Repair of Scalp Lacerations

It is not necessary to shave the scalp prior to closure shaving actually increases the likelihood of a wound infection and produces a less desirable cosmetic result in the short term. In most cases, the hair can be brushed aside. One can also apply an ointment such as bacitracin zinc or petrolatum to mat down the hair adjacent to the laceration. Hair braiding has been described as an alternate closure technique. 13 Large galeal defects should be repaired if possible to prevent a wide, depressed...

Wound Preparation and Repair

The repair of foot lacerations, and especially plantar surface lacerations, has been poorly studied. 5 Few clinical practices regarding foot lacerations have been scientifically evaluated. Due to the inherent risk of infection with foot lacerations, excellent wound irrigation with copious amounts of saline irrigation is essential. The ideal time to perform a thorough dry-field exploration to determine tendon integrity and to detect foreign bodies is when the wound is completely anesthetized....

Complications Of Percutaneous Nephrostomy Tubes

While initially developed as emergent procedure for the relief of urinary obstruction, the use of percutaneous nephrostomy PCN has expanded beyond urinary diversion to a variety of other diagnostic procedures and therapeutic interventions. Patients with nephrostomy catheters may present to the emergency department days after placement, with complications relating either to the procedure or to the device itself. Other patients may present with complications related to the long-term use of...

Bulimia Nervosa Algorithm

Eating Disorder Algorithm

Emergency management of patients with eating disorders involves consideration of the complications and effects of the disorder. Nutritional rehabilitation should be the primary goal of treatment in both anorexia and bulimia. Anorexics tend to need a very gradual introduction of macronutrients. Bulimics tend to need fewer calories initially, and it is important to normalize the eating pattern. Normotensive, hypokalemic, hypochloremic metabolic alkalosis is typical of purging eating-disorder...

Infected Vaginal Cuff Hematoma Cellulitis or Abscess

CLINICAL FEATURES A vaginal cuff is formed during a hysterectomy and is composed of the contiguous retroperitoneal space immediately above the vaginal apex and the surrounding soft tissue. This cuff may become infected, leading to cellulitis, hematoma, or abscess. Vaginal cuff cellulitis is a common complication following both abdominal and vaginal hysterectomy. Symptoms and signs usually present between postoperative days 3 and 5, and may begin in the hospital, or just after discharge....

Disorders Involving the Foreskin

Differentiation of the genitalia occurs between the ninth and thirteenth gestational week. The prepuce of the glans penis, which forms the foreskin, is adherent to the underlying glans penis and remains so throughout gestation and during the first several years of postnatal life. The foreskin of the newborn and infant cannot easily be retracted. Doing so shears the attachments between the epithelial layers of the glans penis and the foreskin. This normal adherence of the foreskin of the infant...

Incision And Drainage Of Thrombosed Hemorrhoid

Midicin And Sat

Most treatment is local and nonsurgical unless a complication is present. Hot sitz baths for at least 15 min three times a day and after each bowel movement are the most effective way to relieve pain. Following the bath, the anus must be dried gently but thoroughly to avoid maceration of the perianal skin. Iopical analgesics and steroid-containing ointments may provide relief. The patient should not sit for a prolonged period on the commode. Bulk laxatives, such as psyllium seed compounds, or...

UShaped Flaps and Jagged Lacerations

Trapdoor Deformity

A U-shaped skin flap is often caused by compressive forces on skin overlying bone. The flap usually has abraded skin and extends deep with attached subcutaneous tissues. The edges of the flap are usually irregular and fit together with adjacent wound edges, like a jigsaw puzzle. The survival of a rectangular-shaped flap is dependent on the blood supply from vessels that enter the flap at its base. Survival of a flap is more dependent on its length and not the width of the base wide and...

