Volume 32 Number 10 October 2018

Pain in the Neck

Although musculoskeletal complaints are common among
athletes who present to the emergency department,
injuries to the neck, especially the cervical spine, warrant
heightened concern. Clinicians must be prepared to
recognize and manage the complex and potentially
devastating complications associated with acute neck pain.
In particular, injured athletes must be promptly evaluated
for neurological, vascular, and soft-tissue injuries associated
with spinal cord trauma.

Fighting the Good Fight

Compassion fatigue stemming from difficult
interactions with patients is a principal — and often
avoidable — cause of emergency physician burnout.
Stress related to patient conflicts, satisfaction scores,
and complaints can persist, even decades into
practice. By arming themselves with the necessary
communication tools, clinicians can more readily
navigate and rebound from these tense interpersonal
encounters.

THE OFFICIAL CME PUBLICATION OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

IN THIS ISSUE
Lesson 19 n Cervical Spine Injuries in Athletes . . . . . . . . . . . . . . . . . . . 3
LLSA Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Critical Decisions in Emergency Medicine is the official
CME publication of the American College of Emergency
Critical Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Physicians. Additional volumes are available.
Critical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 EDITOR-IN-CHIEF
Michael S. Beeson, MD, MBA, FACEP
Lesson 20 n Novel Ways to Avoid and Resolve Patient Conflicts . . . 19
Northeastern Ohio Universities,
Critical ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Rootstown, OH

CME Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 SECTION EDITORS

Drug Box/Tox Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Joshua S. Broder, MD, FACEP
Duke University, Durham, NC
Andrew J. Eyre, MD, MHPEd
Brigham & Women’s Hospital/Harvard Medical School,
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 Pain in the Neck
Cervical Spine Injuries
in Athletes

LESSON 19

By Herman Kalsi, MD; Elizabeth Kaufman, MD, CAQ-SM;

and Kori Hudson, MD, FACEP, CAQ-SM
Dr. Kalsi is a senior emergency medicine resident at Georgetown University
Hospital/Washington Hospital Center in Washington, DC. Dr. Kaufman is
an attending physician in the Department of Sports Medicine at Kaiser
Permanente San Jose in San Jose, CA. Dr. Hudson is an associate professor
of emergency medicine at Georgetown University School of Medicine in
Washington, DC.

Reviewed by Michael Beeson, MD, MBA, FACEP

OBJECTIVES
On completion of this lesson, you should be able to:
1. Devise a systematic approach for the evaluation of
suspected c-spine injuries.
2. Describe the history and physical examination findings
that should raise suspicion for a c-spine injury.
3. Explain evidence-based clinical decision tools that help
determine the need for imaging of the cervical spine.
4. Recognize transient neurological deficits that can mimic
more serious diagnoses.
5. Define the initial stabilization and management of a
suspected c-spine injury.
FROM THE EM MODEL
18.0 Traumatic Disorders
18.1 Trauma
CRITICAL DECISIONS
n What is the appropriate initial assessment for a
suspected c-spine injury?
n What history and physical examination findings
should raise concern for a c-spine injury?
n When should the cervical spine be imaged?
n What are the most common vascular injuries
associated with c-spine trauma?
n What are the most common transient neurological
injuries associated with c-spine trauma?
n What has changed in the management of patients
with c-spine injuries?

Although musculoskeletal complaints are common among athletes who present to the emergency
department, injuries to the neck, especially the cervical spine (c-spine), warrant serious concern. Clinicians
must be prepared to recognize and manage the complex and potentially devastating complications associated
with acute neck pain. In particular, injured athletes must be promptly evaluated for vertebral fractures,
subluxation injuries, vascular injuries, intervertebral disc herniation, brachial plexus injuries, and/or nerve root
injuries.

