Volume 33 Number 3 March 2019

Force of Nature
A growing number of adventure-seekers are departing
their urban confines to explore the great outdoors. As
such, clinicians must be prepared to initiate life- and
limb-saving treatment for wilderness-related injuries,
even in the most challenging of environments. Proper
planning and appropriate interventions can greatly
affect the outcomes of these patients, both in the field
and in the emergency department.

Buckled Up
While there's no question that seat belts save lives and
reduce the severity of trauma caused by motor vehicle
accidents, there are a number of serious injuries that
can be inflicted by the restraint itself. Despite the ever-
increasing number of safety features used by modern
car manufacturers, children remain at particular risk
for seat belt–associated trauma, including unique
injuries to the abdomen and spine.

THE OFFICIAL CME PUBLICATION OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

IN THIS ISSUE
Lesson 5 n Pediatric Seat Belt Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Critical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Critical Decisions in Emergency Medicine is the official
CME publication of the American College of Emergency
LLSA Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Physicians. Additional volumes are available.
Critical ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 EDITOR-IN-CHIEF
Michael S. Beeson, MD, MBA, FACEP
Critical Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Northeastern Ohio Universities,
Lesson 6 n Trauma in the Wilderness . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Rootstown, OH

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

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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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 Buckled Up
Pediatric Seat Belt
Injuries

LESSON 5

By Megan F. McClung, MD, FAAP; and

Timothy K. Ruttan, MD, FACEP
Dr. McClung is a pediatric emergency medicine fellow, and Dr. Ruttan is a clinical
assistant professor in the Department of Pediatrics at Dell Children's Medical Center
at the University of Texas at Austin.

Reviewed by David J. Pillow, Jr., MD, FACEP

OBJECTIVES
On completion of this lesson, you should be able to:
1. Recognize restraint-related injury patterns.
2. Identify which pediatric patients are at highest risk
for restraint-related injuries.
3. Identify and manage the unique injury patterns seen
in children with seat belt–related trauma.
4. Initiate appropriate diagnostic tests when evaluating
a child who has been involved in a car accident.
5. List strategies for counseling parents on child restraint
safety and injury prevention.
FROM THE EM MODEL
18.0 Traumatic Disorders
18.1 Trauma
CRITICAL DECISIONS
n What are the most common restraint-related
injuries sustained by children during MVCs?
n Which patients are at high risk for restraint-related
injuries?
n Which examination findings can reliably indicate
an underlying injury?
n Which diagnostic tests are most valuable for
evaluating children with restraint-related injuries?
n How can clinicians educate parents about the
proper use of child safety restraints?

When used properly, age- and size-appropriate car safety restraints (eg, car seats, booster seats, and seat
belts) significantly reduce the incidence of serious and fatal injuries caused by motor vehicle collisions (MVCs).
Car seats reduce the danger of death in infants and toddlers by 71% and 54% respectively, and booster seats reduce
the danger of serious injuries in children between the ages of 4 and 8 years by 45% when compared with the use of
seat belts alone.1,2

March 2019 n Volume 33 Number 3 3

 CASE PRESENTATIONS
■ CASE ONE
An unresponsive 6-year-old girl
arrives via ambulance. Her mother
reports that the child was well when
she picked her up from school about
an hour ago. They stopped at the
grocery store on the way home, and
her mother left her unattended in
the back seat of the car while she
shopped. When she returned to the
car, she found the child choking,
with the seat belt tightly wound twice
around her neck.
■ CASE TWO
A 5-year-old girl who was involved
in a high-speed MVC arrives via
ambulance. EMS reports that she was
found in the rear, middle passenger
seat, restrained by a two-point lap
belt. The patient is alert and oriented
but complains of abdominal pain.
Faint ecchymosis is noted across her
lower abdomen, which is tender to
palpation in the left lower quadrant.
Her vital signs are normal.
Child restraint laws, the benefits of
which are well documented, have been
in effect in the United States since the
1970s. The number of car seats used in
North America has risen over the last
30 years — progress that has reduced
the number of MVC-related fatalities
in children between the ages of 1 and
3 years by 50%. While this decrease
may be partly due to improved vehicle
safety regulations and driving patterns,
intense public education has also played
a significant role in encouraging the use
and acceptance of child restraints.
Despite improved compliance,
however, MVC-related morbidity and
mortality rates remain high. According
to the Centers for Disease Control
and Prevention, accidents are the
leading cause of death and disability
in every pediatric age group. MVCs,
in particular, are the leading cause of
death in children between the ages of
1 and 17 years. Although seat belt use
reduces the risk of death and serious
injuries by approximately 50% in
4 Critical Decisions in Emergency Medicine
Initial laboratory tests, including
liver function tests (LFTs), are
unremarkable, as are radiographs
of the pelvis and the thoracic and
lumbar spines. She is given ibuprofen
and reassessed 1 hour later, at which
time she complains of increasing
abdominal pain. A contrast-enhanced
CT scan of her abdomen appears
benign, aside from a small amount of
physiological free fluid in the pelvis.
The patient is admitted to the
surgical floor for observation and
serial examinations. Several hours
after admission, she develops
tachycardia, hypotension, and altered
mental status. Despite resuscitation
with intravenous (IV) fluids and
packed red blood cells, she remains
tachycardic with borderline low-
normal blood pressures and a
concerning abdominal examination.
She is taken to the operating room for
exploratory surgery.
adolescents and adults, more than half
of teens who died in crashes in 2015
were unrestrained at the time of their
accident.3,4 In addition, the National
Highway Traffic Safety Administration
(NHTSA) reports that more than 25%
of children between the ages of 4 and
7 years are prematurely transitioned
from booster seats to seat belts.
While unquestionably protective,
the lap and shoulder belts themselves
can also cause unique injury patterns
in children, particularly in those who
are improperly restrained. These
injuries, collectively termed “seat
belt syndrome,” frequently affect
structures adjacent to the belt(s),
especially the abdomen and spine.
Emergency clinicians must be aware
of these potentially life-threatening
presentations and be prepared
to address the anatomical and
physiological differences that impact
a child’s susceptibility to MVC-related
trauma.
■ CASE THREE
EMS arrives with a 4-year-old boy
who was the rear passenger in a high-
speed MVC; he was restrained by a
three-point seat belt. His family’s vehicle
was struck by an oncoming truck that
was traveling approximately 75 miles
per hour. EMS reports that the boy was
crying at the scene and refused to move
his neck.
On arrival, the patient appears
anxious and is wearing a hard cervical
collar. His vital signs are normal except
for mild tachycardia, which is presumed
to be secondary to situational anxiety.
A linear abrasion with bruising is noted
on the left side of his neck anteriorly.
His neurological examination is
unremarkable, but he grimaces when
his upper cervical spine is palpated. A
lateral x-ray of the boy’s cervical spine
reveals bilateral fractures through
the pedicles of C2. A CT angiogram
confirms this finding and further
reveals a posterior disc herniation and
dissection of the left vertebral artery.
CRITICAL DECISION
What are the most common
restraint-related injuries
sustained by children during
MVCs?
Neck Injuries
Although cervical spine injuries are
relatively rare in children, MVCs are
the most common cause of pediatric
neck trauma.5 Interestingly, these
presentations tend to be more severe
in younger children, a discrepancy that
is likely due to age-related anatomical
differences and the improper use of
age-matched restraints.6 Specifically,
younger children are more likely to
suffer permanent spinal cord deficits
and closed head injuries.6 Additionally,
mortality rates are higher in young
children who have sustained trauma
(30% vs 7%).5
Patients younger than 10 years have
relatively large heads, a feature that
creates a higher center of gravity. This
physiological anomaly is likely to blame
for the fact that 85% of restraint-related
injuries in this age group affect the upper
cervical spine. Older children (>8 years)
have greater skeletal maturity and
relatively smaller heads. As such, their
cervical spines have a lower center of
gravity, which is protective and lends to
injury patterns similar to those in adults.
Fractures account for more than
two-thirds of cervical spine injuries
in older children.5 Younger children
have a higher incidence of ligamentous
injuries, which are notoriously
challenging to detect on x-ray.5 A
high index of suspicion is warranted;
if symptoms persist despite negative
initial imaging, further consultation or
advanced imaging (eg, MRI) should be
considered. On the other hand, trauma
is improbable in an asymptomatic
child with a normal neurological
examination. Imaging based on the
mechanism of trauma alone is unlikely
to have a high diagnostic yield.
Small children wearing three-point
shoulder and lap belts are susceptible to
cervical spine fractures and ligamentous
injuries due to severe hyperflexion
and extension of the neck around the
shoulder strap. In older children who
are tall and heavy enough to wear
shoulder belts properly, the strap
should lay across the sternum and
clavicle. The straps should be positioned
to protect the child’s chest against
excessive forward motion without
imparting significant force directly to the
underlying soft tissues of the neck.
According to current NHTSA
guidelines, children should remain in
a rear-facing car seat until they reach
the age of 2 years or have exceeded
the manufacturer’s upper weight or
height limits. Children older than
2 years should ride in a forward-facing
car seat until they can be transitioned
to a booster seat, usually around the
age of 4 years. A booster seat should
be used until the child is 8 years old
and has reached a minimum height of
4 feet 9 inches.1 Unfortunately, only a
minority of children (5%) between the
ages of 4 and 8 years use booster seats.7
While age-based guidelines are
generally useful, it must be noted that
safety relies on properly fitted, height-
and weight-appropriate restraints.
Parents should always refer to the
manufacturer’s specifications regarding
their device.
While several reports have described
vascular and vertebral injuries associated
with neck bruising, no controlled study
directly supports the significance of
this finding in pediatric patients.8-10
Fortunately, blunt cerebrovascular
trauma in this population is rare. Any
patient with a depressed Glasgow Coma
Scale (GCS) score, upper cervical spine
injury, and/or neurological deficit is at
increased risk.11
Seat Belt Syndrome
The injury pattern classically
associated with the use of car restraints
(ie, seat belt syndrome) is characterized
by abdominal wall bruising (ie, seat
belt sign). This presentation is
most commonly linked to flexion-
distraction fractures of the lumbar spine
(ie, Chance fractures) and underlying
intra-abdominal injuries. First used to
describe injury patterns seen in adult
passengers wearing two- or three-point
seat belts, the syndrome is characterized
by damage in the plane of the lap belt,
particularly gastrointestinal and spinal
trauma. Vascular injuries and trauma
to the solid organs and spinal cord have
also been noted.
Forces from the restraint can cause
flexion injuries, in which the seat belt
acts as a fulcrum. This contact with the
lap belt results in cutaneous bruises on
the lower abdomen as well as underlying
intra-abdominal or lumbar spine injuries
(and sometimes both). While injuries can
occur in both properly and improperly
restrained passengers, the risks are
greatest for children who prematurely
graduate from a booster seat to a
three-point seat belt. It is important to
remember that a lap belt is designed to
rest on the anterior superior iliac spine
(ie, pelvic brim) of an adult.
A child’s pelvis is too small to
properly support the restraint, a problem
that can trigger a “submarine effect,” in
which the belt rides high, resting directly
over the soft tissues of the abdomen.
Because soft tissues do not absorb
high-impact forces as well as the bony
structures of the pelvis, traumatic MVC-
and restraint-related forces to the spine
and underlying organs during moderate-
and high-impact crashes are enhanced.12
It is important to remember that children
have weaker abdominal musculature and
less intra-abdominal fat than adults, a
dynamic that renders their rib cage less
protective of the underlying organs.
The most common pediatric spine
injury associated with seat belt use is a
Chance fracture (Figure 1), a flexion-
distraction injury of the vertebra and
ligamentous elements of the spine. These
injuries, which arise from an improperly
placed lap belt that transmits forces to
the spine, usually occur during rapid
deceleration. Although these fractures
can occur at any level, they are most
common in the lumbar spine at levels
L2 and L3.
Most patients with Chance fractures
have favorable outcomes. Appropriate
restraints seem to mitigate the risk
of severe trauma, including unstable
fractures and spinal cord injuries.
Research suggests that approximately
10% of restrained children with
this injury pattern suffer permanent
neurological deficits, compared to
approximately 42% of unrestrained
children.13 Clinicians should look
aggressively for associated abdominal
trauma in any child with a Chance
fracture, as the incidence of coinjury is
an estimated 15%.14
Intra-abdominal trauma associated
with the seat belt sign can involve both
solid organs and hollow viscera. A
recent multisite study found that more
than one-third of children evaluated
in emergency departments with MVC-
related seat belt signs had associated
abdominal injuries, predominantly
underlying gastrointestinal trauma
(11%).14,15 The spectrum of
gastrointestinal injuries includes
perforations, bowel wall hematomas,
mesenteric tears, and devascularization
of the mesenteric vessels.16
The relationship between solid organ
trauma and the abdominal seat belt
sign is poorly defined. When present,
however, these injuries typically affect
the spleen, liver, kidneys, or pancreas.15
While most of these patients can be
managed conservatively, some may
require operative treatment.
March 2019 n Volume 33 Number 3 5
 FIGURE 1. Thoracolumbar Spine Chance Fracture FIGURE 2. Abdominal Seat Belt Sign

