Volume 33 Number 1 January 2019

Counterattack
Emergency physicians play a critical role in the
diagnosis and treatment of acute chest pain and heart
attacks, which can be caused by a host of potentially
deadly disorders. Although non-ST-segment elevation
acute coronary syndrome can be particularly
challenging to diagnose and treat, recent advances in
risk-stratification tools and high-sensitivity biomarker
assays have improved the options for managing
these complex cases.

Winter Wipeout
More than 100,000 skiers and snowboarders seek care in
US emergency departments every year for falls, collisions,
and lift-related accidents. During the winter months,
clinicians must be prepared to identify and manage the
specific injury patterns commonly associated with these
high-risk sports. By taking a careful history, recognizing
subtle imaging findings, and using appropriate
immobilization techniques, emergency physicians
can initiate rehabilitation and prevent the long-term
morbidity associated with these diagnoses.

THE OFFICIAL CME PUBLICATION OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

IN THIS ISSUE
Lesson 1 n Non-ST-Segment Elevation Acute Coronary Syndrome . . . 3
Critical ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Critical Decisions in Emergency Medicine is the official
CME publication of the American College of Emergency
Critical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Physicians. Additional volumes are available.
LLSA Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 EDITOR-IN-CHIEF
Michael S. Beeson, MD, MBA, FACEP
Critical Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Northeastern Ohio Universities,
Lesson 2 n Skiing and Snowboarding Injuries . . . . . . . . . . . . . . . . . . . . 17 Rootstown, OH

CME Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 SECTION EDITORS

Drug Box/Tox Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Joshua S. Broder, MD, FACEP
Duke University, Durham, NC
Andrew J. Eyre, MD, MHPEd
Brigham & Women’s Hospital/Harvard Medical School,
Contributor Disclosures. In accordance with the ACCME Standards for Commercial
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Support and policy of the American College of Emergency Physicians, all individuals with
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CME content have no significant financial interests or relationships to disclose. Christian A. Tomaszewski, MD, MS, MBA, FACEP
This educational activity consists of two lessons, a post-test, and evaluation questions; University of California Health Sciences,
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ASSOCIATE EDITORS
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 Counterattack
Non-ST-Segment Elevation
Acute Coronary Syndrome

LESSON 1

By Carlos Velasco, MD; Samuel Lee, MD; and Alvin Chandra, MD

Dr. Velasco is an assistant professor of emergency medicine, and Dr. Lee is a resident
physician in the Department of Emergency Medicine at UT Southwestern Medical
Center in Dallas, Texas. Dr. Chandra is a cardiovascular imaging fellow at Brigham
and Women’s Hospital in Boston, Massachusetts.

Reviewed by Walter L. Green, MD, FACEP

OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Recognize the signs and symptoms of acute coronary
syndrome and non-ST-segment elevation acute coronary
n What findings differentiate STEMI from NSTEMI?
syndrome (NSTE-ACS). n What clinical signs and symptoms should raise
2. Describe the approach to diagnosing NSTE-ACS in the suspicion for ACS?
emergency department.
3. Recognize the ECG findings of NSTE-ACS. n Which diagnostic tools are most valuable for
4. Understand the utility of cardiac biomarker assays and identifying UA and NSTEMI in the emergency
risk-stratification scores for managing NSTE-ACS. department?
5. Describe the recommended treatment for and n How should UA and NSTEMI be managed in the
disposition of NSTE-ACS. emergency department?
FROM THE EM MODEL
3.0 Cardiovascular Disorders
3.5 Diseases of the Myocardium, Acquired

Acute coronary syndrome (ACS) describes a spectrum of clinical presentations, including unstable angina
(UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial
infarction (STEMI). These potentially deadly disorders result from inadequate myocardial perfusion that fails to
meet the patient’s oxygen demand — a shortfall that can lead to myocardial ischemia or infarction.

January 2019 n Volume 33 Number 1 3

 CASE PRESENTATIONS
■ CASE ONE
A 56-year-old man presents
with chest pain and dyspnea that
began approximately 5 hours earlier
while he was walking to work. The
patient, who is a former smoker
with diet-controlled type 2 diabetes,
describes his pain level as an 8 out of
10; it is substernal and pressure-like
and radiates to his right back and
flank. He says he experienced several
episodes of exertional chest pain
about 3 months ago; however, each
previous episode resolved within 45
minutes with rest.
The patient’s initial ECG
shows T-wave inversions in leads
I, AVL, and V5-V6 . A second ECG
2 hours later shows changes that
are questionable for an inferior and
anterolateral infarct. His initial
troponin T level is 0.03 ng/mL; a
second troponin measurement
4 hours later is 0.06 ng/mL.
CRITICAL DECISION
What findings differentiate
STEMI from NSTEMI?
In most cases, ACS is caused by
an acute disruption or the erosion of
underlying CAD, which leads to reduced
coronary blood flow.1 Approximately
16.5 million Americans over the age
of 20 years suffer from underlying
coronary heart disease, the leading cause
of death in the United States.2
While STEMI is associated with
complete occlusion of the involved
vessel(s), UA and NSTEMI are
associated with partial occlusion. The
pathogenesis of UA and NSTEMI is
defined by five mutually nonexclusive
factors: an acute nonocclusive thrombus
formation on a pre-existing coronary
artery plaque (most common), dynamic
obstruction, progressive mechanical
obstruction, inflammation, and
secondary unstable angina due to an
increased cardiac workload.3
UA and NSTEMI have traditionally
been differentiated by elevated cardiac
4 Critical Decisions in Emergency Medicine
■ CASE TWO
A 51-year-old woman presents with a
complaint of chest pain that began 8 days
ago. She has a history of hypertension,
rheumatoid arthritis, coronary artery
disease (CAD), and a previous stent
placement in the left anterior descending
(LAD) coronary artery. The patient was
initially awakened from sleep with a
sudden, severe, pressure-like chest pain
at the left sternal border, which radiated
to her midepigastric region and was
associated with nausea. The pain resolved
after 10 minutes. She also describes a
similar episode yesterday, which lasted 30
minutes, and another one today, which
lasted 1 hour.
In the emergency department, the
patient is hemodynamically stable with
a heart rate of 60 and blood pressure
of 134/58. An initial ECG shows only
nonspecific T-wave changes; however, her
creatine kinase-muscle/brain (CK-MB)
level is elevated to 13, and her initial
troponin T level is elevated to 0.15. The
markers that herald myocardial damage,
including troponin I (cTnI), troponin T
(cTnT), and CK-MB. An elevation above
the 99th percentile of normal indicates the
presence of an MI and necrosis — findings
that qualify as NSTEMI.4 However,
the 2014 American Heart Association/
American College of Cardiology (AHA/
ACC) guidelines combine UA and
NSTEMI into a new classification
called non-ST-segment elevation acute
coronary syndrome (NSTE-ACS), as
the two patient populations are difficult
to distinguish clinically by their initial
presentations.5
NSTE-ACS is much more common
than STEMI and often trickier to
diagnose.6 Out of the 1.4 million patients
admitted to US hospitals with ACS each
year, approximately 70% are diagnosed
with either UA or NSTEMI.1 Compared
to STEMI, NSTEMI has a lower 30-day
mortality rate, a higher risk of recurrent
ischemia, and a similar 1-year mortality
rate.5
An ST-elevation or a new left bundle
branch block accompanied by instability
troponin level decreases to 0.13 over the
next 3 hours. The clinician administers
aspirin and two doses of sublingual
nitroglycerin, which relieves the patient’s
symptoms.
■ CASE THREE
A 64-year-old man presents with
“crushing” substernal chest pain that
began 3 days ago and has progressively
worsened. He also complains of sweating,
nausea, and shortness of breath. The
patient is homeless, has smoked tobacco
for more than 40 years, and has a history
of myocardial infarction (MI) and CAD.
Of note, he underwent a stent placement
in 2007 after suffering an MI and had
an automatic implantable cardioverter
defibrillator placed in 2008 for possible
ventricular tachyarrhythmia.
An initial ECG in the emergency
department shows T-wave inversions in
the lateral precordial leads. The patient’s
initial troponin T level is 1.74; subsequent
measurements are 5.56
and 6.03.
or Sgarbossa findings puts patients on
a path toward immediate coronary
angiography and reperfusion therapy
(Table 1). When managing NSTE-ACS,
however, clinicians must decide whether
to pursue an early invasive strategy or
a more conservative approach based on
the presence of particular risk factors.
TABLE 1. Conditions Requiring
Immediate Angiography/
Revascularization in Patients
with ACS
• Cardiogenic shock
• Severe left ventricular dysfunction
or acute heart failure
• New ST-segment elevations
• Recurrent or persistent rest angina,
despite intensive medical therapy
• New or worsening mitral regurgitation
or a new ventricular septal defect
• Sustained ventricular arrhythmias
• Percutaneous coronary intervention
in the last 6 months or a previous
coronary artery bypass graft
CRITICAL DECISION
What clinical signs and symptoms
should raise suspicion for ACS?
Clinicians must not only recognize
and exclude life-threatening causes of
chest pain, they also must be prepared
to distinguish between ACS and
nonischemic etiologies (Figure 1). Early
and appropriate care using the three
diagnostic cornerstones of management
— a thorough clinical assessment, a 12-
lead ECG, and measurements of cTnI or
cTnT — can dramatically improve the
prognosis for patients with ACS.
Clues in the history of chest pain
that increase the likelihood of an acute
myocardial infarction (AMI) include:
• Pain that radiates to the right arm or
shoulder (likelihood ratio [LR] 4.7)
• Pain that radiates to both arms and
shoulders (LR 4.1)
• Pain associated with exertion
(LR 2.4)
• Pain associated with diaphoresis
(LR 2.0)
• Pain associated with nausea and
vomiting (LR 1.9)
• Pain that is worse than previous
angina pain or similar to a previous
MI (LR 1.8)
• Pain described as “pressure-like”
(LR 1.3)
FIGURE 1. Initial Assessment of Patients With Chest Pain
1. Presentation
2. ECG Findings
3. Troponin Levels
4. Diagnosis
Elements in the history of chest pain
that decrease the likelihood of an AMI
include:
• Pain described as pleuritic (LR 0.2)
• Pain described as positional (LR 0.3)
• Pain described as sharp (LR 0.3)
• Pain that is reproducible with
palpation (LR 0.3)
Patient descriptions of pain such as
“sharp” or “stabbing” are powerful
indicators of a nonischemic etiology
(eg, aortic dissection, pulmonary
embolism, or esophageal rupture).7
Neither the subjective severity nor the
location of chest pain appears to have
a statistically significant correlation to
the risk of AMI. In addition, discomfort
that can be relieved by nitroglycerin or a
GI cocktail cannot differentiate ischemic
from nonischemic pain. Although certain
risk factors for CAD can figure into
prognostic scores for predicting ACS-
related mortality, on their own, they are
poor predictors of AMI and ACS.8
Importantly, clinicians should not
dismiss atypical or nonspecific symptoms
such as dyspnea, weakness, nausea and
vomiting, palpitations, and syncope.
These potentially significant complaints
are more common in older patients,
diabetics, and women.
Low Likelihood
Back view
Other
Noncardiac UA Cardiac
Etiology
CRITICAL DECISION
Which diagnostic tools are most
valuable for identifying UA
and NSTEMI in the emergency
department?
ECG
When managing any patient with a
chief complaint of chest pain, it is vital
to obtain a 12-lead ECG within the first
10 minutes of arrival. If initial clinical
suspicion is high and the first ECG is
nondiagnostic, it is prudent to repeat
the test every 10 to 15 minutes. NSTE-
ACS can be associated with persistent or
transient ST-segment depressions, T-wave
inversions, flat T waves, the pseudo-
normalization of T waves, or some
combination of these findings (Figure 2).
A new ST-segment deviation of as little
as 0.05 mV can be an important and
specific prognostic indicator of ischemia.
It is important to note that, by itself,
the 12-lead ECG has a limited sensitivity
(20%-60%) for detecting ACS.9 In
addition, the test is limited in its ability
to represent the posterior, lateral, and
apical walls of the left ventricle (LV).
According to the AHA/ACC guidelines,
patients who are hospitalized for NSTE-
ACS should undergo serial ECGs or
continuous cardiac monitoring.5
High Likelihood
NSTEMI STEMI
January 2019 n Volume 33 Number 1 5

