Lower Extremity Diseases

Homeless patients have a variety of lower extremity disorders.9 Such patients may spend a disproportionate amount of time with their legs in a dependent position while sleeping upright or ambulating for extended periods. The poverty associated with homelessness may prevent some patients from obtaining adequate or appropriately fitting socks and shoes that are seasonally appropriate. Ulcers and wounds from lack of foot protection, blisters from poorly fitting shoes, or bites from rats or insects...

Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a common complication among children with IDDM, accounting for 14 to 31 percent of all diabetes-related hospital admissions. 67 It is the single most common cause of death in diabetic patients under 24 years of age.7 DKA is considered to be present when there is hyperglycemia (i.e., blood glucose level > 250 mg dL), ketonemia (i.e., ketones > 1 2 dilution of serum), and metabolic acidosis (i.e., pH < 7.2 and plasma bicarbonate 15 meq L)5 accompanied by...

Coping With The Death Of A Child

Both family members and the resuscitation team members will mourn the death of a child. Little attention has been focused on this issue for either the family or the emergency department staff. Several tasks of mourning have been described that must occur for successful resolution of grieving (I bJ.e, 10 6)13 Whether a child dies in the emergency department or after several days of hospitalization does not seem to affect the grieving process. 14 Pathologic grief reactions are often the result of...

Skin And Soft Tissue Infections

Etiology Epidemiology pathophysiology Clinical Features Diagnosis Epidemiology pathophysiology ClinicaLFeatures Diagnosis Epidemiology pathophysiology Clinical , , Features Diagnosis Epidemiology pathophysiology C i,n.ical , , Features Diagnosis This chapter discusses several of the more common skin and soft tissue infections of childhood, including conjunctivitis, impetigo, sinusitis, and cellulitis. Because of its particular severity, orbital periorbital cellulitis will be highlighted in a...

Repair of Eyebrow Lacerations

The eyebrow marks the lowest portion of the forehead. The eyebrows should never be clipped or shaved because their delicate contour and form are valuable landmarks for the meticulous reapproximation of the wound edges. Furthermore, it is unlikely that they will grow back in exactly the same fashion as they had been prior to the injury. If debridement in any hairy area must take place, the scalpel should cut in an angle parallel to the hair follicles to minimize the area of subsequent alopecia.

Medication Related Soft Tissue Abnormalities

Gingival hyperplasia is associated with many commonly used medications (Fig 2.34 -11.). Historically, phenytoin-related gingival hyperplasia has been described. Approximately 50 percent of patients on phenytoin will develop significant gingival hyperplasia. Many other medications are known to cause gingival hyperplasia, such as calcium channel blockers, especially nifedipine, and cyclosporine. Concomitant use of two agents known to cause gingival hyperplasia results in accelerated gingival...

Vitamin B1 Thiamine

Vitamin B-, is converted to thiamine pyrophosphate which acts as a cofactor for several metabolic reactions, including transketolations. Measurement of erythrocyte transketolase activity is used to reflect the availability of thiamine pyrophosphate in the tissues. Food sources of thiamine include fruits, grain, meats, fish, and milk, among others. The highest levels are found in pork products (0.63 mg serving). The average daily adult requirement is 1.5 mg. 1 Intestinal absorption of thiamine...

Defibrillation And Synchronized Cardioversion

Defibrillation and cardioversion is the technique of passing a short burst (about 5 ms) of direct electric current across the thorax to terminate tachyarrhythmias. The electric current simultaneously depolarizes all excitable cardiac tissue and terminates any areas of reentry by halting further propagation of the impulse around the reentry loop. This places all cardiac cells in the same depolarized state, and a dominant pacemaker (usually the sinus node) paces the heart in a regular manner....

Focused Abdominal Sonography for Trauma

Abdominal CT scanning remains an important tool in evaluating trauma, with an accuracy of more than 90 percent in detecting intraabdominal injuries. However, CT is expensive and requires a hemodynamically stable, cooperative patient. It also involves contrast-medium administration and ionizing radiation. Diagnostic peritoneal lavage (DPL) has sensitivities greater than 90 percent for hemoperitoneum. However, up to one-third of laparotomies performed on the basis of positive DPL findings are...

Disaster Medical Assistance Teams

The National Disaster Medical System (NDMS) is a federally coordinated initiative designed to augment the emergency medical response capability of the United States in the event of a catastrophic disaster.69 This system is a cooperative program of four federal government agencies the Department of Defense, the Department of Health and Human Services, FEMA, and the Department of Veterans Affairs. The NdMs provides an interstate medical mutual-aid system linking federal, state, and local agencies...

Inorganic Lead

PHARMACOLOGY Absorption is by the respiratory and gastrointestinal tracts, whereas skin absorption is negligible. Dietary deficiencies in calcium, iron, copper, and zinc may contribute to increased gastrointestinal absorption in children. Absorption also occurs when retained lead bullets or shot are in contact with body fluids such as synovial fluid. Lead can be transferred placentally to the fetus of a mother with an elevated blood lead level, which can be further exacerbated by increased bone...

Scrotum

Because the scrotal skin is loose and elastic, dramatic enlargement of the scrotum may occur secondary to either scrotal or testicular pathologic conditions. SCROTAL EDEMA Simple, isolated scrotal edema is uncommon. It usually occurs secondary to insect or human bites, contact dermatitis, or, in young boys, to idiopathic scrotal edema. Contiguous scrotal and penile edema occurs in older men in conjunction with lower extremity edema in fluid overload states (congestive heart failure),...