This sagittal CT reconstruction shows a severe fracture dislocation sec- Note the incorrect position of the seat belt.
ondary to a seat belt injury. This horizontally directed fracture disloca-
COPYRIGHT © 2012 P. RAYCHAUDHURI ET AL
tion, which results from hyperflexion, is a variant of the Chance fracture.

CRITICAL DECISION
Which patients are at high risk
for restraint-related injuries?
The literature is clear: Parental
compliance with child safety seat
regulations is poor, and improper use
yields significant risk for restraint-
related injuries. Although prior research
suggests that older children are more
likely to be improperly restrained,
patients of all ages can be affected.17
Only an estimated 28% of children
between the ages of 5 and 8 years are
properly restrained in booster seats.18
Accurate information about the
mechanism of injury can be helpful when
evaluating potential trauma patterns.
As such, it is worthwhile to note that
EMS providers are uniquely equipped to
identify the proper use of safety restraints
in the field. Interestingly, professional
crash reconstruction experts disagree
with EMS regarding proper restraint use
only about 7% of the time.19
Children in rural locations are more
likely to be improperly restrained than
those in urban environments. Children
between the ages of 4 and 8 years, who
frequently transition out of car and
booster seats prematurely, are at greatest
risk.20 It is unclear to what extent factors
such as poor parental education and
financial barriers result in the improper use
of restraints. Regardless, all demographic
groups suffer from undesirable compliance
rates. As such, appropriate questioning,
counseling, and support should be directed
toward all families in the emergency
department setting.
Ligamentous and cervical spine
injuries are more common in infants
and young children restrained in car

6 Critical Decisions in Emergency Medicine

or booster seats than they are in older
children and teenagers.21 Head trauma
is also more common in infants and
toddlers. Interestingly and for reasons
that the literature does not make entirely
clear, improperly and unrestrained
children younger than 2 years appear
to have the same risk of injury as those
who are adequately restrained.22 This
suggests that car seats may not protect
against head trauma as well as restraints
designed for older children. In addition,
infants’ larger heads predispose them
to head injuries, a dynamic that may
mitigate the protective effect of infant
car seats. Two- and three-point seat belts
are typically worn by older children
and are associated with higher rates of
abdominal, gastrointestinal, and lumbar
spine injuries.21
A growing number of injuries have
been linked to the use of car seats
for unintended purposes. In fact, an
estimated 88% of car seat–related
injuries occur outside of a motor vehicle.
The most common non–MVC-related
injuries include positional asphyxiation,
strap-related strangulation, and trauma
due to falls from elevated surfaces
(eg, table tops, shopping carts).23
CRITICAL DECISION
Which examination findings can
reliably indicate an underlying
injury?
Improperly restrained children often
present with cutaneous evidence of
restraint-related trauma in the form of
abrasions or bruising. In fact, abdominal
wall or flank ecchymosis in the
distribution of a strap and secondary to
a safety restraint is the hallmark of seat
belt syndrome (Figure 2). This finding
should increase clinical suspicion for
trauma and prompt further evaluation.
TABLE 1. Prediction Tool for Children at Low Risk for
Intra-Abdominal Injuries (in descending order of importance)
1. No evidence of abdominal wall trauma or a seat belt sign
2. Glasgow Coma Scale score >13
3. No abdominal tenderness
4. No evidence of thoracic wall trauma
5. No complaints of abdominal pain
6. No decreased breath sounds
7. No vomiting
A patient who presents with an
abdominal seat belt sign is at greater risk
for trauma to the abdomen and spinal
column than a patient without this
finding. Children with lower-abdominal
bruising are significantly more likely to
have intra-abdominal injuries than those
without cutaneous symptoms (odds ratio
232.1, 95% CI 75.9-710.3).14  valuable for evaluating children
The seat belt sign is usually, but
not always, accompanied by back and
abdominal pain or tenderness. Pediatric
patients with abdominal or cervical
spine tenderness, a GCS score below
15, hypotension, or external signs of
thoracic trauma are at greatest risk for
these injuries. The presence of a seat
belt sign alone, even in the absence of
abdominal tenderness and subjective
pain, should heighten suspicion for
underlying trauma. Nearly 6% of
asymptomatic children who present
with an abdominal seat belt sign have
underlying intra-abdominal injuries.15
In addition, it is important to
remember that an abdominal seat belt
sign will not be present in every patient
with a lap belt–related injury. In fact,
the literature suggests that the presence
of an abdominal seat belt sign is only
about 73% sensitive for detecting
significant intra-abdominal trauma.14
Clinicians should use caution when
assessing symptomatic patients with
abdominal pain or tenderness. Most
of these children require admission
for observation and serial abdominal
examinations, at the very least; advanced
imaging should also be considered.15
Bruising over the neck (Figure 3)
should heighten suspicion for an
underlying vascular pathology and
prompt further diagnostic testing in
select patients. CT angiography has
become the screening modality of
choice for evaluating vascular trauma;
however, recent studies demonstrate
relative sensitivity, specificity, and
positive and negative predictive values
to be only 74%, 86%, 65%, and 90%,
respectively.26
CRITICAL DECISION
Which diagnostic tests are most
with restraint-related injuries?
Laboratory Tests
Unfortunately, no single laboratory
test can reliably predict or exclude
a pediatric intra-abdominal injury
following blunt abdominal trauma.27
Although glucose and aspartate amino­
transferase (AST) measurements are the
most reliable studies for detecting these
injuries, the sensitivity of these tests
is only 75% and 63%, respectively.27
Lipase tests have the highest positive
predictive value (75%), and AST has the
highest negative predictive value (71%).27
Several studies suggest that a low systolic
blood pressure, a serum ALT level above
125 U/L, an AST level above 200 U/L,
hematuria (>5 RBC/hpf), and abdominal
tenderness are all independently
associated with intra-abdominal trauma.28
Prediction Tools
Although it has yet to be externally
validated, a clinical prediction tool
derived from the PECARN Network
in 2012 can help identify children at
low risk for significant intra-abdominal
injuries.29 The rule (Table 1), which
consists of seven historical and clinical
variables (excluding ultrasonography
and labwork), has a negative predictive
value of 99.9%. Specifically, children
who lack the listed characteristics are
determined to be at very low risk for
injuries that require intervention and
should be spared from the radiation
emitted by CT imaging.29
Abdominal Imaging
While CT is the modality of choice
for evaluating abdominal injuries in
children, stable, low-risk pediatric
patients with one or more variables can
often be evaluated with observation
alone.30 While CT imaging can reliably
identify solid-organ injuries, hollow
viscus (gastrointestinal) injuries can
be subject to false-negative results,
March 2019 n Volume 33 Number 3 7
 especially when the test is performed
early in the clinical course. In addition,
symptom onset can be delayed in
children with hollow viscus injuries,
including bowel wall hematomas,
perforations, and mesenteric tears,
due to the slow accumulation of fluid
and/or air.
Ongoing observation should be
considered for any child with a seat
belt sign, tenderness on examination,
or abdominal pain, whether or not CT
imaging has been performed. Since a
normal abdominal CT cannot completely
rule out abdominal trauma, laparoscopy
and/or laparotomy should be considered
for patients in whom seat belt syndrome
is suspected (eg, worsening abdominal
examination or concerning vital signs).  or deficits and display a full, comfortable
A bedside ultrasound can be
valuable for detecting significant
intra-abdominal bleeding in unstable
trauma patients. Early identification
via ultrasound may help patients
avoid additional imaging and undergo
definitive surgical treatment sooner;
however, research suggests that the
modality can pinpoint these injuries
with only modest sensitivity (~80%), a
limitation that significantly hinders its
utility.31
FIGURE 3. Neck Seat Belt Sign
Diagonal abrasions are present along the course of the shoulder strap.
8 Critical Decisions in Emergency Medicine
Moreover, the increasing use of
nonoperative management for even high-
grade pediatric organ injuries reduces
the urgency of surgical interventions.32
Additionally, recent findings fail to
support the routine use of focused
assessment with sonography for trauma
(FAST) examinations for evaluating
hemodynamically stable children.33  cervical vertebral tenderness and focal
Portable radiographs can be
helpful for the early identification of
important abdominal injuries, including
pelvic fractures and gastrointestinal
perforations with free air. However,
x-rays are not definitively diagnostic
and lack the sensitivity to exclude all
restraint-related injuries.
Orthopedic Imaging
Radiographs and CT scans are the
initial studies of choice for evaluating
bony trauma, with a focus on the
skull, spinal column, pelvis, and long
bones, which are at greatest risk for
irreversible injuries and/or hemodynamic
compromise. While CT is superior
to plain radiography, it imparts a
significantly higher radiation burden
that increases the long-term risk of
malignancies. As such, CT should be
used judiciously; when the clinical need is
relevant, plain radiographs are favored.34
COURTESY OF NICK SAWYER, MD, MBA
C-Spine Imaging
Although there are myriad decision
tools for guiding the radiographic
workup of adult trauma patients
with suspected cervical spine injuries,
their applicability in pediatric
patients — especially those who are
very young — is less clear. Midline
neurological deficits should prompt an
early radiographic evaluation. Children
without neck pain who are unstable or
have other distracting injuries should be
managed with cervical spine precautions
until they have been stabilized and
properly cleared.
Patients should not be cleared until
they are free of neurological symptoms
range of motion without any midline
vertebral tenderness. While MRI may be
superior to CT for detecting spinal cord
and soft-tissue injuries, the time required
to complete the study limits its clinical
utility in the acute setting.35
Patients who present after a
high-velocity MVC with a neck seat
belt sign are at risk for blunt carotid
artery injuries, including arterial
dissection, intramural thrombus
formation, pseudoaneurysm, and/
or thromboembolic events leading to
ischemic stroke. However, the practice
of screening an otherwise asymptomatic
patient who presents with only a seat
belt sign on the neck is controversial.
Research suggests that no single
risk factor (apart from a low GCS score
and/or the presence of neurological
deficits) reliably predicts cerebrovascular
injuries.11 While the cervical seat belt
sign should heighten suspicion for
potential vascular trauma, in the absence
of other risk factors or symptoms,
this finding does not mandate CT
angiography.
CRITICAL DECISION
How can clinicians educate
parents about the proper use of
child safety restraints?
Although the benefits of child
safety restraints are well known,
many families continue to use these
devices improperly or fail to use
them altogether. The expense, time-
 FIGURE 4. NHTSA Car Seat Recommendations
There are many car
seat choices on the
market. The information
below can help parents
choose the type of car
seat that best meets
their child’s needs.
• Select a car seat
based on the child’s
age and size, choose
a seat that fits in the
vehicle, and use it
every time.
• Always refer to the
specific car seat
manufacturer’s
instructions (check
the height and
weight limits) and
read the vehicle
owner’s manual on
how to install the car seat, using the seat belt or lower anchors and a tether, if available.
• To maximize safety, keep the child in the car seat for as long as possible, as long as the child fits within the manufacturer’s height and
weight requirements.
• Keep the child in the back seat until they are at least 13 years old.

