cap refi l l and movement, look and feel inside the wound (usually with local anesthetic) to assess de pth, pres- ence of foreign bodies and involvement of deep structures (eg tendons). Table 15.1 Types of wound Puncture Incisional wound Deep wound with a small skin defect, eg cat bite, nail Wound caused by sharp objects, eg kn ife/broken glass, often have straight edges and can be deep Wound following blunt trauma, e g banging head on sidewalk, edges are often ragged and bruised Graze Wound that fully penet rates the skin (epidermis and dermis) so that subcutaneous fat is visible Wound that does n ot fully penetrate the skin Laceration Abrasion Full thickness Superfi cial Cleaning all wounds should be thoroughly cleaned with sterile water or 0.9% saline. Abrasio ns may need to be scrubbed and deeper wounds may need cleaning with high-pressure 0.9% sali ne (use a syringe and green needle hub with the needle broken off ). Cleaning can be done a fter local anesthetic infi ltration. Important rules \200 X-ray all wounds involving brok en glass or metal foreign bodies \200 Wounds should not be closed if: \200 older than 1 2h (unless facial) \200 very dirty or infected foreign bodies present \200 bites Refer wounds that involve tendons or joints (to orthopedics), arteries (to vascular surgeons) or nerves (to orthopedics or plastics). Primary closure is closing the wound in ED; several options are available: \200 Glue for faces, children and small wounds (<2cm) if the edges are not gaping. The glue should just h old the edges together, not enter the wound. Be very careful not to get the glue in the eye Steristrips \204 for small wounds, especially pretibial or facial lacerations \200 Sutur es (b p560) for wounds which are large, deep or over joints. Simple, interrupted stitches o f non-absorbable suture are used for the vast majority. A layered closure with absorbable s utures may be required if the wound is especially deep; seek senior help. Delayed primary closure the wound is left open for 3 \200\2235d then reviewed and closed if no infection is evident. Secondary closure allowing the wound to heal without intervention . Tetanus status should be documented for all wounds. Ensure adequate prevention (eg wound irrigation) and remember that patients over 50yr and immigrants may have received no previo us tetanus vaccinations. OHFP.indb 436 OHFP.indb 436 30/05/2014 16:18 30/05/2014 16:18 437 TRAUMA Table 15.2 Tetanus prophylaxis Immunization status Full course (5 injections) or booster <1 0yr ago Partial course and booster \211 10yr ago Not immunized or unknown Start tetanus co urse Start tetanus course and give Tetanus-prone wound1 HATI2 only if contaminated with manure Tetanus booster and HATI2 Clean wound No prophylaxis needed Tetanus booster HATI2 1 Tetanus-prone wounds: Heavy contamination especially with soil or manure (remember gardeners) \200 \200 Punct ure wounds (eg cat bites, nails) \200 Devitalised tissue. Infection or wounds >6h old 2 Human anti-tetanus immunoglobulin. Antibiotics (check local guidelines) eg fl ucloxacillin 1g/6h PO for 5d for puncture wounds , and wounds involving bones (eg crushed fi ngertips). Co-amoxiclav 625mg/8h PO for 5d for heavily contaminated wounds (consider leaving these wounds open). Antibiotics are no substi tute for thorough wound irrigation/washout. Animal/human bites treat with eg co-amoxiclav 6 25mg/8h PO for 5d. Assaults the notes you make may be used in a legal case many years from now so think carefully about what you write. For example: \200 Distinguish facts from hea rsay; make it clear where information came from, eg \200\230Patient alleges assaulted with an iron bar \200\231 Document injuries accurately including location, size (measure) and type of wound (see Tabl e 15.1); use simple line diagrams. Do not interpret what potentially caused the wound. Write your notes imagining them being read out in public by someone wishing to make you appear stupid. Osteoporosis (OHGP3 b p516) The ED is a common place of presentation for elderly fallers; o ften there may be no signifi cant injury sustained, but the patient may not be so fortunate next