Complications Of Ureteral Stents

The common use of ureteral stents has greatly increased since the 19th century, when Gustav Simon first placed a tube into the ureteral opening during an open cystostomy. Ureteral stents are primarily used to support internal upper urinary tract drainage, especially in cases where healing is required. Such uses for stents occur in cases of urinary obstruction from nephrolithiasis, as well as obstruction from external malignancies. Stents can also be placed after surgery involving the urinary...

Cirrhosis and Complications of End Stage Liver Disease

Emergency Medacine For Liver Disease

Hepatic cirrhosis results from fibrous scarring mixed with hepatocellular regeneration in response to sustained inflammatory, toxic, metabolic, and congestive insults. Over time, the functional anatomy of the liver is replaced by scar tissue isolating nodules formed by foci of regenerating hepatocytes. Normal function of the liver is dependent not only on preservation of hepatocyte number but also on the elaborate microscopic architecture of the functional hepatic units. In addition to...

Skin Disorders Affecting The Nipple And Breast

Any disorder of the skin can affect the breast. Some of the more important ones specific to the breast and nipple are discussed below. Colonization of the nipples or the lactiferous ducts by Candida albicans may cause chronically sore nipples during or after lactation. The appearance of the nipple may be normal however, more commonly, scaling, fissuring, and erythema are present. Predisposing factors for candidal colonization include antibiotic use, vaginal candidiasis, mastitis, and nipple...

Scabies Feces Pictures

Scabies Poop

The diagnosis is based on a high clinical suspicion and a positive scabies preparation. The diagnosis should be entertained when more than one family member itches. Other disorders to consider in the differential diagnosis include other bite reactions, body lice, atopic dermatitis, neurotic excoriations, and delusions of parasitosis. Suspected cases of scabies should be confirmed by performing a scabies preparation. To perform a scabies preparation, one scrapes or superficially shaves a lesion...

General Approach to Treatment of Ischemic Stroke

Upon entry of patients with ischemic stroke into the emergency medical service (EMS) or emergency department setting, priority should be given to airway management and oxygenation. Patients should be placed on oxygen, the head of the bed slightly elevated, and a monitor and intravenous line established. Unless there is hypotension, fluids should be administered judiciously to prevent cerebral edema. Volume depletion in patients with ischemic stroke deserves prompt treatment, because it may...

Medical Clearance For Detoxification

Medical clearance for transfer to a detoxification or other treatment facility should include the following components 1. Past history. Inquire about past history of hospitalization for delirium tremens, alcohol-related seizures, hepatitis, and pancreatitis screen for severity of alcohol withdrawal signs and symptoms review past medical illness and medications and rule out underlying medical conditions related to substance abuse. 2. Recent history. Inquire about and document recent falls,...

Dermatologic Zoonotic Infections

Dermatologic findings are common in zoonotic infections, as the dermis is often the site of inoculation and may display focal findings. The common dermatologic infections of impetigo, ecthyma, and cellulitis can be transmitted zoonotically, as can human infestations with mites and lice. The dermatophytoses Tinea verrucosum and Microsporum canis account for the majority of zoonotic dermatophyte infections, with M. canis accounting for 15 percent of all human dermatophytoses.51 Chancriform...

Physical Examination

Supine Position For Vaginal Examination

As is the case for most pediatric presentations in the ED, children should be completely undressed and thoroughly examined. This enables physicians to look for subtle signs of disease, injury, and abuse. A child's development of secondary sex characteristics should be assessed and compared with the Tanner stages of breast and pubic hair growth. Most premenarchal girls should not undergo a speculum examination or vaginoabdominal palpation except in the event of vaginal bleeding and trauma. The...

Clinical Features

Initially, hidradenitis suppurativa begins as a painful deep erythematous nodule usually in the axilla or groin. The inflammatory nodule may resolve on its own or develop into a sterile abscess that may open to the surface and drain. Such a lesion may persist and periodically drain, develop a sinus tract and continually drain, or heal with scarring. New lesions may develop in the same area and interconnect. Open comedones, which normally are not present in these body regions, may be seen....