intensiveness of installing these devices,
and the hassle of moving them between
vehicles can all hinder compliance.
Whenever possible, parents should be
counseled on the importance of child
restraints and instructed on their proper
use (Figure 4).
Car Seats
Car seats do not need to be
automatically replaced following a
minor MVC; however, the NHTSA
recommends replacing these devices
following medium- or high-impact
crashes. Minor crashes are defined by the
following criteria:
• The vehicle could be driven away
from the scene.
• The vehicle door nearest the safety
seat was undamaged.
• There were no injuries to any of the
vehicle occupants.
• The airbags (if present) did not
deploy.
• There is no visible damage to the car
seat.
A number of national programs
provide parental education and car seats
for families who cannot afford them.
These initiatives, including safercar.gov
and safekids.org, have positively impacted Airbags
compliance rates.36 Children 12 years of age and
A child should never be left in a car younger should not ride in the front
seat unattended. The American Academy of seat due to the increased danger caused
Pediatrics (AAP) discourages the use of car by airbag deployment. Children should
seats for sleeping, as some infants may not ride in the back seat until they are at
be strong enough to move themselves out least 13 old. Cervical spine injuries and
of an asphyxiating position. It should also closed head trauma are the most serious
be emphasized that car seats are unstable airbag-related injuries; less severe
on table tops and other elevated surfaces. presentations include facial abrasions;
n Children involved in rapid-deceleration MVCs are at increased risk for
abdominal injuries and Chance fractures of the spinal column when they
have been improperly restrained with only a lap belt.
n The hallmark of the lap belt complex is abdominal or flank ecchymosis in the
pattern of a strap.
n As many as 50% of children with Chance fractures have concomitant intra-
abdominal injuries.
n Children younger than 13 years who ride in the front seat are at risk for
trauma caused by airbag deployment, including cervical spine injuries,
closed head trauma, burns, abrasions, and ocular trauma.
n Limit unnecessary ionizing radiation in children by referencing clinical
prediction tools (eg, PECARN rules) when possible.

March 2019 n Volume 33 Number 3 9

 CASE RESOLUTIONS
■ CASE ONE
The mother tried but ultimately
failed to loosen the seat belt
wrapped tightly around her 6-year-
old’s neck; a bystander arrived
seconds later and successfully cut
through the belt with his pocket
knife. The girl was not breathing, so
the bystander immediately started
CPR until medical units arrived.
The child was taken to the nearest
pediatric hospital and improved
after aggressive resuscitation. She
recovered fully after spending 2
days on ventilator support in the
pediatric ICU.
■ CASE TWO
The 5-year-old girl in this scenario
was initially asymptomatic. Her
abdominal examination was benign, and
CT scans were negative. Noting a seat
belt sign (lower-abdominal ecchymosis),
the emergency physician appropriately
admitted her for observation,
understanding that some gastrointestinal
injuries take hours to evolve and declare
themselves clinically.
A laparotomy revealed a perforation
of the small bowel with surrounding
necrosis, which required a resection of
approximately 6 cm of affected bowel.
The patient improved postoperatively
and was discharged home 10 days later.
■ CASE THREE
The 4-year-old boy was too small
to be wearing a three-point seat belt
and should have been secured in a
booster seat instead. Because of his
small size, the shoulder portion of
the three-point restraint misdirected
pressure across his neck, instead
of his sternum. During the MVC,
his head flexed over the misplaced
shoulder belt, injuring the underlying
soft tissues and vasculature of
his neck and damaging the bony
elements of his cervical spine.
The boy was admitted for further
treatment of his vertebral artery
dissection and C2 pedicle fractures.

ocular trauma; and chemical, thermal,
and friction burns.
Proper Fit
• When the sitting child’s back is
The AAP’s policy statement
regarding child passenger safety
emphasizes proper restraint use
according to age:
• Infants should ride in a rear-facing
car seat until they reach 2 years
of age or outgrow the maximum
weight and height limits set by the
manufacturer.
• Toddlers older than 2 years (and
those who have outgrown their
rear-facing car seats) should ride in
forward-facing car seats until they
have outgrown the manufacturer’s
weight and height restrictions.
• Toddlers and small children
younger than 8 years should ride
in booster seats once they have
outgrown their forward-facing
car seats. Booster seats should be
secured with both lap belt and
shoulder belt components (three-
point restraint), and the shoulder
strap should never be placed behind
the child’s arm or back.
• Older children can safely wear
three-point seat belts if the lap and
shoulder sashes fit properly (usually
when the child exceeds 4 feet 9
inches in height). It is important
to note that while 8 years old is
a common cutoff, every child is — The shoulder portion of the seat
different; some children will need a belt should rest on the child’s
booster for much longer. shoulder and sternum and not
on the face or neck.
pressed against the back of the car Summary
seat: Although seat belts greatly reduce
­— The knees should bend at or the severity of trauma and risk of death,
beyond the anterior edge of the the restraints themselves are sometimes
seat. to blame for significant pediatric injuries.
— The lap portion of the seat belt Despite the improved safety features that
should rest on the child’s thighs come standard with newer cars, injuries
and pelvis and not across the related to child restraints and car seats
abdomen. are likely to persist, especially when used
n Assuming that a child was restrained properly at the time of the MVC.
n Relying on abdominal pain or tenderness as the sole indicator of gastro­intes­
tinal trauma. Many such injuries do not manifest clinically for several hours.
n Ruling out a ruptured viscus based on a normal abdominal CT scan.
Laparo­scopy should be considered for children in whom injury is highly
suspected.
n Misinterpreting the x-rays of a pediatric patient’s cervical spine, which can
be complicated by the appearance of synchondroses, normal physiological
variants, and injury patterns that are unique to children. When in doubt, keep
the cervical spine immobilized until a pediatric radiologist can review the
images and/or until the child’s neck pain or tenderness subsides.
n Overlooking key anatomical and physiological differences that impact a
child’s susceptibility to certain injuries.

10 Critical Decisions in Emergency Medicine

improperly. In the meantime, emergency 21. Ernat J, Knox JB, Wimberly RL, Riccio A. The effects
of restraint type on pattern of spine injury in children.
clinicians should be prepared to identify Spine J. 2013 Sep;13(9):S48.
22. Stewart CL, Moscariello MA, Hansen KW, Moulton
restraint-related injuries and take every SL. Infant car safety seats and risk of head injury. J
opportunity to counsel parents about the Pediatr Surg. 2014 Jan;49(1):193-197.
23. Desapriya EB, Pike I, Singhal A. Analysis of paediatric
proper use of these potentially dangerous injuries related to child restraint seats: are children at
higher risk of injury outside the vehicle than inside?
devices. Int J Inj Contr Saf Promot. 2007 Sep;14(3):196-198.
24. Null J. Heatstroke deaths of children in vehicles. No
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25. Zonfrillo MR, Ramsay ML, Fennell JE, Andreasen
1. Durbin DR; Council on Injury, Violence, and Poison
A. Unintentional non-traffic injury and fatal events:
Prevention. Child passenger safety. Pediatrics. 2011
threats to children in and around vehicles. Traffic Inj
Apr;127(4):e1050-e1066.
Prev. 2018 Feb 17;19(2):184-188.
2. Arbogast KB, Jermakian JS, Kallan MJ, Durbin
26. Malhotra AK, Camacho M, Ivatury RR, et al.
DR. Effectiveness of belt positioning booster
Computed tomographic angiography for the
seats: an updated assessment. Pediatrics. 2009
diagnosis of blunt carotid/vertebral artery injury: a
Nov;124(5):1281-1286.
note of caution. Ann Surg. 2007 Oct;246(4):632-643.
3. WISQARS (Web-Based Injury Statistics Query and
27. Capraro AJ, Mooney D, Waltzman ML. The use of
Reporting System). Centers for Disease Control and
routine laboratory studies as screening tools in
Prevention website. www.cdc.gov/injury/wisqars/
pediatric abdominal trauma. Pediatr Emerg Care.
index.html. Accessed May 23, 2018.
2006 Jul;22(7):480-484.
4. National Highway Traffic Safety Administration.
28. Holmes JF, Sokolove PE, Brant WE, et al.
Occupant Protection in Passenger Vehicles. Traffic
Identification of children with intra-abdominal
Safety Facts: 2015 Data. Washington, DC: US
injuries after blunt trauma. Ann Emerg Med. 2002
Department of Transportation; February 2017. DOT
May;39(5):500-509.
HS 812 374. https://crashstats.nhtsa.dot.gov/Api/
Public/ViewPublication/812374. 29. Holmes JF, Lillis K, Monroe D, et al. Identifying
children at very low risk of clinically important
5. Kokoska ER, Keller MS, Rallo MC, Weber TR.
blunt abdominal injuries. Ann Emerg Med. 2013
Characteristics of pediatric cervical spine injuries.
Aug;62(2):107-116.e2.
J Pediatr Surg. 2001 Jan;36(1):100-105.
30. Sivit CJ. Imaging children with abdominal trauma.
6. Zuckerbraun BS, Morrison K, Gaines B, Ford AJR Am J Roentgenol. 2009 May;192(5):1179-1189.
HR, Hackam DJ. Effect of age on cervical spine
injuries in children after motor vehicle collisions: 31. Holmes JF, Gladman A, Chang CH. Performance
effectiveness of restraint devices. J Pediatr Surg. of abdominal ultrasonography in pediatric blunt
2004 Mar;39(3):483-486. trauma patients: a meta-analysis. J Pediatr Surg. 2007
Sep;42(9):1588-1594.
7. Winston FK, Durbin DR, Kallan MJ, Moll EK. The
32. Coccolini F, Montori G, Catena F, et al. Splenic
danger of premature graduation to seat belts for
trauma: WSES classification and guidelines for adult
young children. Pediatrics. 2000 Jun;105(6):1179-1183.
and pediatric patients. World J Emerg Surg. 2017 Aug
8. Taylor TK, Nade S, Bannister JH. Seat belt fractures 18;12:40.
of the cervical spine. J Bone Joint Surg Br. 1976 Aug;
33. Holmes JF, Kelley KM, Wootton-Gorges SL, et al.
58(3):328-331.
Effect of abdominal ultrasound on clinical care,
9. Frank EH, Pennington SE, Keenen TL, Frankel P. C5-6 outcomes, and resource use among children with
cervical dislocation resulting from improper seat belt blunt torso trauma: a randomized clinical trial. JAMA.
use. Acad Emerg Med. 1995 Jan;2(1):38-40. 2017 Jun 13;317(22):2290-2296.
10. Deutsch RJ, Badawy MK. Pediatric cervical spine 34. Sadetzki S, Chetrit A, Lubina A, Stovall M, Novikov I.
fracture caused by an adult 3-point seatbelt. Pediatr Risk of thyroid cancer after childhood exposure to
Emerg Care. 2008 Feb;24(2):105-108. ionizing radiation for tinea capitis. J Clin Endocrinol
11. Desai NK, Kang J, Chokshi FH. Screening CT Metab. 2006 Dec;91(12):4798-4804.
angiography for pediatric blunt cerebrovascular 35. Keiper MD, Zimmerman RA, Bilaniuk LT. MRI in
injury with emphasis on the cervical “seatbelt sign.” the assessment of the supportive soft tissues of
AJNR Am J Neuroradiol. 2014 Sep;35(9):1836-1840. the cervical spine in acute trauma in children.
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Technicians, Prehospital Trauma Life Support 36. Palmer KG, Mowery B. Injury prevention: role of the
Committee; American College of Surgeons, hospital-based Child Passenger Safety Program
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Life Support. 8th ed. Burlington, MA: Jones & Bartlett
Learning; 2016:43-85.
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PD, Skaggs DL. Pediatric chance fractures: a
multicenter perspective. J Pediatr Orthop. 2011 Oct-
Nov;31(7):741-744.
14. Lutz N, Nance ML, Kallan MJ, Arbogast KB, Durbin
DR, Winston FK. Incidence and clinical significance
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involved in motor vehicle crashes. J Pediatr Surg.
2004 Jun;39(6):972-975.
15. Borgialli DA, Ellison AM, Ehrlich P, et al. Association
between the seat belt sign and intra-abdominal
injuries in children with blunt torso trauma in
motor vehicle collisions. Acad Emerg Med. 2014
Nov;21(11):1240-1248.
16. Slavin RE, Borzotta AP. The seromuscular tear and
other intestinal lesions in the seatbelt syndrome:
a clinical and pathologic study of 29 cases. Am J
Forensic Med Pathol. 2002 Sep;23(3):214-222.
17. Greenspan AI, Dellinger AM, Chen J. Restraint use
and seating position among children less than 13
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Apr;41(2):183-185.
18. Cease AT, King WD, Monroe KW. Analysis of
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Feb;27(2):102-105.
19. Lerner EB, Cushman JT, Blatt A, et al. EMS provider
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2017 Oct;33(10):663-669.