time. The 1yr mortality after a fractured neck of femur is 30%, so never miss an oppo rtunity to think about prevention of falls (b p443) and osteoporosis. Risk factors include early meno- pause, iage, 5 sex, dBMI (especially previous eating disorder), family history, steroid usage, alcohol excess and malabsorption disorders. Management in all: smoking cess ation, regular weight-bearing exercise, falls reduction measures (b p443), Ca2+ and vitamin D supplements (eg 2 tabs/24h PO). Further treatment with a bisphosphonate (eg Adcal-D3 alendronic acid 70mg/weekly PO) or strontium ranelate (2nd line) should be based upon estim ated 10yr fracture risk. The WHO have developed the FRAX tool for this purpose, available o nline at (cid:27)www.shef.ac.uk/ FRAX Although bone mineral density can be formally assesse d by DEXA scanning, the FRAX tool does not absolutely require this value. FRAX results are linked to guidance developed by the UK National Osteoporosis Guidance Group (NOGG) on wheth er to initiate treatment, give lifestyle advice, or request DEXA. _OHFP.indb 437 _OHFP.indb 437 30/05/2014 16:18 30/05/2014 16:18 438 CHAPTER 15 Emergency department Head injury Worrying features dGCS, vomiting, seizures, basal skull fracture, amnesia. Think about emergency unconscious, iICP, extradural haematoma, subdural haematoma; common c oncussion. Ask about mechanism of injury, time of injury, loss of consciousness, seizures, memory (before, during and after), blood/fl uid from nose or ears, vomiting, weakness/tingl ing/numbness in limbs, time of last meal, dizziness, visual changes, headache; PMH clotting abnormalities, all previous medical, surgical or psychiatric problems; DH anticoagulants, tetanus status; SH occupation, normal mobility, help at home. Obs GCS, HR, BP, RR, glucose. Look for GCS (b p340), orientation, CSF leaking from ears (otorrhoea) or nose (rhinorrhoea ), Battle \200\231s sign (bruising over the mastoid processes, a late sign), blood behind e ardrum (haemotympanum), \200\230panda \200\231 eyes, (bruising around the eyes), focal neu rology (eg weakness or numbness); if head injury caused by fall think about what precipitat ed the fall (?dysrhythmia, hypoglycaemia, postural hypotension; see b p443). Investigations CT if indicated (Fig. 15.1). Treatment \200\223 involve a senior when dealing with any he ad injury 3Unconscious bleep an anesthetist immediately and see b p338. CT head according t o the CT criteria (Fig. 15.1) admission. Criteria for admission: \200 New, clinically signifi cant abnormalities on imaging \200 Not returned to GCS 15 after imaging, regardle ss of the imaging results \200 Criteria for CT scanning fulfi lled, but scan not done, ei ther because CT not available or because patient not suffi ciently co-operative/ stable to allow scanning Continuing worrying signs (eg persistent vomiting, severe headaches) \200 Other sources o f concern (eg drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fl uid leak). Subdural haematoma Venous bleed into the skull; can be acute (dGCS and iICP, usually post- trauma) or chronic (fl uctuating conscious level over days in eg elderly, alcoholics, patie nts on anticoagulation). Management CT diagnosis; drained by craniotomy or burr hole. Extradural haematoma Arterial bleed into skull often from middle meningeal artery after tra uma. Symptoms/signs initially well but dGCS over 4 \200\2238h as blood collects. Management CT diagnosis; drained by craniotomy or burr hole. Post-concussion syndrome Patients may have concussion symptoms for months after a head inju ry, eg headaches, dizziness, tiredness, depression, memory problems. OHFP.indb 438 OHFP.indb 438 30/05/2014 16:18 30/05/2014 16:18 439 HEAD INJURY Adults presenting to the emergency department who have sustained a head injury Are any of the following risk factors present? GCS <13 on initial assessment (cid:129) GCS <15 at 2 hours after injury on assessment in the emergency department (cid:129) Suspected open or depressed skull fracture (cid:129) Any sign of basal skull frac ture (cid:129) Post-traumatic seizure (cid:129) Focal neurological deficit (cid:129) More t han one