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Otolaryngology

Key Concepts Otitis Media Otitis media is caused by eustachian tube inflammation and dysfunction leading to fluid accumulation in the middle ear and proliferation of nasopharyngeal bacteria, most commonly Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Diagnosis of acute otitis media (AOM) is made based on the presence of a middle ear effusion and signs of inflammation, including ear pain, tympanic membrane erythema and bulging, and…

Ophthalmology

Key Concepts Prophylactic topical antibiotics are not indicated for the treatment of corneal abrasions, and eye patches are not recommended because they can mask a worsening infection. Eyelid lacerations that may require referral to a plastic or ophthalmic surgeon include those with lid margin lacerations, a canalicular laceration, or levator or canthal tendon injuries. Alkaline burns to the cornea and conjunctiva need to be irrigated until…

Oral Medicine

Key Concepts Antibiotics do not have a role in the management of pulpitis, whether reversible or irreversible. Missing teeth must be accounted for. They may be hidden, left at the scene, aspirated, swallowed, or traumatically impacted. Avulsed permanent teeth should be stored in milk, saline, or a commercially available solution and reimplanted at the earliest possible opportunity. Primary teeth are not reimplanted. A localized periapical abscess…

Chemical Injuries

Key Concepts For chemical injury, the degree of skin destruction is determined mainly by the properties of the toxic agent, its concentration, and the duration of its contact. Chemical injuries are commonly encountered after exposures to acids and alkalis. Hazardous materials (HazMat) are substances that can cause physical injury and damage the environment if improperly handled. In dealing with HazMat incidents, two distinct goals need to…

Thermal Injuries

Key Concepts After removing the patient from the source of injury, burns should be cooled with room temperature water while avoiding hypothermia in patients with large burns. Clinical signs such as facial burns, hoarseness, drooling, carbonaceous sputum, and singed nasal hairs indicate inhalation injury; however, they are poor predictors of injury severity. Confirmation of inhalation injury is best accomplished by direct visualization of the glottic inlet…

Venomous Animal Injuries

Acknowledgments We acknowledge the efforts and expertise of the previous chapter author for editions (1–9), Dr. Edward Joseph “Mel” Otten. Key Concepts Snake venom causes neurotoxicity and hematotoxicity, but one usually predominates, depending on the species of snake. Pit vipers have triangular or arrow-shaped heads, elliptical pupils, and characteristic pits found bilaterally midway between the eye and the nostril. The amount of crotalid antivenom given depends…

Mammalian Bites

Key Concepts Mammalian bites require an evaluation for both trauma and their risk of infection. Cat and human bites are at higher risk for infection than dog bites. Most mammalian bite wound infections are polymicrobial. Pasteurella species are the most common pathogens in dog and cat bites. Preventing infection from mammalian bites relies more on vigilant cleaning, debridement, and irrigation than prophylactic antibiotics. Prophylactic antibiotics are…

Foreign Bodies

Key Concepts If the history and mechanism of injury are compatible with ocular penetration or if a small puncture wound of the globe is noted, anteroposterior and lateral radiographs of the orbit are an appropriate initial step when the foreign body is thought to be radiopaque. Computed tomography (CT) and ultrasound are complementary diagnostic studies. Although most otic and nasal foreign bodies are amenable to emergency…

Wound Management Principles

Key Concepts Risk factors for wound infection include crush mechanism; long (>5 cm) deep penetrating wounds; high-velocity missiles; diabetes; and contamination with saliva, feces, soil, or other foreign matter. Soaking wounds in povidone-iodine (Betadine) is toxic to healthy tissue. Prepare the skin with a chlorhexidine-alcohol solution. The most effective intervention to decrease wound bacterial counts and infection is thorough cleansing, with use of saline or tap…

Ankle and Foot Injuries

Key Concepts The Ottawa Ankle and Foot Rules should be used to evaluate the need for x-rays in ankle and foot injuries. CT scans are indicated for negative x-rays of the ankle and foot when a high clinical concern of fracture exists. Ankle dislocations with obvious vascular compromise should be reduced promptly, before radiographs are obtained. The entire fibula should be examined if a medial malleolar…

