Is cervical spine X-ray necessary if there is a distracting injury?

Clinical Scenario
 A 40 yo lady arrives in ED by ambulance with neck and spinal immobilization because she fell down a staircare.

 The patient’s vital signs are within normal physiological parameters, she is alert, no deficit, remembers all, denies head contusion and neck pain. She complains for a sharp shoulder pain (NRS 10/10), it seems broken.

If I perform the Nexus C-Spine criteria  X Ray is indicated: a distracting injury mandates cervical spine imaging.

How much the presence of distracting injury reduces my sensibility in rule out cervical spine (c-spine) injury?

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Cellulitis and the role of laboratory

Clinical Scenario

A 72 y/o woman presented to the ED for swollen and painful leg.

Physical examination shows an erythematous, tender and warm leg. 

Probably it is a cellulitis. 

In previous post we stressed the US use to increase diagnostic accuracy. 

Can WBC or CPR help in the differential diagnoses?  

Do they have a role in the decision to admit the patient to the Hospital?  

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Goodbye nasogastric lavage!

Clinical Scenario

A 84 yo woman arrives in ED in midnight coming from a nursing because of a reported episode of coffee ground vomiting. 

Respiratory rate, heart rate and blood pressure are normal, abdomen is not distended, hemoglobin level is 10 g/dl. On rectal examination you find normal stool. 

She takes warfarin. 

Can a nasogasric lavage (NGL) contribute to rule out an upper gastrointestinal bleeding (UGB)? 

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Can Ultrasound rule out a pneumothorax?

Clinical Scenario

You are allerted for a level 3 trauma from the mountain, a cyclist has fallen going down hill.

You prepar the shock room with everything you may need, dress up, and wait.

A 25 y/o cyclist arrives completely immobilized, you immidiately start to  perform ABCDE as you learned in your recent ATLS course (you feel confident).

First stop is a possible problem in “B” (breathing): he has an ecchimosis on the right emithorax, not crepitation, maybe there is a less vescicular murmur on the same side, but you are not sure (the shock room is very crowded an noisy!), he is slightely tachypnoic (RR is 24), O2 saturation is 96%. …you go on….in “E” (Exposure) you find an exposed, bleeding, thigh bone fracture that surly is going to need surgery, at the moment you stop the bleeding, stabilize, allert orthopedic…ect…

FAST is normal. You ask for X-Ray : anteroposterior (AP) chest x-ray, pelvis and thigh bone. Confirmed exposed fracture, no signs of pneumothorax, surgery room is ready…

You recently have reeded the previous post and you don't feel confident about a negative thorax x ray, so you decide to “extend” your FAST and on the right emithorax you find a "lung point"...

are you going to let this patient be intubated?

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Thoracic trauma and chest X-Ray

Clinical Scenario

You are alerted for a level 3 trauma coming from the mountain, a cyclist has fallen going down hill.

You prepare the shock room with everything you may need, dress up, and wait.

A 25 y/o cyclist arrives completely immobilized, you immediately start to  perform ABCDE as you learned in your recent ATLS course (...you feel confident).

First stop is a possible problem in “B” (breathing): he has an ecchimosis on the right emithorax, not crepitation, maybe there is a less vescicular murmur on the same side, but you are not sure (the shock room is very crowded an noisy!), he is slightely tachypnoic (RR is 24), O2 saturation is 96%. …you go on….in “E” (Exposure) you find an exposed, bleeding, thigh bone fracture that surly is going to need surgery, at the moment you stop the bleeding, stabilize, allert orthopedic…ect…

FAST is normal. You ask for X-Ray: anteroposterior (AP) chest x-ray, pelvis and thigh bone. Radiologist confirms exposed fracture, no signs of pneumothorax, surgery room is ready...

…Do you still feel confident?

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Chest X-Ray and aortic dissection

Clinical Scenario 

A 70 yo man come to the ED for restrosternal chest pain and shortness of breath during minimal activity in the last days. He is an ex smoker, with a history of hypertension. On physical examination the patient is not in distress, with a regular blood pressure and regular oximetry. ECG shows no evidence of ischemia. You first think about coronary artery disease, but you also want to exclude an aortic dissection. In Radiology the patient remaine seated and receive an anteroposterior (AP) chest Xray: maximal mediastinal width (MW) is 8,80 cm (the optimal cutoff level is 8,65 cm), no other signs. 

Shall you worry?

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Is CRP correlated to CT result in the evaluation of abdominal pain?

A 74 yo/man complained of diffuse abdominal pain. The pain was intermittent and accompained by vomiting. He has no history of abdominal pain or abdominal surgery.

On examinations the patient presented non icteric, afebrile, not tachicardic. 

The abdomen was mildly distensed with midline tenderness. 

The US evidenced a normal aorta diameter. 

Abdominal x ray showed non specific bowel gas pattern. 

CRP value was 7 mg/L.

The radiologist says it is a little value to perform an abdominal CT, we see tomorrow…..

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