TABLE 2. The HEART Score for Chest Pain
History Highly suspicious
Moderately suspicious
Slightly or nonsuspicious
ECG Significant ST depression
Nonspecific repolarization disturbance
Normal
Age ≥65 years old
>45 to <65 years old
≤45 years old
Risk Factors ≥3 risk factors or history of atherosclerotic heart disease
1 or 2 risk factors
No risk factors known
Troponin Level ≥3x normal limit
>1x to <3x normal limit
≤Normal limit
Cardiac Biomarkers
For more than 20 years, serum
troponin assays have been widely used
to aid in the diagnosis of AMI.
Troponin, a component within the
contractile apparatus in cardiac
myocytes, is made up of three subunits:
T, C, and I. The T and I isoforms are
highly specific and sensitive to cardiac
myocytes. Structurally bound cardiac
troponin degrades over several days,
resulting in a stable, gradual troponin
“leak.” These proteins appear in the
serum 4 to 10 hours after the onset of
AMI, peaking within 12 to 48 hours
and remaining elevated for 4 to 10
days.10
Contemporary cardiac troponin (cTn)
assays can measure normal values below
the 99th percentile in fewer than 50%
of reference populations. Although these
advances greatly improved diagnostic
precision for identifying AMI, cTn
assays also require prolonged serial
sampling to achieve optimal accuracy
— a drawback that can contribute to
emergency department overcrowding
and unnecessary hospital admissions.11
Due to these limitations, high-
sensitivity cardiac troponin assays
(hs-cTn) were developed in the
early 2000s to detect troponin at
concentrations 10 to 100 times lower
than traditional biomarkers. These
improved assays detect troponin with
a higher sensitivity and precision at
an earlier point in time, allowing
6 Critical Decisions in Emergency Medicine
Risk-Stratification Tools
Even with the advent of rapid
2 diagnostic strategies for patients with
1 chest pain, an estimated 2% to 8% of
0 AMI and ACS cases are missed.12 On
2 the other hand, not all patients who
1 are admitted to the hospital for chest
0 pain are determined to have ACS, and
2
unnecessary admissions can impose a
heavy financial burden on the US health
1
care system.13 This is especially pertinent
0
for patients with NSTE-ACS, many
2
of whom do not present with typical
1 symptoms, including ECG changes or
0 increased cardiac biomarkers.
2 Various scoring methods have been
1 developed to better risk-stratify patients
0 with acute chest pain. Ideally, the chosen
tool should identify the largest patient
population at low risk for ACS without
quantification in 50% to 95% of
compromising safety.
healthy individuals. The negative
The Thrombolysis in Myocardial
predictive value (NPV) of hs-cTn is
Infarction (TIMI) risk score, for instance,
more than 95% for the exclusion of
was derived in patients with known ACS
AMI in patients who are tested upon
— cohorts with established NSTEMI and
emergency department arrival. When UA — and has been studied extensively
repeated 3 hours after presentation, the in the acute setting. The score predicts
NPV rises to 99.6%. the risk of all-cause mortality, MI, and
A recent systematic review and severe recurrent ischemia requiring
meta-analysis revealed that using lower urgent revascularization within 14 days
cutoffs when establishing a single of admission.5 While the TIMI risk
baseline hs-cTn T measurement can score is easy to use and derived from a
greatly improve the test’s sensitivity large data set, it identifies only a small
for diagnosing AMI and can be used proportion of patients as low risk.14
reliably to rule out patients who present The Global Registry for Acute
Coronary Events (GRACE) score,
more than 3 hours from symptom
another risk-stratification method, was
onset. This strategy facilitates earlier
also derived from patients with known
exclusion, which can reduce the length
ACS (and, therefore, with a higher risk
of stay, hasten treatment, and improve
of AMI and/or death compared to the
patient outcome.10
average patient). Unfortunately, the
range of outcomes is wide enough to
FIGURE 2. ECG Detail of require a software calculation, making
NSTEMI its application unwieldy in acute
settings.14
The HEART Score
The HEART score, on the other
hand, was specifically developed for
evaluating undifferentiated chest
pain in the emergency department, a
clinical setting fraught with diagnostic
uncertainty. Additionally, patients with
STEMI were excluded. This simple
tool assigns patients a score (0, 1, or
2 points) in five separate categories:
history, ECG, age, risk factors, and
troponin level.15 Although the HEART
score (Table 2) is simple to calculate
and can be used quickly in clinical
practice, assigning the score requires
some subjective clinical judgment
(eg, suspicious history for ACS).14
A prospective evaluation of 2,440
patients at 10 sites in the Netherlands
compared the performance of the
HEART score with the TIMI and
GRACE systems, using a primary end
point of a major adverse cardiac event
(MACE) within 6 weeks. A HEART
score of 0 to 3 corresponded with a
MACE rate of 1.7%, a score of 4 to 6
had a MACE rate of 16.6%, and a
score of 7 to 10 corresponded with a
50.1% MACE rate.
The overall discrimination
(C-statistic 0.90) was highest for the
HEART score when compared to the
TIMI (0.65) and GRACE (0.83) tools.
This finding indicates that the HEART
score has a very good ability to evaluate
all-cause chest pain patients for their
risk of MACE. Furthermore, more than
33% of the subjects with acute chest
pain were determined to have low-risk
HEART scores (0-3), which means that
a significant number of patients can be
excluded from redundant diagnostic
tests and treatment and can be safely
discharged.14
Those who fall into the intermediate-
and high-risk categories should be
admitted to the hospital for further
observation, serial cardiac marker
tests and ECGs, and additional cardiac
studies.
CRITICAL DECISION
How should UA and NSTEMI
be managed in the emergency
department?
The emergent treatment of patients
diagnosed with UA or NSTEMI is
rooted in the following five pillars:
1) Stabilization of hemodynamic
abnormalities
2) Relief of ischemic pain
3) Early risk stratification
4) Emergent cardiologist consultation
5) Decisions regarding medical versus
mechanical intervention
Pain and Ischemia
The classic mnemonic of MONA
(morphine, oxygen, nitroglycerin,
aspirin) has long been the mainstay of
acute ACS therapy; however, recent data
show that some elements of this adage
may not always be beneficial.
While opioid pain control has been
standard initial intervention in the
management of ACS, the efficacy of
these agents in patients with NSTEMI
has recently been called into question.
Data from the CRUSADE National
Quality Improvement Initiative, a
large retrospective observational study,
suggest that the use of morphine may
significantly increase mortality in
NSTEMI patients — a risk that appears
to stem from the binding of the P2Y12
receptor and the diminishing effect of
antiplatelet agents.16 As such, morphine
sulfate should be reserved for patients
with intractable levels of pain. The
authors recommend a starting adult dose
of 2 to 4 mg, followed by a similar dose
at 10 minutes.
The AHA/ACC now recommends
reserving supplemental oxygen for
patients with suspected hypoxemia or a
pulse oxygen saturation less than 90%;
an exception can be made for those in
severe respiratory distress.17 Routine use
for patients with normal oxygenation
has been linked to troponin elevations
and coronary vasoconstriction.18,19 A
large 2013 Cochrane Review found no
difference in mortality in patients with
a presumed MI who received room air
versus supplemental oxygen.20
Sublingual nitroglycerin is considered
standard treatment for suspected
ischemic chest pain. This potent
vasodilator is particularly useful in
patients with concomitant hypertension
and/or congestive heart failure. Nitrates,
which exert their effect by diminishing
right ventricular (RV) preload, can
cause profound hypotension in those
with preload-dependent states (eg, RV
infarction, severe aortic stenosis) and in
those who have used phosphodiesterase
inhibitors (eg, sildenafil, tadalafil) within
the past 24 hours.21
When no contraindications exist, the
commonly prescribed agent is sublingual
nitroglycerin (400 mcg [0.4 mg] with
two repeat doses at 5-minute intervals).
Patients with persistent ischemic pain
may benefit from a subsequent IV
infusion. The AHA/ACC recommends
IV nitroglycerin for NSTEMI patients
with ongoing ischemia, heart failure, or
hypertension.17
Antiplatelet therapy with aspirin
has been shown to significantly reduce
mortality and is indicated for any
patient with NSTEMI, provided that no
contraindication exists (eg, anaphylaxis,
suspected aortic dissection).17 The
authors recommend a 324-mg dose
(chewed). Clopidogrel (a 300-mg loading
dose, or 75 mg in patients >75 years old)
can be substituted in those with a history
of anaphylactic reactions to aspirin.
When administered in addition
to aspirin, P2Y12 inhibitors such as
clopidogrel and ticagrelor significantly
decrease mortality.22 Other antiplatelet
agents such as glycoprotein IIb/IIIa
inhibitors have shown benefit in patients
undergoing a percutaneous coronary
intervention (PCI); however, their role
in the acute management of NSTEMI
is unproven.
Anticoagulant Therapy
Anticoagulant therapy is standard
care for any patient with NSTE-ACS.
Both unfractionated heparins (UFHs)
and low molecular-weight heparins
(LMWHs), including enoxaparin, have
shown benefit in patients managed
with an ischemia-guided strategy (non-
PCI/PCI).
Although recent AHA/ACC
guidelines suggest that enoxaparin is
superior to other anticoagulants for
managing NSTEMI, the drug comes with
several caveats.5 Enoxaparin is costly
and associated with an increased risk of
bleeding. In addition, clinicians should
consider the flexibility of UFH, which
can be reliably stopped or reversed,
as well as ongoing developments in
pharmacotherapeutics.23
Correcting Abnormalities
An appropriate level of preparedness
is warranted, as atrial and ventricular
arrhythmias are common in the acute and
subacute phase of NSTEMI. The authors
recommend moving these patients to
a room with critical care capabilities,
mobilizing nursing staff, preparing a
crash cart, and applying defibrillator
January 2019 n Volume 33 Number 1 7

