Rosen & Barkin's 5-Minute Emergency Medicine Consult (161 page)

GI for all new cases

• Prognosis is highly variable.
  
• Patients present with a wide variety of signs and symptoms related to end-stage liver disease.
  
• New cases need full workup and GI consultation for management.
  
• Any complication puts patient in decompensated state.
  
• SBP symptoms are frequently vague:
  
  • Must have a high suspicion and low threshold for paracentesis when considering SBP
    

• Feldman M.
  Sleisenger and Fordtran’s Gastrointestinal and Liver Disease
  . 9th ed. Philadelphia, PA: WB Saunders; 2010.
  
• Goldberg E.
  Diagnostic Approach to the Patient with Cirrhosis
  . Wellesley, MA: UpToDate; 2012.
  
• Longo D, Fauci A, et al.
  Harrison’s Principles of Internal Medicine.
  18th ed. New York, NY: McGraw-Hill; 2011.
  
• Runyon BA. Management of adult patients with ascites due to cirrhosis.
  Hepatology
  . 2009;49(6):2087–2107.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Ascites
  
• Hepatic Encephalopathy
  
• Hepatitis
  
• Spontaneous Bacterial Peritonitis
  
• Varices
  

CODES

• 571.2 Alcoholic cirrhosis of liver
  
• 571.5 Cirrhosis of liver without mention of alcohol
  
• 571.6 Biliary cirrhosis
  

BASICS

• Clavicular fractures account for 5% of all fractures in all age groups.
  
• 80% of clavicular fractures involve the middle 3rd.
  
• 15% occur in the distal 3rd.
  
• 5% occur in the medial 3rd.
  

Classification

• Group I: Middle-3rd fractures
  
• Group II: Distal-3rd fractures:
  
  • Type I: Coracoclavicular ligaments are intact (nondisplaced).
    
  • Type II: Severing of the coracoclavicular ligaments (conoid)
    
  • Type III: Articular surface involvement of the acromioclavicular joint
    
• Group III: Medial (proximal)-3rd fractures
  

Mechanism:

• Direct trauma to the clavicle
  
• Fall on the lateral shoulder
  
• Fall on the outstretched hand
  

• Most common of all pediatric fractures
  
• May occur in newborns secondary to birth trauma
  

Geriatric patients who sustain a clavicular fracture may have difficulty performing activities of daily living. The patient’s social and living situations should be assessed to determine a safe discharge plan that may require additional assistance at home.

Clavicular fractures are the result of direct trauma. Patients who are pregnant should be appropriately worked up for other injuries but also should receive fetal monitoring to ensure the health of the fetus. Even minor injuries can result in trauma or harm to the fetus.

DIAGNOSIS

• Local pain, tenderness, and swelling over the fracture site
  
• Crepitus is often present owing to the clavicle’s SC position
  
• Arm held in adduction against the chest wall with resistance to motion
  
• Shoulder displaced anteriorly and inferiorly
  

• Palpate the clavicle for tenderness, crepitus, and swelling.
  
• Examine the humerus and shoulder joint for other fractures, dislocations, or subluxations.
  
• Determine whether the fracture is open or closed.
  
• Evaluate for associated injuries (often serious and life threatening) that must be excluded:
  
  • Skeletal injuries:
    
    • 1st rib fracture with underlying aortic injury
      
    • Sternoclavicular joint separation/fracture-dislocation
      
    • Acromioclavicular joint separation/fracture-dislocation
      
    • Cervical spine injuries
      

• AP radiographs of both clavicles are mandatory and must include:
  
  • Upper 3rd of the humerus
    
  • Shoulder girdle (rule out other fractures)
    
  • Upper lung fields (rule out pneumothorax)
    
• Oblique and apical lordotic views:
  
  • May be helpful, especially for medial and distal clavicle fractures that are not easily visualized on the AP view
    
  • Stress views (weight bearing) for distal clavicle fractures are no longer routinely recommended.
    
• Angiography:
  
  • Should be performed if there is any evidence or suspicion of vascular injuries (most commonly subclavian vessels)
    

• Distal fractures: Consider acromioclavicular separation.
  
• Medial fractures: Consider sternoclavicular separation.
  
• Shoulder fracture–dislocation
  

TREATMENT

• Ice packs to affected area
  
• Pain management using either narcotics or NSAIDs
  
• Immobilize affected side in a sling.
  

Airway management and resuscitate as indicated

• Open fracture: Uncommon occurrence, but usually requires open débridement and internal fixation (obtain immediate orthopedic referral)
  
• Closed fracture: If severely displaced, attempt closed reduction and immobilize depending on type of fracture:
  
  • Middle 3rd:
    
    • If nondisplaced, a sling or shoulder immobilizer is enough to provide support.
      
    • Controversy exists as to whether closed reduction is necessary because the alignment is rarely maintained regardless of splinting technique.
      
    • To perform a closed reduction, 1% lidocaine should be injected into the fracture hematoma. The shoulders are pulled upward, outward, and backward, and the fracture is then manipulated into place.
      
    • Sedation may be given to alleviate pain or anxiety.
      
    • A figure-of-eight splint or shoulder immobilizer is then applied.
      
    • Ice should be applied for the 1st 24 hr.
      
    • Analgesia (narcotics or NSAIDs) for pain
      
  • Distal 3rd type I:
    
    • Ice for the 1st 24 hr.
      
    • Immobilization with a sling or shoulder immobilizer
      
    • Orthopedic referral
      
    • Analgesia (narcotics or NSAIDs) for pain
      
    • Early range of motion
      
  • Distal 3rd type II:
    
    • Ice for the 1st 24 hr.
      
    • Immobilization with a sling or shoulder immobilizer
      
    • Orthopedic referral (may require operative repair)
      
    • Analgesia (narcotics or NSAIDs) for pain
      
  • Distal 3rd type III: Same as type II
    
  • Medial (proximal) 3rd:
    
    • Ice for the 1st 24 hr.
      
    • Immobilization in a sling or shoulder immobilizer for support
      
    • Analgesia (narcotics or NSAIDs) for pain
      
    • Orthopedic follow-up
      
• Reassess neurovascular status after all splints are applied.
  

• Children who do not cooperate with the figure-of-eight splint should be referred to an orthopedic surgeon for possible shoulder spica placement.
  
• Most children will tolerate a shoulder immobilizer best.
  

• Acetaminophen: 650 mg to 1000 mg (peds: 10--15 mg/kg) PO q6h prn. Do not exceed 3 g/24 hr
  
• Ibuprofen: 600–800 mg PO q6h PRN with meals (peds: 10 mg/kg PO q6h PRN)
  
• Adults: Hydrocodone/Acetaminophen 5 mg/325 mg one to two tablets PO q6h prn. Do not exceed 3 g/24 hr of acetaminophen. Avoid concomittant use of acetaminophen-containing medications
  
• Hydrocodone, oxycodone, and codeine-containing medications should be avoided in pediatric patients