Avalable Blood Products Whole Blood

Modern transfusion medicine recommends that it is preferable to give patients only the specific portions of blood they require. This is achieved by the use of component therapy. Therefore, whole blood is rarely used in current practice, except for exchange transfusions for neonates. A unit of whole blood contains 435 to 500 mL of blood plus a preservative-anticoagulant solution. CPDA-1 (citrate phosphate dextrose adenine) is the additive in current use. With proper collection and storage of the...

Clinical Features

Uncomplicated internal hemorrhoids are painless, and the chief complaint is painless, bright-red rectal bleeding with defecation. Bleeding is usually limited, with the blood being found on the surface of the stool, on the toilet tissue, or dripping into the toilet bowl. Although the most common cause of rectal bleeding is hemorrhoids, other, more serious causes should be sought in all patients who present with bleeding as the chief complaint. Clinical signs cannot reliably differentiate colonic...

Central Nervous System

Toxic CNS side effects of NSAIDs are far less frequent than GI or renal toxicity however, various CNS effects include headache, cognitive difficulties, behavioral change, and aseptic meningitis. Acute psychosis has been reported with indomethacin and sulindac use and is hypothesized to result from the structural similarity of these NSAIDs to serotonin. One of the most interesting side effects of NSAID use is aseptic meningitis. The literature reports cases in which patients repeatedly present...

Chronic Pain in the Elderly

Elderly patients frequently complain of chronic pain. Unfortunately, many of the commonly used medications for pain have higher complication rates in the elderly. In particular, the nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with higher rates of gastrointestinal bleeding and renal disease in the elderly. Opioids also may cause debilitating sedation and or constipation in the elderly however, opioids may have less debilitating side effects than NSAIDs. Doses of many agents...

Hand Foot and Mouth Disease

Coxsackievirus type A16, and occasionally types A4, A5, A9, and A10, are associated with hand, foot, and mouth disease. This entity is characterized by the development of a few small vesicles on the tongue, gingiva, soft palate, and buccal mucosa. These vesicles rupture, resulting in painful, shallow ulcers with a surrounding red halo. The lateral and dorsal aspects of the fingers and toes are frequently involved and aid the diagnosis. The buttocks, palms, and plantar surfaces of the feet may...

Relaxation Techniques

Relaxation is different from leisure. Leisure activity is an important way to achieve balance. Physicians will find the stressors of leisure enjoyable in part because they are so different from the common stressors of professional life. Leisure activity will also usually involve family and friends. However, leisure activity frequently contains stressors of its own that tend to arouse and fatigue, rather then renew. Relaxation is different from doing nothing. Relaxation actually increases...

Sexually Transmitted Disease Prophylaxis

Most of the literature demonstrates poor compliance of sexual assault patients with follow-up.7,1 l8 Therefore, prophylaxis for sexually transmitted diseases (STDs) should be given to all sexual assault victims. At a minimum, treatment for gonorrhea and chlamydia should be offered. The current guidelines from the Centers for Disease Control and Prevention (CDC) also recommend prophylaxis against Trichomonas and bacterial vaginosis.19 T.a.ble 2.9 0.-.1 presents the current CDC guidelines for...

Clinical Findings

Lower abdominal pain is the most frequent presenting complaint in PID. Other symptoms may include abnormal vaginal discharge, vaginal bleeding, post-coital bleeding, dyspareunia, irritative voiding symptoms, fever, malaise, nausea, and vomiting. PID may be minimally symptomatic or asymptomatic.9 The physical examination is usually notable for lower abdominal tenderness, mucopurulent cervicitis, cervical motion tenderness, and bilateral adnexal tenderness. However, women with PID often present...

Pneumonia

The lungs are the most common site of infection in neonates. Group B streptococcus is the most common cause of lower respiratory infection in newborns. The infection is most likely acquired in utero from a contaminated amniotic environment. Affected infants frequently develop fulminant illness within hours of birth. Other common bacterial pathogens in newborns and infants include Streptococcus pneumoniae and Haemophilus influenzae serotype B. Chlamydial pneumonia usually occurs after 3 weeks of...

Laboratory Studies

The white blood count is usually elevated with a left shift in bacterial pneumonia, especially early in the illness. 35 Typically, viral, chlamydial, and pertussis pneumonias produce lymphocytosis. However, it is not unusual for viral pneumonia to initially provoke a significant polymorphonuclear cell response. In patients with mycoplasmal pneumonia, the total white blood count and differential count are usually normal, but the erythrocyte sedimentation rate may be elevated. Chlamydial...