FIGURE 3. Coronary Angiography Showing 100% LAD Occlusion
pads. The ischemia and catecholamine
surge can make the myocardium more
prone to arrhythmias. Atrial fibrillation/
flutter can lead to hypoperfusion and
shock at rapid rates due to a decreased
preload. Ventricular fibrillation and
cardiac arrest have also been cited.
The administration of oral
beta-blockers within 24 hours can
decrease the progression of UA to
MI by decreasing the inotropic and
chronotropic effects of catecholamines.
However, no definitive trials have
addressed the efficacy of these drugs
in patients with NSTEMI. The AHA
discourages IV beta-blockers for the
acute treatment of NSTEMI, as they
have been linked to worse outcomes
in patients with a decreased systolic
function and a propensity for shock.17
Although IV and intramuscular
lidocaine have been used as prophylaxes
for ventricular arrhythmias in
AMI patients, they are no longer
recommended. A large Cochrane Review
failed to show benefits and suggested
increased harm.24
8 Critical Decisions in Emergency Medicine
levels (3.5-4.5 mEq/L) have been linked
to decreased mortality in patients with
an AMI.25
Invasive Versus Conservative
Therapy
It is of paramount importance
to estimate the risk of further
cardiovascular events when managing
NSTE-ACS; such decisions can help
identify which patients are likely
to benefit from more aggressive
interventions.5,17 Early invasive
therapy (eg, PCI or coronary artery
bypass graft [CABG] within the first
24 hours) has been shown to be of
clear benefit in high-risk patients.26 In
addition, an invasive strategy reduces
the incidence of refractory angina and
rehospitalization and lowers the risk of
a heart attack over 3 to 5 years.
However, this approach is also
associated with an increased risk of
bleeding, recurring MIs during and soon
after initial treatment, and mortality
in elderly populations. In addition, a
Cochrane Review all-study analysis
failed to show significant benefits with
invasive treatments for NSTE-ACS when
examining all-cause mortality, death,
There is no definitive evidence to and nonfatal MIs at 6 to 12 months.27
support the use of acute electrolyte The following high-risk factors
repletion in patients with acute should be considered when initiating
NSTEMI. However, the repletion of early invasive therapy in patients with
magnesium to a level greater than NSTE-ACS: the extent of ST-segment
2.0 mEq/L has been advocated due to depression, elevated cardiac biomarkers,
its ability to reduce pain, heart rate, hemodynamic instability, and chest pain
systolic blood pressure, and myocardial that persists despite appropriate medical
oxygen demand. Normal potassium therapy.28
n Symptoms that increase the likelihood of ACS include chest pain that is:
exertional; radiates to the arms and shoulders (especially the right arm or
shoulder); is associated with diaphoresis, nausea, or vomiting; is similar to
previous anginal pain; and is described as “pressure-like.”
n UA and NSTEMI can be associated with persistent or transient ST-segment
depression, T-wave inversion, flat T waves, a pseudo-normalization of
T waves, or some combination of these findings. However, it is important to
remember that a high clinical suspicion for NSTE-ACS warrants serial ECGs,
troponin levels, and cardiac monitoring.
n The HEART score is a well-validated risk-stratification tool that can categorize
patients with chest pain into low-, intermediate-, and high-risk groups.
 CASE RESOLUTIONS
■ CASE ONE
The man with exertional chest
pain and dyspnea was admitted to
the medicine floor after a cardiology
consultation, with a plan for left heart
catheterization the next morning. He
received aspirin and was started on a
heparin drip, metoprolol, atorvastatin,
and sublingual nitroglycerin, as needed
for pain.
In the catheterization laboratory, the
patient was found to have three-vessel
CAD with severely elevated left heart
filling pressures, a 20% proximal lesion
in the LAD, a diffuse 99% mid-lesion in
the LAD, a 95% ostial lesion in the first
obtuse marginal branch (OM1), and a
95% mid-lesion in the right coronary
artery (RCA).
By the next evening, the patient’s
troponin levels had peaked at 0.13, and
he was given a nitroglycerin infusion
for ongoing chest pain. A transthoracic
ECG revealed a depressed left ventricular
ejection fraction (35%), and he
underwent a CABG the following day.
■ CASE TWO
After being admitted to an inpatient
floor, the middle-aged woman with a
history of heart disease was started on
a heparin drip, metoprolol, atorvas­
tatin, and isosorbide dinitrate. She
underwent left heart catheterization
the following evening, which revealed
single-vessel disease, with a 55%
recurrent lesion of the mid-LAD
(confirmed by fractional flow reserve).
The patient underwent a successful
repeat revascularization with a
drug-eluting stent. Her chest pain
resolved, and she was discharged
with instructions to take aspirin
indefinitely and clopidogrel daily for
1 year.
■ CASE THREE
The homeless man with crushing
substernal pain underwent a
transthoracic ECG, which revealed
a mildly dilated LV, eccentric left
ventricular hypertrophy, apical
dyskinesis, and anteroseptal akinesis
with a mild to moderate decrease in
systolic function and an estimated
ejection fraction of 40%. He was taken
to the catheterization laboratory, where
he was found to have three-vessel CAD
with chronic occlusion of the RCA and
LAD, along with severe stenosis of the
proximal left circumflex (LCx). There
was 100% occlusion of the LAD, 95%
occlusion of diagonals, 90% occlusion
of the LCx, and 100% occlusion of the
RCA. (An example of a solitary 100%
LAD lesion is shown in Figure 3.)
The interventional cardiology
team recommended further
treatment with a CABG, which
the patient refused. He ultimately
agreed to undergo a second left-
heart catheterization, and his LCx
was successfully revascularized. He
was placed on aspirin indefinitely,
clopidogrel (75 mg daily for 1 year),
metoprolol, captopril, atorvastatin,
and furosemide. A follow-up
appointment was scheduled, and the
patient was advised to reconsider
undergoing a CABG.

The TIMI 11B and Efficacy and
Safety of Subcutaneous Enoxaparin
in Non-Q-Wave Coronary Events
(ESSENCE) trials found seven
variables that independently forecast
outcomes in patients with NSTE-
ACS.29 As discussed earlier, the
NSTEMI TIMI score is a widely used
predictive model for determining the
need for invasive versus conservative
therapy. A value of 1 is assigned
when a factor is present, and a 0 is
assigned when a factor is absent. The
TACTICS-TIMI 18 trial demonstrated
the benefits of early PCI in patients
with intermediate- or high-risk scores
(3-4 and 5-6, respectively).30
patients with suspected NSTE-ACS.
These diagnostic elements make up
the HEART score, a validated risk-
stratification tool that clinicians
should use to safely discharge low-risk
patients and improve hospital resource
utilization.
For higher-risk patients with
NSTE-ACS who require an invasive or
conservative ischemia-guided approach,
early treatment provided with the
support of a multidisciplinary clinical
team can significantly improve patient
outcomes.
REFERENCES
1. Kumar A, Cannon CP. Acute coronary syndromes:
diagnosis and management, part I. Mayo Clin Proc.
2009 Oct;84(10):917-938.
2. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease
and stroke statistics—2017 update: a report from the
American Heart Association. Circulation. 2017 Mar 7;
135(10):e146-e603.
3. Deckers JW. Classification of myocardial infarction and
unstable angina: a re-assessment. Int J Cardiol. 2013
Sep 10;167(6):2387-2390.

Summary
Emergency physicians must be
prepared to quickly identify life-
threatening causes of chest pain and
intervene appropriately. A thorough
clinical assessment, including serial
ECGs and troponin measurements,
must be a part of every workup for
n Ignoring nonischemic but life-threatening causes of chest pain, including
aortic dissection, pulmonary embolism, and esophageal rupture.
n Overlooking atypical or nonspecific symptoms such as dyspnea, weakness,
nausea and vomiting, palpitations, and syncope. These symptoms are more
common in older patients, diabetics, and women.
n Relying on traditional treatment modalities such as hyperoxygenation and
opioids, which can worsen coronary vasoconstriction and increase mortality.

January 2019 n Volume 33 Number 1 9

 4. Alpert JS, Thygesen K, Antman E, Bassand JP. 24. Martí-Carvajal AJ, Simancas-Racines D, Anand V,
Myocardial infarction redefined—a consensus Bangdiwala S. Prophylactic lidocaine for myocardial
document of The Joint European Society of infarction. Cochrane Database Syst Rev. 2015 Aug 21;
Cardiology/American College of Cardiology 8:CD008553.
Committee for the redefinition of myocardial infarction. 25. Goyal A, Spertus JA, Gosch K, et al. Serum potassium
J Am Coll Cardiol. 2000 Sep;36(3):959-969. levels and mortality in acute myocardial infarction.
5. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 JAMA. 2012 Jan 11;307(2):157-164.
AHA/ACC guideline for the management of patients 26. Alexander KP, Newby LK, Cannon CP, et al. Acute
with non-ST-elevation acute coronary syndromes: a coronary care in the elderly, part I: non-ST-segment-
report of the American College of Cardiology/American elevation acute coronary syndromes: a scientific
Heart Association Task Force on Practice Guidelines. statement for healthcare professionals from the
J Am Coll Cardiol. 2014 Dec 23;64(24):e139-e228. American Heart Association Council on Clinical
6. Corcoran D, Grant P, Berry C. Risk stratification in non- Cardiology: in collaboration with the Society of
ST elevation acute coronary syndromes: risk scores, Geriatric Cardiology. Circulation. 2007 May 15;
biomarkers and clinical judgment. Int J Cardiol Heart 115(19):2549-2569.
Vasc. 2015 Sep 1;8:131-137. 27. Fanning JP, Nyong J, Scott IA, Aroney CN, Walters DL.
7. Swap CJ, Nagurney JT. Value and limitations of Routine invasive strategies versus selective invasive
chest pain history in the evaluation of patients with strategies for unstable angina and non-ST elevation
suspected acute coronary syndromes. JAMA. myocardial infarction in the stent era. Cochrane
2005 Nov 23;294(20):2623-2629. Database Syst Rev. 2016 May 26;5:CD004815.
8. Edwards M, Chang AM, Matsuura AC, Green M, Robey 28. Invasive compared with non-invasive treatment in
JM, Hollander JE. Relationship between pain severity unstable coronary-artery disease: FRISC II prospective
and outcomes in patients presenting with potential randomised multicentre study. FRagmin and Fast
acute coronary syndromes. Ann Emerg Med. 2011 Dec; Revascularisation during InStability in Coronary
58(6):501-507. artery disease Investigators. Lancet. 1999 Aug 28;
9. Goodacre S, Locker T, Morris F, Campbell S. How 354(9180):708-715.
useful are clinical features in the diagnosis of acute, 29. Antman EM, Cohen M, Bernink PJ, et al. The TIMI
undifferentiated chest pain? Acad Emerg Med. risk score for unstable angina/non-ST elevation MI: a
2002 Mar;9(3):203-208. method for prognostication and therapeutic decision
10. Garg P, Morris P, Fazlanie AL, et al. Cardiac biomarkers making. JAMA. 2000 Aug 16;284(7):835-842.
of acute coronary syndrome: from history to high- 30. Cannon CP, Weintraub WS, Demopoulos LA, et al.
sensitivity cardiac troponin. Intern Emerg Med. Comparison of early invasive and conservative
2017 Mar;12(2):147-155. strategies in patients with unstable coronary syndromes
11. Sandoval Y, Smith SW, Apple FS. Present and future treated with the glycoprotein IIb/IIIa inhibitor tirofiban.
of cardiac troponin in clinical practice: a paradigm shift N Engl J Med. 2001 Jun 21;344(25):1879-1887.
to high-sensitivity assays. Am J Med. 2016 Apr;
129(4):354-365.
12. Pope JH, Aufderheide TP, Ruthazer R, et al. Missed
diagnoses of acute cardiac ischemia in the emergency
department. N Engl J Med. 2000 Apr 20;342(16):
1163-1170.
13. Jain T, Nowak R, Hudson M, Frisoli T, Jacobsen G,
McCord J. Short- and long-term prognostic utility
of the HEART score in patients evaluated in the
emergency department for possible acute coronary
syndrome. Crit Pathw Cardiol. 2016 Jun;15(2):40-45.
14. Poldervaart JM, Langedijk M, Backus BE, et al.
Comparison of the GRACE, HEART and TIMI score
to predict major adverse cardiac events in chest pain
patients at the emergency department. Int J Cardiol.
2017 Jan 15;227:656-661.
15. Backus BE, Six AJ, Kelder JC, et al. A prospective
validation of the HEART score for chest pain patients
at the emergency department. Int J Cardiol. 2013
Oct 3;168(3):2153-2158.
16. Gross GJ, Gross ER, Peart JN. Association of
intravenous morphine use and outcomes in acute
coronary syndromes: results from the CRUSADE Quality
Improvement Initiative. Am Heart J. 2005 Dec;150(6):e3.
17. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014
AHA/ACC guideline for the management of patients
with non-ST-elevation acute coronary syndromes:
executive summary: a report of the American College
of Cardiology/American Heart Association Task Force
on Practice Guidelines. Circulation. 2014 Dec 23;
130(25):2354-2394.
18. Nehme Z, Stub D, Bernard S, et al. Effect of supple­
mental oxygen exposure on myocardial injury in ST-
elevation myocardial infarction. Heart. 2016 Mar;
102(6):444-451.
19. Shuvy M, Atar D, Gabriel Steg P, et al. Oxygen therapy
in acute coronary syndrome: are the benefits worth the
risk? Eur Heart J. 2013 Jun;34(22):1630-1635.
20. Cabello JB, Burls A, Emparanza JI, Bayliss SE,
Quinn T. Oxygen therapy for acute myocardial
infarction. Cochrane Database Syst Rev. 2013 Dec 19;
12:CD007160.
21. Reeder GS. Nitrates in the management of acute
coronary syndrome. UpToDate website. https://www.
uptodate.com/contents/nitrates-in-the-management-
of-acute-coronary-syndrome?source=search_
result&search=nitrates%20chest%20
pain&selectedTitle=1~150. Updated December 27,
2016. Accessed June 29, 2017.
22. Cayla G, Silvain J, Collet JP, Montalescot G. Updates
and current recommendations for the management
of patients with non-ST-elevation acute coronary
syndromes: what it means for clinical practice.
Am J Cardiol. 2015 Mar 14;115(5 Suppl):10A-22A.
23. Mayer M. Anticoagulants in ischemia-guided
management of non-ST-elevation acute coronary
syndromes. Am J Emerg Med. 2017 Mar;35(3):502-507.

