Rosen & Barkin's 5-Minute Emergency Medicine Consult (64 page)

Presence of large thymus may make diagnosis of widened mediastinum difficult.

• Supine CXR can lead to false positive for widened mediastinum; obtain upright PA if possible.
  
• Mediastinal hematoma owing to other causes
  
• Mediastinal lymphadenopathy or tumor
  
• Redundant aorta resulting from HTN
  

TREATMENT

Important information to retrieve at scene of injury:

• Vehicular speed
  
• Patient in driver or passenger seat
  
• Damage to steering column if driver is patient
  
• Ejection or use of seat belt
  

• Follow advanced trauma life support protocols.
  
• Life-threatening intracranial, peritoneal, and retroperitoneal injuries take precedence.
  

• Immediate trauma surgery consultation
  
• Immediate cardiothoracic or vascular surgery consultation (institution dependent)
  
• Avoid maneuvers that may result in a Valsalva-like response (e.g., gagging, straining)
  
• Aggressive pharmacologic treatment of BP and heart rate, as emerging data suggest delaying surgical repair may lead to improved outcomes
  
• Goal of medical therapy is to target heart rate 60 ± 5 bpm, systolic BP 100–120 mm Hg, and mean arterial BP 70–80 mm Hg to decrease risk of sudden free rupture and exsanguination:
  
  • β-blockers such as esmolol and labetalol are 1st-line agents
    
  • Calcium-channel blockers in patients with contraindications to β-blockade (CHF, COPD, 2nd- or 3rd-degree atrioventricular block)
    
  • Add vasodilator (nitroprusside) if needed to reach target BP and heart rate goals.
    
  • Antihypertensives are relatively contraindicated in acute coarctation syndrome.
    
• For significant hypotension, initiate rapid volume expansion, including blood.
  
• Vasopressors for refractory hypotension; norepinephrine and phenylephrine are preferred
  
• Central venous and arterial catheters
  

• Esmolol: 500 μg/kg bolus IV (peds: 100–500 μg/kg bolus), then 50–150 μg/kg/min IV infusion (peds: 25–100 μg/kg/min IV infusion)
  
• Labetalol: 20 mg IV, followed by additional doses of 40 mg and 80 mg (peds: 0.2–10 mg/kg per dose, max. 20 mg per dose) IV q10–15min, to 300 mg IV total; start infusion at 2 mg/min and titrate up to 10 mg/min (peds: 0.4–3 mg/kg/h infusion)
  
• Diltiazem: 20 mg (0.25 mg/kg) IV over 2 min; 2nd bolus 25 mg (0.35 mg/kg) in 15 min if needed; infusion 5–15 mg/h
  
• Norepinephrine: Start with 0.5–1 μg/min and titrate to desired response; 8–30 μg/min is usual dose (peds: Start 0.05–0.1 μg/kg/min, max. 2 μg/kg/min)
  
• Phenylephrine: 0.1–0.5 mg IV boluses q10–15min, initial dose not to exceed 0.5 mg (peds: 5–20 μg/kg/dose q10–15min); 100–180 μg/min or 0.5 μg/kg/min titrated to desired effect (peds: 0.1–0.5 μg/kg/min, titrated to desired effect)
  

FOLLOW-UP

All patients with aortic injuries must be admitted to the ICU if not taken directly to the OR.

All patients with TAI are admitted to the hospital.

• Maintain a high degree of suspicion for TAI in patients with injuries from significant deceleration mechanisms.
  
• Clinical signs and symptoms may be subtle or nonexistent, necessitating some reliance on radiologic imaging for diagnosis.
  
• Special attention should be given to assessment of the mediastinum on CXR in trauma patients.
  
• Early pharmacologic control of BP and heart rate is of utmost importance when diagnosis is confirmed.
  

• Demetriades D, Velmahos GC, Scalea TM, et al. Blunt traumatic thoracic aortic injuries: Early or delayed repair—Results of an American Association for the Surgery of Trauma prospective study.
  J Trauma
  . 2009;66(4):967–973.
  
