⒈ Vertebral Body Trauma Essay

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Vertebral Body Trauma Essay

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Spine Anatomy, Imaging, and Intervention Trauma

A 45 year old woman presents with right upper quadrant pain and fever. The pain is worse after eating. The most likely diagnosis is: A. Appendicitis B. Diverticulitis C. Cholelithiasis D. Cholecystitis E. Mesenteric Ischemia. Cholecystitis The answer is D. A 47 year-old male presents, confused, to the ED. He has limited ability to give a history.

On physical examination of the skin, it is noted that there are erythematous changes to both palms. Also, the face and arms are characterized by a number of superficial, tortuous arterioles which fill from the center outwards. The examination of the abdomen reveals violaceous lines radiating from the umbilicus, and there are generally increased venous markings on the abdominal wall see Figure. Rocky Mountain spotted fever B. A year-old homeless woman with a history of schizophrenia presents to the emergency department complaining of nausea and severe abdominal pain for 48 hours.

The patient is not cooperative with an upright abdominal image, so a flat plate as shown in the Figure is obtained. Which of the following is the most likely operative finding in this patient? Inflamed appendix B. Rectus sheath hematoma C. Ruptured spleen D. Small bowel obstruction. Small bowel obstruction The answer is D. Dilated loops of small bowel with air-fluid levels which are not well-seen on a flat plate indicate small bowel obstruction.

KUB is not often useful in the diagnosis of appendicitis, ruptured spleen, gallstone disease, or a rectus sheath hematoma which is an abdominal wall condition most likely seen in anticoagulated patients with trauma or coughing. Cecal volvulus occurs as a result of abnormal fixation of the right colon and increased mobility of the cecum. Depending on the degree of rotation around the mesenteric axis, cecal volvulus can lead to twisting of the mesentery and its blood vessels. Cecal volvulus occurs most commonly in people years old and should be suspected in cases of bowel obstruction without known risk factors.

Prior abdominal surgery and pregnancy predispose to obstruction or cecal volvulus; however, chronic constipation is not known to predispose to cecal volvulus. Interestingly, marathon runners have been found to have a higher incidence of cecal volvulus, perhaps from having a thin, flexible mesentery that more easily permits rotation of the cecum around the mesenteric pedicle. A 57 year old ill-appearing man presents with fever, chills, abdominal pain, nausea and vomiting. His abdominal CT is shown in the Figure.

Etiologic agents of this condition include bacteroides, E. Elevations of WBC, bilirubin, alkapine phosphatase and serum aminotransferases will be seen on laboratory studies. Emergent percutaneous drainage in the emergency department is indicated. Treatment with triple coverage antibiotics such as gentamicin, metronidazole and ampicillin should be instituted immediately. CXR may demonstrate a right-sided effusion and elevation of the right hemidiaphragm. The patient has a hepatic abscess, typically caused by gram negatives, anaerobic Streptococci or Entameoba histolytica.

Laboratory findings include elevations of WBC, bilirubin, alkaline phosphatase and serum aminotransferases. Treatment with triple coverage antibiotics such as gentamicin, metronidazole and ampicillin should be instituted immediately, however consultation with a general surgeon, interventional radiologist, or gastroenterologist is necessary for definitive treatment, which is drainage of the abscess. Which of the following pairings of referred pain and causal disease is least likely to be encountered? Ovarian torsion may cause lower abdominal pain, pelvic pain, adnexal tenderness, and cervical motion tenderness, but it is not known to cause sacral pain. A 72 year old man with a history of diverticulosis presents with vague abdominal pain for the past day.

His physical exam is notable for normal vital signs, left lower quadrant abdominal tenderness without rebound or guarding, and guaiac positive brown stool. Of the following choices, which is the most appropriate management of this patient? For mild episodes of diverticulitis in which there is no evidence of perforation or peritonitis, there is no indication for immediate surgical intervention. Conservative management with intravenous fluids and antibiotics as well as bowel rest is typically first attempted. Although colon carcinoma may be a precipitating factor in the development of diverticulitis, barium enema should be avoided in the acute period due to high risk of bowel perforation. Although some patients with mild cases of diverticulitis may be discharged home with conservative treatment, the elderly are at higher risk of perforation and should be admitted.

There is no reason to suspect acute blood loss requiring transfusion in diverticulitis. Esophageal perforation has been reported as a complication of nasogastric tube placement, endotracheal intubation, and esophagotracheal Combitube intubation. Esophageal perforation may result from forceful vomiting, coughing, childbirth or heavy lifting. Iatrogenic perforations of the esophagus usually occur in the proximal esophagus or esophagogastric junction. Foreign body or caustic substance ingestion, severe blunt injury or penetrating trauma, and carcinoma are other causes of esophageal perforation.

Working in the ED, you have identified a bony object wedged in the mid-esophagus of a 45 year old patient. Failure to promptly remove a foreign body impacted in the esophagus could result in: A. Esophageal perforation and mediastinitis B. Epiglottal edema and airway obstruction C. The rapid development of xerostomia D. Esophageal perforation and mediastinitis The answer is A.

The complications of esophageal foreign bodies are rare but serious. They include esophageal erosion and perforation, mediastinitis, esophagus-to-trachea or esophagus-to-vasculature fistula formation, stricture formation, diverticuli formation, and tracheal compression from both the esophageal foreign body and resultant edema or infection. Air trapping is a sign of a foreign body of the airway. Rarely, airway foreign bodies act as one-way valves that could cause hyperinflation of a lung segment, with resultant bleb rupture and pneumothorax formation. A mother brings her 35 year old son to the emergency department because of tremor and mutism for the past three days. His mother found him in his room this morning lying stiffly in his bed, soiled with urine and feces.