Alternative Methods Of Closedchest

The rationale for most of the alternative methods of closed-chest CPR that have been decribed are based on one of two proposed mechanisms of blood flow during CPR chest compression. The cardiac pump theory proposes that compression of the heart between the sternum and the spine squeezes blood out of the ventricles in a forward flow direction in a manner generally similar to normal myocardial contraction. The thoracic pump theory proposes that pressurization of the entire thorax, not just the...

Chapter References

Guidelines for Cardiopulmonary Resuscitation and Emergency Care Recommendation of the 1992 National Conference Part III. Adult cardiac life support. JAMA 268 2205, 1992. 2. Echt D, Leibson P, Mitchell L, et al Mortality and morbidity in patients receiving encainide, flecainide, or placebo Ihe Cardiac Arrhythmia Suppression Trial. N Engl J Med 324 781, 1991. 3. Kowey P, Marinchak R, Rial S, et al Pharmacologic and pharmacokinetics profile of class III antidysrhythmic drugs. Am J Cardiol 80 8A,...

STDs without Lesions

CHLAMYDIAL INFECTIONS Chlamydia trachomatis is an obligate intracellular bacterium that has a growth cycle that alternates between two morphologic forms. Chlamydial infections present with a wide spectrum of clinical manifestations. In men, infection causes urethritis, epididymitis, and proctitis. In women, urethritis, cervicitis, and PID are common. In both sexes, the prevalence of asymptomatic infection is high, ranging from 3 to 5 percent in the general population to 15 to 20 percent among...

Systemic Zoonoses Infections

Zoonotic infections are caused by an extremely diverse group of microorganisms. A myriad of classification approaches focus on the pathogen, animal vector, mode of transmission, geographic range, and clinical syndrome. For emergency physicians, the best approach is one of clinical syndrome presentation, but systemic zoonoses are most difficult to diagnose. Often, they present as an undifferentiated febrile illness with pyrexia, cephalgia, myalgia, malaise, and weakness. This presentation is...

Anticholinergic Toxicity

Pharmacologic Properties ClinicalPresentation treatment Jimsonweed Because of the frequent use of tricyclic antidepressants, phenothiazines, antihistamines, and antiparkinsonian drugs, anticholinergic toxicity is commonly seen in the emergency department. Anticholinergic medications are commonly prescribed for elderly patients, often resulting in drug-induced delirium. Many drugs have anticholinergic properties (Table 177-1) that may be mild at therapeutic doses but are life-threatening in...

Venous Access

Morbidly obese patients are notoriously difficult candidates for intravenous catheterization, venipuncture, or arterial puncture. Anatomy is distorted by subcutaneous fat, and landmark vessels are often not visible or palpable. This leads to multiple attempts, delay in access, and an increased incidence of central line placement with delays in changing a line after admission. All these factors contribute to a higher rate of complications, such as wound infection, pneumothorax, phlebitis, and...

Anterior and Posterior Thoracolumbar Spine Implants

Although the number of spinal instrumentation systems is overwhelming, the basic concepts are simple. A rigid plate or rod is connected to the spine to limit motion between vertebral segments and allow healing or fusion to occur. There are three ways of connecting the rod or plate to the vertebrae with a hook, a wire, or a screw. When reduced to these terms, the instrumentation is much simpler. Most advances in spinal instrumentation arose from the treatment of childhood scoliosis. The first...

Sacrum and Coccyx

The sacrum supports the lumbar vertebral column and transmits loads from the trunk to the pelvic girdle and into the lower limbs. It consists of five rudimentary vertebrae fused to form a single wedge-shaped bone. The upper border articulates with the fifth lumbar vertebra. The inferior border articulates with the coccyx. Laterally, the sacrum articulates with the iliac bones to form the sacroiliac joints. The vertebral foramina together form the sacral canal. The sacral canal contains the...

Pancreatitis

Pancreatitis is not common in childhood. The most common cause is abdominal trauma. It can also occur as an idiopathic or postviral process (mumps, influenza, coxsackie, etc.) or be due to drugs or toxins. Systemic diseases such as cystic fibrosis, systemic lupus erythematous and a -,-antitrypsin deficiency can cause Clinical findings include central abdominal pain, vomiting and, sometimes, fever. The abdomen may be distended and is tender to palpation. Patients should receive fluids to correct...

