Educational Objective:

Identify protective responses in the emergency department to physical assault or threat with a deadly weapon.

Key Point:

Recommended responses to physical assault by a violent person include immediately summoning help, avoiding bargaining, avoiding reaching for the weapon, and assuming a protective posture.

Explanation:

Physical assault may occur despite appropriate precautions and interventions. Victims of threats of harm or physical assault can take steps to protect both themselves and others in the ED setting.

If you are physically assaulted, then immediately summon help, maintain a sideward posture, and use an arm or leg to deflect a punch or kick. If you are choked, then tuck in the chin to protect the neck and ability to breathe. If you are bitten, do not pull away but rather push toward the assailant’s mouth and hold his or her nares shut.

If you are threatened with a weapon, appear calm, adopt a nonthreatening posture, and avoid sudden movements, reaching for the weapon, bargaining, arguing, making promises, or lying. Comply with the patient's demands and attempt to establish a human connection.

Reference:

Heiner J, Moore, G. The combative and difficult patient. In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:e23-e32.

Educational Objective:

Know the treatment options for uncomplicated otitis media.

Key Point:

Antibiotic resistance to TMP/SMX is common.

Explanation:

As many as 25% of patients with otitis media are resistant to TMP/SMX. Since there are so many other effective antibiotics for treatment of acute otitis, there is no longer a rationale for the use of TMP/SMX. Amoxicillin alone is the most frequently used antibiotic. A treatment course of 5 to 7 days is recommended for adults. If no improvement is noted within 3-5 days, it is appropriate to switch to amoxicillin clavulanate or cefuroxime.

References:

Kerschner JE, Preciado D. Treatment of Otitis Media. Nelson Textbook of Pediatrics. 2016; 640: 3085-3100

Harmes KM, Blackwood, RA, et al. Oititis Media: Diagnosis and Treatment. American Family Physician. 2013; 88: 435-440

Educational Objective:

Diagnose uterine fibroids.

Key Point:

Diagnose uterine fibroids by pelvic examination and pelvic ultrasound.

Explanation:

Clinically, the physical examination will help confirm the diagnosis of uterine myomas: upon palpation, health care professionals may feel a firm, enlarged, irregular uterus. Although it may be difficult to distinguish these conditions on examination, adenomyosis, pregnancy, and an ovarian neoplasm should be included in the differential diagnosis. However, the diagnostic modality of choice is ultrasonography. Because submucous leiomyomas contribute to a loss early in pregnancy, infertility, and heavy uterine bleeding, it is essential for health care professionals to determine the relationship of the myomas to the endometrial cavity in order to counsel the patient and provide treatment planning. The lesions should be identified and characterized, including the characterization of those submucous in location, thereby distinguishing adenomyomas from leiomyomas. Hysteroscopy, vaginal ultrasonography, or, occasionally, as a filling defect on hysterosalpingography, can be used to diagnose submucosal myomas. Several reports have promoted the use of the more expensive MRI and CT modalities for uterine myomas. However, CT and MRI cannot distinguish between malignant and benign myomas, so they are rarely ordered for routine clinical management. MRI may be helpful for differentiating adenomyoma or adenomyosis from a single, solitary myoma in woman wishing to preserve their fertility. X-ray, CT, and hysteroscopy are not options in this pregnant patient.

References:

Katz VL. Benign gynecologic lesions. In: Lentz GM, et al. Comprehensive Gynecology. 6th ed., 2012. 

Munro M. Uterine leiomyomas, current concepts: pathogenesis, impact on reproductive health, and medical, procedural, and surgical management. Obstet Gynecol Clin North Am. 2011;38(4):703-731.

Educational Objective:

Discuss the initial management of hypoxia in a drowning victim.

Key Point:

If oxygen saturation drops below 90% on 2 L/minute, then inhaled albuterol, very close observation, arterial blood gases, and an increased oxygen flow rate are warranted.

