obstacle race injuries

22 Apr

Interesting article in the March Annals, cases series of a few folks after a Tough Mudder in a Pennsylvania ED:

some highlights from the interesting unique cases:

18 yo M with chest discomfort after electrical shocks in the last obstacle; troponins rose to 23 by the 3rd TnI; diagnosed with myocarditis 2/2 electrical shock

a few syncope/seizure types, with diagnoses ranging from possible pericarditis, electrolyte imbalance (Na+ 127), MCA/PCA strokes, dehydration/rhabdo.

overall, 38 ED patients/22,000 participants (over 100 activated EMS, but many treated & refused transport); an overview of injury types

  • fractures
  • dislocations
  • effusions
  • heat injury
  • electrical injury
  • seizure
  • contusions/abrasions/lacs
  • dehydration
  • sprains/strains

SHOCK OBSTACLE (“Electroshock Therapy”, “Electric Eel”)

interesting notes about the rare folks who came in after this

  • tough to correlate causality, given they just went through an exhausting course before the last obstacle
  • website states as much as 10k vols (for reference, some tazers deliver 50k volts)
  • folks are wet (sweat, other obstacles)
  • troponin elevations have been documented in competitive exercise alone (e.g. marathons)


Please be careful at your next race, and keep an open mind with your next post-race patient.

References: annals article; picture

sweet smells, less pain

21 Apr

 Neat tip in April’s ACEP Now mag by Dr. Mell:


sweet-smelling  (e.g. cherry/blueberry/watermelon) lip balm coated the inside of a pediatric non-rebreather mask

letting patients pick the flavor gives them some small measure of control

some studies suggest sweet/pleasant odors may improve pain tolerance

works with oral solutions, seems like odors might work, too.

add it to the toolbox.

References: ACEP Now article; less pain with odors; less pain with sweets; picture.



quick H2-blocker reference

17 Apr

quick-reference chart put together for your use in a pinch.  I frequently found myself double-checking some of the generic/trade name crossover, and the IV/PO first-dosing at times, so figured this might be helpful for others as well.  Here it is, as a chart and photo.




Generic Name Cimetidine Ranitidine Famotidine Nizatidine
Brand Name Tagamet Zantac Pepcid Axid
equivalent dosing (left-to-right)
PO (avg dose) 400mg 150mg 20mg 150mg
PO (big dose) 800mg 300mg 40mg 300mg
IV 300mg IV 50mg IV 20mg IV


References: UIC pharm referencegihealth patient education site

Special Skills for Reducing Distal Radius Fractures, Part II: Finger Traps.

15 Apr


Colles’ Fractures, wrist fractures with dorsal and lateral dislocation of the radius, often have an element of
radial shortening”. This refers to the length of the radius comparing the carpal articular surface of the ulna and the lunate fossa of the radius.

If the radius is proximal to a line drawn across the end of the ulna the radius is shortened (yellow arrow).  


What to do????wrist2


Finger traps are meant to elongate a shortnened radius.





  • Place the patient supine, with the HOB flatwrist3
  • Flex the elbow to 90 degrees
  • The goal is to achieve radial tilt, so include no more than the first three digits (1&2 or 1-3)
  • Hang 15lb weight from the upper arm (distal humerus)
  • Adequate fracture reduction is considered with

o   <2mm articular step off

o   <20 degree of volar angulation

o   <3mm radial shortening


References: Text & Picture 1-2 ERcast.org; Picture 3


Submitted by K Estes.

Special Skills for Reducing Distal Radius Fractures, Part I: Hematoma Block.

14 Apr

A Colles’ fracture is the most common type of wrist fracture; located at the distal radius with the lower rads1radial fragment dislocated dorsally and laterally


Indications: clean, closed fracture site



  • Prepare skin with clorhexadine or betadine
  • Prepare 5-10cc lidocaine (1-2% without epi)
  • Inject the needle into the fracture site, aspirate, and observe flash back of blood
  • Reinject with aspirated fluid a few times


Adequate anesthesia occurs in 5-10 minutes and lasts for several hours.