10 Critical Decisions in Emergency Medicine

 A 59-year-old man with generalized weakness and chest pain.

The Critical ECG

When a tachydysrhythmia is irregularly irregular, the differential diagnosis By Amal Mattu, MD, FACEP
is primarily limited to atrial fibrillation, atrial flutter with variable Dr. Mattu is a professor, vice chair, and
director of the Emergency Cardiology
atrioventricular (AV) conduction, and multifocal atrial tachycardia. The Fellowship in the Department of
Emergency Medicine at the University
latter two entities should demonstrate distinct atrial activity, which this ECG
of Maryland School of Medicine in
does not; therefore, the diagnosis of atrial fibrillation is made. ST-segment Baltimore.
elevation (STE) is present in the mid and lateral precordial leads as well as in
leads I and aVL, which is consistent with an acute myocardial infarction (MI). Q waves have already appeared in a majority of
these leads, indicating that the duration of ischemia is likely to have been ongoing for at least a few hours (generally considered
the minimal time required for the development of infarction-related Q waves). Q waves are also present in the inferior leads.
Leads lll and aVF lack STE, indicating that the Q waves in those leads are more likely to be from a prior Ml rather than from an
acute MI. Lead ll, although primarily reflecting the inferior portion of the heart, also provides some information about the lateral
areas; therefore, the slight STE noted in lead II is probably the result of the acute lateral Ml. A leftward axis is present and can be
attributed to the prior inferior Ml. Other causes of a leftward axis include left bundle branch block, left anterior fascicular block,
left ventricular hypertrophy, ventricular ectopy, paced beats, and Wolff-Parkinson-White syndrome.

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

January 2019 n Volume 33 Number 1 11

 The Critical Procedure
Laryngospasm Management
Dr. Warrington is the director of the Emergency Medicine Residency Program and academic chair
of the Department of Emergency Medicine at Orange Park Medical Center in Orange Park, Florida.
Laryngospasm is an uncommon but life-threatening complication that emergency clinicians
often associate with the use of ketamine. Other causes of vocal chord closure include the use of
lachrymators (eg, pepper-spray products); toxins (eg, phosgene); airway manipulation; and underlying
conditions such as anxiety, asthma, gastroesophageal reflux disease, and anatomical dysfunction.
Benefits and Risks
The successful management of a
laryngospasm can prevent worsening
hypoxia and the subsequent need
to initiate intubation or a surgical
airway. The direct risks of aborting a
laryngospasm, which are minimal, are
most commonly related to insufflation
of the stomach and potential
aspiration. However, it is critical to
understand that managing these cases
without neuromuscular-blocking
agents (NMBAs) can increase the
risk of cardiorespiratory collapse
and cardiac arrest. The author
recommends preparing an NMBA
prior to beginning the procedure.
Severe hypoxia and rhythm
disturbances are relative
contraindications for the technique
described here. In such cases, consider
establishing a surgical airway.
Reducing Side Effects
Because emergency physicians
are most likely to encounter a
laryngospasm in a relatively
controlled setting (eg, during a
planned sedation or a procedure
involving the airway), preparation is
seldom a major concern. However,
it is important to remember that a
PEEP valve may be required. It is also
important to allow adequate space
between the head of the bed and
the wall. The application of cricoid
pressure can be used to prevent
insufflation of the stomach during the
procedure.
12 Critical Decisions in Emergency Medicine
By Steven Warrington, MD, MEd
Special Considerations
Although a laryngospasm can
occur without warning, it is sometimes
preceded by a high-pitched inspiratory
stridor, followed by complete airway
obstruction. Airway restriction may not
be obvious; a laryngospasm can present
TECHNIQUE
1. Request a bag-valve-mask device
with a PEEP valve and draw up a fast-
acting NMBA.
2. Attempt to break the laryngospasm
by applying significant (ie, painful)
pressure inward and anteriorly behind
the lobules of the pinnas (ie, Larson’s
point/the laryngospasm notch), while
performing a jaw thrust.
3. Attempt positive-pressure ventilation
while Step 3 is underway. Consider
applying cricoid pressure.
as increased work of breathing, vomiting,
or desaturation.
An intralingual injection can be an
effective way to administer NMBAs when
no other access can be obtained. When
using this approach, the agent should be
injected into the tongue (much like an
intramuscular shot).
The laryngospasm
notch is located
behind the lobule of
the pinna of each ear,
which is anterior to
the mastoid process
of the temporal bone
and posterior to the
ascending ramus of
the mandible.
4. Assess the case:
a. If the patient can be oxygenated,
continue manual ventilation until
the laryngospasm has resolved.
b. If the patient cannot be oxygen­
ated, administer an NMBA and
initiate intubation or the use of
a bag-valve-mask device until
the medication has worn off.
5. Consider establishing a surgical
airway if no NMBA is available,
or in the event of impending
cardiorespiratory arrest.
 The LLSA
Literature Review
New-Onset Seizures
By Neil A. Ray, MD; and Michael E. Abboud, MD
University of Pennsylvania, Philadelphia
Reviewed by Andrew J. Eyre, MD, MHPEd

Gavvala JR, Schuele SU. New-onset seizure in adults and adolescents: a review. JAMA. 2016 Dec 27;316(24):2657-2668.

Seizures are globally defined as transient episodes of abnormal activity triggered by excessive
or synchronous central nervous system activation. These events can range from staring spells to
generalized tonic-clonic movements. Epilepsy, subsequently, is defined as two or more unprovoked
seizures that occur more than 24 hours apart, or a single unprovoked seizure with a high risk of
recurrence within the next 10 years.

The first step in the acute evaluation
of a new-onset seizure is to distinguish
the diagnosis from “mimics” such as
transient ischemic attacks, complex
migraines, syncope, and psychogenic
nonepileptic seizures. Seizures can often
be diagnosed based on the patient’s
history, physical examination, and
any witness reports. Risk factors for
the disorder include excessive sleep
deprivation, illicit drug or alcohol use,
metabolic derangements, toxin exposures,
organ failure, and certain medications.
Any patient with a new-onset seizure
should undergo neuroimaging to identify
lesions that could have contributed to
the event. This is especially important for
those who present with new neurological
deficits, prolonged altered mental status,
recent trauma, or a prolonged headache,
or if a structural brain lesion is suspected.
While CT scans are frequently employed
and may be sufficient, they can miss
important lesions. MRI is more sensitive
than CT for detecting intracranial
abnormalities that contribute to seizures
(30% vs 10%, respectively).
An electroencephalogram (EEG)
should be considered for patients who
do not return to their neurological
baseline within 30 to 60 minutes after
the seizure ends, and for anyone with
a focal neurological deficit or a level of
consciousness that waxes and wanes.
For patients who have fully recovered,
an EEG can be safely deferred to an
outpatient setting. A lumbar puncture
should be reserved for cases that are
concerning for encephalitis, subarachnoid
hemorrhage, or meningitis.
Two-thirds of patients with new-onset
seizures do not necessitate treatment.
In addition, the delayed initiation of
antiepileptic agents has had no effect
on long-term prognosis when compared
to immediate initiation. Antiepileptic
medications can be classified as broad
spectrum (effective for most generalized
and focal seizures) and narrow spectrum
(more effective for focal seizures). The
adverse effects associated with these
drugs usually occur within the first few
days of therapy and include somnolence,
dizziness, blurry vision, difficulties with
concentration, memory impairment, and
skin rashes. Medication decisions should
be made with the help of a neurologist
and/or hospital guidelines.
Patients with new-onset seizures
should be carefully counseled about the
various activities that can trigger these
events or lower the seizure threshold.
In addition, clinicians must emphasize
the importance of avoiding potentially
lethal activities, including swimming,
taking baths, operating heavy machinery,
climbing, and using ladders. Each state
has specific laws and regulations that
may limit driving after a seizure. Patients
should be counseled accordingly, and
physicians should remain aware of the
state-specific laws for mandated reporting.
KEY POINTS
n Seizures should be distinguished
from mimics such as transient
ischemic attacks, complex
migraines, syncope, and
psychogenic nonepileptic seizures.
n MRI is more sensitive than
CT for detecting intracranial
abnormalities (30% vs 10%,
respectively).
n An EEG should be considered for
patients who do not return to their
neurological baseline within 30 to
60 minutes, have a focal neuro­
logical deficit, or have a waxing/
waning level of consciousness.
n Decisions regarding antiepileptic
drugs should be made with the
help of a neurologist and/or
hospital guidelines.
n Patient education and counseling
can help minimize the risk of
recurrence.

Critical Decisions in Emergency Medicine’s series of LLSA reviews features articles from ABEM’s 2019 Lifelong Learning and
Self-Assessment Reading List. Available online at acep.org/moc/llsa and on the ABEM website.

January 2019 n Volume 33 Number 1 13

 The Critical Image
A 70-year-old man presents with bleeding from his chest wall. According By Joshua S. Broder, MD, FACEP
to his family, he has been followed by plastic surgery for a chronic wound Dr. Broder is an associate professor and the
residency program director in the Division
at the site of bleeding, which has healed poorly since a surgical procedure
of Emergency Medicine at Duke University
approximately 4 months earlier. The patient’s medical record reveals that, after Medical Center in Durham, North Carolina.
undergoing coronary artery bypass grafting, he developed a pericardial abscess
that eroded into his left pleural space. He subsequently underwent a resection
of an infected anterior seventh rib and a complex thoracotomy closure with a pectoralis muscle flap.
The patient appears critically ill but
denies chest pain, shortness of breath, A
and abdominal pain. His vital signs
are blood pressure 70/40, heart rate
90, respiratory rate 20, temperature
37.2°C (99.0°F), and oxygen saturation
95% on room air. His heart is regular,
and his lungs are clear. He has a left
thoracotomy incision, which appears
mostly healed but is oozing bright blood
from a granulating defect.

Large-bore peripheral IVs are placed,

and the patient is hemodynamically
stabilized after a transfusion of four units
of packed red blood cells. In anticipation
of a worsening clinical course, he is
intubated, and central venous access
is obtained. A cardiothoracic surgeon
is consulted, and the patient is
accompanied to CT by the emergency
physician and surgeon.

A. Chest x-ray following

ä
B Without injected contrast, a soft-tissue
intubation. The left density is seen adjacent to the heart,
costophrenic angle is but its significance is unclear
blunted.

B. Noncontrast chest CT. à

A soft-tissue mass is seen
adjacent to the heart;
however, the borders of
the left ventricular chamber
cannot be visualized
without injected contrast,
and the significance of
the soft-tissue density is
unclear. Without IV contrast,
active hemorrhage is not
apparent.

14 Critical Decisions in Emergency Medicine

 C. Axial CTA. Following the
C A left ventricular pseudoaneurysm administration of IV contrast, the left
fills with vascular contrast ventricle is clearly delineated, as is a
large irregular fluid collection projecting
from the ventricle through the chest
wall (ie, a pseudoaneurysm).