Explanation:

If a patient arrives symptomatic from submersion, then hospital admission is warranted, regardless of the course, over the first 6 hours. Intubation is warranted if clinical deterioration occurs or PaO₂ is below 60 mm Hg or PaCO₂ is above 45 mm Hg on high-flow oxygen.

Continuous positive airway pressure is generally not recommended due to the risk of vomiting and aspirating ingested water.

Empiric antibiotics have not been shown to be helpful.

References:

Sempsrott J, et al. Drowning and Submersion Injuries (Chapter 69). Auerbach's Wilderness Medicine 7^th ed. 2017. Part 10 1-28

Richards DB. Drowning. (Chapter 137) In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018: 1801-1804e.

Educational Objective:

Recognize the clinical findings observed in systemic air embolism.

Key Point:

Retinal examination is clinically indicated in patients with suspected systemic air embolism.

Explanation:

The diagnosis of systemic air embolism can be overlooked in any patient, but it is especially difficult to make in someone who is paralyzed because this leads to an absence of neurologic findings. In a patient who is paralyzed and intubated, even the pupils are nonreactive, and the cold caloric test will be nondiagnostic. The remaining signs and symptoms closely mimic those of hypovolemic shock. If, based on the patient’s mechanism of injury, systemic air embolism is in the differential diagnosis, then it is important to attempt to rule this out as the cause of the cardiovascular collapse.

Presence of hemoptysis prior to or after intubation (implying pulmonary-vascular communication) and the occurrence of cardiovascular collapse after starting PPV are both highly suggestive of systemic air embolism. In addition, retinal examination can reveal a classic sign for systemic air embolism: Air bubbles can sometimes be seen as streaming bubbles or pale silvery sections in the retinal vessels. Presence of such air bubbles confirms systemic air embolism. Succinylcholine-induced paralysis will wear off in 9 to 13 minutes, and temporarily hidden neurologic deficits might become observable, which, in the absence of head injury, are also suggestive of systemic air embolism.

Crepitus is indicative of air escaping into the skin, not the vascular system. No high-pitched cardiac sounds have been reported with systemic air embolism.

References:

Browner BD, Jupiter JB. Skeletal trauma: basic science, management, and reconstruction. 5th ed., 2014.

Chilstrom M. Special neurologic tests and procedures. (chapter 61). In: Roberts RR. Clinical Procedures in Emergency Medicine. 7th ed., 2019:1281-1293e.

Ho AM, Ling E. Systemic air embolism after lung trauma. Anesthesiology. 1999;90(2):564-575.

Miller RD, et al, eds. Miller's Anesthesia. 8th ed., 2014.

Raja A. Thoracic trauma (chapter 38). In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:382-403.e2.

Mercurous chloride is found in some skin-lightening compounds. Mercurous chloride is well absorbed dermally and can result in chronic mercury poisoning. Chronic mercury poisoning is primarily a neurologic disease with symptoms of tremor, fatigue, neurasthenia, and erethism. Neurasthenia encompasses the weakness, depression, malaise, and headaches seen with inorganic mercury poisoning, while erethism includes symptoms of irritability, anxiety, social withdrawal, and other psychiatric symptoms.

Treatment of this patient’s complaints would initially include removal of the exposure and urine testing for mercury. Chelation would be considered based on her response to removal of the exposure and urine mercury testing.

References:
Centers for Disease Control and Prevention. Mercury exposure among household users and nonusers of skin-lightening creams produced in Mexico--California and Virginia, 2010. MMWR Morb Mortal Wkly Rep. 2012;61:33-36.
Centers for Disease Control and Prevention. Mercury poisoning associated with beauty cream--Texas, New Mexico, and California,1995-1996. MMWR Morb Mortal Wkly Rep. 1996;45:400-403.
Sue Y-J. Mercury. In: Nelson LS, et al. Goldfrank's Toxicologic Emergencies. 9th ed., 2010.

