EM Quick Hits 30 Scaphoid Fracture, Therapeutic Hypothermia, HEADS-ED, Pelvic Trauma, Kratom, Femoral Lines

Topics in this EM Quick Hits podcast Arun Sayal on nuances for assessment of scaphoid fractures (0:52) Justin Morgenstern on the TTM2 trial and temperature management after cardiac arrest (7:42) Sarah Reid on HEADS-ED screening tool for pediatric mental health (12:48) Andrew Petrosoniak on pelvic binders and fracture tips (18:54) Michelle Klaiman on what you need to know about kratom (24:43) Anand Swaminathan on why femoral lines have made a come back and procedural tips (30:09) Podcast production, editing and sound design by Anton Helman Podcast content, written summary & blog post by Raymond Cho & Anton Helman Cite this podcast as: Helman, A. Sayal, A. Swaminathan, A. Klaiman, M. Reid, S. Petrosoniak, A, Morgenstern J. EM Quick Hits 30 - Scaphoid Fracture, Therapeutic Hypothermia, HEADS-ED, Pelvic Trauma, Kratom, Femoral Lines. Emergency Medicine Cases. July, 2021. https://emergencymedicinecases.com/em-quick-hits-july-2021/. Accessed [date] Scaphoid fractures: nuances of assessment Epidemiology is important for pre-test probability assessment * carpal injuries represent 20% of wrist injuries in the ED, of which 70% are scaphoid fractures * Less likely in children < 15-years-old and adults > 50-years-old * 20-30% of fractures are occult on initial X-rays Diagnostic usefulness of the 3 physical exam maneuvers for scaphoid fractures * Snuff box tenderness * Poor specificity: many patients have physiologic snuff box tenderness at baseline; tip - palpate for asymmetric snuff box tenderness (i.e. check the contralateral wrist) * Examination should be done with the wrist in ulnar deviation to expose the scaphoid Palpate the snuffbox with the wrist in ulnar deviation to expose the scaphoid bone and compare to the contralateral wrist * Palmar scaphoid palpation -  tenderness at base of the thenar eminence over the palpable scaphoid tubercle with the wrist in radial deviation Palmar location of scaphoid bone brought out by putting the wrist in radial deviation * Axial thumb loading of 1st metacarpal to compress the scaphoid is less specific in elderly as a positive test is more likely indicative of CMC osteoarthritis rather than scaphoid fracture * 3 of 3 portends a 70-90% likelihood of a scaphoid fracture (30-50% likelihood if 1/3). * Consider adding dedicated scaphoid view if any one of the 3 exam maneuvers are positive * Clamp sign has a pooled +LR of 8.6 for a scaphoid fracture. Ask the patient exactly where it hurts the most. If they place their thumb and index finger like a clamp on the volar and dorsal aspects of the base of the thumb, they have a positive Clamp Sign The Clamp Sign has high positive likelihood ratio for the diagnosis of scaphoid fracture. Ask the patient to show you where the pain is the greatest. Grasping their scaphoid with their thumb and index finger is a positive Clamp Sign. Ep 190 Carpal Bone Injuries – The Big 4 Episode 1: Occult Fractures and Dislocations