TABLE 493 Treatment of Cardiogenic Pulmonary Edema7

OXYGENATION AND VENTILATION Oxygen (100 ) should be given by mask and arterial blood gases obtained. The patient should be seated upright to pool systemic blood and reduce venous return. If hypoxia persists with supplemental oxygen, then positive pressure ventilation is required. Positive end-expiratory pressure (PEEP) applied via face mask as continuous positive airway pressure (CpAP) or bilevel continuous positive airway pressure (BiPAP) or via endotracheal tube can be used to prevent...

TABLE 1221 Differential Diagnosis of Vomiting

Most infants and children who come to the emergency department because of vomiting have a self-limited viral disorder. Only a small percentage of these patients will require assessment beyond obtaining a careful medical history and performing a physical exam, and a smaller number will require specific treatment. For most children, the only treatment will be the recommendation to provide additional fluids and to continue age-appropriate feedings. It is important to remember that vomiting need...

Physical Abuse

The spectrum of injuries in children who have been intentionally traumatized is wide. Familiarity with this spectrum enables physicians in the emergency department to arrive at the correct diagnosis in a timely manner. Two-thirds of the victims of physical abuse are under the age of 3 years, and one-third are under 6 months. The physical vulnerability of such small children is easy to understand. Historical data may raise suspicions of inflicted trauma. A history that is inconsistent with the...

Ocular Injury

Half of all lightning victims will have ocular injuries, including optic nerve atrophy, papilledema, retinal hemorrhage, retinal detachment, corneal abrasion, hyphema, uveitis, vitreous hemorrhage, and cataracts. Cataracts are the most common single injury and may develop immediately or as late as 2 years after a strike. Pupillary findings may include iridocyclitis, mydriasis, anisocoria, and Horner's syndrome. Dilated unresponsive pupils may be due to transient autonomic dysfunction and should...

Viral Infection

Viral illnesses tend to present within the first few months. Viral and bacterial illnesses are often seen concurrently. Ihe most common viral agent, and the most common cause of infection after transplantation, is CMV, a herpesvirus. It is reported to occur in between 23 and 85 percent of all liver transplant patients. Despite its high incidence and morbidity, it is rarely fatal unless disseminated and rarely has a significant effect on graft survival. It generally occurs within the first 3...

Penetrating Trauma Ruptured Globe

Penetrating ocular trauma can occur from numerous sources (BB pellets, lawn mower projectiles, hammering, knife and gunshot wounds). Any projectile injury has the potential for penetrating the eye. Any lid laceration from a sharp object, especially if it involves the upper and lower eyelid has the potential to have lacerated the globe and requires a slit-lamp examination. Clues to a ruptured globe or intraocular foreign body include shallow anterior chamber, hyphema, irregular pupil,...

Soft Tissue

LIGAMENTOUS SPRAINS Lateral Ligament Complex Sprains of the lateral ankle are the most common ankle injury, and the great majority are minor. The classification systems for ligamentous injuries to the lateral ankle are quite confusing. Older texts describe a purely anatomic classification scheme A grade 1 injury is described as a complete rupture of one ligament and a grade 3 injury is a complete disruption of the three-ligament complex. More recent articles describe a more functional system In...

Clinical Features

HISTORY The definition of diarrhea varies within the medical literature, so it is not surprising that patients' definitions vary too. Many patients come to the emergency department complaining of diarrhea when what they really have is soft stools or two stools per day compared with their usual one. Strictly speaking, diarrhea is present when the daily stool weight exceeds 200 g.10 Practically speaking, however, diarrhea is present when the patient is making more stools of lesser consistency,...

Barbiturate Abstinence Syndrome

Abrupt discontinuation of barbiturates in a chronically dependent user will produce minor withdrawal symptoms within 24 h and major life-threatening symptoms within 2 to 8 days. The severity of the withdrawal reflects the degree of physical dependence and drug half-life. Cessation of short-acting barbiturates results in more severe abstinence symptoms than stopping long-acting barbiturates. This is consistent with the clinical observation that the brain has more time to adapt to declining drug...

Tips For A Plastic Closure

Ihere are several general principles to cosmetic closure. All wounds heal with some scarring, the goal is to use techniques that make the scar as small and invisible as possible. Scars become visible when they cast a shadow, have a rough surface, are wide, or develop permanent secondary color change. Scars most often cast a shadow when they become concave from wound contraction during healing. Wound-edge eversion during the initial repair will therefore gradually flatten with healing and have a...

Pelvic and Genitourinary Trauma

Trauma to the genitourinary (GU) tract should be considered in all children with multiple trauma, a pelvic fracture, or injury to the flank, back, or groin. GU injuries are uncommon in children, occurring in only 10 percent of trauma patients. Symptoms and physical findings are often nonspecific, including back pain, abdominal pain, hypotension, and abdominal wall trauma. Pelvic fractures, particularly anterior ring fractures, are associated with urethral and bladder injury. Children are less...

Initial Stabilization

The degree and severity of congestive heart failure dictate the types of therapeutic interventions necessary for the initial stabilization phase. Infants who present with mild tachypnea, hepatomegaly, and cardiomegaly simply need to be seated upright in a comfortable position and kept in a neutral thermal environment to minimize preload and to avoid metabolic stress. If the work of breathing is appreciably increased by an increased pulmonary blood flow, 1 to 2 mg kg furosemide parenterally is...

Molar Pregnancy

Gestational trophoblastic neoplasia is a proliferative disease of the trophoblast. The incidence in the United States is about 1 per 1500 live births. Most cases (80 percent) present as a hydatidiform mole and follow a benign course. More malignant forms of the disease are invasive mole (12 to 15 percent) and choriocarcinoma (5 to 8 percent). Patients with a hydatidiform mole most commonly present with vaginal bleeding but may present with early preeclampsia or hyperemesis gravidarum. A...