D. Coronal CTA
also depicting the D
pseudoaneurysm.

KEY POINTS
n A left ventricular pseudoaneurysm
can arise following a transmural
myocardial infarction, after
surgery involving the myocardial
free wall, after trauma to the
ventricle, or (as in this case) as
a complication of a pericardial
infection.
n A rupture of the pseudoaneurysm
— usually intrathoracic and
A left ventricular
not external, as in this case
pseudoaneurysm fills with
— can result in catastrophic
exsanguination or pericardial vascular contrast
tamponade.

CASE RESOLUTION
Immediately following the CT scan, the patient was taken emergently to the operating room for surgical repair.

January 2019 n Volume 33 Number 1 15

 It’s a jungle out there!
Let CDEM be your guide.
Don’t miss Critical Decisions’ new podcast,
hosted by emergency medicine experts
Danya Khoujah, MD and Wendy Chang, MD.

Get entertained and informed by real-life cases and new clinical

approaches to managing everything from animal bites and broken
bones to drug withdrawal and stab wounds.

A
PO LL SUBSCRIBE AND DOWNLOAD TODAY
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D NE AT ACEP.ORG/PODCASTS.
CA W
ST Decisions in Emergency Medicine
16 Critical
!
 Winter Wipeout
Skiing and
Snowboarding Injuries

LESSON 2

By Katherine W.D. Dolbec, MD

Dr. Dolbec is an emergency and sports medicine physician at the University of Vermont
Medical Center and an assistant professor at the Larner College of Medicine in
Burlington, Vermont.
Reviewed by George Sternbach, MD, FACEP
OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Identify the most common injuries sustained by skiers and n What injuries and mechanisms should be
snowboarders.
suspected when managing skiers and
2. Understand how to assess, image, and treat patients with snowboarders?
skiing-related knee injuries.
n How should skiing-related knee injuries be
3. Properly assess skiing-related thumb injuries and
managed in the emergency department?
understand their associated morbidity.
n How should skiing-related thumb injuries be
4. Identify and manage common skiing- and snowboarding-
related shoulder injuries.
managed in the emergency department?
n What unique factors should be considered when
5. Describe how to identify and treat unique snowboarding-
related ankle injuries. evaluating a snow sport-related shoulder injury?
n What differential diagnoses should be
FROM THE EM MODEL considered when evaluating a snowboarder with
18.0 Traumatic Disorders an ankle injury?
18.1.8 Extremity Bony Trauma

As the winter sports season reaches its peak, the number of skiing- and snowboarding-related injuries
mounts. More than 100,000 injured skiers and snowboarders seek care in US emergency departments
annually.1 Although nearly 50% of these presentations involve sprains and strains, these patients are at risk for a
number of unique complications that can result in long-term sequelae. As such, emergency physicians must be
prepared to recognize the mechanisms and nuanced signs of skiing- and snowboarding-related injuries, conduct
appropriate diagnostic tests, employ splinting and bracing, and initiate rehabilitation and orthopedic follow-up.

January 2019 n Volume 33 Number 1 17

 CASE PRESENTATIONS
■ CASE ONE
A 54-year-old man presents
with knee pain resulting from a fall
sustained while skiing. He explains
that he turned quickly to avoid
colliding with another skier, while
shifting his weight toward the tails
of his skis. He immediately heard
a “pop” and felt a sudden, sharp
pain in his right knee. Although
the pain quickly abated after he
fell, his knee felt “wobbly” when
he tried to stand. Unable to bear
weight and walk, the patient had to
be carried down the mountain by
the ski patrol.
On examination, his right knee
is visibly swollen, with a palpable
effusion. There is no tenderness to
palpation along the patella or the
medial or lateral knee joint lines.
He has a limited range of motion
(+5 degrees of extension and 100
degrees of flexion) with end-range
flexion and extension.
He complains of diffuse knee
pain, which is most pronounced
CRITICAL DECISION
What injuries and mechanisms
should be suspected
when managing skiers and
snowboarders?
Most snow-sport injuries are
traumatic, the result of moving at a high
rate of speed on firm, slippery terrain
while surrounded by other people and
obstacles. Falls account for 75% to 85%
of injuries, collisions cause 11% to 20%,
and lift-related incidents prompt 2% to
9% of winter sport-related emergency
department visits.2
Many variables affect injury rates,
including ability, age, gender, physical
fitness, and snow conditions. Patients
younger than 20 years and those older
than 40 years are at greatest risk.3 While
beginners experience injuries three
times more often than expert skiers and
snowboarders, their injuries tend to be
18 Critical Decisions in Emergency Medicine
posteriorly. His quadriceps strength
is 4/5, and his hamstring strength
is 4+/5. The clinician performs the
Lachman test, which is positive
without an end point and with
increased laxity in comparison to
the left knee. Increased excursion is
noted when varus and valgus stress
is applied while the right limb is in
full extension, but no frank knee
pain or gapping is noted. A posterior
drawer test is negative. The emergency
physician orders x-rays.
■ CASE TWO
A 22-year-old woman presents
with pain and swelling at the base of
her right thumb after falling during
a skiing lesson. She explains that she
lost her balance on a beginner slope
and landed on outstretched hands;
she was wearing her pole straps at
the time. She has no history of prior
thumb injuries and is right-hand
dominant.
The patient has some mild swelling
and discoloration around her first
metacarpophalangeal (MCP) joint,
less severe. Experts, who typically move
at higher speeds, are far more likely to
sustain head injuries, fractures, and high-
grade ligament sprains. Hard-packed
snow generally yields a greater number
of high-speed and impact injuries than
powder and heavy snow.
Other factors that predispose
patients to accidents include:
• Time skiing/snowboarding without
rest
• Skiing/snowboarding above one’s
ability level
• Improper or faulty equipment
• An inadequate adjustment to altitude
• Dehydration or fatigue
• Skiing/snowboarding off trail or in
closed areas
• Failure to observe posted warning
signs
Skiers are prone to injuries that
involve the lower extremities, while
snowboarders are more apt to sustain
upper-extremity trauma. Knee injuries
and tenderness is noted on the
ulnar side of the thumb. Although
she has full active range of motion,
opposition movements cause her
pain. The emergency physician
orders x-rays of the patient’s thumb.
■ CASE THREE
A 25-year-old man arrives via
ambulance after a snowboarding
accident at a local terrain park. He
explains that he lost his balance
and fell after landing a large jump.
He complains of ankle pain and is
having difficulty bearing weight.
Mild swelling of the lateral ankle
is noted, but there is no bruising.
Palpation reveals tenderness of the
lateral ankle and lateral malleolus
without crepitus. There is no pain
at the proximal fibula or base of
the fifth metatarsal. The patient is
able to plantar flex and dorsiflex
his ankle with some discomfort. His
ankle strength and sensation are
intact. Suspecting a fracture, the
clinician orders x-rays.
are the most common ski-related
complaints, followed by trauma to
the head, face, shoulder, and thumb.1
Snowboarders are most inclined to
injure their wrists, shoulders, knees,
heads, faces, and ankles.4 Although
serious splenic injuries are rare, they
occur more frequently in snowboarders
than they do in skiers.5
Traumatic brain injuries, ranging
from concussions to intracranial
hemorrhages, are common in both
skiers and snow­boarders (7.2%-17.9%)
and are the most common cause
of death and serious injury among
both.1,6 Chest trauma (eg, rib fractures,
pneumothoraces, hemothoraces) and
spinal injuries also occur.7 Ninety-
five percent of snow sport-related
thoracic and lumbar spinal injuries
involve compression fractures, spinous
process fractures, or transverse process
fractures. In such cases, neurological
sequelae are rare.8
CRITICAL DECISION
How should skiing-related
knee injuries be managed in
the emergency department?
Knee injuries, which account for
approximately one-third of all injuries
in adult skiers, are also common in
pediatric patients.9 Owing to the
combination of gravitational and
centripetal forces inherent in the sport,
in which a large lever arm is to attached
to the foot, medial collateral ligament
(MCL) sprains and anterior cruciate
ligament (ACL) sprains are particularly
common, each accounting for
approximately 25% of all skiing-related
knee injuries.9,10
Approximately 68% of ACL tears
in skiers are associated with trauma
to the menisci or another ligamentous
structure.11 Lateral collateral ligament
(LCL) tears, posterior cruciate ligament
(PCL) tears, and knee dislocations are
relatively uncommon in this population.
The most common cause of ACL
injuries in skiers is the “phantom
foot” (Figure 1), in which the knee is
simultaneously flexed and internally
rotated.9,12 ACL trauma can also be
caused by valgus-external rotation
(Figure 2), a mechanism frequently
associated with concomitant MCL
trauma, or a boot-induced anterior
FIGURE 1. Phantom Foot
Mechanism
This ACL injury occurs when a skier loses
balance and transfers weight over the
back of the skis. The hips drop below the
knees and the uphill arm falls backward.
The uphill ski becomes unweighted,
placing pressure on the inside edge of the
downhill ski, and the upper body rotates
to face the downhill ski, exerting an
internal rotation force on the tibia.
drawer movement (Figure 3), in which
the skis continue downhill rapidly as
the skier’s weight is shifted backward.
These injuries often happen when
skiers land a jump with their weight
distributed in the “backseat.”10
Clinical Clues
A skier with an ACL injury may
report feeling or hearing a “pop”
followed by a sensation of pain.
Although the pain diminishes rapidly,
the affected knee will feel unstable when
the patient attempts to stand or walk.
Effusion develops shortly thereafter, and
with it, the pain returns. The Lachman
test, in which the examiner stabilizes the
patient’s femur with one hand and pulls
and pushes the tibia anteriorly with the
other, is the most sensitive (80%-99%)
and specific (95%) method for detecting
ACL ruptures.
Because the ACL is a primary
medial stabilizer, increased excursion
may be noted when varus and valgus
stress is applied to the knee in full
extension. This finding should not be
misinterpreted as a sign of trauma to the
MCL or LCL, which can be identified
by tenderness with palpation over the
ligaments and painful laxity with the
application of varus or valgus stress in
full extension and 30% of flexion. The
increased excursion caused by an ACL
FIGURE 2. Valgus-External
Rotation Mechanism
These injuries are caused when the skier
falls forward, catching the inner edge of
the ski tip on snow.
rupture will disappear when the knee is
placed in 30 degrees of flexion.
The mechanism responsible for
most MCL injuries is valgus stress
placed on the knee during a fall.
These injuries are especially common
in beginners, who often spend
considerable time skiing in a wedge
position, with their knees in a valgus
position and their hips and knees
internally rotated. On examination,
these patients complain of medial
knee pain; there is tenderness to
palpation over the far medial knee
joint and increased pain when valgus
stress is applied. Grade II and III
sprains are accompanied by a laxity
of the ligament when valgus stress is
applied. Importantly, the laxity of the
affected limb should be compared to
the contralateral, uninjured side, as
some patients inherently have greater
ligamentous laxity.
Between 23% and 55% of
skiing-related meniscal tears are
associated with ACL ruptures.9,13
Lateral meniscal injuries accompany
between 43% and 81% of ACL and
MCL tears and are five times more
common than coincident medial
meniscal tears in skiers with acute ACL
insufficiency.9,11,13 These “shearing”
injuries are sustained when the tibia
rotates on the femur. The diagnosis
FIGURE 3. Boot-Induced
Anterior Drawer Mechanism
With this mechanism, a skier lands from
a jump, and the tails of the skis strike
the snow first, which forces the elevated
ski tips downward. The boot applies a
passive anterior drawer load to the tibia.
January 2019 n Volume 33 Number 1 19
 FIGURE 4. Segond Fracture
can be difficult to observe during the
physical examination, unless the patient
presents with a knee that is locked (a
complication of a bucket-handle tear,
in which a portion of the meniscus has
flipped into the joint).
Patients typically develop an
effusion within hours of injury. The
McMurray maneuver, in which a varus
force is applied to an internally rotated
leg (lateral meniscus) as the knee is
moved from flexion to extension and
valgus force is applied to an externally
rotated leg (medial meniscus) as the
knee is moved from flexion to extension,
may be attempted. However, the test
can be difficult to perform in a painful,
swollen limb. The test is considered
positive when a palpable or audible
“clunk” can be appreciated when the
knee is moved from flexion to extension.
Suspicion can be confirmed by an
outpatient MRI.
Any skier who presents with knee
pain should undergo x-rays in the
emergency department (anteroposterior
[AP], lateral, and tunnel views). A
sunrise view may be helpful if a patellar
pathology is suspected. The films should
be studied for evidence of a tibial plateau
or Segond fracture (Figure 4). Segond
fractures, which represent an avulsion
of the anterolateral ligament of the
knee, appear as small, cortical avulsion
fractures lateral to the proximal tibia.
Although uncommon, Segond
fractures are pathognomonic for an
ACL injury in adults and likely represent
a significant varus stress with internal
20 Critical Decisions in Emergency Medicine
FIGURE 5. Initial ACL Injury Rehabilitation Exercises
Quad sets
Passive knee extension
rotation of the tibia with respect to the
femur.14,15 In addition, Segond fractures
are associated with a high coincidence of
medial meniscal tears.14
A reverse Segond fracture, or an avulsion
fragment medial to the proximal tibia
(where the deep capsular component
of the MCL is attached), frequently
indicates trauma to the PCL, MCL, or
medial meniscus and is typically the
result of a high-energy valgus or external
rotation mechanism.14,16
It is also important to closely study
the tibial spines of any patient with a
suspected ACL or PCL rupture. Tibial
spine avulsions, rare injuries in which
the ligament remains intact but the bone
is fractured at its tibial attachment,
require knee immobilization and a
prompt surgical consultation. All but
the most minimally displaced of these
fractures are managed surgically.14
Tibial plateau injuries are sustained
via the same mechanisms that precipitate
ligamentous injuries of the knee.
Clinicians should maintain a high
suspicion for these diagnoses when
assessing x-rays; a CT scan should be
seriously considered if a displaced,
intra-articular tibial plateau fracture is
suspected but not appreciated or fully
assessed on plain film. Significant knee
injuries should be promptly evaluated
with outpatient MRI imaging to assess for
ligamentous, meniscal, and bony trauma.
Management and Disposition
Ambulation should be tested prior
to discharge, and patients who can
walk unassisted should generally be
Heel slide
allowed to do so. The placement of a
knee immobilizer should be avoided
whenever possible; these devices can
significantly delay surgical management
and hinder rehabilitation by promoting
muscle atrophy and reducing range of
motion in the affected limb. Exceptions
to this rule include quadriceps and
patellar tendon ruptures, displaced
tibial plateau fractures, tibial spine
avulsion fractures, patellar fractures
or dislocations, and knee dislocations.
In these instances, the knee should be
immobilized in extension and the patient
should refrain from bearing weight. An
immobilizer may also be considered
for traumatic knee injuries in children,
who sometimes require more aggressive
bracing for a comfortable and safe
discharge. Pediatric patients are more
likely to regain strength and range of
motion post-injury than their adult
counterparts.
Any patient with one of the above
indications for a knee immobilizer
warrants urgent or emergent orthopedic
management, and orthopedics should
be consulted prior to emergency
department discharge to determine the
appropriate disposition and follow-
up plan. If a knee immobilizer is not
indicated, but the pain is unbearable or
the knee is too unstable for the patient
to walk unassisted, a hinged knee brace
and/or crutches can be supplied and the
patient can be instructed to bear weight
as tolerated.
Rehabilitation should be initiated
upon discharge from the emergency
department, and patients should be
encouraged to perform aggressive
range-of-motion exercises several
times a day to prevent stiffness. In
addition, an effort should be made to
preserve quadriceps and hamstring
strength. Patients should be instructed
to perform quadriceps-flexion exercises
(performed in a seated or supine
position) and heel-slide exercises for
hamstring strengthening (Figure 5) a
minimum of three times per day.
Knee injuries that do not fall
into the category of urgent/emergent
should be referred to orthopedics for
further evaluation and management.
Unfortunately, many skiing-related
knee injuries, including displaced
tibial plateau and tibial spine avulsion
fractures, require surgical repair. ACL
and meniscal injuries may warrant
surgery, depending on the patient’s age,
activity level, goals, and rehabilitation
potential. MCL injuries are generally
treated nonoperatively.
CRITICAL DECISION
How should skiing-related
thumb injuries be managed
in the emergency
department?
An ulnar collateral ligament
(UCL) sprain, or “skier’s thumb,” is
a common and deceptively serious
injury typically caused by a fall onto an
outstretched hand that is attached to
a ski pole strap. Further valgus stress
is placed on the joint by the forward
momentum of the skier, who may
continue to travel downhill with the
hand planted in the snow.9 Long-term
disability can result from a chronic
deficiency of the ligament; potential
complications include a diminished grip
and pinch, pain, and osteoarthritis.17
Injured hands should be
thoroughly inspected for bruising and
swelling, and the joints and bones
should be carefully palpated to identify
the point of maximal tenderness. UCL
trauma should be suspected when
maximal tenderness is noted over
the ulnar aspect of the MCP joint.
The stability of the ligament can be
determined by placing valgus stress on
the MCP joint. This maneuver should
be performed with the thumb in full
extension and at 30 degrees of flexion
to evaluate the proper and accessory
UCLs (Figure 6).
A UCL rupture should be considered
when assessing any thumb with a laxity
of more than 30 degrees, laxity that
is 15 degrees greater than it is on the
contralateral side, or laxity that has
no end point.17 UCL sprains, which
can be graded I to III, are frequently
accompanied by trauma to the dorsal
capsule and the volar plate, potentially
leading to volar subluxation of the
proximal phalanx.17 Grade I injuries are
evidenced by pain with palpation and
stress but no laxity; grade II injuries
involve some laxity of the joint and
a preserved end point; and grade III
injuries are marked by significant laxity
and no end point.17
Because of the significant force
involved, grade III injuries are often
associated with Stener lesions, in which
the distal end of the ruptured ligament
becomes displaced, resulting in the
interposition of the ulnar expansion
of the dorsal aponeurosis between the
ligament and its attachment site on
the proximal phalanx. These lesions
(Figure 7), which can manifest as a
painful lump at the site of the “balled up”
ligament, necessitate surgical repair to
avoid long-term functional compromise.17
FIGURE 6. Valgus Stress Test
for the UCL of the Thumb
Evaluation and Management
There is a theoretical concern
that placing significant valgus stress
on the MCP joint during ligamentous
stability testing could create a Stener
lesion where one did not previously
exist. In practice, however, a relatively
gentle examination is unlikely to
cause significant additional damage or
increase the complexity of the probable
impending surgical repair.
The differential diagnosis of a
skiing-related injury to the base of the
thumb includes a Bennett fracture,
Rolando fracture, and scaphoid
fracture. Four-view x-rays of the
hand (AP, lateral, and oblique views)
should be obtained. Dedicated wrist
films, including a scaphoid view, can
be obtained if a scaphoid fracture
is suspected. In addition, the x-rays
should be studied closely for evidence
of an avulsion fracture of the distal
attachment of the UCL.17 Stress views
can help clarify the degree of instability
at the first MCP joint. Unstable grade
III injuries require an outpatient MRI
for further evaluation and possible
surgical planning. In the hands of an
experienced clinician, an ultrasound
evaluation can also be effectively used
to assess for a UCL rupture.
The patient’s thumb should be
immobilized in a spica splint, and the
FIGURE 7. Stener Lesion
January 2019 n Volume 33 Number 1 21