episode of vomiting since the head injury Yes No Perform CT head scan within 1h of risk factor being identified Current warfarin treatment? Yes No A provisional written radiology report should be made available within 1h of the CT taking place Is there loss of consciousness or amnesia since the head injury? Yes No Perform CT head scan within 8h of the head injury No imaging required/further imaging required Are any of the following risk factors present? (cid:129) Age \211 65 years (cid:129) A history of bleeding or clotting disorder (cid:129) Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall fr om height of >1m or 5 stairs) (cid:129) More than 30 minutes \200\231 retrograde amnesia of events immediately before the head injury Yes No Fig. 15.1 NICE head injury guidance; Selection of adults for CT scanning of head. National Clinical Guideline Center (2014) Head Injury: Triage, assessment, investigation and early m anagement of head injury in children, young people and adults. Clinical Guideline 176 (Part ial update of NICE CG56). Copyright NCGC. Reproduced by permission. NICE guidance availa ble at (cid:27)guidance.nice.org.uk/CG176 _OHFP.indb 439 _OHFP.indb 439 30/05/2014 16:18 30/05/2014 16:18 440 CHAPTER 15 Emergency department Neck injury Worrying features dGCS, large forces, multiple injuries, focal neurology. Think about emergency C-spine injury; common whiplash. Ask about mechanism of injury, walking since the accident, comfort sitting up, neck pain, t ime of neck pain onset, head injury, weakness or tingling of limbs, time of last meal; PMH asthma, previous medical or surgical problems; DH tetanus status; SH occupation. Obs GCS, HR, BP, RR, glucose. Look for midline vs. paravertebral neck tenderness, steps, deformity, look for limb weaknes s, loss of sensation, other injuries; 3 only examine neck movements if safe to do so. This requires the absence of a dangerous mechanism of injury and the presence of an indicator of low risk (see Fig. 15.2). If you are in any doubt, seek senior advice. Only if safe, test the patient s ability to turn their neck 45 each way. Investigations C-spine X-ray or CT neck if indicated (see Fig. 15.2); see b p594 for interp retation of C-spine X-ray. Treatment \200\223 3consult a senior when dealing with neck inj uries \200 Abnormal X-rays/CT leave the patient \200\231s neck immobilized, refer for urg ent assessment, treat other injuries, monitor patient \200\231s neuro obs \200 Normal X-r ays/CT do not exclude ligamentous injury; consult senior and aim to examine neck and clear it clinically No X-rays/CT if imaging is not required according to the algorithm in Fig. 15.2, consult se nior and aim to examine neck and clear it clinically. Neck sprain (if severe called \200\230whiplash \200\231) \200 Symptoms/signs gradual ons et pain and stiff ness not usually present immediately after injury; tender over neck parav ertebral >midline Diagnosis normal imaging (if performed) \200 Treatment advise that symptoms are likely to worsen before improving, give paracetamol and regular NSAIDs, heat/ice may help, soft collars are not use d, initial rest ( \211 48h) then gradual return to normal activity. OHFP.indb 440 OHFP.indb 440 30/05/2014 16:18 30/05/2014 16:18 441 NECK INJURY Adults presenting to the emergency department who have sustained a head injury Are any of the following risk factors present? (cid:129) GCS < 13 on initial assessment (cid:129) Intubation (cid:129) A definitive diagno sis of cervical spine injury is required urgently (e.g. before surgery) (cid:129) Other bod y areas are being scanned for head injury or multi-region trauma (cid:129) The patient is a lert and stable, there is a suspicion of cervical spine injury and any of the following are present: age >65; dangerous mechanism of injury (fall >1m or 5 stairs, axial load to head [e.g.diving], high speed motor vehicle collision, roll over motor accident, ejection from a motor vehicle, accident involving motorized recreational vehicles, bicycle collision); foc al peripheral neurological deficitor paraethesia in the upper or lower limbs Yes No Perform CT cervical spine within 1h of risk