He appears confused and will not respond to questions. He was diagnosed with schizophrenia last year and has been on several medications. Last month after his most recent hospital admission for schizophrenia, he was discharged with a prescription for haloperidol. On physical exam, he is visibly diaphoretic and has vital signs as follows: T What is the most likely explanation for these findings? Neuroleptic malignant syndrome NMS is an idiosyncratic, life-threatening reaction to antipsychotic medications, with haloperidol being the most common cause. It is characterized by elevated temperatures, "lead pipe" muscle rigidity, altered mental status, choreoathetosis, tremors, and autonomic dysfunction e.

NMS is thought to be due to too much D2 blockade in the substantia nigra and hypothalamus. Treatment consists of stopping the causative agent and providing supportive care. Medications such as dantrolene, bromocriptine, amantadine, and lorazepam are also often used. Tardive dyskinesia choice A is a chronic movement disorder that results from prolonged use of antipsychotics and can include involuntary and periodic movements of the tongue or lips, mouth puckering, or flailing movements either of the extremities or of the spine.

Neuroleptic-induced acute dystonia choice C is an acute spasm of a muscle or muscle group associated with the use of antipsychotic agents. It presents with patients complaining of neck twisting torticollis , fixed upper gaze, facial muscle spasms, or dysarthria from tongue protrusions. In a similar family with dystonia, neuroleptic-induced akathisia choice D is an extrapyramidal syndrome that is manifest by agitation and restlessness. Schizophrenia, catatonic type choice B , a diagnosis of exclusion, usually does not present with this degree of impairment. A 25 year old man returns to the ED, 24 hours after being released from the hospital with a new diagnosis of schizophrenia.

He has recently started to take haloperidal for his psychotic symptoms. In the ED he is noted to have involuntary contractions of the muscles of the face, a protruding tongue, deviation of the head to one side, and sustained upward deviation of the eyes. Vital signs are stable, and initial labs show no electrolyte or hematological abnormalities. Of the following choices, the preferred medication for this condition is: A. Dystonic reactions, which can occur at any point during long-term therapy and up to 48 hours after administration of neuroleptics in the emergency department, involve the sudden onset of involuntary contraction of the muscles in the face, neck, or back.

The patient may have protrusion of the tongue buccolingual crisis , deviation of the head to one side acute torticollis , sustained upward deviation of the eyes oculogyric crisis , extreme arching of the back opisthotonos , or rarely laryngospasm. These symptoms tend to fluctuate, decreasing with voluntary activity and increasing under emotional stress, which occasionally misleads emergency physicians to believe they may be hysterical in nature. Intravenous administration usually results in near-immediate reversal of symptoms. Patients should receive oral therapy with the same medication for 48 to 72 hours to prevent recurrent symptoms. A 70 year old male with acute delirium requires administration of haloperidol for agitation.

Which of the following is a recognized side effect of haloperidol? Nephrogenic diabetes insipidus may be associated with lithium. Potential side effects of haloperidol include acute dystonia, prolonged QT interval, Parkinsonism, and akathisia. A 19 year old woman is brought to the emergency department by her friends because she has been saying that she is a superhero and trying to run into traffic to prove that she is indestructible. The friends report that she has been using drugs but they do not know which ones. Which of the following pairs of ocular finding and recreational drug is commonly observed? Sympathomimetics cocaine, amphetamines cause dilated pupils.

Opiates heroin cause pinpoint pupils. Internuclear ophthalmoplegia is associated with multiple sclerosis. CN VI palsy is not associated with any specific drugs. In choosing an antipsychotic medication, which of the following would be the most appropriate choice? Haloperidol is the most studied high potency antipsychotic agent used in agitated patients. Typical dosing is mg IM every minutes. Peak serum levels occur in about 30 minutes after IM dosing. Unlike thioridazine, haloperidol does not cause respiratory depression, has negligible anticholinergic side effects, and rarely causes hypotension.

Although benzodiazepines can be used in the agitated patient, respiratory depression can occur, and close monitoring is essential. A 20 year old college student is brought to the emergency department by campus police after he was found by his roommate saying people in the TV were trying to kill him. Which of the following criteria is not an indication for admission? For an acute psychiatric episode, the first goal is medically stabilizing the patient. Subsequently, a patient who presents without previous history of a psychiatric episode does not necessarily need to be admitted. This, of course, depends on the identity and severity of the condition, and whether it can be treated in the emergency department. A 55 year-old male presents with new onset agitation and confusion.

Which of the following medical histories would suggest a psychiatric non-organic cause? History of diabetes mellitus only B. History of alcohol abuse only C. History of hypothyroidism only D. History of chronic obstructive pulmonary disease only. History of hypothyroidism only The answer is C. Although hyperthyroidism may result in an agitated state, hypothyroidism is not generally associated with violent behavior.

All other answers are potentially treatable medical problems that could account for the presentation of an agitated or violent patient. After assuring the safety of all parties involved, the emergency department physician should rule out organic causes of agitation. In dealing with the potential violent patient, the emergency physician should: A. Approach the patient in a calm, controlled and professional manner B. Assume that the strength of the doctor-patient relationship will ensure safety C. Use a loud voice and threaten to call security if the patient becomes agitated. Approach the patient in a calm, controlled and professional manner The answer is A.

