141.A 71-year-old man is found lying on the ground one story below the
balcony of his apartment. Paramedics bring the patient into the ED. He is
cool to touch with a core body temperature of 96°F. His HR is 119 beats per
minute and BP is 90/70 mm Hg. His eyes are closed but they open when
you call his name. His limbs move to stimuli and he answers your ques-
tions but is confused. On examination, you note clear fluid dripping from
his left ear canal and an area of ecchymosis around the mastoid bone.
Which of the following is the most likely diagnosis?
a. LeFort fracture
b. Basilar skull fracture
c. Otitis interna
d. Otitis externa
e. Tripod fracture
142.A 34-year-old construction worker is brought to the ED by EMS after
falling 30 ft from a scaffold. His vital signs are HR 124 beats per minute, BP
80/40 mm Hg, and oxygen saturation 93% on 100% oxygen. He has obvi-
ous head trauma with a scalp laceration overlying a skull fracture on his
occiput. He does not speak when asked his name, his respirations are poor
and you hear gurgling with each attempted breath. Auscultation of the chest
reveals diminished breath sounds on the right. There is no jugular venous
distension (JVD) or anterior chest wall crepitus. His pelvis is unstable with
movement laterally to medially and you note blood at the urethral meatus.
His right leg is grossly deformed at the knee and there is an obvious fracture
of his left arm. Which of the following is the most appropriate next step in
management?
a. Insert a 32F chest tube into the right thoracic cavity.
b. Perform a DPL to rule out intra-abdominal hemorrhage.
c. Create two Burr holes into the cranial vault to treat a potential epidural
hematoma.
d. Immediately reduce the extremity injuries and place in a splint until the patient
is stabilized.
e. Plan for endotracheal intubation of the airway with in-line stabilization of the
cervical spine.
136 Emergency Medicine