Rosen & Barkin's 5-Minute Emergency Medicine Consult (29 page)

• Open injury
  
• Types IV, V, and VI require admission for operative repair
  

• Types I and II can be discharged with orthopedic referral
  
• Type III should have urgent orthopedic referral
  

• Type I and II: Orthopedic follow-up within 2–4 wk
  
• Type III: Early (within 72 hr) orthopedic follow-up
  
• Type IV–VI: Immediate orthopedic referral
  
• All pediatric injuries should have prompt orthopedic follow-up, with Type IV–VI injuries requiring immediate referral
  

• Type I and II AC injuries:
  
  • No increase in CC space
    
  • Conservative management with rest, ice, sling, and ROM/strength exercises
    
• Type III injuries:
  
  • 100% superior displacement of distal clavicle
    
  • Management somewhat controversial
    
  • Require early orthopedic follow-up
    
• Type IV–VI injuries:
  
  • Identical ligamentous and muscular injuries to Type III
    
  • Difference according to position of distal clavicle
    
  • Operative management is standard of care
    

• Bossart PJ, Joyce SM, Manaster BJ, et al. Lack of efficacy of weighted radiographs in diagnosing acute acromioclavicular separation.
  Ann Emerg Med
  . 1988;17:47–51.
  
• Bussieres AE, Peterson C, Taylor JA. Diagnostic imaging guideline for musculoskeletal complaints in adults – an evidence-based approach-part 2: upper extremity disorders.
  J Manipulative Physiol Ther.
  2008;31(1):2–32.
  
• Hegedus EJ, Goode A, Campbell S, et al. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests.
  Br J Sports Med
  . 2008;42:80–92.
  
• Mazzocca AD, Arciero RA, Bicos J. Evaluation and treatment of acromioclavicular joint injuries.
  Am J Sports Med
  . 2007;35(2):316–329.
  
• Simovitch R, Sanders B, Ozbaydar M, et al. Acromioclavicular joint injuries: Diagnosis and Management.
  J Am Acad Ortho Surg
  . 2009;17:207–219.
  
• Tamaoki MJS, Belloti JC, Lenza M, et al. Surgical versus conservative interventions for treating acromioclavicular dislocation of the shoulder in adults.
  Cochrane Database of Sys Rev.
  2010;(8):CD007429.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Clavicle Fracture
  
• Shoulder Dislocation
  
• Sternoclavicular Joint Injury
  

CODES

• 831.04 Closed dislocation of acromioclavicular (joint)
  
• 840.0 Acromioclavicular (joint) (ligament) sprain
  
• 840.8 Sprains and strains of other specified sites of shoulder and upper arm
  

BASICS

• Chest discomfort, due to imbalance of myocardial blood supply and oxygen requirements
  
• Canadian Cardiovascular Society classification for angina:
  
  • Class I: No angina with ordinary physical activity
    
  • Class II: Slight limitation of normal activity with angina occurring with walking, climbing stairs, or emotional stress
    
  • Class III: Severe limitation of ordinary physical activity with angina when walking 1–2 blocks on level surface or climbing 1 flight of stairs
    
  • Class IV: Inability to carry on any physical activity without discomfort or angina symptoms occur at rest
    
• Typically categorized as either stable or unstable
  
• Stable angina: Predictable, with exertion, and improves with rest
  
• Unstable angina (UA):
  
  • New onset
    
  • Increase in frequency, duration or lower threshold for symptoms
    
  • At rest
    
• UA associated with increased risk of transmural myocardial infarction and cardiac death
  

• Cardiac risk factors:
  
  • Age
    
  • Men >35 yr
    
  • Postmenopausal in women
    
  • Hypercholesterolemia
    
  • DM
    
  • HTN
    
  • Smoking
    
• Atherosclerotic narrowing of coronary vessels
  
  • Stable angina: Chronic and leads to imbalance of blood flow during exertion
    
  • UA: Acute disruption of plaque which can lead to worsening symptoms with exertion or at rest
    
