Clinical Presentation and Diagnosis

There is often a history of dental disease or recent dental work. Symptoms include odynophagia and pain to the floor of the mouth and anterior neck. Difficulty swallowing and speaking occur because of tongue displacement. Examination reveals an indurated edema of the floor of the mouth and anterior neck. Serosanguinous discharge is present but there is usually no frank pus or fluctuance. When significant edema is present, the tongue will be elevated and posteriorly displaced. Drooling, muffled...

Computed Tomography Emergency Department Applications

Computed Tomography (CT) of the Head CT scanning has replaced most other modalities of imaging in the acute evaluation of neurologic injury or disease. No longer are we taught to look for pineal gland calcification on skull film as a way of detecting midline shift, nor do we order plain skull films to identify skull fractures, when what we are really concerned about is underlying brain injury. (Although there may still be a role for skull films in selected cases.) As CT technology has evolved,...

Table 171 Common medical causes of psychiatric symptoms

Hemorrhage Tachycardia Thyroid disease Seizure disorder with medication toxicity Sepsis Hallucinations, delirium tremens, paranoia, agitation, confusion, anxiety, delusions, psychosis Confusion, mood or perceptual disturbances, hallucinations, depression, personality changes, mania, panic attacks, amnesia ALOC, disorientation, olfactory and gustatory hallucinations, psychotic behavior, personality changes. ALOC, agitation, anxiety, confusion, belligerence, fatigue Euphoria, depression,...

Nonketotic Hyperosmolar Syndrome

Nonketotic hyperosmolar syndrome (NKHS) consists of hyperglycemia, hyperosmolarity, severe dehydration and altered mental status without significant ketosis or acidosis. NKHS typically occurs in the elderly type II diabetic although about half of the patients have no known prior history of diabetes. It may also occur in children (rare) and nondiabetics in special circumstances. The classic scenario is that of an elderly, type II diabetic who encounters a stressful event. As with DKA, the...

Urinary Tract Infections

Urinary tract infections (UTIs) pose particular problems in diagnosis and management. Infants present with varied symptomatology not always related to the urinary tract. Also, the significance of the infection and necessary work up will vary depending on age and sex. Urinary tract infections can range from being asymptomatic to causing systemic disease associated with pyelonephritis. The morbidity associated with UTI can be significant. Febrile UTIs reveal pyelonephritis, which can be detected...

Male Genital Problems

The incidence of torsion of the testis is 1 per 4000 males. While it may occur at any age, it is most common during puberty and the second decade of life. Testes that are predisposed to torsion have an anatomic abnormality, where the tunica vaginalis attaches high (above the epididymis) rather than attaching to the posterior aspect of the testis. This abnormality is referred to as the bell clapper deformity, and is usually bilateral and allows the testicles to rotate within the tunica...

Characteristic and Common Rashes with Fever

There are distinct and classic patterns of rashes of which the emergency physician should be aware. Familiarity with the classic presentations of rashes in children will allow for the prompt recognition and treatment of many commonly seen conditions in the emergency department. Regrettably, many rashes look alike. Fortunately, many rashes require the same treatment i.e., antipyretics . This section will review some commonly seen rashes in children and those with distinct clinical patterns or...

Info

Scapholunate Dissociation

Triquetrum fracture Pisiform fracture Perilunate dislocation Lunate dislocation Dorsal wrist pain after or on hyperextension Dorsal wrist pain postor on hyperextension Direct trauma to dorsum of wrist or hyperextension Direct trauma to base of hypothenar with hypothenar tenderness Similar to perilunate but typically more force Forced hyperextension of wrist, clicking with wrist motion Tenderness with longitudinal thumb compression, Snuff box tenderness Tenderness to dorsal wrist palpation with...

Deferoxamine Challenge Test

This test is sometimes performed in cases where toxicity is not clear and laboratory results are still pending 1st 6 h . The patient is given deferoxamine 50 mg kg up to 1 g IM, and all the urine is collected. If the urine turns a vin rose color, the test is positive and chelation is continued intravenously. However it is important to note that the urine color change is an insensitive marker and that a negative challenge test does not rule out the presence of iron toxicity. For that reason,...

Table 4D4 Empiric antimicrobial therapy for meningitis

Penetrating head injury, CSF leak CSF shunt infection Immunosuppressed host Suspected HSV 2 meningitis Ampicillin Ceftriaxone Vancomycin or Ampicillin Cefotaxime Vancomycin Peds Vancomycin Cefotaxime or Vancomycin Ceftriaxone Adults Vancomycin Rifampin Ampicillin Ceftazidime Vancomycin Acyclovir Specific Treatment Meningitis Glucocorticoids, based on studies in children with predominantly H. influenzae type b meningitis, have been shown to reduce the morbidity associated with an inflammatory...

