Management

Emergent ENT or OMFS (oral and maxillofacial surgery) consult for operative I&D and extraction of
dentition if source is dental abscess
Airway Management
Intubation may be very difficult due to trismus and posterior pharyngeal extension
Preference for an awake fiberoptic intubation (ideally in OR if time allows) with setup immediately
available for cricothyrotomy

Question 2
 Management

Drainage
 The recurrence rate after aspiration is 10% and the cure rate is 93% to 95%. Recurrence rate for
aspiration alone may be higher than I&D
 May need IV pain meds, sedation or procedural sedation
o Glycopyrrolate can reduce secretions
Needle Aspiration

1. Apply anesthetic spray to overlying mucosa

2. Have patient hold suction and use as needed
3. Use laryngoscope or disassembled vaginal speculum with wand as tongue depressor and
light source
4. Inject 1-2mL of lidocaine with epinephrine into mucosa of anterior tonsillar pillar using 25
gauge needle
5. Cut distal tip off of needle sheath and place over 18ga needle to expose 1 cm of needle to
prevent accidentally plunging deeper than desired
6. Aspirate using 18 gauge needle just lateral to the tonsil
o Use static ultrasound to determine depth of vasculature.
o Though always a concern, carotid injury has not been clearly documented as a
complications[5]
o May require multiple aspirations to find the abscess
 First try superior then middle then inferior poles
o Consider spinal needle if patient has significant trismus
I&D

1. #11 or #15 blade scalpel

2. Do not penetrate more than 1cm
3. Only advance posteriorly
4. May be indicated if significant pus with needle aspiration
5. Macintosh size 3 or 4 with handle in a "tomahawk" position provides visualization with
lighting[6]
Antibiotics Alone

 The medications below and ED observation for 1-2 hours after, with liquid PO challenge:
o D5-1/2 NS, 1 L bolus
o Dexamethasone 10 mg IV
o Ceftriaxone 2 g IV
o Clindamycin 600 mg IV
o Upon discharge, Clindamycin 300 mg PO QID x10 days
o Pediatric protocol is the same, with weight based dosing
 Studies
o For patients given above and felt better (must improve clinically), similar results can be obtained
compared to I&D[7]
 [8]
o For abscesses <2 cm, the treatment-failure rate is 5% for antibiotics alone.

Antibiotics
Coverage for Streptococcus species, anerobes, Eikenella, H. influenza, S. auresus
Outpatient Options

 Clindamycin 300mg PO Q6hrs x7-10d

 Amoxicillin/Clavulanate 875 mg PO BID x 7-10d
 Penicillin V 500mg PO + Metronidazole 500mg QID
 Pulmonary Contusion

Priapism
 Sustained (> 4h) erection not associated with sexual stimulation
 May lead to erectile dysfunction and penile necrosis
 High rate of sexual dysfunction if present > 24hrs

Management

(a) Penis rigid and firm in consistency on examination (b) Aspiration from cavernosa using 16G
needle showed deoxygenated blood with detumescence.

 Pain control: Morphine and/or penile nerve block

 Running in place or doing squats (or some form of intensive exercise) can potentially achieve
detumescence[4]

Low Flow Priapism

Follow a step-wise approach:

 1. Aspirate 25mL of blood from cavernosum, up to two times

 2. Irrigate cavernosum with 25mL of cold (10°C) saline
 3. Medication injections
Aspiration of corpus cavernosum
 Ensure procedure is appropriate
o Rarely beneficial after 48h
o Risk of impotence is high even with treatment
 Obtain consent
 Prep the area with chlorhexidine and drape appropriately
 Penile nerve block or local anesthesic at puncture site
 Insert 18 gauge needle into penile shaft at 2 and 10 o'clock positions (or 3 and 9 o'clock positions)
 Aspirate blood (usually 20 - 30 cc on each side)
 May follow with intracavernosal injections (most common is phenylephrine)
α/β-2 Agonist