Clinical Approach To The Ventilator And Respiratory Failure

As mentioned earlier, it is best to think of blood gases as participating in two separate systems oxygenation and ventilation. When interpreting blood gas values, the clinician can evaluate the oxygenation system with the Pao2 and the ventilation system with the Paco2 and pH. The therapies can also be separated into oxygenation and ventilation. There are generally five causes of hypoxemia (low Pao2 in the blood). They include hypoventilation, low Fi o2, V Q mismatch, shunt, and diffusion....

TABLE 713 Causes of Esophageal Perforation

Perforation causes a dramatic presentation if esophageal contents leak into the mediastinum. A fulminant, necrotizing mediastinitis with polymicrobic infection that rapidly leads to shock and death can ensue. Perforation into the pleural or peritoneal spaces can occur as well, and contamination of these large potential spaces also tends to result in rapidly progressive infection and shock. If the perforation is small and leakage is contained by contiguous structures, the course may be...

Plates and Screws

Plates and their accompanying screws are commonly used to add stability while fractures, osteotomies, or arthrodeses fuse. They come in many different shapes and sizes because they have been designed to fit different areas of the skeleton. They all share the common function of stabilizing bone in an anatomically acceptable position while it heals to itself. To perform this function, the plate must be securely attached to bone with multiple screws to each fragment. When this method is used to...

Orbital Cellulitis Postseptal Cellulitis

Orbital cellulitis is an orbital infection therefore it is deep to the orbital septum. This is a serious ocular infection that has the potential to be life-threatening. Staph. aureus is the most common pathogen however, H. influenzae flu should be considered in young children and mucormycosis in diabetics and immunocompromised patients. Polymicrobial infection is common. Orbital extension of paranasal sinus infection (especially ethmoid sinusitis) is the most frequent source. Orbital and sinus...

Cestodes Flatworms

The cestodes are flatworms commonly referred to as tapeworms. They have a scolex, or head, equipped with suckers, or hooks. Cestodes grow by segmentation, extending proglottides from the neck. TAENIA Taenia solium (pork tapeworm) is occasionally encountered in the United States in immigrants or visitors from Central America and the Middle East. Taenia saginata (beef tapeworm) is seen more often, especially in those who consume raw beef (e.g., steak tartare). Adult worms live in the small...

Sulfonamides Bactrim

The sulfonamides are bactericidal agents that inhibit folic acid synthesis in bacteria. Sulfonamides are para-aminobenzoic acid (PABA) analogues and competitively inhibit the enzyme dihydropteroate synthetase in the folate synthesis pathway. Available sulfonamides include sulfisoxazole and sulfamethoxazole. Sulfonamides have a high incidence of bacterial resistance, and today the most widely used sulfonamide is sulfamethoxazole in combination with trimethoprim (Bactrim, Septra, Sulfatrim, or...

Diabetic Hypertensive Cranial Nerve Palsies

Chronic diabetes and hypertension can eventually create vascular compromise to the vasa nervorum of any CN. Frequently the patient will present with new-onset diplopia and an isolated CN III or VI palsy will be found on physical examination. The CN palsy is often painful, but it can be painless. The pupil is spared in acute diabetic CN III palsy due to vascular compromise of the central nerve fibers (the efferent pupillomotor fibers run in the periphery of the nerve see Fig.230-19). Extraocular...

Temporomandibular Disorder

Temporomandibular disorder (TMD) refers to persistent discomfort due to dysfunction of the temporomandibular joint (TMJ), surrounding muscles, and ligaments. Symptoms include TMJ noise and pain on movement, limited jaw movements, locking of the jaw on opening, bruxism, and tongue, lip, or cheek biting. Headache may be associated with TMD as well, but in patients with headache and bruxism, it is often not clear which is cause and which is effect. Patients with TMD can usually locate their pain...

Nifedipine

ACTIONS AND PHARMACOLOGY This dihydropyridine calcium-channel antagonist has been one of the most extensively studied agents for rapid control of blood pressure. Until the last few years when awareness of serious side effects became more widespread, it had been the most frequently used agent for acute blood pressure lowering in hospitalized patients. It is a coronary and peripheral arterial dilator, which causes a slight increase in heart rate but rarely causes postural hypotension. It can be...

Renal Colic

Intravenous pyelogram (IVP), spiral CT, and ultrasound are all used in evaluating patients thought to have renal colic. Bedside ultrasound often allows a much more rapid diagnosis and disposition of ED patients than either IVP or spiral CT, and there are situations where the use of contrast material or iodizing radiation is unwise (e.g., pregnancy, renal insufficiency, and volume depletion). False-negative ultrasound results occur, but the sonographic appearance of hydronephrosis in the...

Chest Pain Of Esophageal Origin

Most esophageal causes of chest pain are not immediate threats to life however, differentiating esophageal pain from ischemic chest pain can be impossible in the ED. Patients with esophageal pain can report spontaneous onset of pain or pain at night, regurgitation, odynophagia, dysphagia or meal-induced heartburn however, these symptoms are also found in patients with coronary artery disease (CAD), and there is no historical feature that is sensitive or specific enough to routinely make a...

After Care Instructions

Wounds should be kept clean and dry for 24 h after suturing. Thereafter, they may be cleaned with running water and covered with a clean, dry dressing. Discharged patients should return for suture or staple removal in 7 to 10 days for upper extremity lacerations, 10 to 14 days for lower extremity lacerations, and 14 days for lacerations over joints. This time can be extended a few days in patients over age 65 years because epithelialization and noncollagenous protein accumulation are delayed.8...

Magnetic Resonance Imaging Principles And Some Applications

MR ., in the Emergent Setting Chapter,, References The significant advances in imaging technology of recent years have dramatically expedited diagnosis and improved outcomes in emergency department patients. Magnetic resonance imaging (MRI) has been at the forefront. In just a short time, it has become a major adjunct for neurologic and musculoskeletal evaluation. This chapter briefly describes MRI and elucidates its role in emergency medicine Magnetic resonance imaging has the following major...