Excessive eye contact may be interpreted as a sign of aggression answer A. Emergency physicians are encouraged to maintain intermittent eye contact with the patient and to keep a professional and calm demeanor. Also a physician should never deal with an agitated or violent patient alone in an isolated room answer D. Doors should always remain open and exits should never be blocked. Ample security should be close at hand before interviewing the patient answer E. Finally, involved parties are encouraged to remove any personal effects e.

A 35 year-old male is placed on his back on the gurney in physical restraints for violent behavior. Which life-threatening complication can arise? Metabolic acidosis C. Asphyxia D. Metabolic acidosis The answer is B. Bruises and abrasions are the most common complication of physical restraints. After restraint application, patients need to be monitored frequently and positions changed to prevent neurovascular complications such as circulatory obstruction, pressure sores, and rhabdomyolysis. Positional asphyxia can arise when patients are placed into the prone or hobbled position. Protracted struggle against restraints can promote a significant metabolic acidosis that has been associated with cardiovascular collapse. Patients who continue to struggle with physical restraints should be chemically restrained as well.

Which medication is ideal for the agitated or combative patient? Nitrous oxide B. Hydromorphone C. Haloperidol D. Drugs with a relatively short half-life allow for more careful monitoring of chemically restrained patients. Patients may be given multiple administrations of the restraining agent as needed. Antipsychotics such as haloperidol and benzodiazepines such as lorazepam exhibit most of these characteristics and are commonly used in combination in the emergency department.

Half doses should be used in the elderly. No additional history is available. On arrival, the patient is minimally responsive with sonorous respirations and a palpable rapid pulse. The most appropriate initial diagnostic test would be A. Arterial blood gas B. Electrocardiogram C. Fingerstick glucose D. Urine drug screen. Fingerstick glucose The answer is C. Hypoglycemia is a common and readily treatable cause for altered mental status.

An ABG is unlikely to be diagnostic and more likely to reflect secondary abnormalities caused by respiratory depression. While a urine drug screen may show positives, it cannot quantitate the amount of a substance or the time period in which the exposure occurred so a positive screen may not reflect cause and effect. An EKG, while a part of a toxicology evaluation, is not an appropriate initiate screening test for an unstable patient until airway and readily reversible causes have been addressed.

A 27 year old is found unresponsive in his car in the hospital parking lot and brought in by security. Radial pulses are present at bpm. Pupils are 1mm bilaterally. Your team is having difficulty finding a vein for an intravenous line due to extensive scarring of his arms. You are suspicious of an overdose, which medication would you want to rapidly administer as a potential antidote in this situation? Glucose B. Naloxone C. Thiamine D. Naloxone The answer is B. The patient has stigmata of an opiate overdose with hypopnea, cyanosis, and miotic pupils.

In addition, intravenous drug users often use up their veins. While hypoglycemia can definitely cause a depressed mental status and needs to be assessed, it should not result in respiratory depression or miotic pupils. Flumazenil can be used to temporarily reverse the respiratory depression caused by benzodiazepines but also carries with it the risk of precipitating withdrawal and uncontrollable seizures in chronic benzodiazepine users. As a result, it is not recommended for routine use in patients with altered mental status. A 53 year-old known alcoholic presents with agitation, vomiting and altered mental status. His fingerstick glucose is His serum ethanol level is undetectable and his head CT is normal.

An ABG shows a pH of 7. His basic chemistry panel includes a sodium of , potassium 4. What substance are you concerned that he may have ingested A. Ethylene glycol B. Salicylates C. Isopropyl alcohol D. Isopropyl alcohol The answer is C. The patient is presenting with a non anion gap metabolic acidosis. Isopropyl alcohol is metabolized via alcohol dehydrogenase to acetone which accumulates and causes significant ketosis but not an anion gap. Other toxic alcohols such as methanol and ethylene glycol are ultimately metabolized to formic and glycolic acids which cause toxic effects and an anion gap metabolic acidosis. Salicylates result in an anion gap metabolic acidosis with a superimposed respiratory alkalosis.

Treatment is primarily supportive including fluids and electrolyte correction. Magnesium replacement should be initiated empirically except in the setting of contraindications such as renal failure or hypermagnesemia. Coexisting gastritis should be sought out and treated appropriately. Nutritional status should be assessed with attention to possible protein restriction. Alcoholics often have low thiamine levels due to poor nutrition, and low glucose levels due to the suppression of gluconeogenesis by alcohol.

Magnesium levels may appear normal on laboratory testing, but alcoholics typically have low magnesium stores and should be given magnesium empirically unless contraindications for magnesium exist. Alcoholics should also be evaluated for gastritis and overall nutritional status and should be referred appropriately. A 45 year old man is brought to the E. The patient is very confused and obtunded, and unable to provide a cogent history; the person who brought him to the E. As he lays in the stretcher, his appearance is as depicted in the Figure. Of the following choices, which physical finding is most likely to be present on physical examination? This patient has marked ascites which may incidentally account for his mild tachypnea due to impairment of respiratory excursion.

A 60 year old male presents with new onset confusion. Which of the following suggests a functional, as opposed to an organic etiology? The other findings are all characteristic of organic confusional states. Hallucinations can occur with both organic and functional causes of confusion. Hallucinations associated with organic confusion may be visual, tactile, or auditory. Hallucinations in patients with functional disease tend to be auditory. Delirium is defined as: A. Alterations in mental status resulting from extreme emotional stimulus would usually be functional abnormalities. Patients with delirium manifest increases in alertness and psychomotor activity.