March 2019 n Volume 33 Number 3 11

 The Critical Procedure
Tube Thoracostomy
Orange Park Medical Center, Orange Park, Florida.
Chest tubes are commonly placed to
drain excess air, blood, and other fluids
from the pleural cavity of patients with
thoracic injuries. A tube thoracostomy
can help stabilize high-risk patients
suffering from penetrating chest
trauma; empyema; or a pneumothorax,
hemothorax, or chylothorax. In addition,
the procedure can be used to deliver
medications and manage cases that
have failed to respond to conservative
treatment.
Contraindications
There are no absolute
contraindications to the procedure.
Relative contraindications include
underlying pleural adhesions, the
presence of emphysematous blebs, or
an underlying coagulopathy.
Benefits and Risks
In addition to its utility for
managing thoracic injuries (eg, pneumo-­
thorax, hemothorax), the procedure is
a stabilizing measure for any patient
with penetrating chest trauma who
requires concurrent positive-pressure
ventilation (PPV) or long-distance
transport.
Aside from associated pain, risks
of the procedure include damage
to surrounding organs, including
the lungs, heart, diaphragm, liver,
and spleen. Vascular trauma to the
intercostal and intrathoracic vessels
can lead to significant blood loss
that necessitates surgical treatment.
Infections, treatment failure, and
re-expansion pulmonary edema are
12 Critical Decisions in Emergency Medicine
By Terrell Swanson, MD
Reviewed by Steven J. Warrington, MD, MEd
other potential risks. In addition,
a clamped or stripped tube can
lead to complications (eg, tension
pneumothorax, ongoing infection).
Alternatives
Clinically stable patients who
present with a small, primary
spontaneous pneumothorax (<3 cm
from apex to cupola) can generally
be discharged home following a 3- to
6-hour observation period, provided
there is no underlying lung disease.
Prior to discharge, patients should meet
the following criteria:
• Respiratory rate less than 24
• Heart rate between 60 and
120 bpm
• Normal blood pressure
• Oxygen saturation greater than
90% on room air
A repeat chest x-ray (in 12 hours
to 2 days) should be used to document
resolution of the pneumothorax.
In more complex cases, a small-
bore catheter (<14 Fr) attached to a
Heimlich valve can be considered.
Rib
Intercostal vein
Intercostal artery
Intercostal nerve
Innermost intercostal muscle
Internal intercostal muscle
External intercostal muscle
Collateral branches
Visceral pleura
Parietal pleura
Endothoracic fascia
Lung
Disposition decisions can be made
according to the patient’s condition,
preference, and the potential need
for re-expansion in the emergency
department. Patients should be advised
to follow up within 2 days.
Reducing Side Effects
Full sterile precautions should
be used as time permits. The
post-procedure administration of
antibiotics remains controversial
and is unsupported by evidence.
When used, however, first-generation
cephalosporins are generally the
first-line choice. Ultrasound can
decrease the risks associated with tube
misplacement. Carefully identifying
landmarks, counting ribs, and placing
the tube directly over the rib that is
inferior to the insertion site can help
prevent damage to the organs and
intercostal vessels.
An overly aggressive dissection
should be avoided. The scalpel should
be held in the clinician’s palm with
the index finger straightened along the
device (fingertip at instrument tip). The
most proximal hole should be made in
the pleural cavity.
Special Considerations
Bedside ultrasound using a high-
frequency transducer can be used to
identify or rule out a pneumothorax.
Bear in mind that 10% of trauma
patients with a normal chest x-ray
TECHNIQUE
1. Arrange the patient in a semi-
erect position (30-60 degrees).
The patient’s ipsilateral arm
should be abducted over
the head and, if necessary,
restrained.
2. Provide monitoring and
supplemental oxygen; consider
parenteral medication.
3. Identify the 4th or 5th
intercostal space between the
midaxillary and anterior axillary
lines (lateral to the nipple or
inferior scapula border). If the
landmarks are unclear, choose
a more superior insertion site
to avoid the abdominal cavity.
Ultrasound can help verify the
correct position.
4. Inject a local anesthetic
over the rib and advance
the needle, infiltrating and
will have a small hemothorax or
pneumothorax on CT.
The use of parenteral medications
should be strongly considered. Rib
blocks using both long-acting and
local anesthetics can be administered
along the anticipated tract of tube
passage, including the pleural cavity.
Studies support the use of small-bore
chest tubes (≤14 Fr), except for cases
aspirating until air is withdrawn
(indicating entry into the pleural
cavity). Generously cover the
pleural lining with lidocaine.
5. Make an incision (3-5 cm)
through the skin and
subcutaneous tissues overlying
the interspace.
6. Bluntly dissect a tract over the
rib with a large Kelly clamp,
taking care to avoid the inferior
border of the rib above. Once
the tips of the clamp are in the
pleural cavity, spread them apart
to create a hole in the pleura
that is wide enough to insert
both a finger and the tube. Avoid
making the opening too large, as
this can lead to air leaks.
7. Slide a finger over the clamp and
into the pleural cavity to secure
the dissected tract. Verify the
position of the tube within the
Triangle of safety
for tube insertion
that involve barotrauma, PPV, or post-
pneumonectomy-related complications.
Early blood replacement is
recommended for any patient with
a massive hemothorax (>2000 mL).
Autotransfusion is preferred whenever
possible. Needle decompression may
be required prior to initiating the
procedure in an unstable patient with a
suspected tension pneumothorax.
pleural cavity and the absence of
solid organs. Leave your finger in
place to avoid losing the tract.
8. Pass the tube alongside your
finger, guiding it into the desired
position, and stop if resistance is
met.
9. Secure the tube with sutures.
Consider adding a horizontal
mattress or purse stitch, which
can be left untied until the tube
is removed. Place an occlusive
dressing (eg, petroleum-
impregnated gauze) and secure
it with tape.
10. Attach the tube to a water-
seal or suction system. Ask the
patient to cough. If the system is
patent, bubbles should appear.
11. Confirm the tube placement
with a chest x-ray. Again, verify
that the most proximal hole is
within the pleural space.
Lateral edge of pectoralis major
Base of axilla
Lateral edge of latissimus dorsi
5th intercostal space
March 2019 n Volume 33 Number 3 13
 The LLSA
Literature
Review
Physician Burnout
By Alexa Gips, MD; and Laura Welsh, MD; Boston University, Boston, Massachusetts
Reviewed by Andrew J. Eyre, MD, MHPEd
Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017 Jan;92(1):129-146.

Physician burnout, defined by exhaustion, cynicism, and decreased effectiveness, affects

at least 50% of US physicians. Strategically savvy health care organizations must tackle
this escalating syndrome, which can diminish patient safety and satisfaction.

Preventative approaches must reach
beyond individual physician tactics
(eg, mindfulness, stress-management
workshops) to address institutional
solutions. Organizational strategies to
reduce common stressors and promote
well-being include:
u Physician burnout and well-being
must be publicly recognized by
hospital leaders and regularly
evaluated. Standardized tools should
be used to compare physician
satisfaction rates to national
benchmark data.
v While many aspects of burnout
are universal, others are unique to
certain specialties and environments.
A uniform assessment allows
organizations to identify and engage
units that are at greatest risk.
w Effective leadership can significantly
reduce burnout and improve work
satisfaction. Organizations must
choose and train competent leaders
and continuously measure their
performance.
x Physicians need peer support. These
important personal connections can
be facilitated through space (eg,
inclusive meeting rooms stocked with
food and computers) or time (eg,
protected hours for small physician
groups or shared meals).
y Evidence points to productivity-based
compensation as a risk factor for
burnout. Other options worthy of
consideration include salaried models
and productivity-based approaches
that encourage self-care.
z Similarly, organizations should enact
policies that emphasize work-life
balance. This includes flexible work
schedules, ample vacation time, and
time off for important life events.
{ Health care organizations must be
mindful to align their actions with
their stated mission. The extent to
which an institution is living up to
its claimed values can be evaluated
by asking its staff. These important,
collaborative conversations can help
identify any potential misalignments.
| Any strategy that places the burden
of combating burnout solely on the
physicians themselves is doomed to
fail. Organizations can supply their
clinicians with tools to objectively
assess and foster their own well-
being while providing relevant
training in areas like resilience,
narrative medicine, and mindfulness.
} Cutting-edge programs should focus
on the creation of effective strategies
that can be adopted by other
organizations.
KEY POINTS
n Physician burnout is a significant,
growing issue that negatively
affects patient satisfaction and
safety.
n Burnout should not be viewed
as an individual physician
responsibility but rather as
a systemwide problem that
requires a strategic response.
n Organizations can tackle
physician burnout effectively
without compromising their other
core goals or financial health.