Epidemiology Foodborne Disease

From 1988 to 1992, a total of 2423 outbreaks of foodborne diseases in the United States were reported to the CDC 77,373 persons developed predominantly diarrheal illness.3 This number represents only a small fraction of foodborne outbreaks. Most infections are undiagnosed or unreported. It has been estimated that foodborne illness affects 6 to 80 million people in the United States and causes 9000 deaths each year. 4 On a global scale, the prevalence of all diarrheal illnesses has been...

Noninvasive Positivepressure Ventilation

The widespread use of noninvasive positive-pressure ventilation (NIPPV) for chronic sleep apnea in the 1980s has prompted investigators to look at NIPPV in the acute setting today. NIPPV can be described as an application of a preset volume pressure of inspiratory air through a face or nasal mask. Inspiratory muscle fatigue is the final phase of ventilatory failure in patients with severe reactive airway disease, COPD, and end-state pulmonary edema pneumonia. The airway resistance overcomes the...

Fungal Infections

Candida albicans infection is the result of immunosuppression (especially from steroid use) causing overgrowth of an endogenous gut flora. Mucocutaneous disease affecting the oropharynx, esophagus, and vagina is the most common presentation. Candidal urinary tract infections, usually associated with indwelling catheters, can run a benign course with just cystitis or spread to pyelonephritis. Disseminated candidiasis often results in endocarditis, aortitis, osteomyelitis, meningitis, and brain...

Apnea

Apnea is the absence of respirations for a period of 20 s or if it is associated with a decrease in heart rate of 80 beats per minute and or accompanied by cyanosis or pallor. Apnea is categorized as central apnea when it is of CNS origin. There are no respiratory efforts and no gas flow in central apnea. In obstructive apnea, there is impaired gas flow in the presence of respiratory effort. In mixed apnea, there are components of both of the above. Periodic breathing is apnea of a few seconds'...

Automatic And Implantable Defibrillators

In 1933, William Kouwenhoven observed in dogs that closed-chest electrical shocks delivered within 30 s of inducing ventricular fibrillation (VF) were 98 percent effective in terminating the dysrhythmia. After 2 min of VF, the rate of resuscitation fell to 27 percent. He reported similar results in human subjects. 14 Modern research indicates that the likelihood for successful resuscitation decreases roughly 10 percent min after the onset of VF. Thus, the goal of emergency cardiac care is to...

Chapter References

Farrington PF Pediatric vulvovaginitis. Clin Obstet Gynecol 40 135, 1997. 2. Sobel J Vaginitis, in Pearlman MD, Tintinalli JE (eds) Emergency Care of the Woman. New York, McGraw-Hill, 1998, pp 535-549. 3. Centers for Disease Control and Prevention 1998 guidelines for treatment of sexually transmitted diseases Recommendations and reports. Morb Mortal Wkly Rep 47 1, 1997. 4. McCoy MC, Katz VL, Kuller JA Bacterial vaginosis in pregnancy An approach for the 1990s. Obstet Gynecol Survey 50 482,...

Cholecystitis And Biliary Colic

Brady Judith E. Tintinalli Pathophysiology Clinical Features Differential Diagnosis Diagnostic StM.dies Complications Treatment Chapter References Biliary tract emergencies result primarily from obstruction by biliary calculi in the gallbladder and bile ducts. The four major biliary tract emergencies related to gallstones include biliary colic, cholecystitis, gallstone pancreatitis, and ascending cholangitis. While gallstones are common, most are asymptomatic. The...

TABLE 2473 Intracranial Hematomas

Patients with tSAH can present with mild to severe TBI. Those with isolated tSAH often present with a headache and photophobia and mild meningeal signs. A CT scan is generally diagnostic but care must be taken on reports of delayed intracranial hematomas, especially subdural hematomas, exist in the literature for patients who exhibited nonfocal neurologic exams with negative initial CT scans.27 Unfortunately, delayed findings may not be detected for one to two months after initial insult....

Maternal And Fetal Physiologic Changes That Affect Cardiac Arrest

Uteroplacental blood flow is directly related to maternal blood volume and arterial pressure. Support of maternal blood volume and oxygenation is the best way to prevent fetal hypoxia. With this principle in mind, a detailed understanding of cardiac arrest physiology is important. A full discussion of fetomaternal physiology can be found in Chap 99, but several points are discussed and put in perspective here. The maternal cardiovascular system undergoes dramatic changes. Cardiac output...

Observation and Regional Back Examination

With the patient disrobed, the spine and pelvis should be observed for abnormal spinal curves, pelvic tilts, or the presence of spinal-pelvic lists, all suggesting splinting or guarding in response to pain. Each vertebra should be palpated to identify point tenderness that suggests bony involvement. The gait should be observed for a loss of normal, symmetric spinal-pelvic rhythm. Asymmetric posturing suggests pain or weakness to which the patient is biomechanically accommodating. Guarding or...

Consultation

Orthopedic consultation is required for joint capsule penetration, open fractures, nerve lacerations, lacerations of the EHL, TA, or Achilles tendon, and for suspected compartment syndrome. Hand surgery consultation must be obtained for all flexor tendon lacerations, as well as for extensor tendon lacerations distal to the MCP joint, and should be considered for extensor tendon lacerations proximal to the MCP joint. With peripheral nerve and tendon injuries, it is appropriate for the emergency...

End Points to Resuscitation

Perhaps one of the greatest challenges in shock management facing both clinicians and researchers today is the identification of valid and reliable shock parameters to assess the severity of hemorrhage and the adequacy of resuscitation. 213 In the past, gross physiologic indices such as heart rate, blood pressure, capillary refill, urine output, and central venous pressure have been used to assess the severity of hemorrhage. Despite a long history of frequent clinical use, these parameters have...