Delirium is more than simple alteration of mental status. Delirium is an organic confusional state. Patients with delirium may have hallucinations, but patients who are oriented are more likely to have functional causes for altered mental status. Which of the following statements regarding psychotic behavior is true? Brief psychotic episodes, often precipitated by events such as death of a loved one, can be characterized by extremely bizarre behavior and speech B.

Delusions are defined as false beliefs that are not amenable to arguments or facts to the contrary C. Delusional disorder usually results in impairment in daily functioning D. Schizophreniform disorder is present when a patient meets the diagnostic criteria for schizophrenia but the process has been present for less than one year. Delusions are defined as false beliefs that are not amenable to arguments or facts to the contrary B.

Psychosis can be limited to nonbizarre delusions; patients with this disorder delusional disorder rarely have impairment in daily functioning. Fixed, false beliefs that are not held by others with a patient's cultural background are characteristic of delusional thinking. A 75 year old female is brought the to emergency department by a family member with a history of progressive forgetfulness and confusion. She has a history of dementia.

The most common cause of dementia in the elderly patient is: A. Parkinson's disease C. Vascular dementia. Smaller percentages are attributable to causes such as anoxic encephalopathy, hepatolenticular degeneration, tumors, and slow virus infections. A 65 year old male is brought to the emergency department after he was found wandering on the street. He is unkempt and confused. A diagnosis of delirium, rather than dementia, is more likely if which of the following is true?

Patients with delirium have disturbances in consciousness, cognition, and perception. These disturbances tend to occur over a short period of time hours to days. The delirious patient may be somnolent or agitated. Thought process may be mildly disturbed or grossly disorganized. The clinical presentation may be subdued or explosive, and the course can fluctuate over minutes to hours. An acute confusional state can also be one of the protean manifestations of a metabolic or nutritional abnormality, including hepatic encephalopathy, acute renal failure, and diabetic ketoacidosis or hyperosmolarity.

An 80 year old nursing home patient is brought to the emergency department with an acute onset of confusion. Which of the following metabolic abnormalities is the most likely explanation? The differential diagnosis of acute confusional states is lengthy. Hypokalemia alone, however, is not a common cause of altered mental status. Which factor is least reliable in differentiating between organic and inorganic causes of confusion? Vital sign abnormalities C. Presence of attention deficit D. Signs of trauma. Presence of attention deficit The answer is C.

Presence of an attention deficit is common to all confusional states. All the other options may be used to differentiate organic versus non-organic causes of confusion. With regard to specific causes of hypertension, which of the following is true? Hypertensive encephalopathy is more likely than hypertensive stroke in patients whose mental status changes are reversible B. Hypertensive encephalopathy causes adverse outcomes over days or weeks, rather than hours C. Patients with stroke syndromes must have blood pressure normalized as quickly as possible to reduce the risks of worsening neurological deficit D.

Laboratory analysis is rarely useful in cases of confirmed pediatric hypertension E. Laboratory analysis is rarely useful in cases of confirmed hypertension in pregnant patients. Hypertensive encephalopathy is more likely than hypertensive stroke in patients whose mental status changes are reversible The answer is A. Hypertensive encephalopathy is a true medical emergency, and can cause coma and death over hours; however, encephalopathy due to hypertension is more likely reversible than encephalopathy from other causes.

Avoidance of overzealous blood pressure lowering is particularly critical for patients with strokes. A 29 year old woman is found seizing by her husband and is rushed to the emergency department. Her husband tells you that they are expecting their first child in a few months. Control the seizures with magnesium sulfate. Notify the labor floor that the patient is in the emergency department. Perform a CT scan of head if seizures persist. All the other choices A-D are appropriate in the management of the patient with eclampsia.

Which of the following is not a feature of febrile seizures? Febrile seizure is not associated with a postictal period. The child usually rapidly regains alertness. Intracranial mass or infection should be a concern if the duration of seizure is greater than 15 minutes or if altered mental status persists after the cessation of seizure activity. A 47 year old man with a history of alcohol abuse presents to the emergency department after having a seizure.

His past includes both seizures and blackouts. His last alcoholic drink was the previous evening. This morning he experienced palpitations, diaphoresis, and dizziness before losing consciousness and having a seizure lasting under a minute. Which of the following is a true statement with regard to alcohol and its association with seizures? In people with an underlying seizure disorder, excessive alcohol intake is a risk-factor for seizure due to increased likelihood of head injury, predisposition to metabolic disorders, and lowered seizure threshold.

Alcohol intake itself can precipitate seizures due to the neurotoxic effects of alcohol and its metabolites. Cessation of alcohol can precipitate seizures as part of the alcohol withdrawal syndrome. All of the above statements are true. All of the above statements are false. A patient with a ventriculo-peritoneal shunt presents to the E. What is the diagnosis? A 68 year old diabetic male, previously living independently, is brought in by his family.

He has been acting abnormally for two days. The family reports he is awake all night and sleepy during the day. At other times he appears and acts almost normally. Which of the following is true regarding his condition? Dementia is the most likely cause of his condition and the family must be counseled about the future course of the disease. Medications are an unlikely cause of this condition in the elderly. Patients can be agitated and combative, or calm and quiet in this condition. Treatment includes maximizing sensory input. The scenario describes a patient with delirium, a condition in which patients may be agitated and combative, or calm and quiet. Infection and metabolic abnormalities are other common causes, and delirium may be the first indication that an infection is present.