Osteonecrosis

Osteonecrosis is a bony infarction caused by disruption of blood supply to the bone. Osteonecrosis is divided into two main categories, primary (spontaneous, idiopathic) and secondary. The etiology of primary osteonecrosis remains unknown. Secondary causes include steroid therapy, systemic lupus erythematosus, alcoholism, sickle cell disease, and renal transplantation. Patients with osteonecrosis are typically elderly women who present with acute knee pain. The weight-bearing surface of the...

Bibliography

Charles SC Sued and nonsued physicians' self-reported reactions to malpractice litigation. Am J Psychiatry 142 437, 1985. Gabbard G, Menninger RW, (eds) Medical Marriages. Washington, DC, American Psychiatric Press, 1988. Gabbard G, Menninger RW The psychology of postponement in the medical marriage. JAMA 261 2378, 1989. Howell JB, Schroeder DP Physician Stress A Handbook for Coping. Baltimore, University Park Press, 1984. Marshall AA, Smith RC Physician's emotional reactions to patients. Am J...

Oral Rehydration

It has been repeatedly demonstrated that oral rehydration is as effective as intravenous therapy in treating infants with mild to moderate dehydration. 789 and 10 It has had an enormous impact in developing countries, where prepackaged electrolyte solutions are available in lieu of infinitely more expensive intravenous solutions. Although time constraints may limit oral therapy in emergency departments in the United States, emergency physicians who do work in international medicine must be...

Physical Examination

The physical examination is often normal. Abnormalities in vital signs include hyper- or hypotension, sinus tachycardia, or bradycardia. Tachycardia often results from increased sympathetic tone and decreased left ventricular stroke volume, while bradycardia is often present among patients with inferior wall ischemia. Patients with acute ischemia have a higher incidence of abnormal heart sounds such as a diminished S -,, a paradoxically split S2, and or an S3 or S4 due to changes in ventricular...

Emergency Department Presentations

In addition to being a direct cause of traumatic injury, domestic violence also contributes to other conditions frequently seen in emergency departments, such as depression, anxiety, hyperventilation, substance abuse, suicide attempts, sexually transmitted diseases (including HIV), complications of pregnancy, and headaches and other chronic pain syndromes.18 Both batterers and their victims may abuse alcohol and drugs. Abused individuals with chronic medical conditions may present with...

Control of Oxygen Consumption

The control of Vo2 is important in restoring the balance of oxygen supply and demand to tissues. A hyperadrenergic state results from the compensatory response to shock, physiologic stress, pain, and anxiety. Shivering frequently results when a patient is unclothed for examination and then left inadequately covered in a cold resuscitation room. The combination of these variables increases systemic oxygen consumption. Pain further suppresses myocardial function, thus impairing D o2 and Vo2.15...

TABLE 2884 Possible Signs and Symptoms of Burnout

Detecting impairment in others is much more difficult. Psychologically and chemically impaired professionals are often able to delay notice by protecting their job performance at the expense of every other dimension of their lives. The common signs of uncharacteristic behavior are frequently ignored. The phenomenon of family, neighbors, friends, and coworkers becoming involved in an exhaustive conspiracy enabling an impaired physician to appear to be functioning at his or her job is both common...

Hyperthyroidism

Hyperthyroidism occurs at all ages but is less common under the age of 15. It is 10 times more common in women than in men, with an annual incidence of about 1 per 1000 women.2 Causes of hyperthyroidism are shown in .T.a.ble 2.,0.6-1 Graves disease is by far the most common cause, accounting for more than 80 percent of cases of hyperthyroidism in the United States.3 Toxic multinodular and toxic (adenoma) nodular goiters are the next most frequent causes. Graves' disease is common in the third...

Novel Topical Techniques and Agents

JET INJECTOR Compressed air high-pressure jet injectors are available to deliver LA agents both in liquid and powder form through the epidermis in a needle-less fashion. This is a delivery method suitable for most skin types and has been used extensively by blood banks to minimize pain during blood donation. There is concern about potential cross infection due to splash back when these devices are used on multiple patients without sterilization occurring between each use. However, single dose...

Pharyngitis

Pharyngitis is an infection or irritation of the pharynx and tonsils. It rarely occurs in infants younger than 1 year and is uncommon in infants younger than 2 years. It peaks between the ages of 4 to 7 years but recurs throughout life. Seasonal variation occurs, with a higher incidence in winter. 1 Causal agents of pharyngitis include viruses, bacteria, fungi, and parasites ( Tab-le .2.3.5.-.1). Most often, viruses are the culprits. Rhinovirus and adenovirus are the most common, but...

