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Which physical exam finding is most suggestive of a LeFort facial fracture?
A) CSF rhinorrhea
B) Infraorbital anesthesia
C) Limited upward gaze
D) Mobility of the mandible

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Thermal Burns

This pearl by special request of one Dr. Scofi

Basic thermal burn management:  COOL, ANALGESIA, CLEANSE, TETANUS as needed

1st degree (sunburn or sunburn like; epidermal only) – supportive care, cool under cold running water (no ice directly on burn), analgesia with aloe, NSAIDs are usually sufficient.  these burns usually heal within 1 week.

2nd degree (blisters, partial thickness; epidermal/superficial-partially through dermis) – supportive care, cool under running water, analgesia may require higher doses or stronger medications or opioids, clean with gentle soap/water.

you may consider debriding these blisters if they are very large, obviously contaminated, or over joints, use your clinical judgement to determine if the blister will cause more discomfort unless you debride it.  small blisters or bullae should be left intact as the skin layer forms a barrier from infection.

in terms of dressing these burns, use silvudene (do not use on face because of risk of scarring), or bacitracin (good for face) or a triple antibiotic is just as effective, cover with your choice of gauze, xeroform, tegaderm.  other more expensive/specific dressings exist but are not necessary

these usually heal in 2-8 weeks (depending on if they are superficial or deep 2nd degree)


3rd degree (full thickness, painless; epidermis/dermis all layer) or 4th degree (full thickness, painless; epidermis/dermis/underlying structures – muscles/nerves etc.)- clean, cool, these patients may require escharotomy so be sure to monitor for compartment syndrome, particularly in circumferential burns, these patients are usually admitted to the hospital or a burn center, and ultimately require excision



ABA Classification




Partial thickness>25% BSA age 10-50y

Partial thickness>20% BSA, age <10y or >50 y

Full thickness>10% BSA, any age

Burns involving hands, face, feet, perineum

Burns crossing major joints

Circumferential burns of an extremity

Burns complicated by inhalation injury

Electrical burns

Burns complicated by fracture or other trauma

Burns in high-risk patients

Burn Center


Partial thickness 15-25% BSA, age 10-50y

Partial thickness 10-20% BSA, age<10y or >50y

Full thickness burns <10% BSA, any age

Admission to hospital


Partial thickness <15% BSA, age 10-50y

Partial thickness<10% BSA, age <10y or >50y

Full thickness <2% anyone



Schwartz LR, Balakrishnan C. Thermal Burns. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study GuideNew York, NY: McGraw-Hill; 2011.http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=693&Sectionid=45915557. Accessed September 29, 2014

Rosen’s Emergency Medicine: Concepts and Clinical Practice.  8th ed.  Marx, John A.; Hockberger, Robert S., et al.; Rosen, Peter. (2013)


Pinpoint Pupils

Which of the following does not cause miosis?

a) Clonidine

b) Pilocarpine

c) Scopolamine

d) Pontine bleed

e) Edrophonium

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77-year-old woman, immobile due to advanced rheumatoid arthritis, presented to the emergency department with a 3-day course of a progressively painful and purple left lower extremity. Examination reveals stable vital signs, weak pulses in a very tender LLE, and the leg appears as the image below:

Image not available.


Doppler ultrasound shows extensive clot in the iliofemoral vein.


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Baby Belly Badness

Thank you to Dr. Vazquez for this case.

You are working in the peds ED, a full term 3 day old presents with bilious vomiting after each feed x 1 day associated with increasing abdominal distension.  No pertinent birth or maternal history.  Also noted to have mild jaundice from head to toe.  Per mother patient is having normal wet diapers, no fevers, passed 2 meconium stools after birth but has not had a bowel movement in 24hrs.    Normal activity.


VS: 140, 100/60, 36, 100% RA

Gen: NAD, well appearing, active

HEENT: mild scleral icterus, mucous membranes moist, TMs wnl b/l

CVS: RRR no m/r/g

Resp: CTAB, normal effort, no retractions

Abd: normal bowel sounds, distended, tympanitic, patient cries on palpation diffusely, no hepatosplenomegaly

Ext: warm, well perfused, normal cap refill

DRE: no stool in the vault, however, when you remove your finger, patient has explosive gas and stool.



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