October 2018 n Volume 32 Number 10 3

 CASE PRESENTATIONS
■ CASE ONE
A 24-year-old woman with a
potential c-spine injury arrives via
helicopter. She was transported
from a nearby trail after being
thrown from her horse. Her group,
which was 45 minutes away from
the nearest access road, stabilized
her head and neck while waiting
for EMS. Rescue personnel found
the patient to be awake, oriented,
and in a supine position, but
complaining of severe neck pain.
She did not lose consciousness
at the scene and could move her
extremities; she denied headache,
nausea, and blurry vision.
EMTs noted the patient’s intact
Acute spinal cord injuries (SCIs)
in athletes are rare (accounting for
only 2.4% of all athletic-related
hospitalizations), yet 9.2% of all SCIs
in the US are sustained during athletic
activity.1 Although football players,
wrestlers, and gymnasts are at greatest
risk for c-spine trauma involving axial
loading, hyperextension, traction,
or rotation, such injuries can occur
during almost any recreational activity,
including those traditionally considered
noncontact sports, including baseball.1
CRITICAL DECISION
What is the appropriate initial
assessment for a suspected
c-spine injury?
As with all traumatic injuries,
emergency physicians should approach
patients with suspected c-spine injuries
using the Advanced Trauma Life Support
(ATLS) protocols, which strive not only
to identify immediate threats to life, but
also to minimize the risk of overlooking
secondary and tertiary injuries.2
Generally, if the neck of a patient with a
potential c-spine injury has not already
been stabilized to minimize movement, it
is essential to do so by providing in-line
stabilization before proceeding with the
evaluation.3 If a patient is not breathing,
is unable to manage secretions, or
4 Critical Decisions in Emergency Medicine
helmet lying approximately 10 feet
away from her. She reported
tenderness in her cervical spine, but
her field examination was otherwise
normal. EMTs applied a cervical
collar and used a “scoop stretcher” to
transfer the patient to a cot.
On arrival at the emergency
department, the patient complains of
increasing neck pain.
■ CASE TWO
A 16-year-old boy presents after
being tackled during a high school
football game. Upon falling to the
ground, he experienced a sharp,
“electric pain” that originated in his
neck and moved down his left arm.
He did not lose consciousness during
displays signs of impending respiratory
failure, the airway should be secured
before proceeding.4
Many physicians question the safety of
emergency airway management — using
orotracheal intubation — with known
or suspected c-spine injuries; however,
several studies have shown orotracheal
intubation with in-line stabilization
to be a safe and effective method for
definitive airway management in patients
with suspected c-spine injuries.5-8 No
consensus has been reached on whether
video-assisted laryngoscopy (VAL) is
safer than direct laryngoscopy (DL) with
respect to minimizing vertebral body
movement during the intubation process.6
Studies have produced mixed results
on the use of VAL. One study concluded
that there was no significant difference
between DL and VAL at any level of
c-spine injury, while another found
that c-spine motion was reduced by
50% at the C2-C5 segment when VAL
was used.9,10 Regardless, current ATLS
guidelines list orotracheal intubation with
in-line manual c-spine stabilization as
the definitive airway procedure in apneic
patients with trauma.9 In addition, a
surgical airway should be considered if a
definitive airway is required and cannot
be established by other means.6
Once the airway and breathing have
been addressed, circulation and the
the event and was able to immediately
get up without assistance, remove his
helmet, and walk over to the sideline,
where he was evaluated by the athletic
trainer. He denied headache, nausea,
or blurry vision.
At the time of the injury, he had no
midline c-spine tenderness, no step-
offs or deformities, and complained
only of pain and paresthesias in his left
arm. Approximately 10 minutes after
the injury, however, his left arm began
to feel weaker, so his parents brought
him to the emergency department
for further evaluation. On arrival,
he continues to complain of neck
pain and unilateral upper-extremity
paresthesias and weakness.
degree of disability should be assessed.
More specifically, athletes with suspected
c-spine injuries should be evaluated for
signs of spinal and/or neurogenic shock.
Spinal shock — a state of transient loss
of spinal cord function below the level
of the injury, including hyporeflexia or
areflexia with associated autonomic
dysfunction — occurs immediately after
an injury. Spinal shock can cause an
acute, incomplete SCI that mimics a
complete SCI.
The severity and duration vary with
the spinal level and degree of injury,
but spinal shock usually lasts less than
24 hours. Patients can experience
an initial increase in blood pressure
due to the release of catecholamines,
quickly followed by hypotension. The
bulbocavernosus reflex (S2-S4) can be
used to help diagnose spinal shock;
it can be tested by monitoring for the
contraction of the anal sphincter in
response to squeezing the glans penis
or clitoris, or to a slight tug on an
indwelling Foley catheter, in patients
with acute paralysis after trauma.
Presence of the reflex indicates spinal
cord severance; its absence indicates
spinal shock. The return of the reflex
typically indicates that the spinal shock
is resolving.3
By comparison, neurogenic shock
is the body’s response to the sudden
loss of sympathetic control. It is a
distributive shock that manifests itself
clinically with bradycardia, hypotension,
flaccidity, and areflexia. Neurogenic
shock typically occurs in patients
with SCIs above the T6 level, as these
translate into greater than 50% loss of
sympathetic innervation, which leads
to unopposed vagal tone, a decrease
in vascular resistance, and associated
vascular dilation. For hypotensive
trauma patients, it is crucial not only
to distinguish between spinal and
neurogenic shock, but also to rule out
hypovolemia as the cause of shock.3
Disability should be assessed by
performing a head-to-toe neurological
examination. If an athlete arrives
wearing protective equipment, the
equipment may need to be removed
prior to full evaluation. If a spinal injury
is strongly suspected, initial imaging can
FIGURE 1. Cervical Spine Injury, MRI Sagittal View
(Atlas)
(Axis)
This patient was involved in an automobile accident that resulted in intervertebral disc
herniations compressing the spinal cord, primarily at the level of C4/C5 and C6/C7. The
image also depicts a reverse curvature of the cervical spine, a common injury sustained
when muscles and tendons are strained during high-velocity movements.
occur prior to equipment removal, as
most athletic equipment is radiolucent.
If a long spine board is used for spinal
stabilization during transport, it should
be removed upon arrival, maintaining
in-line stabilization of the spine. A
slider board can be used to minimize
motion during additional transfers.
Once the long spine board and sports
equipment are removed, a rigid cervical
collar should be applied, if not already
placed in the prehospital setting, and
should remain in place until the cervical
spine is “cleared,” either clinically or
radiographically.
A more detailed history should
be obtained, in conjunction with a
secondary survey and a more detailed
exam. Ideally, the mechanism of injury
should be determined so that the
presence of coexisting injuries can be
ascertained. It is important to know
if a helmet was used and whether or
not it was damaged in the incident, as
this information can help stratify the
direction and force of the injury.3
CRITICAL DECISION
What history and physical
examination findings should raise
concern for a c-spine injury?
C-spine injuries are classified
according to the mechanism of trauma,
the extent of vertebral stability, and
the morphology of the injury. As such,
the most common injury patterns in
athletes are related to axial loading,
flexion, extension, and rotation. One key
purpose of the physical exam is to detect
primary injuries, such as damage from
direct contusion and axonal stretch,
spinal compression by bone fragments,
hematoma or intervertebral discs,
and ischemia from damage due to the
impingement on the spinal arteries.6
The cervical spine should be carefully
inspected from the nuchal ridge to
at least the spinous process of the
first thoracic vertebra.11 In addition,
clinicians should pay close attention to
any obvious neck deformities or signs
of instability. The posterior aspect of
the neck should then be palpated by
placing thumbs on the spinous processes
and applying circular pressure down
the midline to detect tenderness. This
process should be repeated 2 cm to 3 cm
lateral to the midline on both sides to
assess for facet pain.
Depending on the mechanism of
injury and complaint of pain, a focused
assessment of the lateral and anterior
aspects of the neck also should be
considered.12,13 Physicians should suspect
acute abnormalities if tenderness,
deformity, edema, ecchymosis, and/or
acute muscle spasm are present.3
Following inspection and palpation, a
thorough neurological evaluation should
be performed, including an assessment of
sensation, motor function, and reflexes.
Table 1 outlines the motor, sensory, and
reflex functions that are lost or decreased
with injury at the respective cervical
spinal levels.
During the evaluation, both nerve
root and spinal cord injuries should
be considered. Although sometimes
October 2018 n Volume 32 Number 10 5
 difficult to detect, the presence of
neurological deficits that indicate
multilevel involvement generally suggest
spinal cord trauma, rather than a nerve
root injury. Additionally, in the absence
of spinal shock, motor weakness with
intact reflexes indicates a spinal cord
injury. In contrast, motor weakness with
absent reflexes often indicates a nerve
root lesion.3,6
Cervical spine injury can also present
more subtly, so it is important not to
discount a serious injury due to a lack of
pain, as neck pain may not necessarily be
severe or it may not be as severe as other
distracting injuries.12 One study found
that most patients with c-spine injuries
did not present with a history of loss
of consciousness or with neurological
deficits. Many had no evidence of
craniofacial trauma, and some patients
exhibited full range of cervical motion.14
Regardless, any indication of neurogenic
and/or spinal shock should raise concern
for a potential SCI.
CRITICAL DECISION
When should the cervical spine
be imaged?
Studies have shown the high cost and
relatively low yield of indiscriminate
c-spine imaging in trauma patients.
However, significant variation exists
between prehospital and emergency
department assessments, so clinicians
should avoid discontinuing spinal
stabilization until the cervical spine has
been adequately assessed and cleared.15
Standard x-rays remain the initial
imaging study of choice for low-risk
patients and those without a significant
mechanism of injury. For patients with
multiple traumatic injuries or a high
suspicion for injury, however, many
hospitals now opt to use standard CT
scans as part of the initial evaluation of
the cervical spine. CT scans can provide
greater detail and can create multi-axis
reconstructions that are better suited for
patients with high-risk injuries.6
Although CT is an excellent modality
for evaluating bony spine injuries, MRI
may be indicated in patients who,
despite a negative scan, have persistent
midline tenderness and/or neuro­
logical abnormalities. Since MRI
6 Critical Decisions in Emergency Medicine
TABLE 1. Neurological Findings and Associated Anatomical Level
C-Spine Level Deficit Found on Exam
C1-C2 • Paresthesia in the occipital-parietal region
• Muscle weakness is rare
C3 • Paresthesia or numbness at the lower pinna, posterior portion of the
cheek, temporal area, and lateral aspect of the neck
• Weakness is clinically not detectable
• Analgesia is rare
C4 • No paresthesia
• A horizontal band of cutaneous analgesia along the spine of the
scapula, mid-deltoid area, and clavicle
• Slight weakness of the trapezius bilaterally
C5 • No paresthesia or sensory deficit
• Weakness of the supraspinatus, infraspinatus, deltoid, and brachial
biceps muscles
• The biceps and brachioradialis reflexes are sluggish or absent
C6 • Paresthesia in the thumb and index fingers
• Analgesia at the tips of the thumb and index fingers
• Weakness of the biceps, brachialis, supinator brevis, and extensor
carpi radialis
• The biceps reflex is sluggish or absent
C7 • Paresthesia in the index, middle, and ring fingers
• Cutaneous analgesia at the dorsal aspect of the index and middle
fingers
• Weakness in the triceps and flexor carpi radialis
• The triceps reflex can be affected
C8 • Paresthesia in the middle, ring, and little fingers
• Cutaneous analgesia of the little finger
• Weakness in the extensors of the thumb, extensor and flexor carpi
ulnaris, adductor pollicis, common extensor of the fingers, and
abductor indicis
T1 • Paresthesia and cutaneous analgesia at the ulnar aspect of the hand
• Weakness of the intrinsic muscles of the hand
(Figure 1) provides more detailed The National Emergency
imaging of the spinal cord, spinal canal, X-Radiography Utilization Study
spinal ligaments, intervertebral discs, (NEXUS) and the Canadian C-Spine
and paraspinal soft tissues, it can be Rule (CCR) are two widely used and
particularly useful when neurological evidence-based decision tools that can be
deficits are caused by hemorrhage, used to evaluate patients with suspected
edema, or injury to the spinal cord. MRI cervical trauma to determine the need for
can also help determine the acuity of imaging. These rules allow emergency
bony injuries and aid in the assessment physicians to make objective decisions
of vascular injury.16,17 Despite access about imaging, which can result in
to CT scans and MRIs, it is important cost savings and reduced radiation
to remember that plain films can still exposure to patients. Both rules have
provide rapid assessment of alignment, been validated to provide useful, highly
fractures, and soft-tissue swelling.6 sensitive criteria to ultimately reduce the
Clinically, the mechanism of injury need for imaging.6,11,20
alone should not determine the need for NEXUS has a 99.8% negative
radiological investigation. Although it is predictive value for c-spine injury with
rare to see an unstable c-spine fracture a sensitivity of 99% and specificity of
or neurological deterioration due to 12.9%. Because of its low specificity,
injury in an asymptomatic patient, researchers were concerned that
emergency physicians should use clinical the NEXUS criteria still resulted in
decision rules to help determine whether overimaging and thus developed the
low-risk patients can forego imaging.18,19 CCR. The objective in developing the
 have a significant risk of injury and radiography.21 However, it is important
TABLE 2. NEXUS Criteria may warrant imaging, even without the to remember that stabilization and
No midline c-spine tenderness on application of a clinical decision tool. In imaging of the spine should not take
palpation these cases, even if none of the NEXUS precedence over life-saving diagnostic
No focal neurological deficit criteria are present, c-spine imaging is still and therapeutic procedures.3,5
Normal alertness: GCS 15; alert and recommended.6,11
oriented to person, place, time, and/or
The CCR helps determine the need CRITICAL DECISION
events; able to correctly remember
three objects at 5 minutes; and for c-spine imaging based on high-risk What are the most common
appropriate response to external stimuli factors or the combination of low-risk vascular injuries associated with
No distracting injuries, such as long- factors and a physical exam finding
c-spine trauma?
bone fractures, visceral injuries requiring (Table 3). The three high-risk factors
surgical consultation, large lacerations that mandate imaging include age 65 For a patient with a suspected
or burns, and crush injuries c-spine injury, the need to evaluate
years and older, a dangerous mechanism
Patient is not intoxicated for skull and intracranial injuries is
of injury, and the presence of a sensory
neurological deficit. Low-risk factors often recognized. Although traumatic
CCR was to derive a highly sensitive include a simple rear-end collision, the vertebral artery injury is well recognized
clinical rule with improved specificity ability to sit, ambulation at any point in trauma, it can often be overlooked
that would allow physicians to be more in time after the injury, delayed onset of in a patient with c-spine trauma.
selective in the use of radiography.11,20,21 neck pain, and the absence of midline Its incidence increases greatly in the
According to the NEXUS protocol, cervical tenderness. If patients have a presence of a head or c-spine injury.
a c-spine injury cannot be excluded low-risk factor, they should be asked to Traumatic vertebral artery injuries
if any of the following findings are rotate their head 45 degrees to the right are most commonly precipitated by
present: midline cervical tenderness, and then 45 degrees to the left. If unable blunt trauma or a rotating or bending
altered mental status, focal neurological to do so, imaging is required.20 mechanism.
deficit, evidence of drug or alcohol Note inclusion criteria from the two Symptomatic injuries can manifest
intoxication, or the presence of another studies differ: The Canadian c-spine posterior circulation ischemia, such
injury that is considered painful enough study did not include children younger as dysarthria, ataxic gait, visual field
to distract from a neck injury. If none than 16 years and patients with Glasgow defects, Horner syndrome, impaired
of these criteria are noted, the patient is Coma Scale (GCS) scores less than 15, consciousness, or impaired balance
considered low risk for a c-spine injury while the NEXUS study did. One article and coordination directly after injury.
and, in most cases, does not require concluded that the CCR is superior to the However, many injuries can remain
c-spine imaging (Table 2). Patients with NEXUS criteria with respect to sensitivity asymptomatic, which presents a clinical
severe osteoporosis, advanced arthritis, and specificity for c-spine injury, and challenge. If an injury goes undetected,
cancer, or degenerative bone disease use of the CCR would reduce rates of it can lead to potentially fatal posterior
circulation ischemia.23,24
Traumatic vertebral artery injuries
TABLE 3. Canadian C-Spine Rule20 appear to account for as much as 22%
of blunt c-spine injuries; the incidence
High-Risk Factors That Mandate Radiography
can be upward of 70% in cases of
• Age ≥65 years
• Paresthesias in the extremities c-spine fracture. Thus, if the mechanism
• Dangerous mechanism: of injury was significant enough to
— Fall >1 m (or 5 stairs) produce a c-spine fracture, evaluation
— Axial load to the head/spine (eg, diving injury) for vascular injuries is strongly
— High-speed motor vehicle accidents (>100 km/hr) recommended.25,26
— Motorized recreational/all-terrain vehicle accidents Blunt traumatic vertebral artery
— Ejection from a vehicle injuries tend to occur at junctions
— Bicycle accident with an immovable object
between fixed and mobile segments
Low-Risk Findings That Allow for Further Evaluation With Range of Motion Testing
of vessels, as shearing forces are
Patients who DO NOT have one or more of the following should have radiographs:
particularly overwhelming in
• Simple, rear-end motor vehicle collision
these regions. The more common
• Patient in seated position in the emergency department
• Patient ambulatory at any time since the injury mechanisms that produce such forces
• Absence of midline neck tenderness are hyperflexion, hyperextension,
• Delayed onset of neck pain distraction, and facet dislocation forces.
Range of Motion Testing Cervical spine fractures that are more
Can the patient move the neck 45 degrees to the right and left (regardless of pain)? likely to have coexisting vertebral
If yes, then no imaging is required. artery injury are those that involve
the C1-C3 segment and the foramen