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.

14 Critical Decisions in Emergency Medicine

 A 60-year-old woman with palpitations while receiving continuous beta-agonist nebulizers for asthma.

The Critical ECG

Supraventricular tachycardia (SVT) rate 200. The differential diagnosis of a By Amal Mattu, MD, FACEP
regular narrow QRS complex tachycardia includes sinus tachycardia (ST), atrial Dr. Mattu is a professor, vice chair, and
director of the Emergency Cardiology
flutter, and SVT. ST can almost certainly be ruled out based on the rate of 200 beats Fellowship in the Department of
Emergency Medicine at the University
per minute. (The maximum sinus rate for most patients can be estimated as
of Maryland School of Medicine in
220 # age; therefore, it is unlikely that this 60-year-old woman could develop ST Baltimore.
at a rate much greater than 160 beats per
minute.) Evidence of atrial flutter is absent
a)
as well, leaving the diagnosis of SVT as the
only possibility. Small retrograde P waves
a) Retrograde
can be seen just after the QRS complexes,
P waves (black
a finding common in some types of SVT. arrows).
Another common finding in patients with
SVT is ST-segment depression, noted b) ST-segment
depression (red
here in the inferior and lateral leads. This arrow) noted in
abnormality is sometimes inappropriately b) numerous leads.
referred to as “rate-related ischemia.” The so-called “
rate-related”
In fact, this ST-segment depression is an
change is unlikely
unreliable indicator of ischemia and does to be related to
not reproduce during exercise testing. Its coronary ischemia.
significance and etiology are uncertain.

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

March 2019 n Volume 33 Number 3 15

 The Critical Image
A 30-year-old woman presents following a motor vehicle collision in which By Joshua S. Broder, MD, FACEP
she was a restrained front-seat passenger. The vehicle was traveling at Dr. Broder is an associate professor and the
residency program director in the Division
approximately 45 miles per hour when it was T-boned by a second car and
of Emergency Medicine at Duke University
the airbags deployed. The patient denies loss of consciousness but complains Medical Center in Durham, North Carolina.
of lower abdominal pain. Case contributor: Bahaadin Al-Jarani, MD
Her vital signs are blood pressure
113/70, heart rate 71, respiratory rate
A
17, temperature 37.2°C (99°F), and Fluid
oxygen saturation 99% on room air. The density
patient is alert, and her examination 25 HU
is normal, with the exception of an
abrasion over the right iliac crest
and lower abdomen, with associated
tenderness. Her laboratory tests reveal
a WBC count of 14.7 and hematocrit Liver
level of 40.9. She is not pregnant, and
her urinalysis is normal.
A CT scan of her abdomen and
pelvis with intravenous (IV) contrast
demonstrates free fluid without
evidence of a solid organ injury. She
is discharged home with follow-up
Free
fluid in
precautions.
the
The patient presents to a second Morison
emergency department 48 hours pouch
later with increasing abdominal pain
Kidney
and distension. Her vital signs are
A. Initial CT with IV contrast. Dense, free fluid is seen in the right upper
blood pressure 105/67, heart rate 138, quadrant. No solid organ injuries can be visualized. Following blunt trauma, fluid
respiratory rate 20, temperature 36.8°C in the absence of a solid organ injury suggests a bowel or mesenteric injury.
(98.2°F), and oxygen saturation 99% on
room air. She is alert but uncomfortable. B
She is tachycardic, and her abdomen
is diffusely tender. A seat belt mark is
visible across her lower abdomen. New
laboratory studies reveal a WBC count
of 8.5 and a hematocrit level of 44.3.
The emergency physician repeats Liver
an abdominal/pelvic CT scan with IV
contrast.

à
B. Second CT with IV contrast.
Greatly increased free fluid is
seen in the right upper quadrant.
Free fluid in the Morison
pouch has greatly increased
Kidney
compared with the initial CT

16 Critical Decisions in Emergency Medicine

 C
Free air
Normal Normal
subcutaneous Free air fat
Free air and
fat bowel-wall
discontinuity
Fat stranding,
indicating
inflammation

C. Second CT. The new scan demonstrates free air, inflammatory fat stranding, and an apparent discontinuity in the wall of the
jejunum (ie, a bowel perforation).

KEY POINTS
n Although CT is extremely sensitive
for detecting solid organ injuries,
bowel and mesenteric injuries
are more difficult to identify.
Bowel injuries are relatively rare,
occurring in only about 1% to 5%
of blunt trauma cases.1 Following
a blunt trauma mechanism, a CT
scan that reveals free fluid without
evidence of a solid organ injury
should raise suspicion for a bowel
or mesenteric injury. In such cases,
the fluid may be blood or bowel
contents, urine, bile, or ascites
unrelated to the trauma.
n The density of fluid can be
measured on a digital PACS
system, using a Hounsfield unit
(HU) probe. Clinicians can select
a region of interest and measure
its average density. By definition, including bowel injuries caused
water has a density of zero. Urine by blunt trauma, and is not
and simple ascites should be close recommended by the American
to this value, and bowel contents College of Radiology or the
are usually less than 15 HUs. The American College of Emergency
density of blood varies; however, Physicians.5-9
values greater than 30 to 45 HUs
are suggestive of blood. 2-4
n Bowel-wall discontinuities are
CASE RESOLUTION
rarely seen (<10%) on CT, and free
air is detected in only about 20% The patient underwent a
of patients with bowel injuries.3 laparotomy, which revealed
Some of these injuries begin as a jejunal perforation with
contusions; perforation, if it arises
an adjacent mesenteric
at all, may be delayed for several
avulsion, as well as a cecal
days. Small perforations may not
result in free peritoneal air. contusion. She recovered well
n The addition of oral contrast after undergoing a jejunal
has not been shown to improve resection.
the detection of injuries,

1. Virmani V, George U, MacDonald B, Sheikh A. Small-bowel and mesenteric injuries in blunt trauma of the abdomen. Can Assoc Radiol J. 2013 May;64(2):140-147.
2. Atri M, Hanson JM, Grinblat L, Brofman N, Chughtai T, Tomlinson G. Surgically important bowel and/or mesenteric injury in blunt trauma: accuracy of multidetector CT
for evaluation. Radiology. 2008 Nov;249(2):524-533.
3. Brofman N, Atri M, Hanson JM, Grinblat L, Chughtai T, Brenneman F. Evaluation of bowel and mesenteric blunt trauma with multidetector CT. Radiographics. 2006
Jul-Aug;26(4):1119-1131.
4. Lubner M, Menias C, Rucker C, et al. Blood in the belly: CT findings of hemoperitoneum. Radiographics. 2007 Jan-Feb;27(1):109-125.
5. Stuhlfaut JW, Soto JA, Lucey BC, et al. Blunt abdominal trauma: performance of CT without oral contrast material. Radiology. 2004 Dec;233(3):689-694.
6. Stafford RE, McGonigal MD, Weigelt JA, Johnson TJ. Oral contrast solution and computed tomography for blunt abdominal trauma: a randomized study. Arch Surg. 1999
Jun;134(6):622-627.
7. Tsang BD, Panacek EA, Brant WE, Wisner DH. Effect of oral contrast administration for abdominal computed tomography in the evaluation of acute blunt trauma. Ann Emerg Med.
1997 Jul;30(1):7-13.
8. American College of Radiology. Blunt abdominal trauma. ACR Appropriateness Criteria. ACR website. https://acsearch.acr.org/docs/69409/Narrative. Published 1996.
Updated 2012.
9. Diercks DB, Mehrotra A, Nazarian DJ, et al. Clinical policy: critical issues in the evaluation of adult patients presenting to the emergency department with acute blunt abdominal
trauma. Ann Emerg Med. 2011 Apr;57(4):387-404.

March 2019 n Volume 33 Number 3 17

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ST Decisions in Emergency Medicine
18 Critical
!
 Force of Nature
Trauma in the Wilderness

LESSON 6

By Andrew Park, DO, MPH; and Thomas Seibert, MD, MS

Dr. Park is a fellow of the Wilderness Medical Society and an assistant professor in the
Department of Emergency Medicine at the University of Kansas Medical Center in
Kansas City, Missouri. Dr. Seibert is a fellow of the Wilderness Medical Society and a
wilderness medicine fellow at the University of Utah in Salt Lake City.
Reviewed by Nathaniel Mann, MD

OBJECTIVES
On completion of this lesson, you should be able to:
1. Identify the most common traumatic injuries sustained
in wilderness settings.
2. Decide when to perform an emergent needle
decompression of the chest in the field.
3. Describe the factors to consider in evacuations.
4. Determine the appropriate use of orthopedic
reductions.
5. Determine the appropriate use of tourniquets.
FROM THE EM MODEL
18.0 Traumatic Disorders
CRITICAL DECISIONS
n How should a patient be evaluated after a
traumatic event in the wilderness?
n When should needle decompression of the chest
be performed in the field?
n When should a patient be treated in place versus
being evacuated to definitive care?
n When should an orthopedic fracture or dislocation
be reduced in the wilderness?
n What factors should be considered before
applying a tourniquet?

A growing number of adventure-seekers are departing their urban confines to explore the great outdoors.
As such, clinicians must be prepared to initiate life- and limb-saving treatments for wilderness-related injuries, even
in the most austere environments and with limited resources and manpower.1,2 Proper planning and appropriate
interventions can greatly affect outcomes, both in the field and in the emergency department. In light of the
rising global interest in outdoor activities, it is increasingly important for clinicians to understand how to prevent,
evaluate, and manage the traumatic injuries they are most likely to encounter as expedition medical officers,
guides, trip leaders, or participants.