FIGURE 8. Squared-Off Appearance of a Shoulder Dislocation
patient should receive close orthopedic
follow-up. The interphalangeal joint
should be left free to preserve optimal
function and avoid stiffness. Patients
should be advised against removing the
splint until definitive care is sought.
Grade I and II injuries can generally
be treated nonoperatively, while grade
III injuries (with or without a Stener
lesion) typically require surgical repair.17
CRITICAL DECISION
What unique factors should
be considered when
evaluating a snow sport–
related shoulder injury?
Falls are the most common cause
of shoulder trauma. The most common
mechanisms are direct blows, eccentric
muscle contractions with shoulder
abduction and external rotation, and an
axial load on an outstretched arm.18
Rotator cuff tears, anterior
glenohumeral dislocations, acro­
mioclavicular (AC) joint sprains, and
clavicle fractures are the most common
shoulder injuries sustained by skiers.18
Less common shoulder injuries include
greater tuberosity fractures, trapezius
strains, proximal humerus fractures,
22 Critical Decisions in Emergency Medicine
during falls in which the shoulder is
abducted and externally rotated. These
injuries can also occur when a skier
or snowboarder catches an arm or ski
pole on a stationary object while the
remainder of the body continues its
forward momentum. In snowboarders,
anterior shoulder dislocations frequently
result from jumps, aerial maneuvers,
and falls backward.19 Luxatio erecta
humeri is a rare form of dislocation in
which the humeral head is displaced
inferiorly and the arm becomes locked
in a flexed, overhead position.
Rotator cuff tears are closely
associated with glenohumeral
dislocations and greater tuberosity
fractures. A skier older than 40 years
who presents with a shoulder
dislocation has a 35% risk of a
concomitant rotator cuff tear. This
risk increases to 40% in patients
with greater tuberosity fractures and
to 100% in those with neurological
findings involving the axillary nerve.9,18
Weakness with resisted shoulder
biceps strains, glenoid fractures, scapula abduction in the scapular plane suggests
fractures, humeral head fractures, a rotator cuff tear. These presentations
sternoclavicular separations, and are often delayed, however; as such,
acromial fractures. it is important to elicit a good history
AC separations are the most regarding the onset of symptoms.
common snowboarding-related shoulder Patients with an anterior shoulder
injuries, followed by glenohumeral dislocation present with pain and
joint dislocations, clavicle fractures, decreased passive and active range
anterior and posterior sternoclavicular of motion in the affected limb. The
dislocations, rotator cuff strains, and shoulder will have a squared-off
proximal humerus fractures.18 appearance (Figure 8), and there may be
a palpable mass indicating the displaced
Shoulder Dislocations humeral head. The neurovascular
Anterior shoulder dislocations, examination may reveal numbness in
which far outnumber posterior the axillary nerve distribution over the
dislocations, most commonly occur lateral arm.
TABLE 1. Rockwood Classification of AC Injuries
Deltopectoral CC Interspace Radiographic Appearance
Type AC Ligaments CC Ligaments Fascia Difference* of an AC Joint
I Sprained Intact Intact Normal Normal
II Disrupted Sprained Intact <25% Widened
III Disrupted Disrupted Disrupted 25% to 100% Widened
IV Disrupted Disrupted Disrupted Increased Clavicle posteriorly
displaced (axillary)
V Disrupted Disrupted Disrupted 100% to 300% N/A†
VI Disrupted Disrupted Disrupted Decreased Clavicle displaced
inferior to coracoid
*Distance between the superior aspect of the coracoid process and the inferior aspect of the clavicle, as
measured radiographically.
†
N/A = information unavailable
 Prereduction x-rays (including AP,
true AP, scapular Y, and axillary views)
should be obtained to confirm the
dislocation and identify alternative or
concomitant pathologies. X-rays can
help confirm the position of the humeral
head in relation to the glenoid fossa and
enable the identification of fractures. A
humeral neck fracture that accompanies
a shoulder dislocation can make closed
reduction difficult or impossible. Greater
tuberosity fractures are often seen
in patients with traumatic shoulder
dislocations and can be identified by
prereduction plain films. In rare cases,
this fragment interferes with reduction
attempts.
Plain x-rays can also identify
alternative diagnoses such as AC joint
sprains, distal clavicle fractures, and
isolated humeral neck fractures. If a
dislocation is suspected clinically but
is not identified on x-rays, the clinician
should look for subtle signs of a
posterior dislocation (eg, a light bulb
sign) (Figure 9). The axillary view can
also help reveal these injuries.
Once a shoulder dislocation has
FIGURE 9. Light Bulb Sign of a Posterior Shoulder Dislocation
been confirmed, reduction should be
attempted promptly. The patient’s pain
level and the difficulty of the procedure
increase commensurate with the amount
of time since the injury.20 An isolated,
uncomplicated shoulder dislocation can
be successfully reduced using one of
many described reduction techniques.
Most anterior glenohumeral dislocations
can be reduced without sedation.19
The value of post-reduction films is
controversial, and clinicians may be
able to accurately assess these injuries
clinically. In addition, a fracture that
is identified after reduction was almost
certainly present before the reduction
attempt and is unlikely to alter decisions
regarding the pursuit of surgical repair.21
Following reduction, patients should
be discharged in a sling and instructed
to avoid performing overhead activities
and abducting, externally rotating, or
extending the shoulder. However, they
should also be encouraged to begin
gentle, passive range-of-motion exercises
(eg, pendulum swings) as soon as can be
tolerated.
FIGURE 10. Lateral Process
Talus Fracture
Courtesy of Matthew Gammons, MD
Shoulder Separations
Snowboarding-related AC
separations most often result from
falls in which the patient lands directly
on the lateral acromion.19 When
managing a patient who has been
injured in a snowboarding accident,
the shoulders should be carefully
inspected by palpating the joints and
bony landmarks, noting any deformities
and identifying the point of maximal
tenderness. Range-of-motion testing
should be attempted; however, due to
the underlying pathology or secondary
to pain, most shoulder injuries will
be accompanied by a decreased range
of motion. A thorough neurovascular
examination should be performed.
The AC ligaments are primarily
responsible for the horizontal stability of
the clavicle in relation to the acromion,
while the coracoclavicular (CC)
ligaments control vertical stability.19 Any
trauma to these structures constitutes
an AC sprain, the severity of which can
be assessed using a variety of diagnostic
tools. The Rockwood classification
system (Table 1), the most widely used
scale, can help facilitate communication
between the emergency physician and
the orthopedist.
January 2019 n Volume 33 Number 1 23
 CASE RESOLUTIONS
■ CASE ONE
X-rays of the skier’s injured knee
revealed a small avulsion fragment
lateral and superior to the fibular
head, which was identified as a
Segond fracture. The emergency
physician suspected an ACL rupture
based on the mechanism of injury,
rapid development of an effusion,
instability, positive Lachman test,
increased varus-valgus excursion of
the knee in extension, and presence
of a Segond fracture.
The patient was able to walk
unassisted in the emergency
department and did not require a
brace or crutches. He was advised
to take it slow, while contracting
his quadriceps and hamstrings
with each step to stabilize the knee,
and was urged to follow up with
an orthopedist in the next week
to discuss management options. The
clinician also showed him how to
perform quadriceps sets and heel-slide
exercises to maintain his muscle mass
and stave off atrophy. In addition, he
encouraged the patient to work hard
on regaining full flexion and extension
of the knee by performing aggressive
range-of-motion exercises multiple times
per day.
■ CASE TWO
X-rays of the patient’s thumb
revealed no signs of a fracture, an
avulsion fragment, or subluxation.
Suspecting a rupture of the UCL,
the clinician consulted with the
hand surgeon on call, who suggested
performing a valgus stress maneuver
on the MCP joint. The test revealed
considerable valgus angulation without
a ligamentous end point.
The clinician diagnosed an
unstable grade III UCL injury and
placed the thumb in a spica splint.
The patient was warned about the
risks of long-term pain and disability
and was advised to follow up with a
hand surgeon in 5 to 7 days.
■ CASE THREE
The snowboarder’s plain films
revealed soft-tissue swelling without
any evidence of a fracture. The
alignment of the osseous structures
was normal. Given the mechanism
of injury and ongoing exquisite
tenderness over the lateral aspect of
the ankle, the emergency physician
obtained a CT scan, which revealed a
nondisplaced LTPF. The patient was
placed in a splint, discouraged from
bearing weight, and advised to seek
orthopedic follow-up care.