October 2018 n Volume 32 Number 10 7

 transversarium.23,27 In addition, carotid
artery injuries can lead to stroke-like
symptoms, amaurosis fugax, Horner
syndrome, and neck pain.23
Vascular surgery should be consulted
for any suspected vascular injury.
For patients with suspected blunt
cerebrovascular trauma, the Denver
criteria (Table 4) also can be used to
determine the need for screening CT
angiography. In addition to routine
laboratory studies, it is important to
obtain a basic metabolic panel, type
and screen, coagulation screen, and
platelet count, particularly for patients
taking anticoagulants and those who
may require radiological or surgical
intervention.23
TABLE 4. Denver Screening Criteria for Blunt Cerebrovascular Injury23
Signs and Symptoms of BCVI
• Arterial hemorrhage
• Cervical bruit
• Expanding hematoma in the neck
• Focal neurological deficits that do not correlate with head CT findings
• Stroke on secondary CT scans
Risk Factors for BCVI
• High-energy mechanism of injury
— Mid-face fractures: Le Fort II or III–type injuries
— Cervical-spine fracture patterns, including subluxations, fractures that extend
into the transverse foramen, and any fracture of C1-C3
— Basilar skull fracture with involvement of the carotid canal
• Diffuse axonal injury with GCS <8
• Near hanging with anoxic injury
• Seat belt sign or other soft-tissue injury in the neck, leading to significant swelling
and/or altered mental status

CRITICAL DECISION
which manifests as a sharp, stinging or with preserved cervical range of motion.
What are the most common burning pain down one of the arms, These cases can be marked by notable
transient neurological injuries and is usually due to a compression or weakness or decreased sensation in the
associated with c-spine trauma? traction force in the region of the neck affected arm; however, this weakness
Short-lived neck injuries include and shoulder. This type of injury can can be so transient that it resolves
“stingers” (sometimes known as occur when a player’s head is abruptly by the time the athletic trainer or
“burners”) and transient quadriplegia twisted toward or away from an impact physician evaluates the patient on the
(also known as cervical cord to one of the shoulders. The player often field. Lastly, pulses should be normal.
neurapraxia). These injuries can occur experiences sudden pain, as well as a The unilaterality, short duration of
in almost any sport but most often occur paresthetic sensation in the distribution symptoms, and relatively pain-free
in contact sports such as football and of a nerve down the unilateral arm. This range of neck motion can assist in
wrestling. Stingers are more common discomfort typically lasts seconds to discriminating between a stinger and a
and reportedly affect as much as minutes, and the majority of strength more serious SCI.6,29
50% of athletes involved in collision and sensation returns within 24 hours. By contrast, patients with transient
sports. Transient quadriplegia is much However, in some instances, it can take quadriplegia typically have a bilateral
less common, with an incidence of up to 6 weeks for strength and sensation burning and tingling pain, with an
approximately 1.3 per 10,000 athletes, to completely return.28,29 associated loss of strength and sensation
but it is notably more dangerous.28 Neck tenderness and muscle spasms in the affected arms and/or legs. This
A stinger is a neurapraxia of the may or may not be present in patients weakness can range from a mild decrease
cervical nerve roots or brachial plexus, with stingers, but they usually present in strength to complete paralysis, and
symptoms can last up to 36 hours.
Transient quadriplegia is usually caused
by a hyperextension injury to the neck,
as well as axial loading of the neck. It
is more commonly seen in patients that
have some degree of cervical spinal
n For an apneic patient with a suspected c-spine injury, follow the Advanced stenosis or disc protrusion.6,28
Trauma Life Support guidelines by maintaining in-line spinal immobilization, If an injury is due to transient
securing the airway, and then moving on to the rest of the primary survey. quadriplegia, strength and sensation will
n To determine which patients need c-spine imaging, use the Nexus criteria resolve, but it is difficult to know in the
or Canadian C-Spine Rule to guide the decision. early moments after an injury whether
a severe neurological deficit is present.
n Remember that stabilization and imaging of the spine should not take
Even athletes with a rapid return of all
precedence over life-saving diagnostic and therapeutic procedures.
neurological function should be carefully
n Stingers and transient quadriplegia are often diagnoses of exclusion. It
observed and prevented from returning
may be necessary to obtain imaging studies or a consultation with a spine
to play until after a spine specialist can
expert to rule out more serious conditions.
perform a complete evaluation.28 If an

8 Critical Decisions in Emergency Medicine

athlete has paralysis or a significant
neurological deficit, spinal precautions
should be instituted immediately, and
the athlete should be transported by
ambulance to the nearest emergency
department for further evaluation.
Emergency physicians must remember
that stingers and transient quadriplegia
are often diagnoses of exclusion. Many
times, patients have a severe neck strain
or herniated disc that mimics some of
the symptoms associated with these
transient processes. It is crucial that
more serious conditions are excluded
before making these diagnoses. Thus,
it may be necessary to obtain imaging
studies or to consult a spine expert. With
standard radiographs, nondisplaced
and minimally displaced fractures can
be difficult to see. Additionally, the
degree of cervical instability cannot be
accurately obtained on standard c-spine
x-rays, so a CT of the cervical spine
should be performed if more serious
conditions are suspected. An MRI is
required if suspicion of a herniated disc
injury, spinal stenosis, or spinal cord
contusion exists.28
CRITICAL DECISION
What has changed in the
management of patients with
c-spine injuries?
Once a physician suspects or diagnoses
a c-spine injury, a few key precautions
should be taken. First and foremost, the
cervical spine must be immobilized. If
the mechanism was significant enough
to cause a c-spine injury, a thorough
investigation must then be performed
to ensure that no additional, associated
injuries occurred. Throughout this
process, clinicians must ensure that
the patient remains hemodynamically
stable and that no signs or symptoms
suggest neurogenic or spinal shock.3
A consultation with a neurological
surgeon should be considered, and/or
the transfer of the patient to a facility
with neurosurgical capabilities should be
arranged, if needed.
Over the years, the administration
of methylprednisolone to patients with
spinal injuries has been the topic of
much debate. Although the drug was
once considered the standard of care,
there is limited evidence to support its
benefit in treating traumatic SCIs in
humans.6 Randomized, controlled trials
have shown limited efficacy and many
adverse outcomes for certain patient
groups that receive methylprednisolone
for acute SCI. In recent years, enough
evidence has mounted that the
administration of methylprednisolone
for the treatment of acute SCI is no
longer recommended. Furthermore, the
Food and Drug Administration has not
approved the use of methylprednisolone
for the treatment of acute SCI, as no
Class I or Class II medical evidence
supports its clinical benefit. However,
much Class I, II, and III evidence
exemplifies the harmful side effects,
including death, associated with high-
dose steroids.30
Evidence is also emerging regarding
the use of therapeutic cooling for
patients with acute SCIs. In 2011,
investigators found improved SCI
outcomes with mild hypothermia in a
rat model.31 Another recent prospective
study was done, in which 20 patients
with a complete SCI were treated with a
combination of surgical decompression,
glucocorticoid administration, and
regional hypothermia. These patients
experienced a better recovery rate
than expected for traditional forms of
treatment.32
Given the potential confounding
factors, how much of the recovery was
due to cooling alone is unclear. Again,
the benefit of steroid treatment for cord
injury was not supported with Class I
evidence, but the investigators felt
that research into the effects of cord
cooling should be expanded. An optimal
neuroprotective temperature was not
defined; however, other studies have also
been promising enough to encourage
further research to investigate the use of
cooling in patients with acute SCIs.6,32
Summary
Emergency physicians must be
able to identify and correctly manage
patients with suspected c-spine injuries,
including assessing concerning physical
examination findings and high-risk
mechanisms of injury. Clinical decision
rules — the NEXUS, CCR, and Denver
criteria — can help guide imaging and
management planning. In addition to
spinal cord and bony injuries, physicians
must be aware of common vertebral,
vascular, and soft-tissue injuries that
are associated with c-spine trauma.
They also must be familiar with updates
in treatment options. Since athletes
account for roughly 10% of SCIs in the
United States, emergency physicians
must be aware of which sports and
mechanisms place a patient at high risk
for injury.

n Ignoring high-risk patients who do not fit clinical decision rules. Patients with
severe osteoporosis, advanced arthritis, cancer, or degenerative bone disease
have a significant risk of c-spine injury and may warrant imaging, even without
the application of a clinical decision tool.
n Administering methylprednisolone for the treatment of an acute spinal cord
injury, which is no longer recommended.
n Failing to maintain a high index of suspicion for vascular and soft-tissue injuries
associated with c-spine injuries, especially when neurological symptoms
do not match head CT findings. Left undetected, these injuries can lead to
potentially fatal outcomes.
REFERENCES
1. Schroeder GD, Vaccaro AR. Cervical spine injuries in
the athlete. J Am Acad Orthop Surg. 2016 Sep;
24(9):e122-e133.
2. Williams MJ, Lockey AS, Culshaw MC. Improved
trauma management with advanced trauma life
support (ATLS) training. J Accid Emerg Med. 1997
Mar;14(2):81-83.
3. American College of Surgeons, Committee on
Trauma. ATLS: Advanced Trauma Life Support for
Doctors. 8th ed. Chicago, IL: American College of
Surgeons; 2008.
4. McGill J. Airway management in trauma: an update.
Emerg Med Clin North Am. 2007 Aug;25(3):603-
622,vii.
5. Walls RM. Airway management in the blunt trauma
patient: how important is the cervical spine?
Can J Surg. 1992 Feb;35(1):27-30.