March 2019 n Volume 33 Number 3 19

 CASE PRESENTATIONS
■ CASE ONE
A 23-year-old musher and his
dog team are making good time
on the Iditarod Trail in Alaska.
As the trail turns away from the
river and into a wooded area, the
musher’s sled slides off the edge
of a thin snow bridge, propelling
him onto the end of a large branch.
An emergency physician and
his friend discover the musher
while following the race on snow
machines. The physician finds the
man awake and alert but bent over
with labored breathing.
On examination, the musher
has a heart rate of 120 with good
distal perfusion, right chest wall
tenderness, distended neck veins,
and a slight tracheal deviation to
the left. His mental status is good,
but he is in pain. The nearest
hospital is approximately 80 miles
away, and there is no road access.
■ CASE TWO
A 50-year-old rock climber falls
to the ground after her camming
device fails. Her frantic climbing
partner summons help from a
group of hikers, which includes an
emergency physician, who rushes to
the scene. The climber’s airway and
breathing are intact, but she is lying
on the ground in obvious distress.
Her right leg appears shortened
compared to the left and is held in
The distribution of death from
trauma is trimodal in nature. The first
fatalities, which occur within the first
few minutes of the event, usually arise
from catastrophic injuries (eg, aortic
rupture, high spinal cord injuries).
The second peak of fatalities occurs
in the first few hours and is usually
associated with intracranial injuries,
pneumothoraces, and hemorrhagic
anemia. The third peak is delayed
for days to weeks, likely secondary
to infection or other complications.
The term “golden hour” in trauma
literature is used to describe the second
peak of fatalities, which can be greatly
20 Critical Decisions in Emergency Medicine
external rotation. Her left leg has a
visible deformity just above the knee.
The patient’s pulse is 130, her
respiration rate is 24, and she feels
euthermic. An examination of her
head, neck, arms, and torso are
unremarkable, and her Glasgow Coma
Scale (GCS) score is 15. She is moving
both arms and has 2+/4 bilateral radial
pulses. The physician removes the
patient’s climbing shoes to measure her
lower-extremity pulses, which are 2+/4
in the right foot but weakly palpable in
the left foot. Additionally, the left foot
and calf feel cooler to the touch than
the right leg. Her sensation to light
touch is intact and symmetrical in all
bilateral lower dermatomes.
The physician’s backpack contains
a small first-aid kit with oral over-the-
counter medications, hiking poles, duct
tape, a multi-tool, and an emergency
locator GPS system. The climbers have
rope and small packs with snacks and
water. The group is 4 miles from the
trailhead, which is 2,200 feet lower
in altitude, and there is no cell phone
reception.
■ CASE THREE
A mountain biker loses control on
a tight turn and is thrown off the trail
into a pile of rocks. As others slow
oncoming cyclists, one of the riders,
an emergency physician, approaches
and sees blood dripping from the
patient’s sleeve at a concerning rate.
reduced with proper assessment and
treatment. In the wilderness setting,
however, it is unlikely that the victim
will arrive at a trauma center within
the “golden hour.”3
From 2007 to 2011, the US
National Park System reported an
average of 280 million annual visits.
An estimated 32.5 out of every
1 million visitors require a trauma or
first-aid evaluation.4 Although this
frequency is low, it equates to 9,076
annual incidents.4 One study suggests
that as many as 80% of these fatalities
occur prior to evacuation.5
The bicyclist is able to speak in full
sentences and remembers the accident.
He denies shortness of breath, and
the physician notes an equal rise and
fall of the chest. The patient’s radial
pulse bilaterally is 2+/4, and he is
tachycardic. His GCS score is 15, and
he is moving all extremities without
difficulty. He was wearing a helmet
and has no deformities or signs of
other injuries.
The physician cuts open the
patient’s sleeve to reveal a deep
puncture wound and laceration to
the anterior aspect of the proximal
forearm. Brisk, bright red blood is
pulsating out. Re-examination distally
reveals an intact radial pulse and
sufficient capillary refill. As pressure
is applied to the wound, a medical
history is taken, which reveals no
significant medical problems, no
surgeries, and no allergies.
Collectively, the cyclists are
carrying a moderate amount of first-
aid supplies, oral pain control, bike
repair kits, water, and cell phones.
The group is 2 miles from the parking
lot, so one of the riders bikes out to
the trailhead while another contacts
911 and confirms that EMS is en
route. Despite the application of direct
pressure, the wound is still bleeding
around the bandage after 15 minutes.
The patient thinks he can walk but is
feeling weak.
CRITICAL DECISION
How should a patient be
evaluated after a traumatic
event in the wilderness?
Researchers have described applying
the “golden principles” of prehospital
trauma care in the urban setting.
Although these guidelines were not
intended for use in wilderness medicine,
several key components are applicable
to outdoor settings. Rescuers should
continually evaluate the safety of both
the patient and the provider; employ
primary and secondary surveys; ensure
cervical spine immobilization (Figure 1);
address external hemorrhage; keep the
patient warm; initiate early evacuation;
and, above all, do no harm. 3
Once the patient is in the safest,
most stable environment possible,
the Advanced Trauma Life Support
(ATLS)–based steps of trauma
management should be implemented, as
adapted for the outdoors:6
1. Primary survey
2. Resuscitation
3. Secondary survey
4. Definitive plan
5. Packaging and transfer
preparation
Even in the wilderness, the primary
survey should employ the ABCDEs of
any trauma evaluation:6
• Airway maintenance and
cervical spine stabilization
• Breathing
• Circulation and control of
significant external hemorrhage
• Disability: neurological status
• Exposure/environmental control
Following the primary survey, the
patient should be resuscitated with
the available equipment and supplies.
Next, a secondary survey should be
performed to evaluate the patient
from head to toe. When appropriate,
it is important to completely undress
the patient and examine all aspects of
the body for signs of injury. In some
environments, however, full exposure
can lead to hypothermia and further
complications. In potentially dangerous
locations, a full examination may be
impossible. In such cases, physicians
should minimize exposure to the
elements and use auscultation and
palpation to evaluate the patient.
A thorough medical history should
also be taken, using the AMPLE
pneumonic (Allergies, Medications,
Past medical history, Last meal, Events
leading to injury) from the ATLS
guidelines.6 The history and physical
examination can be used to generate
a list of injuries and discern which, if
any, require immediate intervention or
evacuation. In addition, factors such
as the severity of the trauma, possible
methods of evacuation, and potential
routes must be weighed.
When managing chest trauma,
for example, the most serious
complications should be considered
first, including pneumothorax,
tension pneumothorax, flail chest,
and cardiac tamponade. A traumatic
aortic dissection or rupture is likely
to be fatal before interventions can be
employed. A patient with chest trauma
also must be evaluated for shortness of
breath, tachycardia, and altered mental
status, which can signal hypoxia. In
these situations, a handheld pulse
oximeter can be invaluable.
The chest should then be examined
for major deformities, symmetry,
and other signs of trauma, including
tenderness with palpation and skin
damage or changes. An uneven
chest wall rise, however subtle, is a
pathognomonic sign of flail chest
secondary to multiple rib fractures. A
deviated trachea away from the side
of injury, tachycardia, distended neck
veins, and increased work of breathing
or hypoxia are all signs of a tension
pneumothorax. Altered mental status
may be present in cases of severe or
prolonged hypoxia or significant blood
loss from severe chest trauma, with or
without concomitant injuries.

FIGURE 1. Wilderness Medical Society Focused Spine Assessment
Blunt trauma
with a mechanism Awake, alert, and reliable?
suspicious for
YES
spine trauma YES
• Severely injured patient?
• Evidence of intoxication?
• Neurological deficit?
• Thoracic or other
significant distracting
injury?
NO
Significant spine pain
or tenderness (≥7/10)?
NO
Isolated
penetrating
trauma? Patient voluntarily able
to flex, extend, and
rotate spine in each plane
YES
regardless of pain?
• 45° cervical spine
No spine injury? • 30° thoracolumbar
YES
No spine injury?
CRITICAL DECISION
When should needle
decompression of the chest
be performed in the field?
NO Patients with severe symptoms
following chest trauma must be
evaluated for life-threatening injuries,
including a pneumothorax or tension
pneumothorax. Patients with a
YES
suspected pneumothorax should be
transported as quickly as possible
to the nearest medical facility for
Possible further evaluation and definitive
YES
Spine Injury treatment. Any patient without severe
symptoms should be monitored for
signs and symptoms of an expanding
pneumothorax and a subsequent
NO tension pneumothorax.
The pathophysiology of a
tension pneumothorax includes the
development of a one-way valve
secondary to the injured lung tissue,
which allows air to enter and expand
the pleural space. Because the air
is unable to escape and volume
expansion is limited, the pressure in