Type I injuries involve partial
tearing of the AC ligament. Type II
sprains are defined by a complete
tearing of the AC ligament and partial
disruption of the CC ligament, with
a slight elevation of the distal clavicle
in relation to the acromion. Type III
sprains are accompanied by a 25% to
100% elevation of the distal end of the
clavicle in relation to the coracoid, as
the CC ligaments and the AC ligament
are completely disrupted.
In types IV through VI, the CC
and AC ligaments are completely
disrupted and the trapezius and
deltoid are detached from the distal
half of the clavicle. In type IV
injuries, the trapezius is impaled by
the distal clavicle. Type V sprains
are characterized by 100% to 300%
superior displacement of the distal
clavicle in relation to the coracoid. In
type VI injuries, the distal clavicle is
depressed into the subcoracoid space.
X-rays should be performed on any
patient with a skiing- or snowboarding-
related shoulder injury. Weighted views,
in which the patient holds a 10- to
15-pound dumbbell in the affected hand,
can help verify any instabilities related
to a suspected AC sprain. A cross-body to prevent stiffness. Shoulder pendulum
adduction film, in which the hand on the exercises, which can often be initiated
affected side is reached across to grasp within a week, should be demonstrated to
the contralateral shoulder, can accentuate the patient prior to discharge.
the elevation of the clavicle in cases of Type IV to VI injuries warrant
CC ligament disruption. an orthopedic consultation prior to
AC separations warrant orthopedic discharge; these presentations are
or sports medicine follow-up to ensure associated with significant soft-tissue
appropriate healing without functional damage, and urgent surgical repair may
impairment. Patients with Rockwood type be required. In some cases, surgical repair
I to III fractures, who generally can be is warranted for unstable type III injuries,
managed nonoperatively, should be placed particularly in patients with pain or
in a sling for comfort and encouraged to disability that persists remote from the
mobilize the injured shoulder as tolerated initial trauma.
n Avoid the use of a knee immobilizer, unless it is truly indicated.
n Initiate physical therapy exercises in the emergency department for knee injuries
that do not require immobilization. Advise patients to begin aggressive range-
of-motion and strength-preserving exercises immediately upon discharge.
n Ensure prompt hand surgery follow-up care for any patient with an injury of any
grade to the UCL of the thumb. Surgery may be the only way to avoid long-term
pain and functional compromise.
n Maintain a high index of suspicion for an LTPF in any snowboarder with an
appropriate mechanism of injury. Additional imaging may be warranted, even if
the initial x-rays are negative.

24 Critical Decisions in Emergency Medicine

CRITICAL DECISION
What differential diagnoses
should be considered when
evaluating a snowboarder
with an ankle injury?
Lateral talar process fractures
(LTPFs), which account for 32% of
snowboarding-related ankle fractures,
are nearly exclusive to snowboarding.9
Prior to the advent of the sport, these
injuries accounted for only 0.86%
of reported ankle fractures and were
typically associated with high-energy
mechanisms such as motor vehicle
accidents and falls from height.
In snowboarders, LTPFs (Figure 10)
typically involve a high-velocity impact
and significant axial loading (eg, landing
a jump). It is believed that dorsiflexion,
inversion, and possibly external rotation
forces also play a role.22 A high level of
suspicion should be maintained for these
injuries in any patient with a convincing
mechanism.23
The physical examination will reveal
tenderness over the anterolateral ankle,
including the lateral process, lateral
malleolus, anterior talofibular ligament,
and sinus tarsi.33 Trauma to the lateral
talar process is notoriously difficult
to diagnose, and clinical clues can be
subtle. Many of these cases are initially
misdiagnosed as ankle sprains, and
as many as 50% are missed on initial
radiography.9
A high index of suspicion should be
maintained when managing patients with
normal x-rays but a concerning history or
examination findings, and there should
be a low threshold for initiating CT scans
n Placing a knee immobilizer on every patient with traumatic knee pain. This
approach can impede rehabilitation, accelerate muscle atrophy, and diminish
range of motion. If required for stability and comfort, other assistive devices
and methods of bracing should be considered.
n Failing to recognize a possible UCL injury of the thumb. Unrepaired complete
ruptures lead to long-term pain and functional impairment. It is safe to apply
firm but gentle valgus stress to the first MCP joint when evaluating such cases.
n Failing to recognize mechanisms and examination findings consistent with
an LTPF. These fractures are missed on as many as 50% of plain films; when
possible, a CT scan should be obtained.
to definitively diagnose or rule out these
fractures. MRI should not be the first-line
imaging modality for evaluating such
cases, as it can fail to distinguish between
small avulsion fractures of the talus and
adjacent ligamentous injuries.9
Summary
Despite the popularity of these
winter past times for people of all ages,
snow sports carry an element of risk.
Snowboarders frequently suffer from
injuries to the upper extremities, feet,
ankles, head, and shoulders; however,
snowboarding appears to be gentler on
the knees than skiing. Knee trauma is the
most common injury in skiers, followed
by trauma to the head, face, shoulder,
and thumb.
Although many knee injuries require
surgical management, there are very
few indications for the placement of
a knee immobilizer and enforcement
of non-weight-bearing status. When
possible, it is important to limit
bracing, maximize weight-bearing, and
initiate rehabilitation directly from the
emergency department.
Without proper treatment, UCL
injuries of the thumb can cause long-term
morbidity. It is imperative to manage
these cases with a thorough physical
examination, appropriate diagnostic
imaging, proper bracing, and a prompt
hand surgery referral.
Skiing- and snowboarding-related
shoulder injuries should be managed with
early mobilization and prompt follow-up
care to minimize the recovery time and
maximize long-term function. LTPFs are
well-described, albeit uncommon, injuries
that are almost exclusively associated
with snowboarding. Misdiagnosing
these injuries as ankle sprains can result
in chronic pain and loss of function. A
CT scan is the imaging study of choice
in any patient with normal x-rays but
a suspicious mechanism and physical
examination findings.
REFERENCES
1. Xiang H, Kelleher K, Shields BJ, Brown KJ, Smith GA.
Skiing- and snowboarding-related injuries treated in
U.S. emergency departments, 2002. J Trauma. 2005
Jan;58(1):112-118.
2. Ryan SW, Harvey J. Skiing injuries. ACSM Current
Comment. American College of Sports Medicine website.
3. Girardi P, Braggion M, Sacco G, De Giorgi F, Corra S.
Factors affecting injury severity among recreational skiers
and snowboarders: an epidemiology study. Knee Surg
Sports Traumatol Arthrosc. 2010 Dec;18(12):1804-1809.
4. Coury T, Napoli AM, Wilson M, Daniels J, Murray R,
Milzman D. Injury patterns in recreational alpine skiing
and snowboarding at a mountainside clinic. Wilderness
Environ Med. 2013 Dec;24(4):417-421.
5. Prall JA, Winston KR, Brennan R. Severe snowboarding
injuries. Injury. 1995 Oct;26(8):539-542.
6. Sulheim S, Holme I, Rødven A, Ekeland A, Bahr R. Risk
factors for injuries in alpine skiing, telemark skiing and
snowboarding — case-control study. Br J Sports Med. 2011
Dec;45(16):1303-1309.
7. McBeth PB, Ball CG, Mulloy RH, Kirkpatrick AW. Alpine
ski and snowboarding traumatic injuries: incidence, injury
patterns, and risk factors for 10 years. Am J Surg. 2009
May;197(5):560-564.
8. Gertzbein SD, Khoury D, Bullington A, St John TA,
Larson AI. Thoracic and lumbar fractures associated with
skiing and snowboarding injuries according to the AO
Comprehensive Classification. Am J Sports Med. 2012
Aug;40(8):1750-1754.
9. Deady LH, Salonen D. Skiing and snowboarding injuries:
a review with a focus on mechanism of injury. Radiol Clin
North Am. 2010 Nov;48(6):1113-1124.
10. Järvinen M, Natri A, Laurila S, Kannus P. Mechanisms
of anterior cruciate ligament ruptures in skiing. Knee Surg
Sports Traumatol Arthorosc. 1994;2(4): 224-228.
11. Duncan JB, Hunter R, Purnell M, Freeman J. Meniscal
injuries associated with acute anterior cruciate
ligament tears in alpine skiers. Am J Sports Med.
1995 Mar-Apr;23(2):170-172.
12. Ettlinger CF, Johnson RJ, Shealy JE. A method to
help reduce the risk of serious knee sprains incurred
in alpine skiing. Am J Sports Med. 1995 Sep-Oct;
23(5):531-537.
13. Paletta GA Jr, Levine DS, O’Brien SJ, Wickiewicz TL,
Warren RF. Patterns of meniscal injury associated with
acute anterior cruciate ligament injury in skiers.
Am J Sports Med. 1992 Sep-Oct;20(5):542-547.
14. Gottsegen CJ, Eyer BA, White EA, Learch TJ, Forrester
D. Avulsion fractures of the knee: imaging findings and
clinical significance. Radiographics. 2008 Oct;28(6):1755-
1770.
15. Claes S, Luyckx T, Vereecke E, Bellemans J. The Segond
fracture: a bony injury of the anterolateral ligament of the
knee. Arthroscopy. 2014 Nov;30(11):1475-1482.
16. Escobedo EM, Mills WJ, Hunter JC. The “reverse
Segond” fracture: association with a tear of the posterior
cruciate ligament and medial meniscus.
AJR Am J Roentgenol. 2002 Apr;178(4):979-983.
17. Avery DM 3rd, Caggiano NM, Matullo KS. Ulnar collateral
ligament injuries of the thumb: a comprehensive review.
Orthop Clin North Am. 2015 Apr;46(2):281-292.
18. McCall D, Safran MR. Injuries about the shoulder in skiing
and snowboarding. Br J Sports Med. 2009 Dec;43(13):987-
992.
19. Kocher MS, Dupré MM, Feagin JA Jr. Shoulder injuries
from alpine skiing and snowboarding. Aetiology,
treatment and prevention. Sports Med. 1998 Mar;25(3):
201-211.
20. Kanji A, Atkinson P, Fraser J, Lewis D, Benjamin S.
Delays to initial reduction attempt are associated with
higher failure rates in anterior shoulder dislocation: a
retrospective analysis of factors affecting reduction failure.
Emerg Med J. 2016 Feb;33(2):130-133.
21. Gottlieb M, Nakitende D, Krass L, Basu A, Christian E,
Bailitz J. Frequency of fractures identified on post-
reduction radiographs after shoulder dislocation.
West J Emerg Med. 2016 Jan;17(1):35-38.
22. Mahmood B, Duggal N. Lower extremity injuries in
snowboarders. Am J Orthop (Belle Mead NJ). 2014
Nov;43(11):502-505.
23. Miller, SJ. Fractures of the lateral process of the talus:
snowboarder’s fracture. The Podiatry Institute Update.
2008;23.
January 2019 n Volume 33 Number 1 25
 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 Which of the following factors is most concerning for