Chlamydia Trachomatis Genital Infections

Genital infection with Chlamydia trachomatis is sexually transmitted and may present in several different manners. There may be evidence of urethritis, epididymitis, cervicitis, or acute salpingitis, or the infection may be completely asymptomatic. It is therefore essential to test for Chlamydia whenever there is a suspicion of infection or when there is evidence of other sexually transmitted infection. Chlamydia also may cause conjunctivitis or pneumonia in newborns through perinatal...

Psittacosis

Psittacosis is a disease found among bird handlers that presents with fever, chills, headache, photophobia, cough, and myalgia. In the laboratory, any of the following methods will confirm the diagnosis (1) isolation of Chlamydia psittaci from respiratory secretions, (2) a fourfold or greater increase in antibodies against C. psittaci by complement fixation or microimmunofluorescence (MIF) to a reciprocal titer of at least 32 between paired acute and convalescent serum samples, or (3) detection...

Clinical Diagnosis

The diagnosis of MS is clinically based, relying heavily on the neurologic history and physical examination. The diagnosis is suggested when a patient has either two or more prolonged (days to weeks) episodes with neurologic dysfunction that suggests distinct white matter pathology or spinal cord dysfunction that worsens over several months.11 Optic findings, lack of focal pathology, clinical remissions, cerebrospinal fluid (CSF) findings, and typical features such as dysautonomias all suggest...

Differential Diagnosis

Careful history taking and physical examination should be used to rule out neurologic disease. A high index of suspicion should be maintained for physical disorders that have a vague onset, such as systemic lupus erythematosus, multiple sclerosis, polymyositis, Lyme disease, and drug toxicity or poisoning. Schizophrenia and depression may have associated conversion disorders. In somatization disorders, the symptoms are more chronic and involve multiple organ systems. With hypochondriasis,...

Pathology and Risk Factors

Most cases of PID are presumed to originate with sexually transmitted disease (STD) of the lower genital tract followed by ascending infection of the upper tract. The original STD may not be symptomatic. It is estimated that 10 to 20 percent of untreated gonococcal or chlamydial cervicitis may progress to PID. The precise mechanisms by which infection in the upper genital tract is initiated and propagated remain unclear. The female genital tract is an open system therefore a vehicle to...

Radiographs

The chest radiograph is considered the pragmatic reference standard for making the diagnosis. 25 The finding of consolidation on radiograph is thought to be a reliable sign of pneumonia.32 Differentiating the various microbiologic causes of pneumonia is often more difficult. Typical patterns of clinical presentation and epidemiologic data on incidence have been described above but often overlap. Radiographically, viral pneumonias tend to appear as diffuse interstitial infiltrates, frequently...

TABLE 1973 Assessment and Treatment Essentials

Neurologic symptoms are typically classified either as immediate but transient or as delayed and usually progressive. However, some neurologic injuries can be severe, immediate, and permanent.11 Immediate but transient symptoms include confusion and amnesia, loss of consciousness, temporary lower extremity paralysis, and temporary upper extremity paralysis.10 Lower extremity paralysis (keraunoparalysis) is often a consequence of step-voltage injury and is usually associated with paleness,...

TABLE 1783 Adverse Effects of Chelating Agents

For symptomatic patients without encephalopathy, and for asymptomatic patients with elevated PbB levels requiring chelation, the use of BAL or DMSA (see discussion below) with or without CaNa2-EDTA and the dosing schedules are determined by the PbB levels, the presence or absence of symptoms, and changing practice as more experience with DMSA is obtained. Treatment may be initiated in the ED. Children who are symptomatic but not encephalopathic can be treated as discussed earlier, except with...

Orbital Fractures

Blowout fractures are the most common orbital fractures. These injuries occur when a blunt object strikes the globe, resulting in expansion of orbital contents and subsequent rupture through the bony floor. A direct blow to the orbital rim will also result in a blowout. Four clinical findings suggest the diagnosis. (1) Rare patients may have enophthalmos, or sunken globe, when a large section is ruptured. (2) Infraorbital anesthesia is a more common finding and develops when the infraorbital...