Widespread use of DNAR orders are limited more by lack of physician-patient communication regarding their implementation than by availability of process or forms. Prehospital providers and their medical directors should discuss cases involving DNAR to address potential conflicts, such as the relationship between patients with DNAR orders who have attempted suicide and patients with potentially reversible problems (e.g., choking on meat, anaphylaxis). Although specific comments on the DNAR order would assist in this decision, these are often not available. Wider utilization of DNAR orders with specific discussion and counseling of family members would help to clarify decisions regarding prehospital resuscitations in most circumstances.

When DNAR forms are not immediately available, maximal resuscitation should occur, including transport, regardless of the circumstances.

Premedicate 10 to 15 minutes before starting exercise

Exercise-induced asthma is best controlled by using the Proventil inhaler (bronchodilator) approximately 10 to 15 minutes before exercise, to prevent vasospasm of the bronchioles and shortness of breath with exercise. The effects of these bronchodilators usually last approximately 4 hours. They also work quickly to open up the bronchioles if an acute attack/shortness of breath occurs.

Anterior epistaxis

Trauma to the small blood vessels in Kiesselbach’s triangle (or plexus), located inside the nose anteriorly, causes anterior nosebleeds (anterior epistaxis). This is the most common type of nosebleed and is usually self-limited. Up to 10% of nosebleeds are posterior nosebleeds (hemoptysis, melena, nausea, anemia), which can result in hemorrhage. Posterior nosebleeds can cause significant hemorrhage. If suspected, call 911. Trauma to Kiesselbach’s triangle does not cause stroke or subdural hematoma.

Of the diagnoses consistent with erratic or violent behavior, oppositional defiant disorder, conduct disorder, bipolar disorder, personality disorder, and substance use disorders are known to increase a patient's suicide risk.

Among adolescents who commit suicide, many have a psychiatric disorder, the most common of which is depression. Other psychiatric disorders known to increase suicide risk in adolescents include anxiety disorder and eating disorders.

References:

Kyaga, Simon, et al. "Mental illness, suicide and creativity: 40-year prospective total population study." Journal of psychiatric research 47.1 (2013): 83-90.

Soloff, Paul H., et al. "Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study." American Journal of Psychiatry (2014).

Educational Objective:

Identify the effects of illicit drug use on the fetus.

Key Point:

Symptoms of withdrawal may occur prior to birth because opiates cross the placenta.

Explanation:

Pregnant women who use illicit drugs often have poor prenatal care. They also typically have a higher rate of sexually transmitted infections, preterm labor, growth restriction, and perinatal complications.

Opiates cross the placenta and cause addiction and, potentially, withdrawal symptoms prior to delivery. Use of heroin and methadone most commonly causes withdrawal syndromes.

Drug abuse during pregnancy can result in growth restriction as well as behavioral and cognitive deficits later in life, even in the absence of withdrawal syndromes.

Reference:

Carlo WA, Ambalavanan N. Metabolic disturbances (chapter 106). In: Kliegman R, et al, eds. Nelson Textbook of Pediatrics. 20th ed., 2016:891-896.

Respiratory failure occurs when oxygenation and ventilation are insufficient to meet the metabolic demands of the body. Failure can result from an abnormality in the lungs or airways, from an abnormality of the chest wall and muscles of respiration, or from an abnormality of the central and peripheral chemoreceptors (as is the case here). Classically, failure is defined as a PaO2 value of less than 60 Torr on room air and a PCO2 value greater than 50 Torr resulting in acidosis; however, the patient’s general state, respiratory effort, and potential for impending exhaustion are more critical than the Torr values. Clinical observation is the most important component of monitoring for impending respiratory failure, and the goal of the management of respiratory distress is to ensure a patent airway and provide necessary support for adequate oxygenation of the blood and removal of CO2. This management supersedes the need for gastric lavage or the need to contact a legal guardian, although both of these actions will likely become necessary as management moves forward. The patient most certainly could have had a head injury either as a cause for her symptoms or as a result of her collapse. A cervical collar and stabilization of the head and neck are necessary in tandem with airway control, but adequate oxygenation of the blood still is the over-riding concern here. A counselor will become necessary in time but will not be involved in the emergency care of this patient.

Reference:

Marx JA, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed., 2014.