1. Consider terbutaline[5]
o Dose: 0.25-0.5mg SQ in deltoids OR 5-10mg PO, may repeat in q20min
2. Phenylephrine
o Dilute phenylephrine 1ml of 1mg/ml in 9mL NS for final concentration of 100mcg/mL
 For 500 mcg/ml, take 0.5 ml of 10mg/ml phenylephrine, and dilute in 9.5 cc NS
o Inject base of penis with 19-Ga needle (after blood aspiration to confirm position)
 100-200 mcg every 3-5min (max 1000 mcg) until resolution or 1 hour
o Ensure patient fully monitored, with BP, HR, pulse oximetry
 Reflex bradycardia is expected, so consider dosages relative to toleration of drop from
baseline HR
 Only one side needs to be injected since there exists a vascular channel between the 2
corpora cavernosa
o Compress injection area to prevent hematoma formation
o Use with caution in cardiovascular disease
3. Epinephrine
o In pediatric population, intracavernosal injection of epinephrine instead of phenylephrine
has been shown more successful in achieving detumescence
Wrap penis in elastic bandage after detumescence is achieved

Refractory
 Emergent urology consult for possible shunt procedure (can often be done in ED)

 High Flow Priapism

 May resolve with observation
 Consult urology for consideration of surgical correction or embolization by interventional radiology [6]

Sickle Cell Disease

 IV hydration
 Pain control
 Supplemental oxygen
 Transfusion for goal HCT>30% with consultation for partial exchange transfusion (HGB-S<30%)
o Exchange transfusion is associated with ASPEN syndrome (Association of Sickle
cell Priapism, Exchange transfusion & Neurological events)
o Urology consult

Fifth metatarsal fracture

Fractures of the fifth metatarsal base. Frontal radiograph

(A) demonstrates fifth metatarsal base fractures based on location. Frontal radiograph

(B) in a 24-year-old runner following inversion injury demonstrates an avulsion fracture of the fifth
metatarsal base. Oblique radiograph (

C) in an 11-year-old boy demonstrates an unfused fifth metatarsal base apophysis, a common

fracture mimic.
Management

Stable reduction: Immobilize in thumb spica wtih MCP joint in 20 deg flexion for 4wk

Unstable reduction: ORIF

Reduction

Radial and median nerve blocks

Pressure directed distally on base of prox phalanx with metacarpal flexed and abducted
Sialolithiasis
Clinical Features
 Pain, swelling, and tenderness may resemble parotitis
o Sialolithiasis is exacerbated by meals and may develop
over course of minutes when eating
 Typically unilateral
 A stone may be palpated within the duct and the gland is firm
We do not use stitches to close the wound because the skin is usually
very thin on your leg, and stitches may cause further damage to the
skin. Instead we use paper stitches called steri-strips and a large
padded dressing is applied to provide protection against further
injury.

Question Rigor Mortis baby, mother insists for CPR

Management
Infants with rigor mortis, livedo reticulrais, pH <6, or reduced
temperature in absence of environmental hypothermia should not be
resuscitated
Do not manipulate body - all cases require evaluation by coroner/ME
Question Single magnet ingestion
https://rcem.ac.uk/wp-content/uploads/2021/10/
RCEM_BPC_Ingestion_of_Super_Strong_Magnets_in_Children_17052
1.pdf
The ingestion of a single rare earth magnet is unlikely to cause significant harm,
The following patients should be considered suitable for discharge after rare earth magnet ingestion.
1. Single magnet ingestion,
2. Accidental ingestion,
3. No co-morbidities, t
4. Tolerating oral intake,
5. Presents within 24hr of ingestion,
Care-giver able to provide close observation (there is no need to examine the child’s faeces).
All patients who are being discharged with rare earth magnet ingestion require follow-up imaging after
6-12 hours, repeated earlier imaging is not indicated. If the child becomes symptomatic before the
repeat radiograph urgent surgical review will be required.

Question
Child/infant with foreign body airway obstruction , becomes, unconscious,

Open the airway and attempt 5 rescue breaths.

move to treatment with the paediatric BLS algorithm.