October 2018 n Volume 32 Number 10 9

 CASE RESOLUTIONS
■ CASE ONE
The 24-year-old woman
thrown from a horse underwent an
assessment of her airway, breathing,
and circulation that revealed an
intact airway. She had nonlabored
and regular respirations, as well
as strong and equal pulses in all
four extremities. She was acting
appropriately. She had a 3-cm
occipital laceration, in addition to
significant midline tenderness in the
cervical spine upon palpation, but
no step-off, crepitus, or edema. No
carotid bruits were appreciated.
Given the patient’s midline
cervical tenderness, the cervical
collar was not removed. Because she
did not have any thoracic midline
tenderness, step-off, or lower-
extremity paresthesias, she was
cleared from use of the rigid spine
board. The remainder of the exam
showed 5/5 strength in the proximal
and distal muscle groups, in both
the upper and lower extremities. No
abnormalities were found on her
sensory exam.
Because her mechanism of injury
was a fall from over 5 feet and
6. Kanwar R, Delasobera BE, Hudson K, Frohna W.
Emergency department evaluation and treatment
of cervical spine injuries. Emerg Med Clin North Am.
2015 May;33(2):241-282.
7. Criswell JC, Parr MJ, Nolan JP. Emergency airway
management in patients with cervical spine injuries.
Anaesthesia. 1994 Oct;49(10):900-903.
8. Shatney CH, Brunner RD, Nguyen TQ. The safety
of orotracheal intubation in patients with unstable
cervical spine fracture or high spinal cord injury.
Am J Surg. 1995 Dec;170(6):676-680.
9. Robitaille A, Williams SR, Tremblay MH, Guilbert
F, Thériault M, Drolet P. Cervical spine motion
during tracheal intubation with manual in-
line stabilization: direct laryngoscopy versus
GlideScope videolaryngoscopy. Anesth Analg. 2008
Mar;106(3):935-941.
10. Turkstra TP, Craen RA, Pelz DM, Gelb AW. Cervical
spine motion: a fluoroscopic comparison during
intubation with lighted stylet, GlideScope, and
Macintosh laryngoscope. Anesth Analg. 2005 Sep;
101(3):910-915.
11. Hoffman JR, Wolfson AB, Todd K, Mower WR.
Selective cervical spine radiography in blunt
trauma: methodology of the National Emergency
X-Radiography Utilization Study (NEXUS). Ann Emerg
Med. 1998 Oct;32(4):461-469.
12. Spitzer WO, Skovron ML, Salmi LR, et al. Scientific
monograph of the Quebec Task Force on Whiplash-
Associated Disorders: redefining “whiplash” and its
management. Spine (Phila Pa 1976). 1995 Apr 15;
20(8 Suppl):1S-73S.
10 Critical Decisions in Emergency Medicine
her helmet sustained visible damage,
concern for intracranial injury existed,
so a noncontrast head CT was ordered
in addition to a c-spine CT. The head
CT did not reveal any evidence of
acute bleeding or fractures; the c-spine
CT did not reveal any fractures,
dislocations, or obvious areas of
instability.
The patient continued to complain
of neck discomfort and a feeling of
being unable to support her head.
Since the imaging was unremarkable
for vertebral pathology, concern
for possible ligamentous injury was
investigated. She continued to have
normal neurovascular exams and
remained hemodynamically stable.
She was discharged on a nonsteroidal
anti-inflammatory medication in a
Miami J cervical collar, and a follow-up
appointment was made to see a spine
surgeon.
■ CASE TWO
The 16-year-old football player’s
airway, breathing, and circulation were
intact. A head-to-toe exam was only
significant for decreased sensation
along the ulnar side of his left forearm
13. American Spinal Injury Association. International
Standards for Neurological Classification of Spinal
Cord Injury. Revised ed. Chicago, IL: American
Spinal Injury Association; 2000: 1-23.
14. Walter J, Doris PE, Shaffer MA. Clinical presentation
of patients with acute cervical spine injury. Ann
Emerg Med. 1984 Jul;13(7):512-515.
15. Domeier RM, Evans RW, Swor RA, et al. The reliability
of prehospital clinical evaluation for potential spinal
injury is not affected by the mechanism of injury.
Prehosp Emerg Care. 1999 Oct-Dec;3(4):332-337.
16. Daffner RH. Helical CT of the cervical spine for
trauma patients: a time study. AJR Am J Roentgenol.
2001 Sep;177(3):677-679.
17. Hunter BR, Keim SM, Seupaul RA, Hern G. Are
plain radiographs sufficient to exclude cervical
spine injuries in low-risk adults? J Emerg Med. 2014
Feb;46(2):257-263.
18. Roberge RJ, Samuels JR. Cervical spine injury in
low-impact blunt trauma. Am J Emerg Med. 1999
Mar;17(2):125-129.
19. Kreipke DL, Gillespie KR, McCarthy MC, Mail
JT, Lappas JC, Broadie TA. Reliability of indications
for cervical spine films in trauma patients. J Trauma.
1989 Oct;29(10):1438-1439.
20. Stiell IG, Wells GA, Vandemheen KL, et al. The
Canadian c-spine rule for radiography in alert
and stable trauma patients. JAMA. 2001 Oct 17;
286(15):1841-1848.
21. Steill IG, Clement CM, McKnight RD, et al. The
Canadian c-spine rule versus the NEXUS low-risk
criteria in patients with trauma. N Engl J Med. 2003
Dec 25;349(26):2510-2518.
22. Desouza RM, Crocker MJ, Haliasos N, Rennie A,
Saxena A. Blunt traumatic vertebral artery injury: a
clinical review. Eur Spine J. 2011 Sep;20(9):1405-1416.
and 3/5 muscle strength in flexion of
his left elbow. It was reassuring that
he did not lose consciousness during
the incident and was ambulatory
immediately afterward; however,
the development of decreased
muscle strength after the injury was
concerning.
Fortunately, the clinician found
no evidence of cervical step-offs
or midline tenderness, and the
patient had full and complete
range of motion, with only mild
discomfort. The patient’s ability
to fully range his neck, in addition
to being ambulatory after the fall,
made a transient neurological
injury more likely than a significant
SCI. Given that his symptoms
were unilateral and he had some
remaining strength in the affected
extremity, the emergency physician
suspected he had a stinger. The boy
was monitored in the emergency
department as his paresthesias
resolved, and his strength improved
to 4+/5 in the affected extremity.
He was ultimately discharged and
instructed to follow up with his
team physician.
23. Biffl WL, Cothren CC, Moore EE, et al. Western
Trauma Association critical decisions in trauma:
screening for and treatment of blunt cerebrovascular
injuries. J Trauma. 2009 Dec;67(6):1150-1153.
24. Taneichi H, Suda K, Kajino T, Kaneda K. Traumatically
induced vertebral artery occlusion associated with
cervical spine injuries: prospective study using
magnetic resonance angiography. Spine (Phila Pa
1976). 2005 Sep 1;30(17):1955-1962.
25. Cothren CC, Moore EE, Biffl WL, et al. Cervical spine
fracture patterns predictive of blunt vertebral artery
injury. J Trauma. 2003 Nov;55(5):811-813.
26. Fassett DR, Dailey AT, Vaccaro AR. Vertebral artery
injuries associated with cervical spine injuries: a
review of the literature. J Spinal Disord Tech. 2008
Jun;21(4):252-258.
27. Bailes JE, Hadley MN, Quigley MR, Sonntag
VK, Cerullo LJ. Management of athletic injuries of
the cervical spine and spinal cord. Neurosurgery.
1991 Oct;29(4):491-497.
28. Cantu RC. Stingers, transient quadriplegia, and
cervical spine stenosis: return to play criteria. Med
Sci Sports Exerc. 1997 Jul;29(7 Suppl):S233-S235.
29. Resnick DK. Updated guidelines for the management
of acute cervical spine and spinal cord injury.
Neurosurgery. 2013 Mar;72 Suppl 2:1.
30. Hulbert RJ, Hadley MN, Walters BC, et al.
Pharmacological therapy for acute spinal cord injury.
Neurosurgery. 2013 Mar;72 Suppl 2:93-105.
31. Kao CH, Chio CC, Lin MT, Yeh CH. Body cooling
ameliorating spinal cord injury may be neurogenesis-,
anti-inflammation- and angiogenesis-associated in
rats. J Trauma. 2011 Apr;70(4):885-893.
32. Hansebout RR, Hansebout CR. Local cooling for
traumatic spinal cord injury: outcomes in 20 patients
and review of the literature. J Neurosurg Spine. 2014
May; 20(5):550-561.
 The LLSA
Literature Review
Shared Decision Making
By Justin Boyle, AWS2; and Daphne Morrison Ponce, MD, LCDR
Naval Medical Center, Portsmouth, Virginia
Reviewed by Andrew J. Eyre, MD, MHPEd
Hess EP, Grudzen CR, Thomson R, Raja AS, Carpenter CR. Shared decision-making in the emergency department: respecting patient autonomy when seconds count. Acad Emerg Med.
2015 Jul;22(7):856-864.

Shared decision making (SDM) is
the process by which collaborative
health care choices are made by
patients and their physicians. Such
decisions are based on both scientific
evidence and each patient’s individual
values. Researcher Valerie Billingham
famously summed up SDM at the
1998 Salzburg Global Seminar by
coining the phrase “nothing about
me without me.” In other words, any
decision made regarding the care of
a patient must include input from the
balance between these components
differentiates between three decision-
making models (ie, paternalistic,
shared, and informed), which must be
tailored to each individual scenario.
Finally, Charles et al defines four
criteria that must be present before
SDM can be achieved:
1. At least two participants are
involved.
2. Both participants share
information.
3. Both participants work together
In summary, shared decision
making in the emergency department
can help patients feel comfortable,
informed, and involved in their own
medical care. Emergency physicians
should incorporate these important
principles into their practice whenever
possible.
***
The views expressed in this article are those of the
authors and do not necessarily reflect the official
policy or position of the Department of the Navy,
Department of Defense, or the United States

patient or his/her proxy. to build a consensus. Government.

