Carolinas Core Concepts Core Concepts in EM; a repository for Carolinas lecture summaries.


Fragility Fractures “Small Fall, Large Costs”

  • Plain films miss fractures; 3.1% of all ED patients with "negative" hip x-ray studies actually have an occult hip fracture. If still clinically suspicious, MRI is the gold standard in low energy falls.
  • Having an organized, streamlined process to admit fragility fractures with goal of time to surgery less than 24 hours improves mortality, decreases length of stay and costs, and allows for earlier mobilization.
    • Dominquez S. et al. Prevalence of traumatic hip and pelvic fractures in patients with suspected hip fracture and negative initial standard radiographs—a study of emergency department patients. Academic Emergency Medicine. 2005 Apr; 12(4):366-9
    • Verbeeten KM, et al. The advantages of MRI in the detection of occult hip fractures. Eur Radiology. Jan 2005: 15(1): 165-9
    • Cannon J, Silvestri S. Munro M. Imaging choices in occult hip fracture. J Emergency Medicine. 2009 Aug; 37 (2): 144-52
    • Kates SL, Mears SC. A guide to improving the care of patients with fragility fractures. Geriatric Orthopaedic Surgery and Rehabilitation. 2011 2(1) 5-37

Hyperkalemia, Marine Envenomations, and SBO

  • In addition to the 1st line treatments of calcium, insulin-d10, bicarbonate and dialysis, effective treatment of hyperkalemia involves β2-agonists; 20mg albuterol nebulized over 10 minutes or terbutaline 0.5mg IV quickly drives potassium intracellularly.
  • Proper treatment of most marine envenomations, catfish being the most common, is hot water soaks for 30-90 minutes with good wound care and a quinolone or augmentin for 5 days.
  • CT abd/pelvis is only 92% sensitive for small bowel obstruction.  Keep an open mind if you have strong clinical suspicion.
    • Allon M. Hyperkalemia in end-stage renal disease: mechanisms and management. J Am Soc Nephrol. 1995;6(4):1134.
    • Allon M, Copkney C. Albuterol and insulin for treatment of hyperkalemia in hemodialysis patients. Kidney Int. 1990;38(5):869.
    • Carrette TJ, Cullen M, et al. 2002. Temperature effects on box jellyfish venom, a possible treatment for envenomated patients? Med J Aust. 177: 654.
    • Glenister KM, Corke CF. Infarcted intestine: a diagnostic void. Journal of Surgery 2004. 74:260

C-Spine Imaging in the ED

  • In low-risk groups with an adequate c-spine XRay, the negative predictive value is 99.9%.   However, C-spine XRay sensitivity for all comers is only 36-64% and average time-to-dispo is 1.9 hours vs 1 hour on average for CT.
  • CT c-spine disadvantages:  Cancer risk 1:200 in 15 y/o, 1:2,000 in 30 y/o, 1:5,000 in 70 y/o.  Cost is also higher, although when inadequate CSXR and "missed fracture" costs are added in they may be comparable.
  • In the alert patient with a negative CT c-spine but persistent bony tenderness there are three options: continue collar upon discharge, MRI for ligamentous injury, or flex-extension films.