 Question

Myasthenia gravis

Clinical Features

Cranial nerve palsy and ptosis in a patient with myasthenia gravis

 Muscle weakness
o Proximal extremities
o Neck extensors
o Facial/bulbar muscles (dysphagia, dysarthria, dysphonia)
 Ocular weakness
o Ptosis
o Diplopia
o CN III, IV, or VI weakness
 Symptoms worsen with repetitive use / as the day progresses[3]
 Question
Retropharyngeal abscess

Question Guillain-Barre syndrome

Clinical Features
 Viral illness → ASCENDING, symmetric weakness or paralysis and loss of DTRs
 Little or no sensory involvement
 May progress to diaphragm resulting in need for mechanical ventilation (33% of patients)
 Autonomic dysfunction occurs in 50% of patients
 Required
 Progressive weakness of more than one limb
 Areflexia

Suggestive
 Progression over days to weeks
 Recovery beginning 2–4 wk after cessation of progression
 Relative symmetry of symptoms
 Mild sensory signs and symptoms
 CN involvement (Bell's Palsy, dysphagia, dysarthria, ophthalmoplegia)
 Autonomic dysfunction
o Tachycardia, bradycardia, dysrhythmias, wide variations in BP, postural hypotension
o Urinary Retention
o Constipation
o Facial flushing
 Absence of fever at onset

Question
Variceal Bleeds
Somatostatins and vasopressins

Two classes of drugs are widely used in the management of variceal haemorrhage.
These include somatostatins (Octreotide) and vasopressins (Terlipressin).

Somatostatins cause a relaxation of vascular smooth muscle and reduce portal venous
pressure. Vasopressins cause arterial vasoconstriction, reducing portal venous
pressure but at the risk of end-organ ischaemia. A systematic review has shown no
reduction in the number of deaths with somatostatins.

However, Terlipressin was noted to be safe and effective. Terlipressin has been
shown to reduce blood loss from actively bleeding varices and confers a 34% relative
risk reduction in risk of mortality. Terlipressin is also more convenient as it can be
given as a bolus.
Question
Regarding cardiac arrest secondary to hypothermia, which ONE of the following statements is TRUE?

A. Defibrillation should only be attempted when temperature is >30°C

B. Temperature of gas delivered to facemask or endotracheal tube (ETT) as well as IV fluids should be
warmed to 40°C

C. Endotracheal intubation should be delayed due to myocardial irritability and subsequent

predisposition to VF

D. Adrenaline dose should be reduced due to decreased drug metabolism and potential toxicity

Answer

Defibrillation is less effective in hypothermia. For ventricular fibrillation/ventricular

tachycardia (VF/VT) defibrillation may be tried up to three times but is then not tried
until the temperature reaches 30 ° C.

Do not try pacing unless bradycardia persists when normothermia is reached. Sinus
bradycardia may be a physiological response and is not treated specifically.

Drugs are often ineffective and will undergo reduced metabolism; so these are withheld
below 30 ° C then given with twice the time interval between doses until either normothermia
is approached or circulation restored. So, adrenaline would be given about every 8-10
minutes once the core temperature is above 30 ° C.

Question Clinical presentation of posterior shoulder dislocation

On physical examination, patient noted to have his arm flexed to 90° at the elbow, internally
rotated, and slightly adducted. Shoulder appeared squared off with a prominence of his coracoid
process. Neurovascular intact, to include axillary nerve testing. The presentation of posterior
shoulder dislocations can be as subtle as a dimple in the shoulder, which increases the difficulty of
diagnosis. The pain of the dislocation often limits the range of motion of the shoulder and this injury
is most commonly misdiagnosed as frozen shoulder. Patients typically present with the shoulder
held in internal rotation with a prominent coracoid process. Palpation will be notable for axillary
fullness. On range of motion there will be decreased external rotation.
Clinical Presentation of Posterior Shoulder Dislocation: Arm is internally rotated
and adducted with resistance to external rotation. May also find flattened anterior
shoulder, prominent acromion and coracoid, or palpable posterior humeral head.
The arm is held adducted and internally rotated, and the greater tuberosity of the humerus feels
prominent. Any attempts at external rotation are severely limited and painful

Question Renal colic

Per rectal administration of NSAIDs may provide better symptomatic control as there is an increased
local anti-inflammatory effect

Question

A six-week-old baby is referred to you for urgent assessment for blood-stained loose stools. He was born
at term and there were no antenatal/postnatal complications of note. He was initially breastfed for two
weeks and then started on feeds with cow’s milk formula. He is thriving well and the clinical examination
was unremarkable.