Similarly, a survey conducted by
the Picker Institute identified eight
traits that can help reassure patients
that they are in a safe, high-quality
medical setting. SDM fulfills these
specifically identified characteristics,
including respect for patients’ values,
integration of care, communication
and education, and involvement
of friends or family. Although the
approach has been embraced by
emergency physicians, SDM can be
challenging to implement in the fast-
paced acute setting.
Shared decision making is
typically described using the Charles
et al conceptual framework, which
describes three core components
of SDM: information exchange,
deliberation, and choice. The
4. An agreement on treatment is We are military service members. This work was
reached. prepared as part of our official duties. Title 17
While other strategies might be U.S.C. 105 provides that “Copyright protection
under this title is not available for any work of the
appropriate in a given situation, they
US Government.” Title 17 U.S.C. 101 defines a US
cannot satisfy the requirements of Government work as a work prepared by a military
shared decision making without these service member or employee of the US Government
key components. as part of that person’s official duties.
KEY POINTS
n Shared decision making can be applied to both treatment and diagnostic
decisions in the emergency department.
n Effective communication is key. Communication with patients, family,
friends, and other physicians is crucial to creating a safe, effective, and
smooth operation.
n SDM involves two parties who share information and work to build a
consensus decision.
n SDM can occur with the patient or the patient’s health care proxy.

Critical Decisions in Emergency Medicine’s series of LLSA reviews features articles from ABEM’s 2018 Lifelong Learning and
Self-Assessment Reading List. Available online at acep.org/llsa and on the ABEM website.

October 2018 n Volume 32 Number 10 11

 The Critical Image
A 41-year-old woman with asthma and diabetes presents with By Joshua S. Broder, MD, FACEP
hyperglycemia and an ongoing fever that she says has been as high Dr. Broder is an associate professor and the
as 38.3°C (101°F). She complains of chronic left facial pain, which was residency program director in the Division
of Emergency Medicine at Duke University
reportedly diagnosed as sinusitis about 3 months earlier and has worsened Medical Center in Durham, North Carolina.
in the last few days. She reports chronic nasal congestion and rhinorrhea,
Case contributor: Kendrick Kennedy, MD
with no improvement following a multitude of oral antibiotics, including
azithromycin, clindamycin, levofloxacin, cefdinir, doxycycline, and trimethoprim-sulfamethoxazole. She has also received oral
prednisone without symptom resolution.
The patient’s vital signs are blood pressure 135/82, heart rate 98, respiratory rate 16, temperature 36.2°C (97.2°F), and oxygen
saturation 100% on room air. Although she is well-appearing, tenderness is noted in the left maxillofacial region, and swelling
can be seen in the left infraorbital region. Her extraocular movements are normal, and she has no proptosis. There is no
purulent discharge from the nares. Laboratory tests reveal a glucose level of 563, with an anion gap of 13. Her WBC count is
normal. The patient has a history of anaphylaxis when receiving iodinated IV contrast, so the emergency physician orders a
noncontrast CT scan.

A Abnormal B Abnormal
Normal maxillary Normal maxillary
maxillary sinus, opacified maxillary sinus, opacified
sinus, sinus,
air-filled air-filled

Other soft
tissues for
comparison

A. Noncontrast facial CT, axial image, soft-tissue window. The right maxillary sinus is air-filled (black, normal); the left maxillary
sinus is opacified. Without IV contrast, mucosal tissue and fluid within the sinus have the same density (similar to other soft
tissues) and cannot be readily distinguished. If IV contrast is administered, inflamed mucosa will enhance (become brighter),
while fluid will not.
B. Noncontrast facial CT, axial image, bone reconstruction algorithm, and bone window. A specific bone reconstruction
algorithm and bone windows improve the resolution of skeletal detail, increasing the detection of any bone involvement.

CASE RESOLUTION
The patient underwent endoscopic sinus surgery, which revealed a necrotic nasal mucosa. Pathology
confirmed invasive mucormycosis, and the patient underwent extensive debridement, followed by
intravenous and topical amphotericin therapy.

1. Don’t obtain radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis. Choosing Wisely website. http://www.choosingwisely.org/clinician-
lists/american-academy-otolaryngology-head-and-neck-surgery-radiographic-imaging-for-uncomplicated-acute-rhinosinusitis. Published February 21, 2013. Updated April 3, 2018.
2. Aribandi M, McCoy VA, Bazan C 3rd. Imaging features of invasive and noninvasive fungal sinusitis: a review. Radiographics. 2007 Sep-Oct;27(5):1283-1296.

12 Critical Decisions in Emergency Medicine

 C D
Abnormal Enhancement
Normal maxillary Normal of sinus
maxillary sinus, maxillary mucosa
sinus, opacified sinus,
air-filled air-filled

Fluid Lack of
enhancement

C. Noncontrast facial CT, coronal image, bone reconstruction algorithm, and bone window. The opacified left maxillary sinus
is again seen; however, the fluid and mucosa cannot be distinguished from one another.
D. T1-weighted MRI with fat suppression sequence and IV gadolinium contrast; coronal image. On T1-weighted images,
fluid, air, and calcified bone are black. Fat normally appears bright on T1-weighted images but appears black when fat
suppression techniques are applied. Tissues with contrast enhancement, such as the thickened mucosa of the left maxillary sinus,
are bright white. Areas within the mucosa with a lack of enhancement indicate necrosis, as contrast is not delivered to devitalized
tissue.

KEY POINTS
n Acute sinusitis, defined as up to
4 weeks of purulent nasal drainage,
nasal obstruction, and facial
pain, generally does not require
imaging. The American Academy
of Otolaryngology – Head
and Neck Surgery Foundation
discourages radiographic
imaging for patients who meet
uncomplicated acute rhinosinusitis
criteria.1 By contrast, acute
sinusitis in immunocompromised
n CT with IV contrast can reveal
hosts and chronic sinusitis often
require imaging, as the differential
diagnosis includes malignancy,
fungal disease, and invasive
bacterial species.
n The patient in this case has
several high-risk features that
suggest the need for imaging
and provide clinical context for
image interpretation. The duration
of her symptoms is prolonged,
suggesting chronic sinusitis with
its complex differential diagnosis.
She also has a history of steroid
use and diabetes, which can
create immune compromise and a
predisposition to fungal infections.
The failure of oral antibacterial
drugs also suggests that her
symptoms might be a consequence
of a fungal infection, resistant
bacterial species, or malignancy.
A variety of fungal species can
infect diabetic patients, sometimes
with sudden fulminant progression
and death (with mortality as high as
50%-80%). Fungi can invade blood
vessels and spread intracranially,
even when the bony walls of the
sinuses are intact.2
sinus mucosal thickening and
enhancement, but even without
IV contrast, CT will reveal the
presence of fluid and/or mucosal
edema, and bony destruction
(when present). Fluid and
thickened mucosa have a similar
noncontrast appearance and
can be difficult to differentiate;
in these images, for example,
the contents of the left maxillary
sinus appear as a homogeneous
gray area, similar to the adjacent
soft tissues. Other noncontrast
CT clues can include increased
density (stranding) of fat adjacent
to infected sinus spaces. When the
clinical context suggests a mass
or infectious sinusitis, noncontrast
CT may provide sufficient initial
information for patients for
whom iodinated contrast is
contraindicated; however, without
IV contrast, CT cannot identify
vascular complications, including
cavernous sinus thrombosis.
n When CT with IV contrast is
performed, enhanced and
thickened mucosa indicates
inflammation. If focal areas of
mucosa do not enhance, this can
indicate necrosis concerning for
fungal organisms. Fluid within the
sinus will not enhance and can be
distinguished from the adjacent
enhancing mucosa.2
n MRI can provide more soft-tissue
information than CT (particularly
compared with noncontrast
CT) and is generally considered
superior to CT for the evaluation
of orbital and intracranial
extension. In the MRI image
above, areas of necrotic mucosa
concerning for fungal infection
are identified (not seen on the
noncontrast CT images).2

October 2018 n Volume 32 Number 10 13

 The Critical Procedure
Excision of Thrombosed External Hemorrhoids
By Steven Warrington, MD, MEd
Orange Park Medical Center, Orange Park, FL

Despite the self-limiting nature of thrombosed external hemorrhoids,

acute management with excision and clot removal can improve symptoms
immediately. External hemorrhoids can be easily differentiated from
internal hemorrhoids by their characteristic squamous epithelia and
sensory innervation. (Internal hemorrhoids, on the other hand, are
covered by mucosa and lack sensory innervation.)

Contraindications
n Bleeding disorders/anticoagulation
(relative)
n Overlying infection
n Patient’s inability to tolerate the
procedure
n Immunodeficiency
n Internal hemorrhoid
Benefits and Risks
The primary benefit of excising
a hemorrhoid is improved short-
term symptom control. In addition,
the procedure can reduce the risk of
appendageal skin tag formation, which
can cause long-term complications. Risks
of the procedure include bleeding and
infection, as well as the inappropriate
excision of misdiagnosed tissue (eg, an
internal hemorrhoid, nonthrombosed
hemorrhoid, or skin tag).
Alternatives
Conservative therapy with sitz baths,
topical medications, diet modification,
and stool softeners generally lead to
resolution, but this can take weeks.
Although a surgical consultation can be
requested, these generally are reserved
for patients with suspected strangulated
hemorrhoids.
Reducing Side Effects
It is important to confirm that
the hemorrhoid is both external and
thrombosed prior to excising the clot
in the emergency department. The
diagnosis can usually be confirmed
by evaluating the skin overlying the
hemorrhoid (external hemorrhoids will
have a squamous covering, not a mucosal
covering). Thrombosed hemorrhoids
can be differentiated from non-
thrombosed hemorrhoids by palpation;
the thrombosis is easily palpable as a
firm nodule or cord.
Because the procedure can often
be uncomfortable and embarrassing
for patients, premedication should be
considered. Topical anesthetics (eg,
lidocaine and prilocaine cream, or
lidocaine with epinephrine and tetracaine)
can reduce the pain of a local anesthetic
injection. Benzodiazepines (oral or
injectable) can alleviate some of the
anxiety associated with the procedure.
A long-acting agent generally is preferred
for anesthesia (eg, benzocaine). Some
clinicians prefer to use a mixture
containing epinephrine, which can
TECHNIQUE
1. Consider premedication with
topical anesthetics or systemic
medications (for anxiolysis or
severe pain).
2. Arrange the patient in a prone
position while ensuring adequate
lighting of the rectal area. An
assistant should hold the buttocks
apart to stabilize the patient and
allow visualization of the field.
3. Clean the overlying area and inject
the anesthetic superficially over the
thrombosis and the entire length
decrease bleeding; however, the author
routinely performs the procedure
without encountering this complication.
A mixture of short- and long-acting
anesthetics might be beneficial.
An elliptical incision can reduce the
likelihood of complications (eg, reclosure
or incomplete clot expulsion) and is
preferable to a simple linear incision.
Special Considerations
Patients should minimize straining
and use medications and diet to avoid
constipation. Sitz baths and topical
agents can also help manage symptoms.
Any additional ulcerations usually
can be removed when the thrombosed
tissue is excised. Ongoing bleeding
can be controlled with silver nitrate
or additional injections with an
epinephrine-containing anesthetic.
of the planned excision. Consider
injecting the periphery of the
hemorrhoid as well.
4. Check for sensation and re-
anesthetize or wait, if indicated.
5. Make an elliptical incision and excise
the tissue overlying the thrombosis.
6. Apply gentle pressure to milk out the
thrombosis, using forceps to remove
any remaining pieces.
7. Dress the wound with gauze and
instruct the patient on wound care
and follow-up.