Radiography

The clinical examination should determine which radiographs are necessary to support the diagnosis. Standard views of the wrist include posteroanterior, lateral, and oblique views. Although these views are sufficient in the majority of cases, other projections may be necessary to profile specific carpal injuries. The key to interpreting the radiograph is to first assure proper positioning, then identify specific features on each projection. On a properly positioned posteroanterior view, the...

Rotator Cuff Tears

Tears in the rotator cuff muscles can occur from acute trauma, chronic overuse, or a combination of the two. Acute rotator cuff tears account for approximately 10 percent of all rotator cuff tears and usually occur as a result of significant trauma. Traumatic causes typically involve a fall on an outstretched arm, causing extreme hyperabduction or hyperextension. Lifting a heavy object or catching a heavy object as it falls can also cause acute rotator cuff tears. Chronic rotator cuff tears...

Gallbladder Disease

Ultrasound is generally accepted to be the modality of choice in the evaluation of biliary disease. 4 Greater than 90 percent of biliary disease is calculous in origin, and, regardless of composition, even the smallest of gallstones are visible sonographically. Conversely, only 15 percent of gallstones are visible with standard radiographs. SONOGRAPHIC CONSIDERATIONS The gallbladder is an ideal organ for sonographic evaluation. This cystic structure is typically filled with anechoic bile and...

Prader Willi Syndrome

Prader-Willi syndrome is a condition characterized by mental retardation, hypotonia, hypogonadism, and obesity. It is a sporadic multisystem disorder with an incidence of 1 in 10,000. It is due to a chromosomal deletion on the 15th chromosome. Presentation in infancy is of poor suck, hypotonia, developmental delay, and early failure to thrive. During childhood, the poor eating habits change to hyperphagia and obesity, which becomes a major problem for health and life. Consequences of obesity...

Heterocyclic Antidepressants Hcas

Although tricyclic antidepressants (named for their three-ring structure) were first synthesized in the nineteenth century, their antidepressant properties were not recognized until the late 1950s. Since that time, other cyclic antidepressant agents have been formulated thus creating need for the more general term heterocyclic (Table., .282-3). The therapeutic effect of HCAs is believed to be related to secondary downregulation of norepinephrine and serotonin postsynaptic receptors after...

TABLE 473 Short Term Risk of Death or Nonfatal Myocardial Infarction in Patients with Unstable Angina

Hypoxia is a reduction in oxygen supply to tissue despite adequate perfusion. Ischemia is oxygen deprivation accompanied by inadequate removal of metabolites due to reduced perfusion. Both ischemia and hypoxia must be discussed in relative terms, since conditions that result in ischemia in one patient may not result in ischemia in another. Ischemia occurs when there is an imbalance between oxygen demand and oxygen supply. Oxygen supply is influenced by the oxygen-carrying capacity of the blood...

Inconsistent Findings and Pain Behavior

The patient who embellishes a medical history, exaggerates pain perception, or provides responses on physical examination inconsistent with known physiology can be particularly challenging.15 This condition can be objectified in the physical exam with the use of Waddell's nonorganic physical signs. 20 Tests can be included in the flow of the general physical exam for the back. Testing includes tenderness to superficial skin rolling report of low back pain with axial loading or when the whole...

Modifications Of Cardiopulmonary Resuscitation

The etiology of cardiac arrest in pregnant patients is different from that in nonpregnant patients and includes pulmonary embolism, amniotic fluid embolism, eclampsia, drug toxicity (e.g., magnesium sulfate or epidural anesthetics), cardiomyopathy, aortic dissection, trauma, and hemorrhage. As always, one should address the potential underlying etiology as well as the cardiovascular collapse. Cardiopulmonary arrest in a pregnant patient must be considered under two scenarios prior to fetal...

Otitis Externa

Otitis externa includes infections and inflammation of the external auditory canal (EAC) and auricle. It may be divided into acute diffuse and malignant types. ACUTE DIFFUSE OTITIS EXTERNA Definition and Diagnosis Also known simply as otitis externa (OE) or swimmer's ear, this infection is characterized by pruritus, pain, and tenderness of the external ear. Physical signs include erythema and edema of the EAC, which may spread to the tragus and auricle. Other signs are clear or purulent...

Child Neglect

Child neglect includes both physical and emotional neglect. Nearly 1 million cases of neglect occur annually in the United States. Neglect results from failure of the child's caregiver to provide adequate clothing, shelter, food, health care, and or schooling. Children who are the victims of neglect may appear in the emergency department dirty, improperly clothed, and unimmunized. Their medical problems may not have been attended to in a timely manner. They may have suffered from burns or...

Airway Obstruction

Potential causes of upper airway obstruction are shown in Tibie 1.4.-1. Basic management of the obstructed airway is discussed in Chap.8. Most of these entities cause soft tissue swelling or themselves are soft tissue masses that compromise the upper airway, but a few need mentioning. Certain medical diseases like respiratory syncytial virus (RSV) and cystic fibrosis produce copious secretions in the upper airway that can lead to partial or complete occlusion. Angioedema may present with soft...

[NaJ tfHCOj [CI AG

The difference between the serum sodium (the contribution of potassium, largely an intracellular ion, is usually neglected) and the sum of serum chloride and bicarbonate, then, equals the concentration of the unmeasured anions. Correction of serum sodium for hyperglycemia is unnecessary because this condition similarly reduces chloride concentrations.4 The unmeasured anion concentration is commonly called the anion gap (AG), and in the past its normal value had been considered to be 12 4 meq L....