Endocrine and Electrolyte Emergencies

Diabetic ketoacidosis DKA is a syndrome of hyperglycemia, acidosis, dehydration, and electrolyte depletion caused by a relative or absolute deficiency of insulin in the setting of increased stress counter-regulatory hormones. It usually occurs in type I diabetics but may also occur in type II diabetics associated with major concurrent illness, which alters the balance between insulin and counter-regulatory hormones. In either case the end result is uncontrolled catabolism. DKA can be...

Table 62 Differential diagnosis of renal colic

May have similar clinical presentation, with gross or microscopic hematuria More likely in older males May present with hypotension Palpate for pulsatile abdominal mass with focal tenderness Listen for bruit Palpate distant extremity pulses Mild to severe flank pain, although typically not as acute as renal colic More prolonged prodrome, with fever Urinalysis shows pyuria and bacteruria CAUTION renal obstruction with pyelonephritis is a urologic emergency requiring prompt consultation Secondary...

Specific Treatment

Intravenous Thrombolytics IV rt-PA In the NINDS rt-PA stroke study, patients treated with rt-PA within 3 h of symptom onset were at least 30 more likely than patients given placebo to have minimal or no disability at 3 mo on various clinical scales. However, 6.4 of patients in the treatment arm had a symptomatic ICH within 36 h of stroke onset, compared with 0.6 of patients given placebo. Mortality was similar in both groups. Based on these results, the FDA approved the use of IV rt-PA in...

Table 4D3 Etiology of CNS abscess

Local or remote infection Sinuses, teeth Otitis media, pulmonary infection Endocarditis Other sources Neurosurgical procedure, penetrating head injury Enterobacteriaceae, Nocardia rarely S. aureus, Enterobacteriaceae Other important historical factors include Duration of symptoms a fulminant course indicates a bacterial meningitis or aggressive viral encephalitis, while a subacute presentation suggests a viral, fungal, or parasitic infection. Antecedent infection recent otitis media, sinusitis,...

Table 4A1 Primary headache treatment options

Acetaminophen 325 mg tablets, up to 6 PO Ibuprofen 200 mg tablets, 1-4 PO Naproxen sodium 275 mg tablets, 2-3 PO at onset may repeat 1-2 tabs in 2 h Ketorolac 15-30 mg IV IM Sumatriptan 6 mg SQ may repeat in 1 h maximum 2 doses day Prochlorperazine 5-10 mg slow IV push may be repeated in 30-60 min Metoclopramide 10 mg PO IM IV Promethazine Peds 0.25 mg kg 6-9 yr, max 25 mg DHE 0.5-1 mg IV IM may repeat in 1 h, up to 3 doses in 24 h Pediatric dosing 0.1-0.15 mg IM 6-9 yr 0.2 mg IM 9-12 yr...

Part A Hypertension and Hypertensive Emergencies

Hypertension is one of the most common conditions affecting patients in developed countries. As the population ages and the emergency department continues to serve populations without access to appropriate primary care, issues regarding hypertension will become more important. Emergency Physicians must be comfortable in evaluating and treating patients with conditions associated with an acute rise in blood pressure, conditions secondary to long-standing hypertension, as well as with the...

Assistant Editors

Division of Pediatric Emergency Medicine Department of Emergency Medicine Loma Linda University Medical Center and Children's Hospital Loma Linda, California, U.S.A. Email lbrownmd aol.com Chapter 22 Department of Emergency Medicine Keck School of Medicine University of Southern California Los Angeles, California, U.S.A. Email greenspanj adelphia.net Chapter 2 Department of Emergency Medicine Keck School of Medicine University of Southern California Los Angeles, California, U.S.A. Email swadron...

Table 3D4 Radiographic presentation of pneumonia

Klebsiella pneumoniae classically RUL, bulging fissure Pneumocystis carinii Tuberculosis and other fungi Staphylococcus aureus Streptococcus pneumoniae Staphylococcus aureus Mycoplasma pneumoniae Viruses Tuberculosis Tuberculosis Klebsiella pneumoniae receive IV antibiotics and outpatients appropriate oral therapy as indicated for their age, comorbid conditions, and suspected pathogen see Table 3D.6 . All discharged patients should follow-up with their primary care physician. 1. Feldman CF....