Photosensitivity

The types of reactions to ultraviolet light are varied. In many disorders, ultraviolet light aggravates, but does not cause, the disease. Examples of this type of reaction include lupus erythematosus, porphyria cutanea tarda, dermatitis associated with niacin deficiency (pellagra), and recurrence of HSV. Other disorders are caused primarily by the sun. The most common is a sunburn reaction. Sunburn reaction, exogenously induced photosensitivity, and polymorphous light eruption are discussed...

TABLE 2381 Medications Commonly Causing Photosensitivity Eruptions

The diagnosis is based on identifying the offending agent. If the diagnosis is unclear, other photosensitivity disorders, such as lupus erythematosus and polymorphous light eruption, should be excluded. Photopatch testing performed by a dermatologist or allergist may be helpful in identifying the photosensitizing agent. The causative agent should be discontinued, if possible. Initial management includes topical corticosteroids and management similar to a sunburn reaction. The patient should...

Clinical Approach

The overall approach to trauma is discussed in Chap 243. Only issues specific to genitourinary trauma are discussed here. Renal system injuries rarely require immediate intervention. Investigation of renal injuries should not supercede evaluation of more life-threatening injuries. For example, with a pelvic fracture, determining the need for pelvic angiography is more important than determining whether a urethral injury exists. The patient may well die from a sheared major artery, whereas an...

History

Routine questions should determine the quality, location, radiation, intensity. frequency, associated symptoms, and precipitating factors of chest pain. For patients who have difficulty explaining symptoms in a narrative fashion, directed questions should be asked. Patients without previously diagnosed ischemic heart disease may have difficulty describing the quality of pain and may resort to textbook terms. Specific questioning is needed about radiation to the jaw, neck, arms, back, or...

Clinical Features And Treatment

The spectrum of disease caused by HIV infection varies greatly. Many patients with asymptomatic infection may come to the emergency department for complaints unrelated to HIV disease.12 Others may have involvement of virtually any organ system, commonly with multiple interrelated problems. Because of the complexity of HIV infection and related opportunistic infections or malignancies, specific diagnoses often cannot be made in the emergency department. Evaluation of HIV-infected patients should...

Cardiac Resuscitation And Outcomes

There are an estimated 750,000 sudden deaths in the United States annually. The outcome of resuscitative efforts for victims of cardiac arrest is uniformly poor, but varies, dependent on a variety of factors. The most important factor determining outcome is the time elapsed since arrest (downtime). One study showed a 27 percent resuscitation rate for patients who received advanced cardiac life support (ACLS) within 8 min of arrest, and a dismal outcome if more than 20 min elapses. 1 Improved...

Constrictive Pericarditis

PATHOPHYSIOLOGY Constrictive pericarditis is pathologically distinct from acute pericarditis. 18 Following pericardial injury and the resultant inflammatory and reparative process, fibrous thickening of the layers of the pericardium may occur. This fibrous reparative process is most commonly encountered after cardiac trauma with intrapericardial hemorrhage, after pericardiotomy (open-heart surgery, including coronary revascularization), in fungal or tuberculous pericarditis, and in chronic...

TABLE 1551 Pharmacologic Classification of Typical and Atypical Antipsychotic Agents

Conventional, or typical, antipsychotics are a diverse group of older agents that gained widespread acceptance for the control of the positive symptoms (e.g., hallucinations, delusions, and disordered thought) of schizophrenia and related psychoses. These agents cause numerous adverse effects, however, and do little if anything to ameliorate the cognitive dysfunction and negative symptoms (e.g., withdrawal, flat affect, and loss of drive) that are also characteristic of the disease. Thus, a...

Chiari II Malformation

Chiari II malformation is present in the majority of children with meningomyelocele. Chiari II malformation consists of malformation of the cerebellum, hindbrain, and brainstem. Aqueductal stenosis is commonly associated. Symptomatic Chiari malformation is characterized by apnea, vocal cord paralysis, stridor, oral motor dysfunction, visual dysfunction, and upper limb weakness and incoordination in the infant. In older children it presents with visual dysfunction, motor incoordination,...

Mental Status Examination

The goal of the mental status examination is to determine if an abnormality of mental status exists and whether it points to a structural, metabolic, toxic, or infectious etiology. An alteration of mental status requires a deficit in alertness or awareness or both. Alertness requires the normal functioning of the ascending reticular activating system (ARAS), which passes through the midline of the brainstem up through the thalamus, resulting in arousal of the cerebral hemispheres. Awareness,...