• Kwolek CJ, Blazick E. Current management of traumatic thoracic aortic injury.
  Semin Vasc Surg
  . 2010;23(4):215–220.
  
• Moore MA, Wallace EC, Westra SJ. The imaging of paediatric thoracic trauma.
  Pediatr Radiol
  . 2009;39(5):485–496. Review.
  
• Ng CJ, Chen JC, Wang LJ, et al. Diagnostic value of the helical CT scan for traumatic aortic injury: Correlation with mortality and early rupture.
  J Emerg Med
  . 2006;30(3):277–282.
  
• Weidenhagen R, Bombien R, Meimarakis G, et al. Management of thoracic aortic lesions–the future is endovascular.
  Vasa
  . 2012;41(3):163–176.
  

CODES

• 901.0 Injury to thoracic aorta
  
• 902.0 Injury to abdominal aorta
  

BASICS

Painful ovoid or round ulcerations on the mucous membranes of the mouth, tongue or genitals:

• Commonly referred to as “canker sores”
  

• Unknown
  
• Etiology likely multifactorial with some correlation with:
  
  • Immunologic dysfunction; alteration of cell-mediated immune system
    
  • Infection
    
  • Food hypersensitivities (i.e., gluten)
    
  • Vitamin deficiency
    
  • Pregnancy
    
  • Menstruation
    
  • Trauma
    
  • Stress
    
  • Ethnicity
    
  • Immunodeficiency
    
  • Medications: β-blockers, anti-inflammatory
    
• Epidemiology: Usually occurs in children and young adults (Peak age of onset: Between 10 to 19 yr old)
  
  • Most common inflammatory ulcerative condition of the oral cavity (20-40% of general population)
    
  • More common in women
    
  • May be familial
    

DIAGNOSIS

• Minor aphthous ulcers:
  
  • 70–90% of all aphthae
    
  • <5 mm in diameter; up to 5 appear at a time
    
  • Painful, shallow ulcers with necrotic centers
    
  • Raised, circumscribed margins and erythematous halos
    
  • Gray-white pseudomembrane
    
  • Affect nonkeratinized mucosa of anterior oral cavity
    
    • Labial and buccal mucosa
      
    • Floor of mouth
      
    • Ventral surface of tongue
      
  • Rarely found on dorsum of tongue, hard palate, or gingiva
    
  • Last for 10–14 days; do not scar
    
  • Fever/constitutional symptoms rarely associated
    
• Major aphthous ulcers or Sutton disease:
  
  • 10–15% of all aphthae
    
  • Similar in appearance but more painful than minor form
    
  • >5 mm in diameter; 1–10 ulcers at a time
    
  • Deeper than minor form
    
  • Involve all areas of oropharynx including pharynx, soft/hard palate, lips
    
  • Last for weeks to months, may scar
    
  • Onset after puberty
    
  • Often associated with underlying disease
    
  • Fever is rarely associated
    
• Herpetiform aphthous ulcers:
  
  • 7–10% of all aphthae
    
  • Multiple small clusters
    
  • <5 mm in diameter, 10–100 at any time, may coalesce into plaques
    
  • Herpetiform in nature, but herpes simplex virus cannot be cultured from lesions.
    
  • Predisposition for women
    
  • Last for 7–30 days; scarring can occur
    

• Prodrome of burning or pricking sensation of oral mucosa 1–2 days prior to appearance of ulcers
  
• Inquire about patient or family history of:
  
  • Systemic lupus erythematosus (SLE)
    
  • Inflammatory bowel disease (IBD)
    
  • Behçet disease
    
  • Reiter disease
    
  • Gluten sensitivity
    
  • Cancer
    
  • HIV
    
• Inquire about patient sexual history of syphilis or herpes virus
  
• Inquire about current medications:
  
  • NSAIDs
    
  • β-blockers