TABLE 2221 Common Etiologies of Acute Ataxia and Gait Disturbances

The summation and integration of proprioceptive information from the joints and tendons, visual information, and vestibular inputs while the head, body, or limbs are moving, and the production of a smooth, steady muscular movement is a complex process involving different areas of the central nervous system (CNS) and elements of the peripheral nervous system. Transmission of proprioceptive information from the peripheral nervous system into the CNS is required, as well as integration and...

Definition

Impetigo is a superficial bacterial infection of the skin confined to the epidermis. Deeper spread to the dermis leads to ecthyma. There are two varieties of impetigo impetigo contagiosa and bullous impetigo. Etiology Traditionally, group A b-hemolytic streptococcus (GABHS) was considered the major pathogen in impetigo contagiosa. However, recent studies have suggested that Staphylococcus aureus often can be the primary infecting agent and that therapy which does not include coverage for this...

Introduction and Definition

Consciousness has long been a perplexing subject for philosophers and physicians, and it may be argued that human consciousness is still poorly understood. However, emergency physicians need an operational definition for the disorders of consciousness that are frequently encountered in emergency departments. Dementia is a chronic state of reduced cognitive ability. The individual once was able to function but has lost intellectual skills and memory so that normal functioning has become...

TABLE 236 Clinical Manifestations of Hypernatremic States Related to Serum Osmolality

Virtually all hypernatremia encountered in the ED is related to volume loss, usually severe. There are two potential mechanisms seemingly opposed but having the same result. The first is the ADH response to low volume and hypertonicity. The renal response to ADH, conservation of free water, results in low urine output (less than 20 mL h) that has a high osmolality (usually greater than 1000 mosm kg H2O). The second mechanism is failure of ADH response, either central or peripheral (vide infra)....

TABLE 2712 Complications of Rhabdomyolysis

The serum potassium level is elevated in 10 to 40 percent of cases, due to release of potassium from injured skeletal muscle. -I3 Renal function, however, appears to be the most important determinant of the degree of elevation. Hyperkalemia can be a significant complication of rhabdomyolysis if acute renal failure occurs. Elevated uric acid levels can occur, especially in crush injures, due to release of muscle adenosine nucleotides and subsequent conversion to uric acid by the liver. Uric acid...

Step 1 Define the Problem

Population-based data on the incidence and impact of injury are essential to define the scope of the problem and mobilize the resources necessary to achieve change. Public health surveillance is needed to monitor patterns and trends, and to evaluate the impact of countermeasures. Several sources of information can be used for this purpose. Vital records or death certificates are useful to document the impact of injuries on overall rates of mortality, but they do not provide information about...

Rocky Mountain Spotted Fever

Rocky Mountain spotted fever (RMSF) is an infectious disease caused by Rickettsia rickettsii which is transmitted by ticks. The prominent clinical manifestations of RMSF can be directly related to the primary pathologic lesion in the endothelial cells lining small blood vessels where the rickettsia multiply. Rash, headache, mental confusion, terminal heart failure, and shock are manifestations of the generalized vasculitis. The incubation period is from 2 to 12 days with either a sudden or...

Pathophysiology

Monoamine oxidase (MAO) is an intracellular enzyme bound to the outer mitochondrial membrane.5 It has been identified in most human cells. A notable exception is erythrocytes, which do not contain mitochondria. MAO removes amine groups from both endogenous and exogenous biogenic amines. This oxidation deamination process is the primary mechanism by which endogenous biogenic amines such as norepinephrine (NE), dopamine (DA), and 5-hydroxytryptamine (serotonin or 5-HT) become inactivated. A...

Injuries to the Penis

Self-inflicted injuries of the penis include vacuum cleaner injuries and blade injuries. Vacuum cleaners cause extensive injury to the glans penis and some loss of the urethra, requiring debridement of devitalized tissue and reconstruction. Blade injuries range from superficial lacerations to complete amputation. Amputation of the penis is managed by reimplantation or local repair. Reimplantation is preferable if the distal penis is in satisfactory condition, and the ischemia time is less than...

Recognizing The Violent Patient

The only agreed upon predictors of violence are gender and alcohol abuse. Most perpetrators of violence are males with a history of substance abuse. The amount of education, ethnic background, marital status, or diagnosis are not reliable predictors, but they may be barriers to patient-staff interaction, which in itself may lead to frustration and anxiety for both the staff and patient. In turn, this subconscious conflict may precipitate a violent encounter. The most obvious predictor of...

Elbow Dislocation

The elbow is one of the most stable joints in the body. This stability is due to the adjacent muscular attachments, collateral ligaments, and inherent stability afforded by the hingelike articulation. Because of this stability, surgical repair for acute instability is usually not required, and chronic dislocations are unusual. Despite this, however, dislocations of the elbow are commonly seen, being third in large-joint dislocations, after glenohumeral and patellofemoral dislocations. There are...

Diagnostic Techniques

The potassium hydroxide preparation is used in patients with suspected molluscum contagiosum and dermatophytic infections. The test is performed on loose skin scales, nail pairings, subungual debris, short residual hairs, or small pearly globules (from a molluscum body). The material is placed on the microscope slide, gently crushed, and mixed with two drops of a 20 KOH solution. The specimen is then warmed boiling will produce artifactual change. Excess solution may be removed by placing a...

Complications Of Airway Devices

Hackeling Endotracheal .Tubes Tracheostomy Tubes Laryngeal Stents Sp.ee.c.h Devic.e.s Even with expertise and meticulous planning, complications of airway management are bound to occur. Most complications are due to many factors, including inadequate preparedness, inadequate assessment, failure to anticipate or recognize the complication, and inadequate skill during the airway crises. 1 This chapter focuses on complications of airway devices, including...

Open the Airway

Once unresponsiveness has been determined, assistance obtained, and a defibrillator requested, the next step is to assess the upper airway of the victim. This usually requires positioning the individual supine on a flat, firm surface with arms along the sides of the body, followed by opening the person's airway. Unless trauma can be definitely excluded, any movement of the victim must take into account the potential of a spine injury as the patient is placed supine, stabilize the cervical spine...