TABLE 513 Effect of Bedside Interventions on the Murmur of Hypertrophic Cardiomyopathy Compared to Mitral Valve Prolapse

ECG findings of LV hypertrophy and left atrial enlargement are found in 30 percent and 25 to 50 percent, respectively, of HCM patients. Evidence of chamber enlargement is most common in patients with large gradients across the LV outflow tract. Q waves of considerable amplitude (more than 0.3 mV), termed septal Q waves, are seen in about 25 percent of patients and may be encountered in the anterior, lateral, or inferior leads. These Q waves may mimic those seen following myocardial infarction...

Sodium Nitroprusside Nipride

ACTIONS AND PHARMACOLOGY This rapidly acting arteriolar dilator and venodilator is the drug of choice for hypertensive emergencies and is the standard against which all other agents are compared. It acts by reacting with cysteine to form nitrosocysteine, a potent activator of guanylate cyclase, which in turn stimulates the formation of cyclic gMp to relax smooth muscle in both arteries and veins. This decreases preload and afterload, resulting in decreased myocardial oxygen demand. The heart...

TABLE 1026 Radiation Exposure to the Uterus Fetus

A common nuclear medicine imaging study used by the emergency department physician is the ventilation perfusion scan. Total fetal exposure to xenon 133 and technetium 99m is about 0.5 rad, and they can be used safely in pregnancy. Fetal exposure from other studies using technetium 99 range from 0.03 to 0.06 rad mCi and are safe in pregnancy. Because the excretion of these radionuclide particles is often via the maternal bladder, which is close to the fetus, hydration and frequent voiding need...

Procedures

Procedures are more difficult to perform on the obese emergency patient (Table 304 1). Landmarks are obscured or nonpalpable, access is often impaired by excessive tissue, and positioning problems are common. Airway management may be difficult, intravenous access delayed, and investigations cumbersome or impossible to obtain in the obese patient. These factors all contribute to inevitable obstructions to rapid assessment and resuscitation. Having alternative approaches readily available is the...

Bursae

The bursae facilitate motion between the components of the shoulder. There are eight identifiable bursae in the shoulder complex. However, only one, the large subacromial bursa, also known as the subdeltoid bursa, is clinically significant. The subacromial bursa is extraarticular its roof adheres to the undersurface of the deltoid, and its floor to the underlying rotator cuff. A thick layer of synovial fluid between the roof and the floor normally allows smooth frictionless motion between the...

Special Issues Affecting Diagnosis

Mentally challenged children can be especially difficult to evaluate. Often they have dysautonomia as well as feeding difficulties. A low threshold for blood glucose evaluation is appropriate in these patients, especially if the caretakers note a change in baseline behavior or mental status. 2. Most children who present with self-harming thoughts, suicidal threats, or true suicide attempts should have their glucose checked as part of their medical clearance. This is especially true of diabetic...

Hematologic Complications

ANEMIA Anemia in ESRD patients is of multifactorial origin, secondary to decreased erythropoietin, blood loss from dialysis, and decreased red blood cell survival times. In addition, wide fluctuations in plasma blood volume seen in dialysis patients often cause factitious anemia. Without treatment, the hematocrit in ESRD patients will usually stabilize at 15 to 20 percent, with normocytic and normochromic red blood cells. Bone marrow will show erythroid hypoplasia with little effect on...

TABLE 1841 Manifestations of Hypoglycemia

In healthy persons, complex regulatory systems maintain a constant level of glucose in the blood. Unfortunately, certain medical conditions may impair the ability of the body to maintain glucose levels, and hypoglycemia results. Chronic ethanol users are at increased risk for hypoglycemia due to diminished glycogen supply and impaired gluconeogenesis. Persons at extremes of age are also potentially at increased risk for hypoglycemia. Young children have a disproportionately higher brain...

TABLE 2194 Emergency Department Treatment Options for Migraine Headache

Dexamethasone has been touted as effective in reducing the rate of recurrent migraine following standard treatment. 2 In one ED-based RCT, patients received either 20 mg intravenous dexamethasone or placebo after standard migraine therapy. A significant reduction in the rate of 48- to 72-h recurrent migraine was found in the dexamethasone group as compared to the placebo group.19 Special mention is reserved for the use of opioid analgesics in migraine. Meperidine is still used as an acute...

Laboratory Evaluation

The selection of particular laboratory tests emerges from diagnostic needs suggested by the history and by the findings of mental status examination and physical examination. Fluid and electrolyte disorders are common in elderly patients. Hypoglycemia can precipitate aggressive or agitated behavior, and an elevated white blood cell count may signify infection in patients with acute changes in mental status. Tests that can be helpful when a patient presents with agitation are listed in Table...