acute coronary syndrome (ACS)?
A. Chest pain associated with diaphoresis
B. Chest pain associated with nausea and/or vomiting
C. Chest pain described as “pressure-like”
D. Chest pain that radiates to the right arm or shoulder
6 A patient with which presentation is least likely
to benefit from immediate angiography and
revascularization?
A. Cardiogenic shock
B. New ST-segment depressions
C. Recent history of intracranial hemorrhage
D. Severe left ventricular dysfunction or acute

2 A 51-year-old man with a history of hypertension and

type 2 diabetes presents with 6 hours of ongoing,
heart failure

7
pressure-like chest pain that radiates to the left Which five categories comprise the HEART
shoulder. His ECG shows nonspecific ST-segment score?
and T-wave changes; his initial troponin T level is
A. Age, gender, ECG findings, risk factors, and
within normal limits. According to the HEART score,
systolic blood pressure
approximately what is this patient’s risk for a major
B. Age, pain score, ECG findings, risk factors,
adverse cardiac event within the next 6 weeks?
and troponin level
A. 2%
C. History, ECG findings, age, risk factors, and
B. 17%
troponin level
C. 35%
D. History, pain score, age, risk factors, and
D. 50%
troponin level

3 Which of the following interventions for confirmed

ACS has been shown to significantly improve
mortality?
8 A patient with which of the following risk
factors is least likely to benefit from urgent
revascularization?
A. Aspirin
A. Age over 65 years
B. Morphine sulfate
B. Chest pain that resolves with appropriate
C. Sublingual nitroglycerin
medical therapy
D. Supplemental oxygen via nasal cannula
C. Elevated cardiac biomarkers

4 According to AHA/ACC, IV nitroglycerin is D. Prior documented stenosis above 50%

recommended for patients with non-ST-segment
elevation myocardial infarction (NSTEMI) and
which concomitant disorder? 9 Which of the following agents can decrease
the progression of unstable angina to
myocardial infarction by decreasing the
A. Aortic stenosis
inotropic and chronotropic effects of
B. Hypotension
catecholamines?
C. Ongoing ischemia
A. Anxiolytics
D. Right ventricular infarction
B. Beta-blockers

5 Which of the following symptoms is a strong C. Magnesium

indicator of nonischemic chest pain? D. Morphine sulfate
A. Pain associated with diaphoresis
B. Pain associated with exertion
C. Pain described as “sharp” or “stabbing”
D. Pain that can be relieved by nitroglycerin

26 Critical Decisions in Emergency Medicine


10 Which ECG finding necessitates immediate
coronary angiography and reperfusion therapy?
A. Brugada pattern
16 What grade should be assigned to an AC sprain
evidenced by a 100% elevation of the distal clavicle
in relation to the coracoid?
B. Diffuse ST-segment changes A. Grade I
C. New bundle branch block accompanied by B. Grade II
instability or Sgarbossa findings C. Grade III
D. Sinus arrhythmia D. Grade IV

11 What is the most sensitive clinical test for

diagnosing an anterior cruciate ligament (ACL)
rupture?
17 Which of the following injuries should be
considered when treating a snowboarder with
ankle pain after landing a jump?
A. Anterior drawer test A. Calcaneal fracture
B. Lachman test B. High ankle sprain
C. McMurray test C. Lateral malleolus fracture
D. Valgus stress test D. Lateral talar process fracture (LTPF)

12 What is the most commonly sustained

snowboarding injury? 18 Assuming the patient’s initial radiographs are
negative, what is the next study of choice for
A. ACL rupture evaluating a suspected LTPF?
B. Acromioclavicular (AC) joint sprain A. CT scan
C. Lateral process of the calcaneus fracture B. MRI
D. Wrist fracture C. No further imaging is required
D. Ultrasound

13 Which of the following is an absolute indication

19
for placement of a knee immobilizer? A skier presents with right knee pain after falling
A. ACL rupture during a beginner lesson. You note ligament
B. Medial collateral ligament (MCL) sprain laxity and tenderness to palpation over the far
C. Segond fracture medial knee joint, which is exacerbated by the
D. Tibial spine avulsion valgus stress test. Which of the following injuries
is most likely?

14 Which of the following injuries can result from

displacement of the ruptured end of the ulnar
collateral ligament (UCL) of the thumb?
A. ACL rupture
B. Knee dislocation
C. MCL sprain
A. Sever lesion D. Tibial plateau fracture
B. Steinbeck lesion
C. Stellar lesion
D. Stener lesion
20 When assessing a patient with a suspected
shoulder dislocation but no clear radiographic
evidence of humeral head displacement, what

15 Which physical examination maneuver is most

effective for evaluating the degree and stability
of a strain involving the UCL of the thumb?
injury should be considered?
A. Grade I AC sprain
B. Occult fracture
A. Lachman maneuver
C. Posterior shoulder dislocation
B. Resisted flexion maneuver
D. Shoulder subluxation
C. Valgus stress test
D. Varus stress test

ANSWER KEY FOR DECEMBER 2018, VOLUME 32, NUMBER 12

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

January 2019 n Volume 33 Number 1 27

 Drug Box
LINEZOLID
By Frank LoVecchio, DO, MPH, FACEP,
Maricopa Medical Center, Phoenix, AZ
Linezolid is a synthetic oxazolidinone-class antibiotic used to treat
severe Gram-positive bacterial infections of the skin and soft tissue.
Although it is infrequently used as a first-line antibiotic, the drug
can help treat vancomycin-resistant enterococci (VRE) infections,
methicillin-resistant Staphylococcus aureus (MRSA) infections, and
nosocomial and community-acquired pneumonia. It is also used off-
label for the management of meningitis, osteomyelitis, prosthetic joint
infections, and septic arthritis.
Mechanism of Action
Linezolid inhibits protein synthesis; in addition, it is bacteriostatic
against enterococci and staphylococci and bactericidal against most
strains of streptococci.
Dosing
ADULTS
Complicated skin/soft-tissue infections and pneumonia: 600 mg
PO/IV every 12 hours for 10-14 days (If VRE, lengthen to 14-28 days)
Uncomplicated skin/soft-tissue infections: 400 mg PO/IV every
12 hours for 10-14 days
CHILDREN
Complicated skin/soft-tissue infections and pneumonia:
• <12 years – 10 mg/kg PO/IV every 8 hours for 10-14 days
• >12 years – 600 mg PO/IV every 12 hours for 10-14 days
(If VRE, lengthen to 14-28 days)
Uncomplicated skin/soft-tissue infections:
• <5 years – 10 mg/kg PO every 8 hours for 10-14 days
• 5-12 years – 10 mg/kg PO every 12 hours for 10-14 days
• ≥12 years – 600 mg PO every 12 hours for 10-14 days
Side Effects
Common: headache, diarrhea, nausea, vomiting, dizziness
Serious: myelosuppression, lactic acidosis, peripheral and optic
neuropathy, serotonin syndrome
Precautions
Contraindications include hypersensitivity or anaphylaxis and recent
use (within 2 weeks) of an MAO inhibitor. Monitor patients for
myelosuppression. Prolonged use can lead to superinfection and
peripheral and optic neuropathy. Pregnancy category C.
Tox Box
IBUPROFEN/NAPROXEN TOXICITY
By Tony Gao, MD; and Christian A. Tomaszewski, MD, MS,
MBA, FACEP, University of California, San Diego
Ibuprofen and naproxen are nonsteroidal anti-inflammatory
drugs with a wide safety margin. Acute toxic effects are
rarely seen unless more than 5 to 10 times the usual
therapeutic dose is ingested.
Toxicokinetics
• Symptom onset: usually <4 hours post-ingestion
• Toxic dose: serious symptoms with quantities of
ibuprofen >400 mg/kg (child) or >10 g (adult)
Clinical Presentation
• GI distress – nausea/vomiting, occasional
hematemesis
• Neurotoxicity – CNS depression, coma, seizures,
aseptic meningitis (massive ingestions)
• Acute kidney injury – usually due to acute
tubulointerstitial nephritis
• Metabolic acidosis – elevated anion gap, lactic
acidosis (massive ingestions)
Diagnosis
• Specific serum levels are rarely available and are not
clinically useful.
• When managing seriously ill patients, consider
ordering a CBC, a PT, kidney and liver function tests,
electrolyte measurements, and a pH level test.
Management
• There is no antidote, and management is largely
supportive.
• Provide airway protection in cases of severe CNS
depression.
• Consider activated charcoal for asymptomatic awake
patients who have potentially ingested a large quantity.
• Monitor patients for seizures and treat with
benzodiazepines or phenobarbital.
• Administer sodium bicarbonate for severe metabolic
acidosis.
• Hemodialysis can be used to manage refractory
metabolic acidosis and renal failure.