Syndrome Of Inappropriate

Primary and metastatic malignancy of the brain Small cell lung carcinoma Pancreatic adenocarcinoma Prostate carcinoma Ectopic secretion of antidiuretic hormone (ADH) may come from a variety of malignancies. In addition, excessive endogenous secretion of ADH may be caused by chemotherapy (Vinca alkaloids, cyclophosphamide), narcotics, phenothiazines, antidepressants, and head trauma. Regardless of etiology, the syndrome of inappropriate ADH (SIADH) consists of serum hyponatremia, less than...

TABLE 1372 Clinical Features of Genital Ulcers

GENITAL WARTS Human papillomaviruses (HPVs) are DNA viruses that cause genital warts by direct transmission. Different genotypes also have been implicated in cervical cancer, but the relationship is far from clear. The warts usually appear after an incubation period of 3 to 4 months and may coalesce to form condylomata acuminata. Although painless, their location or size may cause discomfort. Diagnosis Diagnosis is clinical, with care to exclude other STDs. Treatment Treatment decisions are...

Esophageal Bleeding

The general approach to upper gastrointestinal bleeding (UGIB) from an esophageal source does not differ from the approach for bleeding from other sources and is addressed in more depth in Chap. i70, Gastrointestinal Bleeding. Resuscitation proceeds concurrently with the diagnostic effort of history, physical examination, and laboratory evaluation. Gastric lavage through a nasogastric tube or larger-bore gastric tube is generally accepted, and early airway management should be considered....

Immediate Transfusion Reactions

Transfusion Reactions Images

ACUTE HEMOLYTIC TRANSFUSION REACTION This is a medical emergency that occurs when incompatible RBCs are transfused. Most often this is an intravascular event resulting from incompatibility in the ABO blood group system. Iable.215.-4 reviews compatibility in the ABO blood group system. An acute hemolytic reaction occurs when the incompatible transfused cells are immediately destroyed by antibodies. The overall incidence of acute hemolytic transfusion reactions is estimated at 1 in 21,000 to 1 in...

Diagnostic Peritoneal Lavage

Diagnostic peritoneal lavage (DPL) is used for the early recognition of intraabdominal injury requiring celiotomy. In many centers, the use of DPL has been supplanted by imaging techniques because of increased accessibility to improved computed tomography (CT) and ultrasonography. However, size and weight restrictions and transport difficulties may preclude the use of CT scanning in the obese trauma victim. Abdominal ultrasonography is also less reliable in the morbidly obese patient. Therefore...

Constitutional Symptoms and Febrile Illnesses

OVERVIEW Systemic symptoms, such as fever, weight loss, and malaise, are common in HIV-infected patients and account for the majority of HIV-related emergency department presentations.12 In the emergency department, systemic infection and malignancy must be excluded. Appropriate laboratory investigation may include electrolyte determinations, complete blood count, blood cultures (aerobic, anaerobic, and fungal), urinalysis and culture, liver function tests, chest radiograph, and serologic...

Dentoalveolar Trauma

Dentoalveolar trauma is a very common reason for ED visits. Approximately 20 percent of all school-age children will experience oral trauma. The most common mechanism of injury is falls. Sporting injuries, fights, and motor vehicle collisions account for most of the remainder. Injury to the maxillary central incisors accounts for 70 percent of dental injuries.27 The management of dentoalveolar trauma depends on the extent of tooth and alveolar involvement, the degree of development of the apex...

Fractures and Dislocations

CLASSIFICATION SCHEMES There are multiple classifications of ankle fractures. The more complex utilize both the position of the foot at the time of injury and the deforming force. These classifications are useful in predicting associated injuries. In the Lauge-Hansen classification system, the first word refers to the position and the second word refers to the force. The Danis-Weber classification is based on the level of the fracture of the fibula. Proximal fractures of the fibula are...

Hypercalcemia Of Malignancy

Renal cell carcinoma Multiple myeloma Squamous cell lung carcinoma Breast carcinoma Lymphoma Mild elevations of serum calcium are well tolerated and produce little in the way of symptoms. However, when serum calcium levels rise rapidly or exceed ionic thresholds, cardiac, neural, and muscular electrophysiology may be greatly altered. A number of mechanisms have been identified that promote release of bony calcium into the circulation. Bony involvement with myeloma, carcinoma of the breast, or...

Hemodynamically Stable Asymptomatic Patients

This class of patients presents to the emergency department for reasons that are not referable to the heart and are discovered to have findings suggestive of cardiac disease. Some of the more common cardiac defects have already been mentioned including mildly affected tetralogy of Fallot, small to moderate-sized VSDs, and coarctation of the aorta. Several common structural defects warrant mention here. ATRIAL SEPTAL DEFECT Most children remain symptomatic throughout childhood until adolescence,...

Prolapse

The female pelvic organs, i.e., vagina, uterus, bladder, and rectum, are held in proper alignment by supporting ligaments, fascia, and the pelvic floor muscles. When any or all of these structures fail, the pelvic organs may prolapse within and occasionally protrude through the vagina. This prolapse or displacement may occur singly or more commonly combined. Prolapse can be divided into two broad categories, uterine and vaginal. Uterine prolapse is graded as first through third degree. 1. First...

Sulfonylureas

Sulfonylureas stimulate the b-islet cells of the pancreas to release insulin through inhibition of potassium channels and changes in membrane potential. 7 First-generation sulfonylureas, such as chlorpropamide, reduce hepatic clearance of insulin and have active metabolites. These agents are renally excreted, complicating glycemic control in diabetics with intrinsic renal disease. Second-generation sulfonylureas, such as glyburide and glipizide, have half-lives that exceed 24 h and are...