Chronic Vesiculoulcerative Disease

PEMPHIGUS VULGARIS Pemphigus vulgaris is a rare disease with an incidence of 0.5 to 3.2 per 100,000 persons annually. It is important, though, because without treatment, its mortality rate is high. Oral manifestations occur in up to 70 percent of patients and are frequently the first sign of disease, preceding cutaneous lesions by up to a year. Oral lesions are also the most difficult to treat. Ulceration results from autoantibodies attacking the deeper layer of the stratum spinosum of the...

Periorbital and Orbital Exam

Nasal Palpation

The eye exam deserves particular attention, especially when there is periorbital injury. The exam should be performed early during the ED encounter, because, if not timely, progressive lid edema may prevent further examination. If lids are already swollen, lid retractors help visualize the globe. The bird's-eye and worm's-eye views help detect exophthalmos or enophthalmos. The pupil exam includes reactivity, and whether the pupils line up in the horizontal plane. A teardrop-shaped pupil...

Complications Of The Artificial Urinary Sphincter

The artificial urinary sphincter (AUS), a device used to treat urinary incontinence, has undergone five revisions since first being described in use in 1972. All types of artificial sphincters perform similar functions to open partially when bladder pressure exceeds physiologic limits, to equalize pressures of stress, to open fully when operated, to fail in the open position, and to allow catheterization without further operations on the device. 8 The most current model, the AS-800 (American...

Three Joint Complex Degeneration

The combined retrogressive and proliferative changes in the disk anteriorly and in the posterior joints present with both clinical symptoms and roentgenographic changes referred to as combined three-joint complex degeneration. The vertebra-disk-vertebra joint and the paired facet joints comprise the three-joint complex. Three distinct stages in the evolution of this process can be recognized clinically. The stage of dysfunction is associated with complaints of pain and stiffness, often without...

Chiggers Trombiculidae

Chigger infestations are caused by mite larvae that feed on host skin cells. European varieties of these arachnids are called harvest mites. The combination of the effect of digestive enzymes secreted by the mite and an immune response of the host produces the typical pruritic lesions. Although the usual response is intense pruritus at the bite site, more severe systemic reactions and chigger-borne diseases also may occur. Mites live comfortably in warm and cold climates. There are...

High Altitude Pharyngitis and Bronchitis

Most unacclimatized persons exercising at altitudes over 2500 m develop a dry, hacking cough. With exposure to extreme altitudes for prolonged periods of time, a purulent bronchitis and a painful pharyngitis become nearly universal. These problems may not be of an infectious nature high volumes of dry, cold air through the lungs may induce respiratory heat loss and cause purulent secretions on that basis alone. Bronchospasm may also be triggered by respiratory heat loss. Severe coughing spasms...

Direct Effects of Pressure Barotrauma

The pressure-related diving syndromes can be divided into problems caused by the mechanical effects of pressure i.e., barotrauma and problems caused by breathing gases at elevated partial pressures i.e., gas toxicities and decompression sickness DCS . Barotrauma is the most common affliction of divers. It is defined as tissue damage resulting from contraction or expansion of gas spaces that occurs when the gas pressure in the body, or its compartments, is not equal to ambient pressure. For...

TABLE 644 Asthma Mimickers

Directed physical examination reveals hyperresonance to percussion, decreased intensity of breath sounds, and prolongation of the expiratory phase, usually with wheezing. Although wheezing results from the movement of air through narrowed airways, the intensity of the wheeze may not correlate with the severity of airflow obstruction. The silent chest reflects very severe airflow obstruction, with air movement insufficient to promote a wheeze. A pulsus paradoxus above 20 mmHg is also indicative...

Approach To Low Probability Of Ischemia

After initial evaluation, early data collection, and interpretation, a high potential for the presence of an ACS will be recognized in many patients. The approach to further risk stratification and treatment of these patients is detailed in Chap.47. Many others can be classified as having a low probability of acute ischemia based on clinical information available at the time of their ED visit. However, there is currently no consensus in the literature on their optimal management or even a...