March 2019 n Volume 33 Number 3 21


FIGURE 2. Pain Treatment Pyramid
Transdermal
Oral Opioids
Nonopioids
Comfort Care/PRICE Therapy
PRICE: Protection, Rest, Ice, Compression, Elevation
IM: Intramuscular IN: Intranasal
Adapted from the Wilderness Medical Society Practice Guidelines for the Treatment of Acute Pain in
Remote Environments.
the injured hemithorax increases. The
lung on the affected side collapses, and
the increased pressure displaces the
mediastinum contralaterally, resulting
in compression of the superior and
inferior venae cavae. These events
subsequently affect venous return
and reduce preload, prompting signs
and symptoms of shock. Indications
for immediate needle decompression
in a patient with chest trauma in the
wilderness include:
• Significant shortness of breath
• Hypoxia or cyanosis
• Distended neck veins
• Tracheal deviation
• Altered mental status
Once a tension pneumothorax has
been identified, the severity of the injury
and the next steps should be discussed.
If help is available, someone else should
arrange for emergent evacuation while
the physician explains the importance
of needle decompression to the patient.
It is important to emphasize that the
procedure is a potentially lifesaving
therapy for a tension pneumothorax,
a condition that can rapidly lead to
cardiovascular collapse and death if left
untreated.
22 Critical Decisions in Emergency Medicine
IV/IO
Meds
IM/IN
IV: Intravenous IO: Intraosseous
When managing a patient in
the wilderness setting, it is always
important to minimize exposure and
alleviate pain as much as possible
(Figure 2). As in the hospital setting,
once the needle decompression has
been performed, the catheter should
be secured in place. While preventing
entanglement, the patient should be
reclothed to prevent further exposure.
Frequent reassessments should
be performed to look for signs of
decompensation and reaccumulation of
the pneumothorax.
CRITICAL DECISION
When should a patient be
treated in place versus being
evacuated to definitive care?
Patients who become sick or injured
in the wilderness must be quickly
evaluated, and a determination must
be made as to whether they can be
managed on-site or must be evacuated
for definitive treatment (Figure 3).
Patients who are at risk of significant
complications or death require urgent
evacuation. Nonurgent evacuation
can be considered for those who need
further evaluation and treatment but
are at low risk of rapid decompensation
or death.
This determination should be made
with the help of everyone in the group,
including the patient, if possible. It
is imperative for medical or rescue
leaders to:
• understand the capability of the
group and the experience of its
members;
• know the capability of any local
rescue organizations and how to
contact them; and
• consider the geographical area
and the timing necessary for an
evacuation.
Rescue leaders should also develop a
coordinated plan that is communicated
to at least one person not involved
in the trip. An awareness of these
limitations can help to more clearly
define when such decisions must be
made.
After a trauma evaluation, the
clinician must determine whether the
patient’s injury can be definitively
treated in the field with the supplies
available or whether the injury, if
not managed urgently, could worsen
significantly. These decisions can be
much easier to make when assessing
injuries at each end of the severity
spectrum. For example, patients with
minor wounds can often be treated in
the field and released to continue their
journey.
Paul Auerbach’s authoritative
Wilderness Medicine describes which
patients require evacuation, including:7
1. Those who do not improve or
deteriorate after treatment
2. Those with debilitating pain
3. Those with an inability to
sustain travel at a reasonable
pace due to a medical problem
4. Those with persistent
abdominal pain
5. Those with signs and symptoms
of serious high-altitude illness
6. Those with infections that do
not improve after 24 hours of
treatment
7. Those with chest pain
not clearly from a minor
musculoskeletal injury
 8. Those who develop a psychiatric
issue that puts the patient or the
group at risk
9. Those with large or serious
injuries or wounds with
complications (eg, an open
fracture, fractures with
deformity, fractures with
impaired neurovascular status,
gunshot wounds, a suspected
spinal cord injury, and certain
burns)
Travel toward definitive medical
care can continue in scenarios 3,
4, and 8, or when descending in
scenario 5. Evacuating a patient from
a wilderness setting requires relaying
important factors to EMS and search
and rescue (SAR) personnel, including
a description of the patient’s injuries,
the treatment given, the environmental
conditions, and the type of evacuation
required. Evacuation is a time- and
personnel-intensive task that often
moves more slowly than 1 mile per
FIGURE 3. Evacuation Plan Flowchart
Is the injury or illness severe
enough to require additional
NO
medical treatment? Make
this assessment in a timely
manner.
YES
Can the patient walk NO
out on their own
without aggravating the
condition?
YES
Can the available evacuation
routes be safely traveled by NO
the patient?
YES
Will walking out and carrying
gear create additional NO
accident potential for the
patient or the group?
YES
Allow the person to hike
out with appropriate group
support, but do not let them
carry gear.
hour, depending on the injury, terrain,
and supplies.
Patients who are severely ill or have
sustained an injury with a high risk of
morbidity or mortality necessitate both
on-site treatment and timely evacuation.
Any urgent medical needs must be
addressed on-site while evacuation is
simultaneously arranged.
CRITICAL DECISION
When should an orthopedic
fracture or dislocation be
reduced in the wilderness?
Musculoskeletal trauma accounts
for approximately 80% of wilderness-
related accidents. Ankle fractures
are the most commonly encountered
injuries in the outdoor setting. Without
immediate access to radiographs, a
detailed history can help properly
diagnose orthopedic trauma. The
patient may be able to describe force
vectors that led to the injury or state
Is the person unable to
continue with the trip?
YES
Send
appropriate
This person needs a litter
members
evacuation. Does the group
NO of the
have the skills, people,
group out
and equipment to safely
to secure
evacuate the person?
professional
help.
YES
Prepare for evacuation.
Allow the patient to hike
out with appropriate group
support and with gear.
whether a “pop” was heard. After
the primary survey and a focused
evaluation of the spine and pelvis, the
clinician should concentrate on focal
extremity injuries.8 It is paramount
to evaluate for deformities,
crepitus, swelling, skin changes,
and neurovascular function. When
uncertain, the injured limb should be
compared to the unaffected side.
Any dislocation that appears to
be an isolated injury can and should
be reduced on scene if the procedure
can be accomplished safely. Early
reductions are usually easier, when
swelling and muscle spasms are less
severe. In addition, early intervention
can significantly reduce pain and
mitigate the need for evacuation.
If a fracture is associated with the
dislocation, a reduction is less likely
to be successful and is therefore
discouraged. Techniques for reduction
depend on the treating clinician,
affected joint, and medicines available.
Reductions of the fingers and patellae
can often be completed without any
anesthesia. Ankles and shoulders
can benefit from intra-articular,
intramuscular, or oral pain control
or anesthesia. A dislocated hip or
knee is a major injury that may not
be reducible without sedation; in such
cases, transport may be required.7
As in the emergency department,
patients who require an urgent
reduction in the wilderness include
those with decreased perfusion distally,
those with reduced neurological
function distally, and those at risk of
developing compartment syndrome.
Traditionally, large deformities
without these concerns were reduced
and placed in external traction
splints; however, this approach is no
longer recommended. The Wilderness
Medical Society practice guidelines
discourage the routine use of traction
splints on long-bone fractures
(stereotypically femurs). Initially,
in-line traction can provide relief;
however, prolonged external traction
devices or improvisations can lead to
skin necrosis and reduced circulation,
and have no proven benefit.8
March 2019 n Volume 33 Number 3 23
 Summary
It is imperative for emergency
physicians to recognize how proper
planning, evaluation, and treatment can
greatly affect the outcomes of patients
who have been injured in wilderness
n Patients with chest wounds, extreme dyspnea, loss of unilateral breath sounds,
or signs of a tension pneumothorax require an immediate needle decompression settings. A timely trauma survey can
of the chest. help differentiate between minor injuries
n Patients who have signs of acute blood loss, altered mental status, a life- and those that require immediate life-
threatening condition, or progressively worsening symptoms should be evacuated or limb-saving treatment.
as quickly as possible. The timely identification of a
n Patients with a loss of pulses or feeling in a fractured or dislocated extremity tension pneumothorax is critical when
should undergo emergent reduction of the affected limb. managing patients with chest trauma.
n A tourniquet should be applied to stop bleeding that fails to respond to the Such cases mandate immediate needle
application of direct pressure. decompression of the chest followed
by emergent evacuation to the nearest
medical facility. Patients with fractures
CRITICAL DECISION study were removed prior to the 2-hour
or dislocations that compromise the
mark.10
What factors should be distal tissues, or those with other
One of the biggest mistakes a complicating factors such as evacuation
considered before applying clinician can make when applying a times, require emergent reduction of
a tourniquet? tourniquet in the prehospital setting the affected limb to prevent further
Hemorrhagic shock is the leading is failing to tighten it enough. An morbidity.
cause of death on the military battlefield estimated 83% of extremities have Penetrating trauma to the
and is the second leading cause of palpable distal pulses upon hospital extremities with uncontrolled blood
traumatic deaths in the civilian sector. arrival, which can lead to a “venous loss puts patients at grave risk for
Because of this risk — which is inherent tourniquet” that increases the risk of hypovolemic shock and death; in these
in any low-resource environment, compartment syndrome or increased situations, tourniquets must be applied
including the wilderness — the United blood loss by allowing inflow while promptly and properly. Clinicians
States Armed Forces developed the precluding a return to systemic must also be prepared to weigh a
MARCH mnemonic to direct the initial circulation from the injured limb. 11,12 variety of environment-specific factors
assessment of soldiers injured during Tourniquets are a safe and when devising a treatment plan and
combat operations: effective way to treat wounds with determining the need for evacuation.
• Massive hemorrhage significant bleeding. If direct pressure is
• Airway ineffective, the next step should be the REFERENCES
• Respirations application of a tourniquet proximal to 1. National Center for Injury Prevention and Control.
Ten leading causes of death and injury. Centers for
• Circulation the wound, which should be tightened Disease Control and Prevention website. http://www.
cdc.gov/injury/wisqars/leadingcauses.html. Published
• Head injuries/hypothermia until the distal pulses are occluded. February 25, 2016. Accessed November 20, 2016.
This battlefield protocol has been
successfully employed in wilderness
sectors. Applying a tourniquet before
a victim goes into shock appears to
provide a profound survival benefit
(96% vs 4%). Prehospital application
vs hospital application also appears to
n Failing to prepare for the most common injuries encountered in the wilderness
improve the likelihood of survival or for specific types of travel, an oversight that can adversely impact a
(89% vs 78%, p <0.05).9 physician’s ability to effectively respond to emergencies in the field.
There appears to be no correlation n Waiting too long to reduce a fracture or dislocation. Delays can make the
between morbidity and the time a reduction of the affected limb more difficult due to increased muscle spasms
tourniquet stays in place, and no increase and swelling around the wound. Delaying reduction can also adversely affect the
in thromboembolic events, necrosis, tissue distally.
amputation, or renal failure. Research n Using improper techniques or equipment, including external traction splints,
also shows a slight, but statistically which are no longer recommended.
significant, increase in the need for a n Failing to adapt emergency procedures to the outdoor setting, which can lead
fasciotomy if the tourniquet remains in to complications and death.
place for more than 2 hours; however, n Neglecting to recognize when an emergent evacuation is warranted, a mistake
91% of tourniquets in the referenced that can increase morbidity and mortality.

24 Critical Decisions in Emergency Medicine

 CASE RESOLUTIONS
■ CASE ONE
Within minutes, the musher
became tachycardic and dyspneic.
The initial trauma survey revealed
a chest wound accompanied by
shortness of breath and absent breath
sounds on the right side. Because
the musher also had distended neck
veins and a tracheal deviation to the
left, the physician suspected a tension
pneumothorax, a life-threatening
injury that requires immediate needle
decompression to prevent further
cardiovascular decompensation and
death. As the patient’s symptoms
worsened, treating the tension
pneumothorax became paramount.
While the physician discussed
the urgency of the injuries with
the patient, the friend called for
immediate evacuation to the nearest
medical facility and provided their
coordinates. The physician performed
a needle decompression of the chest
and heard a rush of air from the
musher’s chest. Pain medicine was
administered (800 mg of ibuprofen
and 1 g of acetaminophen by mouth),
and the patient was re-evaluated
frequently to assess for pain, clinical
stability, and comfort. The physician
instructed the musher to slide into his
sled to stay out of the wind, as the
group sheltered in the wooded area.
Approximately 45 minutes later, a
rescue helicopter landed on the frozen
river, and the flight medic signaled
that he was ready for the patient. The
physician relayed to the flight crew
that the catheter used to decompress
the patient’s chest was still in place.
The pilot stated he would fly low to
reduce the chance of re-expansion
2. Hubbell FR. Wilderness emergency medical
services and response systems. In: Auerbach PS,
ed. Wilderness Medicine. 5th ed. Philadelphia, PA:
Mosby Elsevier; 2007:694-707.
3. Collier BR, Riordan PR Jr, Nagy JR, Morris JA
Jr. Wilderness trauma, surgical emergencies,
and wound management. In: Auerbach PS, ed.
Wilderness Medicine. 5th ed. Philadelphia, PA:
Mosby Elsevier; 2007:475-504.
4. Declerck MP, Atterton LM, Seibert T, Cushing TA. A
review of emergency medical services events in US
national parks from 2007 to 2011. Wilderness Environ
Med. 2013 Sep;24(3):195-202.
5. Goodman T, Iserson KV, Strich H. Wilderness
mortalities: a 13-year experience. Ann Emerg Med.
2001 Mar;37(3):279-283.
secondary to decreased barometric
pressure at higher altitude. On arrival
at the medical center, a chest tube was
placed, and the patient was admitted
for further observation.
■ CASE TWO
The physician suspected that the
fallen rock climber had sustained a
right hip fracture and/or dislocation
and a left distal femur fracture with
significant displacement, which was
contributing to vascular compromise
distally. No additional injuries were
found. The skin was intact, and no
signs of external hemorrhage existed.
Because of decreased perfusion, the
physician focused on the left leg first.
He administered ibuprofen (800 mg)
and acetaminophen (1 g) orally and
applied gentle in-line traction, which
initially caused significant pain but led
to improved comfort. Reassessment
of the leg revealed improvement in the
visible deformity and a 2+/4 dorsalis
pedis pulse. The warmth and color of
the leg improved.
The physician was unsure if the
woman’s right leg was fractured or
dislocated but did not believe she
had an open-book pelvic fracture.
Concerned about how painful a
reduction attempt would be given the
lack of pharmacological supplies and
the inability to determine concomitant
pelvic or femur fractures, he deferred
intervention; splinted the legs together
with the knees in slight flexion,
with padding between the thighs
and in the popliteal fossae; and then
confirmed that the patient was still
neurovascularly intact.
6. American College of Surgeons Committee on
Trauma. ATLS: Advanced Trauma Life Support for
Doctors. 8th ed. Chicago, IL: American College of
Surgeons; 2008:2-11.
7. Switzer JA, Ellis TJ, Swiontkowski MF. Wilderness
orthopedics. In: Auerbach PS, ed. Wilderness
Medicine. 5th ed. Philadelphia, PA: Mosby Elsevier;
2007:573-603.
8. Forgey WW; Wilderness Medical Society.
Wilderness Medical Society: Practice Guidelines for
Wilderness Emergency Care. 5th ed. Guilford, CT:
Morris Book Publishing; 2006.
9. Kragh JF Jr, Littrel ML, Jones JA, et al. Battle
casualty survival with emergency tourniquet
use to stop limb bleeding. J Emerg Med. 2011
Dec;41(6):590-597.
The physician indicated an
emergency on the GPS locator, and
the group waited nearly 4 hours
for the SAR team to appear. A
paramedic administered fentanyl
intramuscularly (100 mcg). The
patient was then placed in a vacuum
litter, fitted with a cervical collar,
and packaged into a one-wheeled
litter. It took 8 hours to reach
the ambulance at the trailhead.
At the local hospital, the patient
was diagnosed with a right hip
dislocation and a left distal femur
fracture. With procedural sedation,
the hip was reduced, and she was
admitted for surgical repair of the
left femur.
■ CASE THREE
The physician fashioned a wide
tourniquet from a spare bike tube
and a sturdy branch, which was
placed 4 inches proximal to the
cyclist’s wound. Twisting the branch
increased the tension and eventually
occluded the radial pulse. When
the bleeding abated, the physician
changed the dressing and applied
a pressure dressing directly to the
wound.
Pain medication and oral fluids
were given. With assistance, the
patient ambulated slowly toward
the trailhead. The group was met
by EMS, who established an IV and
transferred the patient to the local
hospital. CT angiography showed
a laceration to the proximal ulnar
artery. The patient underwent urgent
vascular repair and was discharged
in stable condition a few days later.
10. Kragh JF Jr, Walters TJ, Baer DG, et al. Practical
use of emergency tourniquets to stop bleeding
in major limb trauma. J Trauma. 2008 Feb;64
(2 Suppl):S38-S50.
11. King DR, van der Wilden G, Kragh JF Jr,
Blackbourne LH. Forward assessment of 79
prehospital battlefield tourniquets used
in the current war. J Spec Oper Med. 2012
Winter;12(4):33-38.
12. Drew B, Bennett BL, Littlejohn L. Application
of current hemorrhage control techniques for
backcountry care: part one, tourniquets and
hemorrhage control adjuncts. Wilderness Environ
Med. 2015 Jun;26(2):236-245.
March 2019 n Volume 33 Number 3 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 Small children restrained by three-point seat belts