Emergency Department Recognition of Substance Abuse

The percentage of ED patients who test positive for blood alcohol at the time of the visit ranges from 6 to 34 percent for injured patients and 1 to 19 percent for the noninjured.8 At the time of an urban ED visit, 17 percent of patients were found to meet stringent criteria for alcohol abuse and 19 percent for alcohol dependency, while only 9 percent of the study group were breath alcohol positive, and only 14 percent reported a drinking problem. Among a 1-year sample of more than 7100...

Halo Devices

The Halo vest provides one of the most rigid types of cervical immobilization available. The Halo consists of a lightweight radiolucent ring attached to a lightweight adjustable vest. Current vests allow adjustment of the cervical spine in multiple planes. Titanium pins that do not interfere with MRI images, are stronger, lighter, and more expensive than older stainless steel pins. Pins are usually tightened to 6 to 8 in lb. 45 INDICATIONS Halo devices are indicated for stabilization of an...

Fluids

A prerequisite to the anatomy of body fluids and the physiologic principles that maintain normal fluid and electrolyte balance is a firm understanding of the extent and composition of the various body fluid compartments. Homeostasis is the maintenance of the composition of the internal environment that is essential for health. This includes consideration of the distribution of water in the body, along with appropriate maintenance of pH and electrolyte balance. Water is the major constituent of...

Molecular Pathophysiology of Sepsis

There is now compelling evidence that septic shock and its morbid consequences are the direct result of endogenous proteins and phospholipid mediators secreted by the infected individual. Molecular pathophysiology of sepsis can be divided into 3 phases induction of cytokine synthesis, cytokine synthesis and secretion, and cascade phase of sepsis. The induction of cytokine synthesis involves the interaction of certain microbial molecules that, when recognized by the host, results in the...

High Altitude Cerebral Edema

HACE is defined clinically as the presence of progressive neurologic deterioration in someone with AMS or HAPE. It is characterized by altered mental status, ataxia, stupor, and progression to coma if untreated. Headache, nausea, and vomiting are not always present. Because of raised intracranial pressure, focal neurologic signs such as third and sixth cranial nerve palsies may result from distortion of brain structures or by extraxial compression. HACE is usually associated with pulmonary...

TABLE 238 Etiology of Hyperkalemia

Vaginal Cuff Cellulitis

Clinical manifestations of hyperkalemia usually result from derangement in membrane polarization. Cardiac manifestations are the most serious. They include ECG 6.5 to 7.5 meq L tall peaked T waves, short QT interval, and prolonged PR interval 7.5 to 8.0 meq L QRS widening, and flattening of the P wave 10 to 12 meq L the QRS complex may degrade into a sine wave pattern Ventricular fibrillation, complete heart block, and asystole may occur. Death from hyperkalemia is usually the result of...

TABLE 1206 Differential Diagnosis of Asthma

INFECTION Fever and focal wheezing implicate infectious etiologies such as pneumonia or bronchiolitis. Nocturnal wheezing, nocturnal cough, and poor exercise tolerance may be clues of more chronic illness. Sinusitis can exacerbate asthma symptoms a history of nasal congestion and nocturnal cough or snoring should be treated with at least a 2-week course of antibiotics and nasal steroids. Recurrent attacks, failure to thrive, and a history of sinusitis and chronic ear infections should raise...

Acquired Immunodeficiency Syndrome

There are numerous oral manifestations of HIV infection. Primary HIV infection, occurring from 1 to 6 weeks after contact, is an acute viral syndrome but may have associated intraoral findings such as a sore throat, mucosal erythema, and focal ulceration. Persistent generalized lymphadenopathy, particularly of the cervical lymph nodes, is present in 70 percent of otherwise asymptomatic HIV-infected patients. The presentation of acquired immunodeficiency syndrome (AIDS) is highly variable, and...

Renal Cortical Scintigraphy RCS

RCS, using dimercaptosuccinic acid (DMSA), is a radionuclear study that evaluates kidney function. RCS is most commonly used in the evaluation of children with suspected pyelonephritis and, occasionally, assessment of a renal transplant. Two hours after administration of Tc99m-DMSA, scanning is performed using a gamma camera. DMSA binds to the renal tubules and accumulates in the functioning renal cortex. Intrarenal blood flow and proximal tubular cell membrane transport determine cortical...

Common Parasitic Infections

Pathophysiology Clinical.Features Diagnosis Helminths Nematodes, (Roundworms) TrematodesiFlukes) Ce.stodes jfiatworms) Protozoa Amebas Protozoan .jnfe.ctions.in ,immunocompromised H.o.sts Respiratory Tract Treatment Disposition Chapter References Despite significant advances in medical knowledge and technology over the last half century, parasitic disease remains prevalent world-wide. It is estimated by the World Health Organization that 200 million people, living mostly in the rural tropics,...

TABLE 1992 Types of Radiation

The biological effect of these forms of radiation is a function of the mass, charge, and energy that the type of radiation possesses. Linear Energy Transfer (LET) describes the rate at which radiation deposits its energy as it travels through matter. In general, particulate radiation has a high LET and electromagnetic radiation has a low LET. High LET radiation interacts readily with matter, creating a dense number of ionizations in the matter through which it passes. Thus, high LET radiation...

Central Venous Pressure Catheterization And Monitoring

Central venous catheterization should be performed (1) when rapid delivery of cardiac medications to the coronary circulation is required during cardiopulmonary resuscitation (CPR) 15 (2) for access when peripheral veins are inadequate and (3) when measurement of central venous pressure is desired. Hypovolemic shock by itself is not, however, an indication for central venous catheterization. Many patients who require large-volume infusions or transfusion with multiple units of blood can be...