factor being identified Is there suspicion of cervical spine injury (neck pain or tenderness) with any of the follo wing low risk factors present, which indicate it is safe to assess the range of movement of the neck?1 A provisional written radiology report should be made available within 1h of the CT taking place (cid:129) Involved in a simple rear-end motor vehicle collision (cid:129) Is comfortable in a sitting position in the emergency department (cid:129) Has been ambulatory at any time s ince injury (cid:129) Absence of midline cervical tenderness (cid:129) Presents with delaye d onset of neck pain No Yes Perform three-view cervical spine X-rays within 1h of risk factor being identified On assessment can the patient actively rotate the neck to 45 to the left and right? Are the three-view cervical spine X-rays technically inadequate, suspicious or definitely a bnormal? No Yes No imaging/further imaging required Yes No Fig. 15.2 NICE neck injury guidance; Selection of adults and children (age 10+) for imaging of the cervical spine. National Clinical Guideline Center (2014) Head Injury: Triage, asse ssment, investigation and early management of head injury in children, young people and adu lts. Clinical Guideline 176 (Partial update of NICE CG56). Copyright NCGC. Reproduced by permission. NICE guidance available at (cid:27)guidance.nice.org.uk/CG176 1 i.e. in the ab sence of at least one of these indicators of low risk , the cervical spine should be cons idered potentially unstable and it is not safe to move the neck \200\223 proceed to three- view imaging within 1h. Children under 10 years Separate guidelines exist for use in children \200\223 see (cid:27 )guidance.nice.org.uk/ CG176 _OHFP.indb 441 _OHFP.indb 441 30/05/2014 16:18 30/05/2014 16:18 442 CHAPTER 15 Emergency department Falls and collapsep Worrying features idHR, dBP, chest pain, palpitations, head injury, los s of consciousness, recurrent vomiting, incomplete recovery, focal neurology, long time spe nt on hard surface, hypothermia. Think about serious MI, dysrhythmias, shock, sepsis, CVA, seizure, hypoglycaemia, hypoxia, PE; common postural hypotension, mechanical fall (see box), syncope (vasovagal, situational , cardiac; Table 15.3), ataxia. Ask about symptoms and activity before falling (aura, dizzi ness, chest pain, palpitations), speed of onset, visual changes, loss of consciousness (can you remember: falling, being on the fl oor, getting up?), inconti- nence, recovery, head i njury, other injuries, mechanism of injury, length of time spent immobile; PMH previous fal ls (and investigations), heart problems, DM, Parkinsonism; DH anticoagulants, antihypertens ives, antiepileptics, hypoglycaemics, diuretics, nitrates; SH usual mobility and aids, abil ity to eat and drink independently, alcohol. Obs temp, HR, lying and standing BP, glucose, GCS, sats, RR. Look for pulse volume, HR and regularity, carotid bruit, volume status (b p3 80), heart murmurs (aortic stenosis), focal neurology, ability to stand, ability to walk, b ruising, lacerations or haematomas on the head or body, movement of all limbs, sites of ten derness. Investigations consider ECG dysrhythmia or MI ( cardiac monitor); blds FBC, U+E, CRP, cardiac markers (repeat at 12h); investigate for injuries as appropriate: CT if focal neurology, persistent dGCS or post- head injury (b p438); X-ray if clinical suspicion of a fracture. Table 15.3 Common causes of syncope History Examination Investigations Vasovagal syncope (b p260) Cardiac syncope (b p250 \200\223261) Onset in seconds, precipitated by fear, stress, pain or standing Sudden onset and recovery, chest pain, palpitations, SOB Postural drop, otherwise normal Fast, slow, irregular or absent pulse Normal Dysrhythmia or MI on ECG, pauses on 24h Holter monitor, icardiac markers CVA or intracran ial hemorrhage on CT; check glucose Initial investigations often normal, check glucose Neurological (b p340) Rapid onset, headache, dGCS, weakness, altered sensation Aura, poor recall, limb movement s, tongue biting, post-ictal confusion/drowsiness, incontinence Focal neurology, persistent dGCS, ataxia Drowsy, injuries, Todd \200\231s paresis Seizure (b p346) Treatment 15l/min O2 and lie fl at initially. Exclude serious conditions (HR, ECG, BP, gluc ose) and establish IV access. Treat according to diagnosis. OHFP.indb 442 OHFP.indb 442 30/05/2014 16:18 30/05/2014 16:18 443 FALLS AND COLLAPSE Please review this patient who has fallen \200 Foundation doctors will frequently be asked to assess patients who have fallen, usually as you near the end of a long night shift. Try to safely but speedily exclude serious causes o f falls (b p442) and post-fall injuries (particularly head and hip). Ask the nurse for a fu ll set of obs including blood glucose postural BP. Establish circumstances of fall and th e patient \200\231s symptoms, specifi cally chest pain, palpitations, head injury, loss of consciousness, vomiting and confusion. Examination A brief cardiovascular and neurological examination is essential. Look over the head for signs of injury, feel for midline C-spine tenderness and check for reduced movement or pain in the shoulders, elbows, wrists, hips, k nees and ankles. Investigations Have a low threshold for an ECG. See b p434 for management of trauma and b p438 for head injury. Other investigations as indicated. Review If any susp icion of head injury, ask the nurses to record hourly neuro obs for eg 4h and bleep you aga in if dGCS or concerned. Document your fi ndings as above; ask nurses to fi ll out an incid ent form (b p32) Some precipitants of falls to consider b p346 b p353 b p340 b p438 b p474 b p363 b p323 b p483 b p241 b p250 b p258 b p271 b p363 Seizures Focal neurology GCS + confusion Head injuries Postural drop Vertigo Hypoglycaemia Sepsis Chest pain Tachyarrhythmias Bradyarrhythmias Hypoxia Ataxia Situational syncope Similar to vasovagal syncope (b p260), but brought on by a specifi c ac tion: Micturition middle-aged/elderly men; advise to sit down to urinate. Carotid sensitivi ty can be brought on by shaving. Cough brought on by coughing fi ts. The elderly, recurrent falls and the \200\230mechanical \200\231 label1 We all trip over t hings from time to time, but it \200\231s a pretty rare occurrence, so think again before y ou ascribe the lazy label of \200\230mechanical \200\231 fall to the elderly lady lying on the trolley in front of you. Age, dementia, and other processes of nature may well be irre versible, but the challenge is to identify and deal with the reversible, before the next fa ll leads to a fractured femur and inexorable decline. Consider delirium (b p341), periphera l neuropathy (b p355), untreated Parkinsonism (b p349), poorly controlled arthritis (b p454 ), cerebellar disease/ataxia (b p363). dVitamin D is common in the elderly and leads to dmu scle tone and bone frailty \200\223 check plasma levels 2 tabs/24h PO). Is there and co nsider oral supplementation (eg Adcal-D3 a history of alcohol excess? Are diuretics and urg e incontinence forcing the patient to rush for a bathroom (b p377)? Does the patient have a nd correctly use appropriate walking aids (sticks, frames) and is the home envi- ronment sa fe (liaise with OT)? Has poor vision been assessed and corrected as much as possible (bi/va rifocal lenses are associated with ifalls risk)? Even if you are still unable to identify a nything reversible, always assess for osteoporosis and consider treatment (b p437). 1. NICE guidelines available at (cid:27)guidance.nice.org.uk/CG161 _OHFP.indb 443 _OHFP.indb 443 30/05/2014 16:18 30/05/2014 16:18 444 CHAPTER 15 Emergency department y Acutely painful limb emergency y p g Check airway is patent; consider maneuvers/adjuncts If no respiratory eff ort \200\223 CAL L ARREST TEAM If no palpable pulse \200\223 CALL ARREST TEAM Airway Breathing Circulation 3Call for senior help early if patient deteriorating. \200 Sit patient up, unless pain wi ll not allow \200 15l/min O2 if ischaemia suspected \200 Monitor O2 sats, HR, BP, temp: is the patient shocked or febrile? Brief history/check notes/ask ward staff : arterial/cardiac problems or DM \200 recent trauma/surgery Examine patient: condensed RS, CVS and abdo exam \200 Examine all limbs: vascular, neuro and joint exams: \200 is