Hypoglycemia

Hypoglycemia is a life threatening endocrine emergency that, once recognized, is easily treatable. Delay in diagnosis or treatment may lead to irreversible neurologic injury or death. Hypoglycemia is generally defined as a blood glucose level < 50 mg dl in adults children, and < 30 mg dl in neonates. Glucose homeostasis involves a tightly regulated balance between insulin and its counterregulatory hormones (glucagon, epinephrine, cortisol, growth hormone). An excess of insulin or deficiency...

Table 179 Diagnostic criteria for vascular dementia according to WHO

Diagnostic Criteria for Vascular Dementia 1. Dementia of a specified level of severity 2. Unequal distribution of deficits in cognitive function 3. If focal damage is evident it will manifest as one of the following unilateral spastic weakness of limbs, unilateral increased tendon reflexes, an extensor plantar response, and pseudobulbar palsy 4. History, examination, or tests disclose severe cerebrovascular disease which may be judged to be related to the dementia Creutzfeldt-Jakob disease is a...

Part B Asthma

Asthma is a chronic disease characterized by increased airway responsiveness to various stimuli. This causes widespread narrowing of the lower airways that reverses either spontaneously or with treatment. Although the exact pathophysiology of asthma is complex and poorly understood, inflammation is thought to play a central role. Pathologic changes that occur in asthma include smooth muscle hypertrophy, mucosal edema, and mucous plugging. Asthma affects 4-5 of adults and 10 of children. Onset...

Table 142 Etiology of epistaxis

Iatrogenic Surgical procedures, nasal foreign body removal, nasogastric nasotracheal tubes Trauma Nose-picking, fractures, foreign bodies Local irritants Cocaine, nasal sprays, cigarette smoke, toxic gases Inflammatory Rhinitis, sinusitis, granulomatous disease Mass lesions Nasal sinus tumors, carotid artery aneurysm Medications Anti-platelet agents, NSAID's, warfarin, heparin Systemic disease Liver renal failure, DIC, thrombocytopenia Congenital Hemophilia, von Willebrand disease,...

Table 3D 1 Risk factors for pneumonia

Alteration of normal oral flora Immunocompromise Stroke, intubation, seizure, altered mental status, Smoking, alcohol, COPD, cystic fibrosis, chronic bronchitis, viral infections Acute illness and antibiotic use AIDS*, diabetes, transplant, steroid use, asplenia, sickle cell disease, uremia, neoplasia, chemotherapy, extremes of age, complement deficiency Indwelling catheters, intrathoracic devices American southwest (Valley Fever), Ohio MississippiValleys (histoplasmosis, blastomycosis),...

Pharmacology and Pathophysiology

Isoniazid blocks the action of metal-pyridoxine enzyme-substrate complexes producing acute pyridoxine deficiency. Pyridoxine deficiency seizures are believed to be related to blockage of decarboxylation and transaminase reactions involving glutamic acid and Y aminobutyric acid. Isoniazid is rapidly absorbed in the small intestine and is excreted by the kidney with no protein binding. Patients may be either slow acetylators (55 Afro-Americans and Caucasians) or fast acetylators (90 Asians)....

Table 152 Ocular medications commonly used by EPs

Antibiotics Ciprofloxacin (S O) Gentamicin (S O) Sulfacetamide (S O) Tobramycin (S O) Cycloplegics Atropine (5-10 days) (Duration of action) Cyclopentolate (6-24 h) Homatropine (2-3 days) Tropicamide (6 h) Mydriatic (no cycloplegia) Phenylephrine Topical Anesthetics Proparacaine Tetracaine Glaucoma Agents -blockers (i.e., timolol) Cholinergic agents (i.e., Pilocarpine) Carbonic Anhydrase Inhibitors (See text below for other treatment) Antibiotics Specific agents will be discussed in the...

Part B Acute Coronary Syndromes

Coronary artery disease is the most common cause of death in the United States, accounting for approximately 600,000 deaths annually. Of 6.0 million ED visits per year for chest pain, about 1.2 million people are diagnosed with myocardial infarction and another million with unstable angina. It has been estimated that the overall cost of coronary artery disease exceeds 100 billion dollars annually in the U.S. There is also a significant cost in terms of malpractice claims, with missed myocardial...

Table 22B4 Causes of chest pain on children

Idiopathic Disorder Psychogenic, Hyperventilation Musculoskeletal disorder Costochondritis Chest wall syndrome Tietze syndrome Xiphoid cartilage syndrome Stitch Precardial catch syndrome Slipping rib syndrome Breast disorder Gynecomastia Reactive airway disease Pneumothorax Cardiovascular disorder Myocarditis Structural heart disease Dysrhythmia Gastrointestinal disorder Esophogitis Other miscellaneous causes of chest pain in children include breast disorders, vertebral disease, drug use, and...

Factors Promoting Acclimatization Pulmonary

Increase respiratory rate hypoxic ventilatory response (HVR) occurs when the carotid bodies detect decrease pO2 and feeds back to the central respiratory center of the medulla to increase ventilation. The ensuing respiratory alkalosis from hyperventilation will act on the respiratory center to slow respiration. Excess bicarbonate is excreted via the kidneys to maintain homeostasis allowing for an appropriate increase in ventilation. Central chemoreceptors reset to lower pCO2, i.e., inspiration...

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,...

Poorly controlled hypothyroidism Acute precipitant Myxedema Coma

Etiologies of hypothyroidism include primary, secondary, or tertiary causes. Primary hypothyroidism disease of the thyroid gland accounts for 95 of hypothyroidism. Diseases include Hashimoto's thyoiditis most commonly, iatrogenic causes post-radiation, post-surgical, anti-thyroid medications , congenital abnormalities, enzymatic defects, neoplasms, or infections Secondary hypothyroidism disease of the pituitary gland accounts for 4 of hypothyroidism. Diseases include pituitary tumors,...

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,...

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...