Knee and Lower Leg Injuries

Key Concepts Knee dislocation often causes vascular injury to the popliteal artery. Early revascularization is crucial. Hard signs of vascular injury include absent pedal pulses, cool mottled foot, expanding popliteal hematoma, or popliteal hemorrhage. When any of these are present, angiography or emergent surgical exploration is indicated. Soft signs of popliteal artery injury include asymmetric pedal pulses and foot or leg paresthesias. Computed tomography (CT) angiography…

Femur and Hip Injuries

Key Concepts A hip dislocation is an orthopedic emergency. The likelihood of avascular necrosis (AVN) is related to both the initial degree of trauma and the amount of time the femoral head remains out of joint. Reduction of the hip within 6 h after dislocation significantly decreases the incidence of AVN. When a painful hip makes ambulation difficult and plain radiographs do not reveal a fracture,…

Pelvic Injuries

Key Concepts The most serious pelvic ring injuries caused by high-energy impact are (1) anteroposterior compression fractures (“open-book” fracture), (2) vertical shear fractures, and (3) fractures involving significant displacement. These injuries are associated with major blood loss and transfusion requirements. Pelvic fractures are a marker for serious injury to other organ systems. The vast majority of patients who die after sustaining a pelvic fracture have multiple…

Shoulder Injuries

Key Concepts Axillary nerve function is best evaluated by testing the motor function of the deltoid muscle. The three-view trauma series of the shoulder (true anteroposterior, scapular Y, and axillary views) leads to an accurate radiographic diagnosis of most fractures and dislocations, although specialized views are sometimes necessary. Consider the presence of unfused epiphyses in adolescents and young adults. Most shoulder girdle fractures can be treated…

Humerus and Elbow Injuries

Key Concepts Clinical decision rules for the elbow joint have not been validated. Radiographs should be obtained when there is limitation in range of motion, moderate to severe pain, obvious deformity, joint effusion, or significant tenderness or crepitus over any of the bony prominences or the radial head. The threshold for radiographic imaging should be lower in pediatric patients (with the exception of radial head subluxations),…

Wrist and Forearm Injuries

Acknowledgment We would like to thank David Williams, Karen G.H. Woolfrey, Michael Woolfrey, and Mary A. Eisenhauer for their contributions to previous versions of this chapter. Key Concepts On plain radiographs of the wrist, three distinct arcs, known as Gilula’s lines , and equal spacing between carpus bones (1–2 mm), known as parallelism , assist in the radiographic diagnosis of carpal injuries. In the setting of…

Hand Injuries

Acknowledgments The authors would like to acknowledge the assistance of Ronald Barry, MD, FACS in the preparation of this chapter, including providing many of the images. Key Concepts For general testing of the motor nerve function of the hand, have the patient make an “OK” sign with their thumb and index finger (testing the median nerve), while spreading/abducting the third, fourth, and fifth fingers (ulnar nerve)…

General Principles of Orthopedic Injuries

Key Concepts Many orthopedic injuries can be stabilized and treated definitively by the emergency clinician. Consultation with an orthopedist should be sought for the treatment of some long bone fractures, open fractures, injuries with joint violation, tendon injuries, and injuries with neurovascular compromise. A careful history and physical examination can predict radiographic findings in orthopedic injuries with a high degree of accuracy. Open fracture management should…

Peripheral Vascular Trauma

Key Concepts The overall condition of the patient with an acute peripheral vascular injury determines the extent of emergency department (ED) evaluation and stabilization. Critically injured patients may require immediate surgery, which should not be delayed for confirmatory studies of obvious vascular injury. Arterial injury may be readily apparent or clinically occult. In patients with high-energy blunt mechanisms, computed tomography angiography (CTA) should be the initial…

Genitourinary Trauma

Key Concepts Microscopic or gross hematuria is suggestive of genitourinary trauma; however, the degree of hematuria does not correlate well with either the severity or anatomy location of injury. The kidney is the most frequently injured genitourinary organ, and imaging should be considered in patients with gross hematuria or microscopic hematuria with hemodynamic instability. Most noniatrogenic ureteral injuries are due to penetrating mechanisms and are unilateral;…