Leukoplakia and Erythroplakia

Leukoplakia is defined by the World Health Organization as a white patch or plaque that cannot be scraped off or characterized clinically or histopathologically as any other disease.21 Leukoplakia is the most common oral precancer however, only 2 to 4 percent of leukoplakic lesions are carcinoma.22 The prevalence is approximately 20 to 39 per 1000 persons, affecting males twice as frequently as females. Etiology is unknown, but tobacco, alcohol, ultraviolet radiation, candidiasis, human...

Miscellaneous Adverse Effects

In addition to the various dopamine-related side effects just described (extrapyramidal disorders, tardive dyskinesia, and NMS), the antipsychotics may cause a variety of other untoward effects, some of which are highlighted here. All antipsychotics may cause sedation and impair mental capacity to some degree 24 patients should be cautioned regarding activities requiring mental alertness, such as driving and operating heavy machinery. Photosensitivity may occur with the typical antipsychotics,...

TABLE 1458 Pet Associated Zoonotic Infections

Parasitic infections are very common among household pets, predominantly dogs and cats. Up to 50 percent of dogs are infected with at least one intestinal parasite, and 15 percent of adult dogs actively excrete Toxocara canis, the source of toxocariasis, visceral larva migrans.52 Despite its prevalence in dogs, human toxocariasis is infrequently diagnosed probably because infection is often subclinical. Typically, the only indication of infection is eosinophilia. Children may display fever,...

Diagnosis Of Valvular Heart Disease

The loud background noise in the emergency department makes the accurate auscultation of subtle murmurs difficult. Despite this, the emergency physician may suspect undiagnosed valvular dysfunction on incidental cardiac auscultation. The ECG and chest radiograph may be of help, but neither is confirmatory. The suspected diagnosis should be confirmed by echocardiography and or consultation with a cardiologist. Transesophageal echocardiography yields a more complete analysis of valvular...

Management Of Patients With Chronic Pain

Epidemiology Pathophysiology Clinical.Features Diagnosis chronicPainjn the, Elderly Disposition Management,, oLP,a.t,i.e.nts., with , Drug-Seeking,, Behavior Specific Issues Legal Implications Treatment and Disposition Chapter, References Chronic pain is defined as a painful condition that lasts longer than 3 months. 1 Chronic pain can also be defined as pain that persists beyond the reasonable time for an injury to heal or a month beyond the usual course of an acute disease. There are four...

Miscellaneous Sources Of Hypoglycemia

The ackee tree is native to Jamaica, where it produces a fruit that is commonly eaten. The unripened fruit contains hypoglycins, a group of toxins that produce vomiting (Jamaican vomiting sickness), central nervous system sedation, and seizures. In addition, hypoglycins inhibit hepatic gluconeogenesis and may contribute to hypoglycemia. Epidemics of hypoglycin-mediated hypoglycemia have occurred only during times of famine, when poor nutrition and the increased eating of unripened fruit are...

TABLE 2318 Causes of Hypermagnesemia

PHYSIOLOGIC EFFECTS Hypermagnesemia only rarely produces symptoms. Mg2+ significantly decreases the transmission of neuromuscular messages and thus acts as a CNS depressant and decreases neuromuscular activity. An initial finding in hypermagnesemic patients is nausea that appears with serum levels greater than 2.0 meq L. Somnolence may develop as levels approach 3.0 meq L. Deep tendon reflexes tend to disappear at serum concentrations of 4.0 to 8.0 meq L, and respiratory compromise or apnea is...

Morbidity Mortality from Acute Renal Failure

Reported mortality rates for ARF have remained the same from before to after the advent of dialysis 40 to 90 percent.1314 This statistic reflects a changing epidemiology and etiology of ARF. Before the availability of effective dialysis, many young patients died directly of complications specific to ARF. Now that dialysis effectively treats life-threatening complications of ARF, the patient's age and underlying diseases determine mortality from ARF. ARF has become an index of the severity of...

Diagnosis and Management

There is general agreement that patients who are hemodynamically unstable or have obvious aerodigestive injury require immediate surgical intervention. In those who are stable, the diagnostic approach is determined by the location of the wound. Nonoperative studies are used to identify injuries in zones I and III. Vascular control is often difficult to obtain in these zones. Zone I injuries require a thoracic surgical approach to gain proximal vascular control, important for arterial injuries....