An elderly patient with delirium resulting from an infection may have a normal temperature, a low temperature, or a high temperature. Delirium is characterized by an acute onset of a disturbance in level of consciousness, cognition and attentiveness. It has a fluctuating course, and alterations in sleep-wake cycles are common. Dementia, in contrast, has a slower course, that is gradually progressive over months to years, and consciousness is preserved. In addition to correcting the underlying cause, it is important to minimize stimulation, because the patient with delirium has difficulty processing stimuli.

The chest X-ray in the Figure was taken in an intoxicated patient who is conversant, but an unreliable historian. The X-ray findings are best described as indicating: [image] A. Esophageal foreign body B. Intratracheal foreign body C. Esophageal foreign body The answer is A. The film reveals a classic appearance of a round foreign body in this case, a pull-top from a beer can in the esophagus. The foreign body appears to lie outside the tracheal shadow. There is no sign of mediastinal air which would be expected with penetrating trauma. The X-ray reveals no signs of mediastinitis, but the risk of esophageal perforation and ultimate mediastinitis prompts endoscopic intervention in this patient. An 18 year old hockey player is hit in the mouth with a puck, fracturing a maxillary canine tooth.

He brings the severed piece of tooth with him. On physical exam, the tooth is fractured halfway between the tip and the gumline. The root of the tooth is still firmly intact. The exposed fracture site has a yellowish tinge without blood. Of the following choices, which is the most appropriate management for this patient? No specific treatment required B. Application of calcium hydroxide, placement of aluminum foil, and dental follow-up C. Placement of tooth fragment in saline gauze, outpatient dental follow-up D. Immediate dental consult to avoid abscess formation E. Replace fractured piece and place acrylic splint. Immediate dental consult to avoid abscess formation The answer is D.

Ellis II dental fracture involves enamel and dentin. The fracture site typically has a yellowish tinge. Ellis III dental fractures are characterized by exposure of pinkish pulp and often blood. These fractures require immediate dental consultation to prevent abscess formation. A 22 year old man is punched in the nose during a fight. He presents to the emergency department with obvious nasal bone deformity. Pressure controls the bleeding. Physical exam reveals no maxillary bone or orbital rim tenderness, intact vision and extraocular movement. The oropharynx and mandible are unremarkable.

Nasal inspection reveals a swollen, ecchymotic, tender nasal septum. Which of the following is the most appropriate initial step? Outpatient follow-up with an ENT specialist to surgically correct a deviated septum B. Plastic surgery consult for immediate reduction of nasal fracture C. Facial CT scan to rule out more serious facial fractures D. Incision and drainage of the septal hematoma followed by nasal packing E.

Needle aspiration of the septal hematoma. Incision and drainage of the septal hematoma followed by nasal packing. A 24 year old woman is playing racquetball and sustains a direct blow from the ball to the right eye. She presents to the emergency department complaining of eye pain and double vision. On exam, her right eye does not track properly with upward gaze. This finding suggests which of the following injuries? Inferior orbital wall fracture B. Superior orbital rim fracture C. Ethmoid fracture D. Zygomatic arch fracture E. Inferior orbital rim fracture.

Inferior orbital wall fracture The answer is A. The patient most likely has an orbital floor fracture with entrapment. A 32 year old man is struck several times in the head with a baseball bat. Upon emergency medical service arrival, he is mildly confused, vomits once, and complains of a severe headache. The emergency medical technicians establish two large-bore IVs. Prior to arrival at the emergency department, he loses consciousness and begins to seize. He is actively seizing when he is brought into the trauma bay.

What should be the first step in the management of this patient? Administration of phenytoin mg IV B. Administration of mannitol 50 g IV C. Rapid sequence intubation using paralytic agent D. Emergency craniotomy E. Administration of 2 liters NS bolus. Rapid sequence intubation using paralytic agent The answer is C. The airway should be managed as the first priority in this patient. Airway comes first! A 46 year old man is brought in by EMS after a motor vehicle collision in which he was an unrestrained driver. Although he has no obvious injury to his head or neck, he complains of chest pain and appears very short of breath.

His vital signs are: T The CXR demonstrates a tension pneumothorax. Placement of a chest tube followed by a chest xray to determine proper placement B. Transfusion of 2 units of O-negative packed red blood cells C. Performance of a chest CT scan to further delineate the pathology D. Placement of a needle decompression device, followed by repeat CXR. Placement of a needle decompression device, followed by repeat CXR This patient needs emergent chest decompression and this is rapidly done by needle thoracostomy. A chest CT may be performed, but only once he is stabilized. A formal chest tube will be placed, but placement may not be rapid enough and he may decompensate in the meantime.

Transfusion of blood does nothing to correct the physiology of a tension pneumothorax. The most sensitive bedside test for nerve injury in a finger after trauma is: A. Light touch is a good screening test, but two-point discrimination is more sensitive and should be used routinely in evaluating injuries to digits. Presence of wrinkling indicates the nerve is intact.

Which is not part of the Ottawa ankle rules? The Ottawa ankle rules are a validated for adults set of physical exam findings to determine if an ankle X-ray is needed after an injury. If any of the first 4 answers is present or if there is tenderness over the navicular or base of the 5th metatarsal, an X-ray should be obtained. If the correct answer to all questions is no, then an X-ray is not needed. An upright chest X-ray should always be performed following a thoracentesis to confirm the successful relief of a tension pneumothorax and the absence of hemothorax or other complications. A to gauge needle is inserted perpendicularly over the superior edge of the rib.