Consider using the hematoma block for your other orthopedic procedures such as ankle dislocation, phalanx fracture or dislocation.


References: Text & Picture 1-Roberts & Hedges; Picture 2- Managing Colles’ Fractures in Rural Practice. Canadian Journal of Rural Medicine. 1998. Vol 3 (1):20-25.


Submitted by K Estes.

Skin Complaints in the Returning Traveler

11 Apr

Typically caused by:

-exacerbations of pre-existing disease (atopic dermatitis, psoriasis, etc.)

-environmental conditions (photosensitivity, contact allergies, etc.)

-infective organisms


Most rashes are minor problems such as sunburn and insect bites, and are self-limiting requiring only symptomatic care.


Top 10 tropical travel dermatoses requiring specific therapy:

-cutaneous larva migrans

-pyodermas (due to staph or strep)

-arthropod-reactive dermatoses

-myiasis (infection with a fly larva)

-tungiasis (infestation by burrowing flea)


-febrile syndromes with rash

-cutaneous leishmaniasis


-fungal infections


rash1Elevated, serpiginous, reddish-brown lesion of cutaneous larva migrans.
leishOld world cutaneous leishmaniasis ulcer.


Syndromes to be on the lookout for…

Fever and rash (petechial or hemorrhagic): dengue fever, arboviruses, rickettsial infections (e.g., scrub typhus), meningococcemia, leptospirosis, malaria, and erythema multiforme caused by drug reaction or common infection
Papules: insect bites, persistent lesions (chiggers), scabies, allergic drug reactions, cercarial dermatitis (swimmers), Pseudomonas folliculitis (hot-tubbing), onchocerciasis (long-term travel)
Nodules: furunculosis, myiasis (movement within the lesion), chancroid, syphilis, systemic parasites/fungi
Migratory: cutaneous larva migrans, strongyloidiasis (fast-moving and often on the buttocks), urticaria from various causes, and Loa loa (rarely)
Ulcerative: pyodermas, spider bites, chancroid and syphilis, cutaneous leishmaniasis



-rarely is it necessary to recommend anything more than symptomatic care in the ED

-referral to your local infectious disease or tropical medicine clinic for suspicious or chronic lesions


Submitted by K. Estes.

References: Tintinalli’s Emergency Medicine:  7th Edition; uptodate.com (pictures)

Clavicle Fractures

10 Apr

Classified into 3 groups

  • -medial third (uncommon, ~5%)

o   think about associated pneumothorax or pulmonary injuries

  • -middle third (most common, ~80%)

o   shoulder typically presents downward, forward, and inward due to pull from pectoralis major and latissiumus dorsi on the distal fragment; proximal component pulled upward due to sternocleidomastoid

  • -lateral third (~15%), further classified into subtypes

o   Type I - stable, minimally displaced due to intact coracoclavicular (CC) ligament

o   Type II - torn CC  ligament, tend to displace due to lack of stabilizing force proximally

o   Type III - involve the articular surface



  • immediate orthopedic consultation for
    • open fractures,
    • associated neurovascular injuries (rare; however injury to the subclavian vessels and the brachial plexus is possible),
    • skin tenting (impending open fracture!),
    • interposition of soft tissues 


  • higher incidence of nonunion and more likely to require surgery (think more urgent follow-up)

o   type II lateral clavicle fractures (up to 30% nonunion)

o   severely comminuted or displaced fractures of the middle third (defined as >20mm shortening)


XR showing complete displacement of a middle-third fracture of the left clavicle with marked shortening (over 40mm).


  • most heal uneventfully and can be discharged in a simple sling with outpatient follow-up

o   a sling should be worn until repeat XR shows callus formation and healing across the fracture site

o   early passive range of motion exercises are encouraged to reduce the risk of adhesive capsulitis (“frozen shoulder”)

o   younger children require shorter periods of immobilization (2-4 weeks) than adolescents and adults (4-8 weeks)


Submitted by K. Estes. 


Reference:  Rosen’s Emergency Medicine:  7th Edition, uptodate.com (picture)




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