the pain localized to a joint or specifi c area? \200 check di stal sensation, pulses and cap refi ll (ischaemia?) Venous access, take bloods: FBC, ESR, U+E, CRP, cardiac markers, sickle-cell, D-dimer, clotting, G+S Check pulses with Doppler if available \200 ECG to exclude acute MI, AF \200 ABG if sys temically unwell \200 Analgesia, eg IV morphine titrated to pain \200 Consider serious causes and treat if present: acute ischaemia 15l/min O2, analgesia, heparin, (vascular) surgeons compartment syndrome 15l/min O2, remove plaster, orthopedics, consider fasciotomy septic arthritis 15l/min O2, joint aspiration, orthopedics \200 necrotising fasciitis 15l /min O2, fl uids, IV antibiotics, surgeons \200 gangrene 15l/min O2, fl uids, IV antibiot ics, surgeons Call for senior help \200 Reassess, starting with A, B, C \200 Life- and limb-threatening causes b p446 b p447 Necrotising fasciitis b p455 b p413 b p447 b p397 Acute ischaemia Compartment syndrome Myocardial infarction (arm) b p244 Gangrene Spinal cor d compression Septic arthritis b p357 Sickle-cell crisis OHFP.indb 444 OHFP.indb 444 30/05/2014 16:18 30/05/2014 16:18 445 ACUTE LIMB PAIN Acute limb painp Worrying features sudden onset, severe pain, dsensation, dpower, absent di stal pulses, cold to touch; shock, pyrexia, recent surgery/trauma. Think about serious acute ischaemia, septic arthritis, compartment syndrome, gangrene, necr otising fasciitis; common muscular, joint or bone pain, DVT, cellulitis, thrombophlebitis, sciatica; other osteomyelitis, Baker \200\231s cyst, vasculitides, myositis, peripheral neu ropathy. See Table 15.4. Ask about location, trauma, speed of onset, change on moving and r aising, back pain, chest pain, SOB; PMH recent surgery, previous limb pain, DM, MI, CVA, DV T, PE; DH anticoagulants; SH exercise tolerance. Obs temp, BP, HR, O2 sats, RR. Look for va scular assessment color, mottling, hot/cold, cap refi ll, pulses (compare both sides); neur ological assessment power, sensation, refl exes; orthopedic assessment evidence of trauma, swelling (distal, joint, calf), range of movement (active and passive), muscle, joint or bo ne tenderness (see b p146 \200\223152 for specifi c joint examinations); respiratory assess ment if SOB or suspect DVT. Investigations most limb pain can be diagnosed from clinical ex amination; consider the following investigations: blds FBC, U+E, ESR, CRP, D-dimer, venous lactate, blood cultures; Doppler for pulses (?ischaemia); ECG for AF; X-rays for joint dise ase or bone fractures; ABG if hypoxic and suspicion of PE/DVT. Management ensure adequate a nalgesia (b p86). Try to determine what structure is causing the pain (eg skin, muscle, joi nt, bone); if there is no obvious structure consider arterial problems, infection or DVT. S uper \201 cial thrombophlebitis Infl ammation and thrombosis of a vein, which can progress to DVT. Symptoms gradual onset of tenderness over a vein. Signs red, tender area with hard palpable vein/varicosity. Risk factors IV cannula, varicose veins, IVDU, DVT risk factors (b p450). Investigations no specifi c investigations but have a low threshold for blood and Doppler studies to exclude underlying DVT. Treatment resite/remove IV cannula, elevation, exercise, compression, NSAIDs (eg ibuprofen 200 \200\223400mg/6h PO); if DVT suspicion, sta rt LMWH. Complications Post-phlebitic pain; if thrombophlebitis recurs or aff ects other si tes (migratory) suspect malignancy or vasculitis. Muscle pain Causes trauma, strains, fi br omyalgia, infection, rhabdomyolysis, drugs (statins, ACEi, steroids), infl ammation (polymy algia rheumatica, poly- myositis, dermatomyositis, SLE), metabolic (dCa2+, dK+, dNa+, alkal osis), endocrine (hypo/hyperthyroid, Cushing \200\231s), referred joint pain. Investigation s often none; FBC, U+E, Ca2+, CK, ESR, CRP, X-ray. Treatment simple analgesia including NSA IDs, rest for fi rst 24h then gradually exercise the joint, ice packs, and elevation. Consi der physiotherapy referral if persists. _OHFP.indb 445 _OHFP.indb 445 30/05/2014 16:18 30/05/2014 16:18 446 CHAPTER 15 Emergency department Table 15.4 Common causes of limb pain History