14 Critical Decisions in Emergency Medicine

 Fighting the
Good Fight
Novel Ways to Avoid and
Resolve Patient Conflicts

LESSON 20

By Andrew Lawson, MD, FACEP

Dr. Lawson is the director of quality assurance for the Emergency Physicians Group
at Mission Hospital Regional Medical Center, and a certified physician development
coach in South Orange County, California.
Reviewed by Michael Beeson, MD, MBA, FACEP

OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Change the way you see and interact with conflict.
n How should conflict be approached in the
2. Understand how and why most conflict and patient
emergency department?
dissatisfaction occurs.
3. Use a set of skills and tips to improve patient satisfaction. n What are the key ways to improve patient
4. Describe a simple mnemonic device to use when fielding satisfaction?
patient complaints.
n What process should be in place to field patient
5. Resolve and rebound from stressful patient encounters.
complaints?

FROM THE EM MODEL

20.0 Other Core Competencies of the Practice
of Emergency Medicine
20.1 Interpersonal and Communication Skills

Compassion fatigue stemming from difficult interactions with patients is a principal — and often avoidable
— cause of emergency physician burnout. Stress related to patient conflicts, satisfaction scores, and complaints
can persist, even decades into practice. By arming themselves with the necessary communication tools, clinicians
can navigate and rebound from these tense interpersonal encounters more readily.

October 2018 n Volume 32 Number 10 15

 CASE PRESENTATIONS
■ CASE ONE
A pregnant 29-year-old woman
presents in her first trimester with
profuse vaginal bleeding. She is
the third of six patients awaiting
evaluation as the emergency
physician begins his shift. As he
picks up the first chart, he overhears
the woman’s husband yelling for
the nurse: “My wife is bleeding to
death. Can someone please help?”
The physician hurries into the room
and sees the patient sitting up on a
gurney, anxious but with normal
vital signs. The husband hovers over
the nurse as she puts an IV into the
patient’s arm. The physician offers
reassurance, obtains a history,
performs a physical examination,
and orders appropriate laboratory
tests.
When the patient returns from
ultrasound, she is bleeding more
profusely and complains of increasing
pain. The physician calls the woman’s
OB/GYN, who agrees to come
down to see the patient. Shortly
CRITICAL DECISION
How should conflict be
approached in the emergency
department?
Most emergency physicians
flee, withdraw, dismiss, or employ
other strategies to avoid unpleasant
interactions with patients. While these
conversations can be unquestionably
stressful and awkward, they can also be
great opportunities for growth — even
celebration.
Our aptitude for coping with
conflict stems, in part, from emotional
intelligence, our ability to identify
and manage our own emotions and
the emotions of others. There are a
variety of assessment tools that can
help clinicians measure their capacity
to discern between different feelings
and emotionally adapt to different
environments. Emotional intelligence
16 Critical Decisions in Emergency Medicine
after arrival, the OB/GYN becomes
visibly frustrated when she can’t
find instruments to her liking in the
emergency department. She appears to
be distracted, and abruptly announces
that she’s “short on time” and wants to
“get the show on the road.”
■ CASE TWO
A 37-year-old woman presents with
upper respiratory symptoms that began
2 days ago. She has normal vital signs;
a normal review of systems, except for
rhinorrhea and a nonproductive cough;
a normal physical examination; and
no medical history. The emergency
physician explains to the patient that
she believes she has a viral upper
respiratory infection (URI), does not
need antibiotics, and should follow up
with her primary care physician if the
symptoms do not resolve within the
next few days.
The physician is about to hand the
discharge paperwork to the nurse,
but the nurse says that the patient has
some additional questions — that the
discharge plan has not been discussed.
is comprised of four principal
components: self-awareness, self-
management, social awareness, and
relationship management (Figure 1).
In his work as an executive coach,
the author has most frequently noted
physician deficiencies in self- and social
awareness, pitfalls that can cause
conflict with both staff and patients.
With deliberate practice, however,
most of us can improve our ability to
manage interpersonal relationships
judiciously and empathetically. For
example, the author often plays a game
with his emergency department scribe
called “Read the Room,” in which they
discuss the behaviors they’ve observed
after leaving a patient encounter. What
was the emotional state of the patient
and/or their family members? What
could be understood from their body
posture, tone of voice, etc.?
It also is important to remember
When the physician returns to the
room, the patient is very upset
and demands antibiotics for her
symptoms.
■ CASE THREE
A 55-year-old man arrives in
excruciating pain. He is writhing
on the gurney as the emergency
physician enters the room. The
patient states that he has never
experienced pain like this before;
he is tachycardic and hypertensive.
The physician calls the nurse into the
room to start an IV and to administer
pain medication. He then orders
blood tests, a urine test, and a CT
scan of the abdomen and pelvis,
which shows a 2-mm right-sided
ureterovesical junction calculus. The
patient is sent home with appropriate
medications and instructions for
follow-up.
Six weeks later, the patient calls to
complain about the care he received.
He does not understand why so many
tests were ordered, and he believes
that he was misdiagnosed.
that it is often easier to prevent conflict
than to resolve it. A number of common
attitudes increase the risk of discord,
including poor communication, a
lack of empathy, intolerance, self-
interest, prejudice, and cultural threats;
however, many of these psychological
traps can be avoided.1,2
CLAP is one mnemonic device
that may be useful when interacting
with patients or their family members
(Figure 2). When starting any
conversation, an objective approach
that involves curiosity (C), listen (L),
a desire to understand the aspirations
of the other person (A), and a refusal
to take the conflict personally (P)
is necessary to effectively avoid
problematic encounters.
C — CURIOSITY
What if physicians approached all
conversations with a nonjudgmental
attitude, openness, and directness?
Rather than anticipating conflict
and entering the situation with fear
and anxiety, physicians can make a
conscious choice to handle patient
interactions with genuine curiosity.
L — LISTEN
Conflict inevitably occurs when one
party feels misunderstood. It is difficult
to hear the patient while actively —
and prematurely — formulating an
answer in your own head. Listen
to understand, not to respond!
Affirmative statements such as “Ok,
this is what I hear you saying…” can go
a long way when trying to convey your
interest in solving the patient’s problem.
Some communication experts suggest
not moving on until the speaker agrees
that you understand what they are
trying to say.
A — ASPIRATIONS
Set aside all assumptions and
preconceived notions about the other
person. Ask them to explain what
they aspire to gain from this situation.
What do they really want? What is
their desired end result?
P — PERSONAL (It’s not!)
Conflicts cannot be resolved when
they are taken personally! When
confronted, it is easy to become
defensive, feel victimized, or dismiss
responsibility. Resist the urge to
blame the patient or yourself, and
instead focus on understanding what
the other person is feeling or trying to
convey.
CRITICAL DECISION
What are the key ways to
improve patient satisfaction?
Emergency physicians must
remember that the stress of the visit
has put most patients into flight,
fight, or freeze mode; they literally
may be unable to hear and process the
information being relayed to them in
the emergency department. 3,4 While
it’s just another day at work for the
clinician, it is important to remember
that patients and their families often
arrive in a state of crisis. This stress-
related amnesia is one reason why
patients so commonly claim that they
don’t remember conversations that
they’ve just had with the physician!
Slow down, embrace the need to
repeat information, and make sure
that patients understand, to the best
of their ability, the information that is
being conveyed.
Ensure Your Own Satisfaction
Emergency physicians have been
taught the great importance of patient
satisfaction, but how content can
patients be when their physician is
unhappy? If your personal satisfaction
at work scores a 2 out of 5, you
cannot expect patients’ satisfaction
scores to be any higher. First and
foremost, focus on improving your
own happiness at work. It starts with
you. What can you and your group do
to meet the needs of the staff? Positive
changes will serve you — and your
patients — well.
What Does the Patient Want?
Emergency physicians routinely
question what symptoms prompted
their patients’ visits. Instead of asking
why they’re there, consider asking
what they are hoping to get out of their
time in the emergency department. An
honest response can be a good starting
point for the medical evaluation and

FIGURE 1. Emotional Intelligence Domains and Competencies11

RECOGNITION REGULATION

Self-Awareness Self-Management
COMPETENCE
PERSONAL

ü Self-confidence ü Getting along well with others

ü Awareness of your emotional state
ü Recognizing how your behavior impacts
others
ü Paying attention to how other influence
your emotional state
COMPETENCE
ü Handling conflict effectively
ü Clearly expressing ideas and information
ü Using sensitivity to understand another
person’s feelings (empathy)

Social Awareness Relationship Management

SOCIAL

ü Picking up on the mood in the room
ü Caring about what others are going through
ü Hearing what the other person is really
saying
ü Getting along well with others
ü Handling conflict effectively
ü Clearly expressing ideas/information
ü Using sensitivity to understand another
person’s feelings (empathy)

October 2018 n Volume 32 Number 10 17

 of communication (7%). Tone of voice
FIGURE 2. CLAP Mnemonic for Productive Conversations (38%) and nonverbal behavior (55%)
account for the majority of information
communicated during any conversation.7
C Approach all conflicts with curiosity, When addressing patients and their
families, it is essential to slow down,
a nonjudgmental attitude, open­
CURIOSITY ness, and directness.
pause, and sit. Your tone of voice, eye
contact, and physical gestures should
convey that you are fully present and
completely focused on the patient,
especially during the initial encounter.