Food Protein Induced Proctocolitis of Infancy

Also known as: milk protein intolerance.

What is Food Protein Induced Proctocolitis of Infancy?

This is when an infant, typically between 2-8 weeks of age pass bloody, mucusy stools. Some infants may
also be fussy or have more bowel movements than normal.
What causes Food Protein Induced Proctocolitis of Infancy?

This is not an allergic reaction to a food, but is an intolerance to the protein in certain foods. We do not
know why this happens in some infants. It occurs in both breastfed and formula fed infants. A majority
of infants are sensitive to cow’s milk, some were sensitive to egg, soy, and corn in the mother’s diet.

What are the symptoms of Food Protein Induced Proctocolitis of Infancy?

Bloody and mucusy stools are the primary symptoms, some infants are also fussy.

What are Food Protein Induced Proctocolitis of Infancy care options?

If the infant is breast fed, the mom can try to eliminate cow’s milk from her diet. If this does not help,
she can also try eliminating egg, soy, and corn. About 8% of infants do not respond to the mom
eliminating foods from her diet, and using an extensively hydrolyzed or elemental formula is
recommended.

For infants who are formula fed, they can be switched to a soy based formula, and if that does not help,
can also be switched to an elemental formula. By 9 months old, over 95% of infants have lost their
sensitivity to the offending food, and these can be reintroduced into the diet with guidance from your
pediatrician.

Question

A 35-year-old known intravenous drug user (IVDU), presents to ED complaining of feeling generally
unwell with low back pain which is worse at night and has been progressively worsening over the last
couple of weeks. On examination he is pyrexic (39.1°C), and has midline tenderness to gentle spinal
percussion over vertebra L4/L5.

Answer

-Acute Spinal infection: Discitis (+/- vertebral osteomyelitis/epidural abscess)

Question

A baby 31 weeks gestational age is brought into ED by parents after they witnessed ALTE (BRUE) For 30
seconds he was full term on normal vaginal delivery,now all vital signs within normal.
What features from (history and examination) indicates low risk factors?

Answer 31 weeks

Questions

Most common Tachycardia in children

Bradycardia
< 1 year < 80 min

> 1 year < 60 min

Tachycardia
Narrow complex

Sinus tachycardia
Infant typically 180–220 min

Child typically 160–180 min

Gradual onset

SVT
Infant > 220 min

Child > 180 min

Abrupt onset

Broad complex

VT Could be VT or SVT, if unsure treat as VT

Question

Subarachnoid hemorrhage
Question

7yr old child came with knee pain since last 2 weeks. Mom thought she must have felt in park. So,
neglected it initially but now came to show in ED. Patient cannot Weight bear due to pain. X-ray done
and shown below: given of knee with increase hyper-density in lower end of femur.

What is your diagnosis?

Answer

Osteosarcoma
Patient attends with acutely painful toe

Answer is Subungual Haematoma

Management

Wait and See:

Patients who are not experiencing significant pain at rest, should not have trephination
performed, and can be treated with simple analgesia, rest, ice, and a protective splint.

Trephination:

Trephination gives good cosmetic and functional result in both adults and children as
long as no other fingertip injury is present.

Trephination makes a closed wound open, and introduces the risk of bacteria entering
causing infection, once procedure completed and haematoma evacuated no need to
further soak digit, and a protective dressing should be applied for 7-10 to prevent
infection.
A subungal haematoma is usually caused by a blow to the toe which may, or may not,
also cause a fracture. The pressure from it often causes pain and this can be
significantly relieved by trephining the nail to allow the release of blood. However
there is no evidence to say that this treatment is better than no treatment.

It is sometimes argued that patients with an underlying fracture should be given

antibiotics as the act of trephining converts a closed fracture to an open one. However
antibiotics do not seem to be necessary

NOF

NOF is a benign well-defined, solitary lesion due to proliferation of fibrous tissue.

It is the most common bone lesion.

NOF is frequently a coincidental finding with or without a fracture.

NOF usually has a sclerotic border and can be expansible.