The recommended insertion site is the second intercostal space, midaxillary line. After the needle is inserted into the pleural space, a rush of air confirms the presence of a tension pneumothorax. If a tension pneumothorax is confirmed via needle decompression, then a thoracostomy tube should be placed as soon as possible. The recommended insertion site for needle decompression of tension pneumothoraces is the second intercostal space along the midclavicular line. If a lateral approach is needed, the recommended insertion site is the fourth or fifth intercostal space in the midaxillary line.

The lateral approach poses a greater risk of parenchymal injury. The needle should always be inserted over the superior edge of the rib as the neurovascular bundle runs along the inferior margin answer B. The remaining answers are all correct statements regarding thoracentesis answers C, D, E. Tonometry should not be performed in patients with suspected ruptured globe, as application of the Tono-Pen pressure to the eye may cause the vitreous humor to exude from the eye, thereby complicating the injury.

Tetanus status is important to check, as ocular injuries, like skin injuries, may be a portal for tetanus exposure. Broad-spectrum antibiotic therapy is indicated. Anti-emetic therapy may be helpful in preventing the elevations in intraocular pressure associated with vomiting. Visual acuity assessment is important and ophthalmology consultation is critical. Following a motor vehicle crash, a 25 year old man presents complaining of a painful right eye. The right eye protrudes from the orbit and the patient has right eye pain with extraocular movement.

What is the most likely cause of his symptoms? Traumatic proptosis with impaired extraocular movements is classic for retrobulbar hematoma. Sequelae include optic nerve ischemia and secondary visual impairment. A ruptured globe presents with enophthalmos, not proptosis, as vitreous humor leaks out of the eye. Neither hyphema nor chemosis causes proptosis. Orbital blowout fractures can cause inferior rectus muscle entrapment and secondary pain with impairment of extraocular movement.

Yet, they do not present with proptosis — unless complicated by retrobulbar pathology. Following a brawl at a local bar, a gentleman presents with an impressive right-sided periorbital ecchymosis. Orbital blowout fractures classically involve the maxillary or ethmoid sinus and consequently often cause either epistaxis through the connection of the maxillary sinus with the nose or subcutaneous emphysema through the entry of air from the sinuses into the subcutaneous tissue.

A fracture through the maxillary sinus may extend through the portal by which the second branch of the trigeminal nerve exits, thus causing anesthesia of the ipsilateral infraorbital region. If the inferior rectus muscle gets trapped within the fracture of the inferior orbital wall, patients will be unable to look upward causing diplopia with upward gaze. Orbital blowout fractures are not typified by proptosis.

In fact, proptosis in the setting of trauma should prompt physicians to suspect the possibility of a retrobulbar hematoma. The patient depicted in the figure presents to the ED just after sustaining a pellet-gun wound to the right eye. What do the arrows most likely indicate? Hypopion collection of purulent material is less likely in this setting, and keratitis corneal inflammation and iritis inflammation of the iris are not indicated by the arrows.

A pterygium is a growth which is visible on the sclera, and which crosses the limbus onto the cornea. Ophthalmological examination is normal, other than the blood as shown in the figure the blood does not cross the limbus. Of the choices below, which diagnosis is the most likely based upon the figure? The subconjunctival blood as depicted in this patient, can be expected to resorb without intervention over days to weeks.

The figure does not suggest rupture of anterior chamber or hyphema; globe rupture and foreign body are less likely given the normal examination and CT scan. A patient presents with a self-inflicted wound, with resultant loss of vision in the right eye. With regard to the figure, which of the following statements is most likely true? Medial canthotomy should be performed immediately. If ambulance providers contact medical control about a patient with this injury, they should be directed to replace the globe back into the orbit.

Search for other self-inflicted injuries or ingestions is paramount. Life-threatening hemorrhage is a major risk with this injury. The patient will probably recover visual function. The patient is unlikely to recover any visual function, which renders more important parallel efforts to identify treatable injuries or ingestions that are less obvious than the ocular avulsion. Lateral not medial canthotomy is an emergency procedure that may be indicated in some patients with ocular injury and retrobulbar hematoma with resultant traction on the optic nerve , but the procedure is unlikely to help this patient.

Since manipulation of an injured globe risks further trauma and extrusion of vitreous humor, prehospital recommendations for eye trauma are limited to protection of the injured eye and expedited transport to definitive care. Life-threatening hemorrhage is not a major risk with this type of injury. What is the most common cause of death in Americans aged 20 to 40 years? Drug overdose B. Trauma C. Cancer D. AIDS-related illness E. Following a motor vehicle collision, in which of the following patients is an emergency department Caesarian section most likely indicated, assuming a fetus at weeks gestation?

Though emergency C-section after maternal death is a rarely indicated procedure, rapid intervention within minutes of maternal demise has resulted in viable births. A 76 year old restrained driver is involved in a head-on collision at about 35 mph. He arrives at the emergency department in a cervical collar and on a backboard. His only complaint is neck pain, and he has mild posterior neck tenderness.

A CT scan of the neck shows no fracture and only degenerative arthritis. Upon re-evaluation you note the patient has difficulty raising his arms against gravity and there is decreased grip strength bilaterally. The remainder of his neurological exam is normal. What is the most appropriate management for this patient? Immediate neurosurgical decompression C. Flexion and extention radiographs to rule out ligamentous injury D. Discharge home with a hard cervical collar with neurosurgical follow-up E. Central cord syndrome results from a hyperextension injury, typically in elderly patients with significant degenerative joint disease.