L When speaking with patients, listen

CRITICAL DECISION
What process should be
LISTEN to understand — not to respond. in place to field patient
complaints?
In most emergency departments,
one physician is elected to handle all
complaints and quality issues for the

A Ask patients to explain what they

aspire to gain from the visit.
ASPIRATIONS
P Remember that these conflicts are
PERSONAL not personal! Defensiveness can
destroy effective communication.
(It’s not!)
ultimate disposition of the patient,
and can open the door to meaningful
conversations about a host of clinical and
social concerns.
What Powerful Questions
Should Be Asked?
Some important questions to ask
— questions often not taught during
residency training — include the
following:5,6
• What is the main reason you came
to see us today, and why are you
concerned?
• Do I have the details of your story
right?
• Is there anything else going on in
your life that might be relevant to
today’s visit?
• What would you like to get out of
your visit?
• Do you plan to make any changes
going forward?
• Do you understand your
medications, their purpose, and the
doses?
• Does what I said make sense, and do
you have any other questions?
It’s Not What You Say,
But How You Say It
The vast majority of communication
is nonverbal and, therefore, subject to
interpretation. In 1967, psychologist
Albert Mehrabian described the
paramount role that words, tone
of voice, and nonverbal cues play
in an individual’s ability to convey
feelings, attitudes, and goals. While
it might be shocking to most “left-
brainers,” research indicates that
words are the least important aspect
group. These representatives, who
seldom have had the benefit of formal
conflict management training, often
fumble through uncomfortable patient
encounters with the singular goal of
ending them as quickly as possible.
Discussions like this one are common:
Mrs. Jones: “I can’t believe
that you call yourselves doctors.
You didn’t even give my daughter
an antibiotic for her fever.”
Doctor: “Mrs. Jones, that is
not how medicine is practiced…”
Conversations like this one can
quickly devolve into tense, heated
exchanges. By implying that patients or
their family members are simply wrong,
you have set the stage for distrust,
defensiveness, and even outright
hostility. It is nearly impossible to have
a productive conversation by insulting
a patient’s intelligence, judgment, pride,
or self-respect. Such exchanges only
affirm any negative assumptions that
patients already have about medical
providers or the health care system in
general.8,9
The LATE mnemonic device can
help when entering into a potentially
problematic conversation:
L — LISTEN
Spend the majority of the
conversation listening. Identify
yourself, ask patients to describe their
experiences, actively listen, make
eye contact, and demonstrate your
engagement by occasionally nodding

18 Critical Decisions in Emergency Medicine

and offering verbal reassurances like
“I understand” or “I would be upset, FIGURE 3. LATE Mnemonic for Conflict De-escalation
too.” Less talking and more listening
is a key component of any successful
interaction. Patients should be allowed
to “talk themselves out.” When they
L Spend the majority of the
conversation listening.
feel they’ve been heard, patients LISTEN
frequently report satisfaction with their
visit, even if their complaints have not
been fully addressed. As bestselling self-
help author Dale Carnegie said:
“Most people trying to win others
to their way of thinking do too much A Use expressions such as “I under­-
stand your frustration” or “I can
talking themselves. Let the other ACKNOWLEDGE understand your anger” to validate
people talk themselves out ... ask
and the patient’s feelings and confirm
them questions ... if you disagree
APOLOGIZE their sense of importance.
with them, you may be tempted to
interrupt. But don’t. It is dangerous.
They don’t pay attention to you
while they still have a lot of ideas
of their own crying for expression.
So listen patiently and with an open
T Always thank patients and their
family members for voicing their
mind. Be sincere about it. Encourage THANK concerns.
them to express their ideas fully.”10
Another useful communication
technique is mirroring, in which
the speaker’s words and feelings are
paraphrased and repeated back to
them. For example, the physician E Ask patients if they have any
can affirm, “This is what I hear you specific requests, and clarify what
saying.... Is that accurate?” Mirroring
END
they hope to get out of their visit.
can build rapport and de-escalate tense RESULT(S)
conversations by demonstrating that
you are interested in seeing the situation
through the patient’s eyes.
necessarily an admission of fault. Often their concerns. Their comments can
A — ACKNOWLEDGE
the following phrases are all that need be validated by explaining that the
and APOLOGIZE
to be said: “I am sorry that you feel discussion will help the emergency
Patients can be acknowledged with
that way” or “I am so sorry that you department better address similar issues
expressions such as “I understand your
had to go through that.” in the future.
frustration” or “I can understand your
anger.” It is paramount to validate T — THANK E — END RESULT(S)
the patient’s feelings and confirm Patients and their family members Complaints are often nothing more
their sense of importance. This is not should always be thanked for voicing than unspoken requests. Be sure to
ask patients if they have any specific
needs, and reassure them that their
concerns will be taken seriously. These
conversations usually should end with a
statement of next steps; however, when
patients feel that they have been heard,
n CLAP to celebrate — embrace conflict as an adventure and an opportunity to they often believe the issue has already
enhance communication and provide a better patient experience. been addressed to their satisfaction.
n Pause, slow down, and be repetitive in patient interactions. Remember that
Summary
patients and family members are likely in flight, fight, or freeze mode and are
unable to easily process information. While conflict is something most
n Be LATE in responding to patient complaints — let patients do the talking. of us try to avoid, it can be a powerful
opportunity for growth. Reframing

October 2018 n Volume 32 Number 10 19

 CASE RESOLUTIONS
■ CASE ONE
When assessing the 29-year-old
woman with the threatened
miscarriage, the physician witnessed
the conflict between the husband
and nurse but immediately entered
the room with curiosity and without
judgment. He greeted and shook
hands with the patient and her
husband before sitting down to listen.
He mirrored them and restated what
he heard them say — summarizing
their concerns and then explaining
the plan for diagnosis and treatment.
When the patient was away getting
her ultrasound, the physician sat
with the husband, acknowledging his
concerns and his deep desire for the
pregnancy to go forward.
In turn, the nurse remembered to
not let the situation get personal. She
interrupted the frustrated OB/GYN
by introducing herself: “Hi, my name
conflict as an adventure and an
opportunity to enhance communication
is key to emergency physicians’ success
with patients and staff. If physicians
are unsatisfied, certainly patients will
be, too.
First, clinicians must develop ways
to improve their own happiness at
work. Second, they must recognize that
emergent patients are in flight, fight, or
freeze mode, which compromises their
ability to easily process information.
Physicians must be patient, slow down,
n Forgetting that patients are experiencing an emergency situation. Pause and be
empathetic to their concerns.
n Engaging in a heated debate during a patient complaint interaction.
n Neglecting to ask more and talk less. Don’t leave your patients without asking at
least one open-ended question.
20 Critical Decisions in Emergency Medicine
is Laura. I am the charge nurse today
in the emergency department. I don’t
think we’ve met. It’s nice to meet you.
How can I be of assistance?” After the
examination, the OB/GYN thanked her
for her kindness and help.
■ CASE TWO
When the woman with the viral
URI appeared to be confused by her
discharge plan, the emergency physician
asked the nurse to join him in the room
to meet with the patient. Remembering
that the patient was in flight, fight, or
freeze mode and therefore not able to
easily absorb information, the physician
sat down at the bedside and introduced
herself again; she intentionally softened
and slowed the pace of her voice and
body movements. She paused and asked
open-ended questions to help the patient
absorb the instructions.
pause, and repeat information clearly so
that instructions can be absorbed and
understood.
Because fielding patient complaints
is stressful, it is not unusual to want
to justify and maybe even lash out at
the patient who complained. Perhaps,
emergency physicians should follow
the lead of Walt Disney, who would
routinely ask guests leaving Disneyland:
“How can we make your experience
better next time?” The process of
addressing patient complaints is a
■ CASE THREE
The quality assurance director
of the group called the 55-year-old
man who had complained about
“unnecessary” tests and misdiagnosis.
The physician introduced himself,
thanked the patient for his concerns,
and told him that he wanted to learn
how the emergency department
could better serve its patients. He
listened to the patient for 15 minutes,
intermittently saying “uh-huh” and
“I see” to affirm that he was listening
intently. He reassured the patient
that his concerns had been heard and
were appreciated. He also relayed
that he would share the patient’s
feedback with the physician who had
treated him. At the end of the call,
he clarified the patient’s desired end
result.
tremendous opportunity to “do better.”
REFERENCES
1. Garmel GM. Conflict resolution in emergency
medicine. In: Adams JG, Barton ED, Collings
JL, DeBlieux PMC, Gisondi MA, Nadel ES,
eds. Emergency Medicine: Clinical Essentials.
Philadelphia, PA: Saunders; 2008.
2. Azoulay E, Timsit JF, Sprung CL, et al. Prevalence
and factors of intensive care unit conflicts: the
conflicus study. Am J Respir Crit Care Med. 2009
Nov 1:180(9);853-860.
3. Chamine S. Positive Intelligence: Why Only 20% of
Teams and Individuals Achieve Their True Potential
and How You Can Achieve Yours. Austin, TX:
Greenleaf Book Group Press; 2012.
4. Anderson RJ, Adams WA. Mastering Leadership: An
Integrated Framework for Breakthrough Performance
and Extraordinary Business Results. Hoboken, NJ:
John Wiley & Sons; 2016.
5. Kimsey-House H, Skibbins D. The Stake: The Making
of Leaders. San Rafael, CA: Co-Active Press; 2013.
6. Scudder T, Patterson M, Mitchell K. Have a Nice
Conflict: How to Find Success and Satisfaction in the
Most Unlikely Places. San Francisco, CA: John Wiley
& Sons; 2012.
7. Mehrabian A. Nonverbal Communication. Chicago,
IL: Aldine-Atherton; 1972.
8. Stone D, Patton B, Heen S. Difficult Conversations:
How to Discuss What Matters Most. New York, NY:
Penguin Books; 1999.
9. Patterson K, Grenny J, McMillan R, Switzler A. Crucial
Conversations: Tools for Talking When Stakes Are
High. 2nd ed. New York, NY:
McGraw-Hill; 2012.
10. Carnegie D. How to Win Friends & Influence People.
Hauppauge, NY: Dale Carnegie & Associates; 1936.
11. Bradberry T, Greaves J, Lencioni P. (2009). Emotional
intelligence 2.0: The worlds most popular emotional
intelligence test. San Diego (California): TalentSmart.
 A 53-year-old man with prior history of myocardial infarction (MI) presents with chest pain and diaphoresis.