They regress spontaneously with gradual fill in.

NOF may occur as a multifocal lesion.

The radiographic appearance is almost always typical, and as such additional imaging and biopsy is not
warranted.

Discriminators:

Must be under age 30.

No periostitis or pain.
Infection

Infection or osteomyelitis is the great mimicker of bone tumors.

It has a broad spectrum of radiographic features and occurs at any age and has no typical location.

In the chronic stage it can mimic a benign bone tumor (Brodies abscess).

In the acute stage it can mimic a malignant bone tumor with ill-defined margins, cortical destruction and
an aggressive type of periostitis.

Only when there is a thick solid periosteal reaction we can recognize the non-malignant underlying
process.
 Type I
o Nondisplaced with evidence of elbow effusion (ant sail sign and/or posterior fat pad)
 Type II
o Displaced with intact posterior periosteum
o Anterior humeral line is displaced anteriorly relative to capitellum
 Type III
o Displaced with disruption of anterior and posterior periosteum
 If distal fragment is posteromedially displaced: radial nerve injury
 If distal fragment is posterolaterally displaced: median nerve, brachial artery injury
 Type IV
o Complete periosteal disruption with instability in flexion and extension

Question

What is the management?

Answer

 Type I fractures may be discharged with ortho follow-up in 48 hours

 Type II and III fractures generally require admission
Early reduction is essential because delay may increase the risk of neurovascular
compromise or damage to the articular cartilage. For patients with vascular
compromise, perform reduction prior to radiologic examination.
Postreduction radiographs should confirm proper joint alignment. Appropriate pain
management is the greatest contribution an emergency physician can make to the
patient's care.

Questions
-What muscle is affected to cause the above finding?
Right Serratus anterior muscle
Right Long thoracic nerve
What analgesia would be most appropriate to give pediatric age group?

-Intranasal diamorphine 0.1 mg/kg

Regarding Brugada syndrome

Brugada syndrome is a recognised cause of syncope and sudden cardiac death in young patients
(especially in Asian males) with structurally normal hearts. It is inherited in an autosomal dominant
manner and is associated with defects in the sodium channel. It is associated with an incomplete RBBB
pattern and the ST segment elevation in the right precordial leads that is either convex and downsloping
with T wave inversion or saddle shaped or concave. Patients with syncope who are suspected of having
Brugada syndrome should be admitted to a monitored bed. Management is with an implantable
defibrillator – there is no place for class Ia and Ic or sodium channel blocking agents.
Regarding complications associated with SAH

When performed within 12 hours of the onset of symptoms, the sensitivity of non-contrast CT in
detecting subarachnoid blood is up to 98%. MRI is not as sensitive as non-contrast CT in detecting acute
blood in the brain. It is generally believed that a reducing number of RBCs in CSF tubes 1–4 would
indicate a traumatic tap. This has not been proven. It has been reported that there could be a 25%
reduction in the RBC count in successive tubes in patients with SAH. Consequently, a reducing RBC count
in tubes should be interpreted with caution. Xanthochromia from a traumatic tap can develop as early
as 2 hours. Otherwise, xanthochromia from SAH may take 6–12 hours to develop. Xanthochromia is due
to the presence of bilirubin. Bilirubin degradation can occur when a CSF sample is exposed to light,
hence less xanthochromia. It has a negative predictive value – when CT is normal, negative
xanthochromia and up to a few RBCs (0–5) reliably excludes SAH. Currently, there is inadequate
evidence to suggest the use of CTA as a first-line investigation for the diagnosis of SAH as there are only
a few studies comparing CTA with non-contrast CT and LP for the diagnosis. CTA may detect an
unruptured aneurysm and a systematic review found the risk of rupture of such an aneurysm in patients
symptomatic with headache to be 8.3%
Question: What would be the next step in managing this patient? A Discharge home with close follow-up
by the primary care doctor and anti-inflammatory medications for the joint pain B Admit for observation
C Admit for intravenous antibiotic therapy D Consult orthopedics for an ankle arthrocentesis E
Administer subcutaneous epinephrine

Diagnosis: Henoch–Schönlein purpura (HSP)