A 46 year old construction worker falls 6 feet off a ladder onto a concrete surface and has sudden and severe low back pain. The pain radiates down his right leg and he develops numbness over the anterior shin and dorsum of the foot. On physical exam he has decreased sensation to pinprick over the dorsum of the right foot medially and some weakness in right foot dorsiflexion. At which level is a protruding intervertebral disc most likely?

L1-L2 B. L2-L3 C. L3-L4 D. L4-L5 E. L4-L5 The answer is D. Sensation of the dorsal aspect of the foot and dorsiflexion of the foot are functions of the L5 nerve root. Herniation of the L disc would result in compression of L5. Which of the following cervical spine fractures is considered stable? Transverse process fracture B. Flexion teardrop fracture C. Bilateral facet dislocation D. Jefferson fracture of C1. Transverse process fracture The answer is A.

A transverse process fracture involves only one of the supporting spinal columns the posterior column and is therefore stable. A 23 year old man is stabbed in the anterior neck with a 3-inch knife during a street fight. At the scene, there is some bleeding, which is controlled with direct pressure. He presents to the emergency department breathing comfortably and in no distress. There is a 1cm laceration 2cm above the right sternoclavicular junction, lateral to the trachea.

There is mild oozing and no obvious underlying hematoma. There is no obvious subcutaneous air, and he has clear lung sounds. Local wound exploration and discharge home if no significant injury identified B. Angiography, esophogram, and admission for observation C. Local wound exploration and discharge home after 6-hour observation period D. CT scan of the neck and discharge home after 6 hours of observation E.

Immediate operative exploration. Angiography, esophogram, and admission for observation The answer is B. Zone I penetrating neck injuries are located between the sternal notch and the cricoid cartilage. A major concern is injury to non-compressible vascular structures such as common carotid, vertebral, subclavian, aortic arch. Other structures in this area include trachea, esophagus, and lung apices. Physical exam is often unreliable and angiography, esophogram, and observation are warranted. Which of the following patients should undergo abdominal trauma evaluation? None of the above E. All of the above. All of the above The answer is E.

The diaphragm can rise to as high a level as the fourth intercostal space and can be injured by stab wounds at this level. Unsuspected injuries are common in high speed motor vehicle crashes. Pelvic injuries are associated with intra-abdominal injuries and can distract a patient from such an injury. Therefore, all of these patients need an evaluation of their abdomens. Which of the following trauma patients can be managed conservatively without immediate laparotomy in the OR? All of the above should go to the OR for exploratory laparotomy. Which of the following is an accurate statement? Bedside ultrasound is the test of choice for diagnosing solid organ injury. Diagnostic peritoneal lavage usually cannot identify the presence of hemoperitoneum.

Bedside ultrasound can image the retroperitoneum. Bedside ultrasound can reliably determine the etiology of hemoperitoneum. Diagnostic peritoneal lavage cannot determine the etiology of hemoperitoneum. Diagnostic peritoneal lavage is extremely sensitive for the detection of hemoperitoneum and can lead to many negative laparotomies. Neither bedside ultrasound nor diagnostic peritoneal lavage can identify the source of the hemorrhage though. A trauma ultrasound at the bedside can only identify fluid in the peritoneal cavity, and CT scan is the test of choice for diagnosing solid organ injury.

His physical exam is significant for a large contusion on his left flank. Periods of hypoxemia or ischemia may occur as a result of intraoperative arrhythmias, deliberate hypotension, or in patients with abnormal cerebral vasculature particularly in neurosurgery, cardiac, and carotid surgery. Hypertension evoked by laryngoscopy and tracheal intubation and extubation as well as prolonged anticoagulant therapy can result in cerebral hemorrhage during anesthesia.

Central anticholinergic syndrome CAS occurs not only with anticholinergic drugs such as atropine, scopolamine, or hyoscine, but also after benzodiazepines, IV, and volatile anesthetic agents and manifests as delayed awakening from anesthesia. Symptoms related to cerebral irritation such as delirium, agitation to CNS depression with stupor, and coma is seen. Overdose of atropine or glycopyrrolate is reported to cause CAS in neonates. Increasing cholinergic transmission by trial of physostigmine 0. Neuroexcitatory symptoms such as twitching, myoclonic movements, opisthotonus, and seizures can present during induction, maintenance, as well as recovery from anesthesia.

The Swedish Adverse Drug Reaction Advisory Committee reported 34—44 patients and the British Committee on Safety of Medicine in reported 8 patients who had delay in regaining consciousness after anesthesia. Many of these patients have been anesthetized with propofol, enflurane, isoflurane, or etomidate. The symptoms are caused by imbalance between excitatory and inhibitory pathways in the brain or reduced inhibitory output from the formation reticularis.

Dissociative coma, myxedema coma, thyroid failure, hunter syndrome mucopolysaccharide storage disease , valproate toxicity, drug abuse, and lidocaine infusion for arrhythmias are some rare causes of delayed recovery. Its diagnosis is based on the exclusion of other organic causes. Knowledge of the recovery profile from a spinal anesthesia is helpful in predicting time to meeting discharge criteria from ambulatory surgery center. Previously used end points to analyze recovery from sensory and motor blockade are not used to determine eligibility for discharge after day-care surgery. Information about the time it takes a patient to void, ambulate, and completely resolve sacral anesthesia after spinal anesthesia is important.