• Vasospasm: Prinzmetal angina, drug related (cocaine, amphetamines)
  
• Microvascular angina or abnormal relaxation of vessels if diffuse vascular disease
  
• Arteritis: Lupus, Takayasu disease, Kawasaki disease, rheumatoid arthritis
  
• Anemia
  
• Hyperbarism, carboxyhemoglobin elevation
  
• Abnormal structure of coronaries: Radiation, aneurysm, ectasia
  

DIAGNOSIS

• Chest pain:
  
  • Substernal pressure, heaviness, tightness, burning or squeezing
    
  • Radiates to neck, jaw, left shoulder, or arm
    
• Poorly localized, visceral pain
  
• Anginal equivalents include:
  
  • Dyspnea
    
  • Epigastric discomfort
    
  • Weakness
    
  • Diaphoresis
    
  • Nausea/vomiting
    
  • Abdominal pain
    
  • Syncope
    
• Symptoms usually reproduced by exertion, eating, cold exposure, emotional stress
  
• Symptoms not usually positional or pleuritic
  
• Usually relieved with rest or nitroglycerin
  
  • Relief with nitroglycerin in nondiagnostic
    
• Lasts more than a few minutes but <20 min
  
• Considered stable angina if no changes in pattern of frequency of symptoms
  

• Women, diabetics, ethnic minorities, and those >65 yr often present with atypical symptoms
  
• Prognosis is worse for people with atypical symptoms
  

• “Levine Sign”: Clenched fist over chest, classic finding
  
• BP often elevated during symptoms
  
• Physical exam often uninformative
  
  • occasional S3/S4,
    
  • mitral regurgitation or new murmur (papillary muscle dysfunction)
    
  • diminished peripheral pulses
    

ECG:

• Standard 12 lead
  
  • Ideally should be obtained and read within 10 min of presentation for patients with acute chest pain
    
• Mostly helpful in detecting acute MI, less so UA
  
• Compare to prior ECG if available
  
  • If normal or unchanged, serial ECGs every 10–30 min
    
• New ST changes or T-wave inversion suspicious for UA
  
  • T-wave flattening or biphasic T-waves
    
  • ≤1 mm ST depression 80 msec from the J point, is characteristic in UA
    
  • Can see evidence of old ischemia, strain or infarct, such as old TWI, Q-wave, ST depression
    
  • Single ECG for acute MI is about 60% sensitive and 90% specific
    
• ECG can also be helpful to diagnose other causes of chest pain
  
  • Pericarditis: Diffuse ST elevations, then TW inversions and pulse rate depression
    
  • Pulmonary embolus S1Q3T3 pattern, unexplained tachycardia and signs of right heart strain
    

• For stable angina, cardiac enzymes not indicated, but if history suspicious for acute MI, should obtain.
  
• CK-MB and troponin I or T
  
  • <50% of patient with UA will have low level troponin elevations
    
  • CK-MB peaks 12–24 hr, return to baseline in 2–3 days
    
  • Troponin peaks in 12 hr, return to baseline 7–10 days
    
• Hematocrit (anemia increases risk of ischemia)
  
• Coagulation profile
  
• Electrolytes, especially Cr and K+
  

• CXR:
  
  • Usually nonrevealing
    
  • May show cardiomegaly, or pulmonary edema, CHF suggests UA or MI
    
  • May be helpful in identifying other etiologies such as pneumonia, pneumothorax, or aortic dissection
    
• Coronary CTA:
  
  • Good for low-risk patients with no known CAD to rule out ischemia as cause of pain in patient if no coronary stenosis
    
  • “Triple rule-out” for ACS, PE, and aortic dissection
    
• Bedside echo: To detect wall motion abnormalities and other etiologies of shock, pericardial effusion, pneumothorax
  
• Technetium Tc-99 sestamibi (rest): Radionucleotide whose uptake by myocardium is dependent on perfusion