Discussion: HSP is the most common systemic vasculitis in children, with rapid onset over the course of
days to weeks. The disease is an example of a leukocytoclastic vasculitis, characterized by immune
complex deposition leading to necrosis and inflammation of small blood vessels, most commonly the
postcapillary venules. The disease course is usually over 6 weeks, with the majority of patients resolving
their disease in 1 month. Relapses can occur in 16–40% of patients, up to 2 years after the initial
symptoms. Clinical manifestations of HSP are seen in several organ systems including the skin, joints,
gastrointestinal tract, and kidney. Cutaneous involvement is seen in 100% of patients and is
characterized by palpable purpura, most commonly on the lower extremities and in dependent areas,
such as the posterior thighs and buttocks. However, the rash can involve upper extremities as well.
When the rash is more widespread, it is imperative to differentiate HSP from more serious conditions
such as meningococcemia, idiopathic thrombocytopenic purpura (ITP), subacute bacterial endocarditis
(SBE) and hemolytic uremic syndrome (HUS). Joint involvement occurs in 50–80% of patients with HSP,
and commonly involves large lower extremity joints, such as knees and ankles. True arthritis is rare, but
pain, periarticular swelling and limitation of range of motion can be significant. Usually anti-
inflammatory medications such as naproxen or Ibuprofen are helpful for these symptoms.
Arthrocentesis is not indicated. Gastrointestinal involvement is seen in 65–70% of patients with HSP,
usually within 1–4 weeks of the onset of rash. Rarely (14–36%) patients may have abdominal pain before
the rash is evident. The symptoms usually involve colicky periumbilical pain and vomiting, with or
without abdominal distention. This results from submucosal and subserosal edema and hemorrhage.
Rarely, emergent gastrointestinal complications such as small bowel intussusception, bowel ischemia
and infarction, and bowel perforation may occur. Although no evidence in the literature supports the
use of glucocorticoids for treatment of abdominal pain, traditionally they are used in hope of shortening
the duration of the gastrointestinal symptoms. Steroids have no effect on the overall course of the
disease. The most significant morbidity associated with HSP is secondary to renal involvement. It is the
risk of renal involvement which will dictate the close follow-up these patients require. Renal disease can
occur in 20–34% of patients with HSP, and the spectrum ranges from microscopic hematuria, with or
without proteinuria, to fulminant renal failure which can occur in 1–5% of patients. Due to this small yet
significant risk, patients with HSP need weekly blood pressure checks and weekly urinalyses throughout
the course of disease. Overall, HSP is a benign vasculitic disease of childhood, requiring mostly
supportive care. Two-thirds of patients will resolve their symptoms within 1 month of onset. Close
follow-up by a primary care physician is appropriate for the majority of cases.

A 30-year-old automobile technician presents to the emergency department with a complaint of pain
and swelling in the dorsum of his left hand near the metacarpal–phalangeal (MCP) joint of the index
finger after injury with a grease injector. On exam there is slight swelling of the dorsum of the hand and
a small pin-point puncture wound just proximal to the MCP joint of the index finger as noted in the
picture. There is pain with passive movement, good capillary refill of the index finger and thumb, and no
neurosensory deficits distal to the injury are appreciated. Question: What is the most appropriate
management? A Check tetanus status, prescribe analgesics, and discharge home B Prescribe antibiotics
and analgesics, check tetanus status, and discharge home C Obtain an X-ray, check tetanus status,
immobilize with a splint, and discharge home with a prescription for antibiotics and analgesics and
instructions to follow-up with an orthopedist in 3–5 days D Obtain an X-ray, check tetanus status, and
arrange an immediate surgical consultation for exploration and decompression debridement
 Recognition of Stroke in the Emergency Room (ROSIER)

Score from -2 to +5

Neuro signs: Score +1 for each

Clinical Hx: Score -1 for each  Face weakness

 Arm weakness
 Loss of consciousness
 Leg weakness
 Convulsive fit
 Speech disturbance
 Visual field defect

A score of 1 or above makes stroke more likely (PPV 90% (CI 85-95%) NPV 88%
(CI 83-93%).

If the score is negative, another diagnosis should be considered: a stroke mimic