Examination Investigations Doppler pulse d or absent; obstruction on angiography iWCC, iCRP, iESR, ofte n iD-dimer Acute ischaemia Rapid onset, distal >proximal, painful (worse with legs raised) Pulseless, cap refi ll >2s, pale, cold, weak, reduced sensation Infection (eg cellulitis) Gradual onset, feels unwell, history of trauma or bite Pyrexia; red, tender, warm, swollen iD-dimer; thrombosis on Doppler USS DVT Gradual onset, painful (improved with legs raised) Red, swollen, hot, tender leg Compartment syndrome Recent trauma or surgery POP Severe pain on passive movement Increased compartment pressure Joint Trauma, pain on movement, unable to bear load Tender over joint, joint eff usion, pain on movement (active = passive) Abnormal X-ray (eg arthritic changes); abnormal synovial fl uid Muscle Trauma, pain on movement Tender swelling on muscle/tendon insertion, pain on movement (active >passive) Normal X-rays, may have a iCK Bone Trauma, pain on movement and at rest Bony tenderness with swelling and reduced range of movement Abnormal X-ray Cause of limb pain covered elsewhere b p424 b p356 b p412 b p448 b p450 b p441 b p452 b p411 \200\223419 b p413 b p434 Ulcers Back pain/sciatica Cellulitis Chronic limb pain DVT Swelling Joint pain Rashes Necrotising fasciitis Trauma 3Acute limb ischaemia This is an emergency; ischaemia is irreversible after 6h. Worrying si gns dsensation; purple, non-blanching mottling. Causes emboli, thrombosis, dissecting aneur ysm, trauma. Risk factors arterial graft, peripheral vascular disease, previous thrombo- em boli, AF, prosthetic heart valves, recent MI, dehydration, malignancy. Symptoms unilateral painful, tingling, weak limb, worse on raising limb. Signs absent pulses, slow cap refi ll (compare with opposite limb), cold and pale (can be red if limb below heart), reduced power and sensation. Investigations a hand-held Doppler probe will show a reduced or absent puls e; angiography may demonstrate an obstruction. Treatment this needs urgent surgery \200 \223 call a senior surgeon who will consider embolectomy, intra-arterial thrombolysis, bypa ss or amputation. Give 15l/ min O2 and analgesia (eg morphine); IV access with IV fl uids i f dehydrated; may require heparinisation (b p406) pre- or post-op. Complications amputation , gangrene, iK+, renal failure, sepsis. OHFP.indb 446 OHFP.indb 446 30/05/2014 16:18 30/05/2014 16:18 447 ACUTE LIMB PAIN 3Gas (wet) gangrene This is an emergency; Clostridium infection causing necrosis and sepsis . Symptoms unwell with painful extremities or wound. Signs pyrexia, shock, tender brown/bla ck area with blistering and oedema, muscle necrosis, crepitus (from gas in tissue). Risk fa ctors ischaemia, DM, malignancy, surgery/trauma. Investigations blds FBC, U+E, LFT, CRP, CK , blood cultures, clotting; ABG acidosis; Gram stain of pus or necrotic tissue; X-ray may s how gas (dark patches in soft tissues). Treatment call a senior surgeon who will consider u rgent debridement. Give 15l/min O2, fl uids and broad-spectrum antibiotics (eg benzylpenici llin 2.4g/4h IV, clindamycin 600mg/6h IV, and metronidazole 500mg/8h IV). Complications amp utation, sepsis, death. Dry gangrene Ischaemic muscle necrosis without infection. Signs wel l-defi ned, painless, shriveled brown/black area. Treatment debridement or amputation may h elp prevent infection; alternatively conservative management awaiting autoamputation. Compl ications wet gangrene. 3Compartment syndrome This is an emergency; call a senior surgeon if suspected. Symptoms excessive pain following an injury or fracture, distal tingling, numbn ess or weakness. Signs pain at rest, worse on passive stretching of a muscle, reduced sensa tion (loss of two point discrimination), redness, swelling, slow cap refi ll; absent pulse and pallor are late signs. Risk factors long bone fractures and plaster casts, signifi cant injury, crush injury, vascular injury, anticoagulants, burns. Investigations clinical diag nosis; blds FBC, U+E, CK, clotting; it is possible to measure compartment pressure by inser ting a manometer through the skin (eg Wick catheter), pressures >30mmHg indicate need for