The Critical ECG

ST with first-degree atrioventricular (AV) block, rate 130, acute inferior- By Amal Mattu, MD, FACEP
lateral MI with possible posterior MI, anteroseptal MI of undetermined Dr. Mattu is a professor, vice chair, and
director of the Emergency Cardiology
age, prolonged QT interval. ST-segment elevation (STE) is present in the Fellowship in the Department of
inferior and lateral leads consistent with acute myocardial infarction (AMI). Emergency Medicine at the University
of Maryland School of Medicine in
Pronounced ST-segment depression is present in leads V1-V3. In the presence Baltimore.
of an inferior AMI, ST-segment depression in the anteroseptal leads can
represent either reciprocal change, or it can indicate acute posterior MI.
Reciprocal ST-segment depression is usually shallow and downsloping, whereas ST-segment depression due to acute posterior
MI is usually horizontal and more than 2-mm depressed. Therefore, the ST-segment depression in this case appears more likely to
be due to acute posterior MI.

Another expected finding in posterior MI is large R waves in leads V1-V3. In this case, however, large Q waves presumably from
a prior anteroseptal MI prevent the development of large R waves. Confirmation of acute posterior MI could be accomplished
by repeating the ECG with posterior leads and finding STE. A slightly prolonged QT interval is also present, which might be
caused by acute cardiac ischemia. Other possible causes of QT-interval prolongation include hypokalemia, hypomagnesemia,
hypocalcemia, elevated intracranial pressure, drugs with sodium channel–blocking effects, hypothermia, and congenital
prolonged QT syndrome.

From Mattu A, Brady W. ECGs for the Emergency Physician 2. London: BMJ Publishing; 2008. Reprinted with permission.

October 2018 n Volume 32 Number 10 21

 CME
Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive

CME certificates for up to 5 ACEP Category I credits, 5 AMA PRA Category 1
Credits™, and 5 AOA Category 2-B credits for completing this activity in its

QUESTIONS entirety. Submit your answers online at acep.org/cdem; a score of 75% or better
is required. You may receive credit for completing the CME activity any time within
3 years of its publication date. Answers to this month’s questions will be published
in next month’s issue.

1 According to the Advanced Trauma Life Support

guidelines, what is the preferred first-line method
for securing the airway in an apneic patient with a
6 An injury at which spinal cord level can be heralded
by paresthesia in the thumb and index fingers and a
sluggish or absent biceps reflex?
suspected c-spine injury? A. C4
A. Cricothyroidotomy B. C6
B. Nasotracheal intubation C. C7
C. Orotracheal intubation with in-line manual c-spine D. C8
immobilization
D. Video-assisted laryngoscopy
7 According to the NEXUS criteria, which of the
following trauma patients can forego imaging to

2 Approximately what percentage of all SCIs in the

United States are sustained during athletic activity?
exclude a c-spine injury?
A. A patient who has an open femur fracture
A. 5%
B. A patient with evidence of drug or alcohol
B. 10%
intoxication
C. 20%
C. A patient with left arm weakness
D. 40%
D. A patient with paraspinal tenderness to palpation

3 Which of the following applies to spinal shock?

A. A permanent depression of spinal cord function
8 When assessing a patient’s need for c-spine imaging,
which of the following is considered a low-risk
B. Associated depression of spinal cord function factor?
above the level of the injury
A. Age ≥65 years
C. Associated with the loss of only some sensory or
B. Delayed-onset neck pain
motor function
D. Can mimic a complete SCI in the acute setting C. Midline cervical tenderness
D. Sensory neurological deficits

4
The return of which reflex is used to indicate the
resolution of spinal shock?
9 According to the Denver criteria, which of the
following is considered a risk factor for blunt
A. Achilles reflex
cerebrovascular injury?
B. Bulbocavernosus reflex
C. Gag reflex A. Fractures of the C1-C3 vertebrae
D. Patellar reflex B. GCS score <10
C. Le Fort fracture

5 Which of the following is a clinical manifestation

of neurogenic shock?
D. Near hanging without evidence of anoxic brain
injury
A. Hyperreflexia
B. Hypotension
C. Rigidity
D. Tachycardia

22 Critical Decisions in Emergency Medicine


10
According to the Canadian C-Spine Rule, which
of the following is considered a high-risk factor
for c-spine injury?

16 What is the best mindset to have when entering
into a conflict?
A. Maybe if I walk away, it will go away
A. Age >60 years B. This is going to be an opportunity and an
B. Delayed onset of neck pain adventure
C. Rear-end collision C. This is going to be a waste of time
D. Right arm numbness D. This is going to be painful

11 A physician colleague openly criticizes you in front of
your staff and calls you a “novice.” What should you do
to diffuse the conflict?

17 During a conversation, what percentage of
information is conveyed by words alone?
A. 7%
A. Call the chief of staff B. 20%
B. Ignore the angry physician and report his behavior to C. 45%
human resources D. 75%
C. Listen with openness and curiosity before responding
to the physician’s complaints
D. Take it personally and accuse him of being the novice
18 What response reassures patients that they are
being heard?

12 What is the most important question to ask someone A. Bringing high-level administrators into the
during a conflict? conversation
A. Why are you such a jerk? B. Offering verbal affirmations such as “I
understand”
B. Why do you hate me so much?
C. Telling them about similar cases you’ve
C. What is your desired end result?
encountered
D. What is your problem?
D. Telling jokes to lighten the mood

13 Which of the following is a component of social
awareness?
19 Why are many patients unable to process the
information they receive in the emergency
A. Controlling your own anger
B. Picking up on the mood in the room department?
C. Self-confidence A. Discharge instructions are typically too detailed
D. Using clear, direct language B. The information they receive during the visit is
likely to be inadequate

14 Which of the following is an effective technique
for communicating with patients?
C. They are likely to be in flight, flight, or freeze
mode
A. Authoritative language D. They distrust doctors and rely more heavily on
B. Ducking the advice of their family and friends
C. Expressions of urgency
D. Mirroring

20 When having any exchange with a patient,
physicians should primarily focus on what?

15 What is the most important thing to do when fielding
patient complaints?
A. Addressing complaints
B. Formulating a response to the patient’s
A. Laugh questions
B. Listen C. Listening intently
C. Tell them they are wrong D. Trying to end the conversation as soon as
D. Try and educate them on the clinical and scientific possible
aspects of their care

ANSWER KEY FOR SEPTEMBER 2018, VOLUME 32, NUMBER 9

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
B C B D B D B B B D A C B A A B D D B D

October 2018 n Volume 32 Number 10 23

 Drug Box
LOFEXIDINE
By Laura Johns, MD; and Frank LoVecchio, DO, MPH,
FACEP, Maricopa Medical Center, Phoenix, AZ
Lofexidine is prescribed for the manage­ment of
opioid withdrawal symptoms in adults. It is associated
with fewer side effects than clonidine but works via a
similar mechanism.
Mechanism of Action
Lofexidine is a central alpha 2–adrenergic agonist
that reduces the release of norepinephrine and
decreases sympathetic tone. It specifically binds to
the 2A subtype receptor, which is thought to account
for its reduced risk of hypotension compared to
clonidine, which is nonspecific.
Indication
The drug is indicated for the amelioration of symptoms
related to opioid withdrawal, including diarrhea,
vomiting, anxiety, malaise, cramping, muscle spasms,
palpitations, myalgia, and insomnia.
Dosing
Lofexidine is supplied in 0.18-mg tablets. The typical
starting dose is 3 tablets 4x/day, with a maximum
dose of 2.88 mg/day and no more than 0.72 mg
(4 pills) in one dose. Dosing is guided by symptoms
and may be titrated up or down. Dosing should
be adjusted in patients with hepatic and/or renal
impairment. The drug is not approved for those
<17 years old. The typical duration of treatment is
7 days, but it can be used for as many as 14 days.
Precautions
The most common reactions are somnolence (42%),
dizziness (39%), hypotension (18%), and bradycardia
(3%). The most serious side effect is syncope. The
rate of overall serious adverse reactions is 2.3%.
Lofexidine can prolong the QT interval, so it should
be used with caution in patients taking methadone or
other medications that also prolong the QT interval.
Rebound hypertension is possible when discontinued;
dosing should be gradually reduced over 2-4 days.
Tox Box
GAMMA-HYDROXYBUTYRATE AND ANALOGUES
By Cliff Masom, MD; and Christian A. Tomaszewski, MD, MS, MBA, FACEP,
University of California, San Diego
Gamma-hydroxybutyrate (GHB), commonly called “G,” “Easy Lay,” “Cherry
Meth,” “Liquid X,” or “Georgia Home Boy,” is ingested for its euphoric
and sedative effects. Common as a date rape and club drug, it is also used
by body builders due to its association with growth hormone secretion.
Because GHB is now a Class 1 drug, precursors 1,4-butanedial (BD) and
gamma-butyrolactone (GBL) have become more popular.
Mechanism
Accidental overdose is seen with all three agents because of the narrow
interval between doses and their desired effects. These agents exert
sedative effects by agonizing the GABA B receptor. Onset and resolution
are usually quick with GHB but can be slightly delayed with BD and GBL.
Pharmacokinetics
• Agents are rapidly absorbed, with peak concentrations of 30-45 minutes.
• Clinical effects can be seen within 15-20 minutes.
• Half-life is 20-50 minutes.
Clinical Manifestations
• Central nervous system — mydriasis or miosis, drowsiness, memory loss,
myoclonus (confused for seizures), euphoria, depression, coma
• Cardiovascular — bradycardia, hypotension
• Respiratory — respiratory depression, aspiration, apnea
• Gastrointestinal — salivation, vomiting
Diagnostics
• Routine drug screens do not identify these agents.
• Order routine lab tests for a depressed level of consciousness: point-of-
care glucose, ethanol, and ECG
• In cases of intentional overdose, test acetaminophen levels.
Management
Supportive therapy is the mainstay of care, with a focus on preserving
the airway. Patients can rapidly improve after intubation, leading to self-
extubation. Atropine can be given for bradycardia, and IV fluids can be
administered for hypotension. Due to rapid absorption, there is no role for
gastric decontamination. There are no effective reversal agents.
Withdrawal
Withdrawal symptoms can be seen in chronic users (eg, body builders)
who abruptly quit. The result is tachycardia, hypertension, tremors, agitation,
hallucinations, and seizures. Withdrawal can be controlled with benzo­dia­
zepines, barbiturates, and other GABAB agonists (eg, baclofen).