The diagnosis is established by magnetic resonance imaging MRI followed by surgical decompression. Rao et al. Narrowed epidural spaces, migration of epidural catheter, intrathecal migration of the drug, faulty infusion pump, potentiation by fentanyl, and clonidine are possible mechanisms for prolongation of block. Delayed recovery after peripheral nerve block is rare. Patients with underlying nerve pathology such as diabetic neuropathy, exposure to neurotoxic chemotherapy, or disruption of neural blood supply are more susceptible to peripheral nerve complications.

Neurological deficits may persist for days after high-pressure intraneural injection of local anesthetic. Therefore, neurological follow-up until resolution or stabilization of the condition is mandatory. Brainstem paralysis due to bupivacaine wound infiltration after foramina magnum decompression and field block is also reported. Delayed recovery from anesthesia is often multifactorial, and anesthetic agents may not always be the culprit. When other causes are excluded, the possibility of acute intracranial event should be strongly considered. While the specific cause is being sought, primary management is always support of airway, breathing, and circulation.

Good intraoperative care ensures the patient safety. A calm, comprehensive, and timely management with a systematic approach is highly rewarding. We, the anesthesiologists, make the patient sleep, so the recovery from anesthesia is our responsibility. National Center for Biotechnology Information , U. Journal List Anesth Essays Res v. Anesth Essays Res. Author information Copyright and License information Disclaimer.

Corresponding author: Dr. E-mail: moc. This article has been cited by other articles in PMC. Abstract Delayed awakening from anesthesia remains one of the biggest challenges that involve an anesthesiologist. Keywords: Anesthetic agents, delayed awakening, delayed emergence, delayed recovery, drug effects, general anesthesia, overdose, prolonged neuromuscular block, regional anesthesia, risk factors. Immediate recovery This consists of return of consciousness, recovery of protective airway reflexes, and resumption of motor activity. Intermediate recovery During this stage, the patient regains his power of coordination and the feeling of dizziness disappears.

Long-term recovery There is a full recovery of coordination and higher intellectual function. Open in a separate window. Table 2 Aldrete score for assessing recovery and discharge from the postanesthesia care unit. Table 3 Risk factors responsible for delayed emergence from anesthesia. Patient factors Extremes of age Geriatric patient Elderly patients have increased sensitivity toward general anesthetics, opioids and benzodiazepines, and slow return of consciousness due to progressive decline in central nervous system CNS function. Pediatric patients Because of larger body surface area, heat loss is greater in children resulting in hypothermia, slow drug metabolism, and delayed return of consciousness.

Genetic factors It is becoming increasingly apparent that genetically controlled variations in drug disposition and response are important determinants of adverse effects of drug therapy. Gender Apfelbaum et al. Body habitus Obesity with increased fat mass requires higher drug doses to attain the same peak plasma concentration than a standard sized person. Comorbidities Preexisting cardiac and pulmonary disease require adjustments in anesthetic doses to avoid delayed emergence. Cognitive dysfunction Structural disorders of CNS and psychological disease may all cause postoperative somnolence.

Seizures Seizures are not uncommon after brain injury and after surgical intervention. Stroke Surgical procedures with increased risk of embolization are coronary artery bypass graft, orthopedic particularly joint replacement surgery, peripheral vascular surgery, and valvular and aortic surgery. Postoperative pain Presence of pain speeds up recovery. Residual drug effects A heavy premedication or the relative overdose of general anesthetic agents may be the cause of delayed awakening.

Potentiation by other drugs Prior ingestion of opioids and benzodiazepines or nonanesthetic drugs that affect cognitive function such as tranquilizers, antihypertensives, anticholinergics, clonidine, antihistamines, penicillin-derived antibiotics, amphotericin B, immunosuppressants, lidocaine, and alcohol will potentiate the CNS depressant effects of anesthetic drugs and delay emergence from anesthesia. Duration and type of anesthetic used The selection of anesthetic technique and anesthetic drugs determines the duration of unconsciousness.

Benzodiazepines They potentiate CNS depressant effects of anesthetic drugs and may delay emergence from anesthesia. Intravenous anesthetic agents The termination of action of IV anesthetic agents given for induction is predominantly determined by redistribution and should not delay recovery. Volatile anesthetic agents The speed of emergence is directly related to alveolar ventilation and inversely related to blood gas solubility.

Neuromuscular blockers Residual neuromuscular blockade results in paralysis that is indistinguishable from delayed awakening though the patient is conscious and aware. Local anesthetic systemic toxicity Repeated doses of local anesthetics in highly vascular area, intracranial spread of local anesthetics after spinal anesthesia, or accidental subarachnoid injection during epidural or interscalene brachial plexus block may cause prolonged somnolence, seizures, coma, and cardiorespiratory arrest. Table 4 Causes of hyperglycemia and hypoglycemia. Electrolyte imbalance The acid-base and electrolyte changes observed in the perioperative period could be secondary to the underlying illness or surgical procedure, for example, hyponatremia occurring with transurethral resection of prostate where glycine or other hypotonic fluid is used for irrigation.

Temperature Hypothermia is usually observed in extremes of ages and in debilitated patients. Respiratory causes Postoperative respiratory failure due to primary muscle problems, metabolic imbalance, obesity, residual NMB, or pulmonary disease results in hypoxemia, hypercapnia, or venous admixture. Neurological complications Residual anesthesia after neurosurgery may either give the false impression of a neurological deficit or prevent the early diagnosis of intracranial lesion such as hematoma, herniation, and cerebral infarction. Conflicts of interest There are no conflicts of interest.

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