u rgent fasciotomy, although some surgeons advocate avoiding intervention if compartment pres sure is 20mmHg of diastolic pressure. Treatment 15l/min O2; elevate limb (lie the patient fl at); ensure adequate analgesia; IV fl uids if dehydrated (monitor urine output); remove plaster cast if present; discuss with surgeons regarding urgent fasciotomy. Complications rhabdomyolysis, iK+, neurological damage, amputation. Osteomyelitis Risk factors DM, immuno compromise, open fractures, prostheses. Symptoms fever, bone pain, malaise (or fever withou t focus). Signs bony tenderness, warm, red, swollen. Investigations blds iWCC, iESR, iCRP, blood cultures; imaging X-ray (insensitive since there are rarely changes in the fi rst 10d ), USS (may show periosteal lifting), MRI (gold standard); bone biopsy where indicated. Cul ture try to obtain a sample for microbiology prior to starting antibiotics (by swabs, USS-g uided aspiration or bone biopsy in theater). Treatment high-dose antibiotics (discuss with microbiology) for at least 6wk; often requires central access; surgical drainage of abscess if present. Complications septic arthritis, fracture, amputation, seeding to other sites. _OHFP.indb 447 _OHFP.indb 447 30/05/2014 16:18 30/05/2014 16:18 448 CHAPTER 15 Emergency department Chronic limb pain Peripheral arterial disease (PAD) Chronic limb ischaemia causes intermittent claudication/c ritical ischaemia. \200 Intermittent claudication cramp in calf, thigh or buttock on walk ing a fi xed distance, worse uphill, relieved by stopping or rest Critical ischaemia pain in limb at night, relieved by hanging legs out of bed; arterial ulcers, dry gangrene. Signs early cool, hairless, pulseless limbs; late pain and pallor on elevation. Investigati ons blds FBC, U+E, lipids, ESR; ECG; ABPI (ankle brachial pressure index, see box); imaging CT or Doppler arteriography. Treatment address vascular risk factors (exercise, stop smoki ng, treat DM, iBP and icholesterol); aspirin 75mg/24h PO, avoid B-blockers; refer to vascul ar team for consideration of angioplasty or bypass graft. g Complications acute ischaemia, gangrene, rest pain, ulcers. , g , p , p Ankle brachial pressure index (ABPI) With the patient lying fl at, a Doppler probe is used to record the systolic BP (ie lowest pressure at which the pulse is occluded) in each arm ( cuff around upper arm, probe over brachial artery) and twice in each leg (cuff around calf, probe over posterior tibial and dorsalis pedis). The result is expressed as a ratio of the highest ankle pressure for each leg, to the highest brachial pressure. Example: left ankle posterior tibial pressure of 126, dorsalis pedis pressure of 124, brach ial pressures of 138 and 142; ABPI = 126/142 = 0.89 0.8 \200\2231.3 Moderate PVD Normal 0.5 \200\2230.8 Severe PVD <0.5 Calcifi cation >1.3 Lumbar spinal stenosis Symptoms cramp in thigh or leg on walking, worse on walking downhill or standing, associated back pain. See Table 15.5. Signs pain on straight leg raise/back e xtension, often no neuro symptoms. Investigations lumbar spine X-ray and MRI spine. Treatme nt exercise, NSAIDs, steroid injections, spinal decompression. Complications cord compressi on, cauda equina syndrome (b p357). Table 15.5 Nerve entrapment syndromes Symptom Syndrome Aching of wrist and forearm, tinglin g of Carpal tunnel syndrome (median) thumb, index, middle, ring fi nger Tingling of ring and little fi ngers, forearm Weak extension of fi ngers and thumb Ulnar entrapment (wrist or elbow) Radial tunnel syndrome or posterior interosseous syndrome Meralgia paraesthetica Common peroneal compression Tingling lateral thigh Weak dorsifl exion of foot Chronic limb pain covered elsewhere b p454 b p355 b p424 b p455 Gout b p357 Sciatica/radiculopathy Analgesia in chronic pain b p86 Osteoarthritis Peripheral neuropathy Limb ulcers OHFP.indb 448 OHFP.indb 448 30/05/2014 16:18 30/05/2014 16:18 449 LIMB SWELLING Limb swellingg Worrying features weight loss, night sweats, pain, hard irregular lump, vomi ting, SOB and chest pain. Think about causes depend upon site (Table 15.6). Table 15.6 Clinical assessment of limb swelling Pitting