are most at risk for which of the following injuries? 6 Which of the following laboratory studies
can reliably exclude injuries caused by blunt
A. Carotid artery injury abdominal trauma?
B. Cervical spine dislocation A. CBC
C. Chance fracture B. LFTs
D. Bladder rupture
C. No laboratory study can reliably exclude such
injuries
2 When examining a child involved in a high-speed
MVC, you note abrasions over the lower abdominal
wall. Which of the following underlying pathologies
D. Urinalysis

is most likely?
A. Gastrointestinal injury 7 Chance fractures are most closely associated
with which of the following coinjuries?
B. Pancreatic injury A. Abdominal trauma
C. Renal laceration B. Bladder rupture
D. Splenic rupture C. Closed head trauma
D. Spinal cord injury
3 Toddlers restrained in car seats are at relatively
higher risk for which of the following injuries?
A.
B.
Abdominal trauma
Cerebrovascular injury
8 Approximately what percentage of teenagers
who died in MVCs in 2015 were unrestrained?

C. Ligamentous cervical trauma A. 1%

D. Pelvic fracture B. 10%
C. 50%

4 What is the preferred test for evaluating MVC-

related injuries in children with lower-abdominal
bruising?
D. 75%

A. CT scan with IV contrast

B. Diagnostic peritoneal lavage
9 A 9-year-old boy presents after a high-speed
MVC. He has faint bruising to his lower
abdomen but normal vital signs and no
C. Flat/upright plain films
complaints of abdominal pain. His abdomen
D. Ultrasound
is soft and nontender, and a CT scan of his
abdomen is normal. What is the best next step?
5 Which of the following intra-abdominal injuries can
be difficult to detect on CT and sometimes renders
false-negative results?
A. Admit the patient for serial examinations
B. Discharge home with instructions to follow up
A. Liver laceration with his primary doctor within 24 hours
B. Pancreatic injury C. Request a surgical consultation
C. Small bowel injury
D. Risk stratify the patient using laboratory tests
D. Splenic rupture

26 Critical Decisions in Emergency Medicine


10 At what age can a child safely ride in the front
seat of a car?
A. 8 years
15 A hiker falls and sustains a femur fracture. She is
in significant pain, and her limb has an obvious
deformity. Which of the following directives is no
B. 9 years longer recommended?
C. 12 years A. Administer pain medication
D. 13 years B. Arrange an early evacuation
C. Perform a full trauma survey

11 Which scenario warrants an emergent reduction

of a fracture and/or dislocation?
D. Use a traction device to stabilize the fracture

16
A. Decreased perfusion distal to the injury A hiker is short of breath after falling and striking her
B. Significant pain at the site of the injury chest on a pointed rock. Which presentation warrants
C. Unstable vital signs with comorbid abdominal urgent needle decompression of the chest?
trauma A. Chest abrasion with bleeding
D. Visible deformity B. Distended neck veins
C. Nausea

12 Which of the following injuries necessitates the D. Tachycardia at 115 bpm

application of a tourniquet?

17
A. Bleeding chest wound Which traumatic injury is most commonly encountered
in the wilderness?
B. Blood oozing from the thigh
C. Pulsatile bleeding in the arm that resolves with A. Ankle fracture
direct pressure B. Blunt head injury
D. Pulsatile bleeding in the calf that persists C. Direct dental trauma
despite direct pressure D. Penetrating chest injury

13 Which of the following is a poor choice for

treating a patient in the wilderness?
A. Evacuating a patient with a head injury and
altered mental status who is not improving with
treatment
B. Performing a needle decompression on an
injured patient with decreased breath sounds
and respiratory distress
C. Using a tourniquet to treat an inner thigh wound
that is bleeding heavily and cannot be managed
with direct pressure
D. Withholding pain medicine from a hiker to avoid
masking his symptoms
18 Which of the following medications should be carried
when embarking on most wilderness adventures?
A. Dexamethasone
B. Doxycycline
C. Lidocaine
D. Oral ibuprofen and acetaminophen
19 What is the most common mistake made when
applying a tourniquet in the prehospital setting?
A. Leaving the tourniquet in place too long
B. Not applying the tourniquet tightly enough
C. Placing the tourniquet too close to the wound
D. Placing the tourniquet too far from the wound

14 Which orthopedic injury mandates an emergent

evacuation?
A. Dislocated shoulder that was reduced after

20
You are managing a right ankle fracture in the field.
Which factor should prompt an immediate reduction
of the injury?
multiple attempts A. Difficulty ambulating and bearing weight
B. Fracture and dislocation of the long finger B. History of anticoagulant use
C. Isolated humeral fracture without a deformity C. Loss of pulses in the right foot
or neurovascular compromise D. Significant swelling of the ankle joint
D. Open fracture or dislocation

ANSWER KEY FOR FEBRUARY 2019, VOLUME 33, NUMBER 2

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

March 2019 n Volume 33 Number 3 27

 Drug Box
OMADACYCLINE
By Frank LoVecchio, DO, MPH, FACEP;
and Laila LoVecchio
Maricopa Medical Center, Phoenix, Arizona
Omadacycline is a new antibiotic derivative
of tetra­­cycline that is used to treat bacterial
infections, including methicillin-resistant
Staphylococcus aureus. It can also be used to
manage community-acquired bacterial pneumonia
(CABP) and acute bacterial skin and skin-structure
infections caused by susceptible organisms.
Mechanism
The drug inhibits protein synthesis by binding with
the 30S ribosomal subunit of susceptible bacteria.
Dosing
CABP:
Loading dose — 200 mg IV as a single dose on
day 1, OR 100 mg 2x/day on day 1
Maintenance dose — 100 mg IV once daily; OR
300 mg PO once daily for 7 to 14 days
Skin and skin-structure infections:
Loading dose — 200 mg IV as a single dose on
day 1, OR 100 mg 2x/day on day 1; OR 450 mg PO
once daily on days 1 and 2
Maintenance dose — 100 mg IV once daily; OR
300 mg PO once daily for 7 to 14 days
Precautions
Side effects include GI symptoms (>10%),
nausea (2%-22%), vomiting (3%-11%), and other
complaints (<3%).
Elderly patients should be monitored closely for
clinical response. The agent may be less effective
for the treatment of CABP in patients ≥65 years.
Omadacycline should be avoided in pregnant
patients and children ≤8 years. It can inhibit bone
growth and cause hypoplasia and discoloration of
tooth enamel in this population.
Tox Box
STRYCHNINE POISONING
By Jenna Otter, MD; and Christian A. Tomaszewski, MD, MS, MBA, FACEP
University of California, San Diego
Seeds from the strychnine tree (Strychnos nux-vomica), a native of Southeast
Asia and Northern Australia, produce an alkaloid toxin that is commonly used
as a rodenticide. The plant’s seeds are also used in Ma Qian Zi, a Chinese
herbal medicine, and Salang chai nut, a traditional Cambodian remedy. It is
also used as an adulterant in street drugs (eg, heroin and cocaine).
Toxicokinetics
• Lethal dose: ~50-100 mg (1-2 mg/kg)
• Absorbed rapidly through the GI tract (symptoms are seen <15-60 minutes
after ingestion)
• Large volume of distribution (13 L/kg)
• Elimination half-life: 10-16 hours
Mechanism of Action
• Strychnine competitively blocks glycine, an inhibitory neurotransmitter,
leading to neuronal disinhibition and increased excitability.
• Its effects are most pronounced in the spinal cord, where a suppression of
reflex arcs leads to uncontrolled muscle contractions.
Clinical Presentation
• Painful, severe muscle spasms (tetanus-like) can be triggered by minimal
stimuli.
• If not treated early, patients develop hyperthermia, rhabdomyolysis, kidney
injury, electrolyte disturbances, lactate acidosis, hyperkalemia, and seizures.
• Respiratory failure is caused by respiratory muscle spasms and inadequate
ventilation.
Management
• Measure electrolyte and arterial blood gas levels (survival reported with
pH levels ≤6.5).
• Assess the airway and intubate for inadequate ventilation.
• Provide GI decontamination with activated charcoal (if <1 hour since
ingestion).
• Inhibit uncontrolled muscle contractions by minimizing stimuli and providing
benzodiazepines.
• Intubate, sedate, and paralyze the patient with nondepolarizing
neuromuscular blockers, as needed, for hyperthermia and other critical
complications.