Peripheral Vasodilators And Ganglionic Blockers

The toxic manifestations of these classes of medications include hypotension and bradycardia. Hypotension is best treated with intravenous fluids and, if necessary, vasopressors. If symptomatic bradycardia develops, atropine should be used. Seizures are a potential complication and should be treated with standard anticonvulsant therapy. In addition to hypotension, a-adrenergic antagonists such as phentolamine may also cause CNS effects. No deaths have been attributed to the acute toxicity of...

TABLE 893 Key Historical Elements for Hemodialysis Patients

Patients should be asked about their HD schedule. The majority of HD patients in the United States are on an every-other-day schedule (Monday, Wednesday, and Friday or Tuesday, Thursday, and Saturday), each session lasting approximately 4 h. Certain centers have begun using high-flux HD machines with higher blood flows, allowing shorter HD sessions. The physician should document all recent missed sessions and the patient's explanations for missing them. Such history taking may provide important...

Rocky Mountain Spotted Fever

This is a tick-borne illness of acute onset and characterized by headache, myalgia, fever, and petechial rash that appears on the palms and soles in two-thirds of patients. Laboratory diagnosis may be made by one of several methods (1) a fourfold or greater rise in antibody titer to Rickettsia rickettsi. antigen by immunofluorescence antibody, complement fixation, latex agglutination, microagglutination, or indirect hemagglutination antibody test in acute and convalescent specimens taken 4...

Lactational Mastitis

Postpartum mastitis is much more common than nonpuerperal mastitis. The pathophysiology involves obstruction of the duct, inspissation of milk, and secondary bacterial invasion. The patient has localized warmth and tenderness of the affected breast. She may even have systemic symptoms and signs, such as fever, malaise, and leukocytosis. The condition is so painful that it may threaten continuation of breast-feeding. Most authors recommend a conservative approach to mastitis in postpartum...

Angiotensin Ii Receptor Antagonist

The antihypertensive medications of this relatively new class are reversible, competitive inhibitors of the angiotensin II receptor. Losartan, the first drug of this class to be approved, has no effect on ACE but is a selective blocker of the AT receptor found in vascular smooth muscle. Experience is limited with losartan, but adverse effects have been reported to be minimal. Toxicity includes hypotension and bradycardia. Supportive measures, including intravenous normal saline, adequate...

Gastrointestinal Zoonotic Infections

With a multitude of etiologies, gastroenteritis is one of the most common illnesses treated by emergency physicians. Many of the parasitic, bacterial, and viral organisms responsible for gastroenteritis share a zoonotic source in addition to a human source. In the evaluation of patients with suspected gastroenteritis, information regarding travel history and animal exposure is extremely important. Occupational exposure to cattle, horses, poultry, sheep, swine, or reptiles and even exposure to a...

Intracerebral Vascular Disorders

Subarachnoid hemorrhage may occur following trauma or spontaneous rupture of a berry aneurysm or arteriovenous malformation. Nuchal rigidity is an inconstant finding. Venous thrombosis may follow severe dehydration or a pyogenic infection of the paranasal sinuses, mastoid, or middle ear. Periorbital edema with cranial nerve abnormalities is a clue. Arterial thrombosis is uncommon in children, except in those with homocystinuria. Children with homocystinuria have a marfanoid appearance,...

Sphygmomanometry

Inadequate cuff width and circumference will artificially elevate pressure readings.16 However, many morbidly obese patients are hypertensive, and a high pressure reading cannot always be blamed on inappropriate equipment. In order to minimize errors in blood pressure recording, a correct ratio of cuff width to arm circumference, approximately 2 5, should be chosen. The bladder length should be 80 percent of the arm circumference. The ED should stock a variety of sizes of blood pressure cuffs...

Gastroenteritis

Treatment of diarrhea changed in the mid-1960s with the introduction of oral rehydration solution (ORS) as an alternative to administration of IV fluids. Although ORS is still not universally used in the United States, it has been proven to be effective and to result in fewer complications than IV therapy. ORS successfully rehydrates 90 percent of children in whom it is used.11 The majority of children with diarrhea and vomiting who become dehydrated may be treated with ORS (Fig 122-1). This...

Cardiovascular Complications

The heart is a major target organ for insulin, and marked changes in cardiac function occur in patients with diabetes mellitus. 16 Whether type 1 or type 2, coronary artery disease accounts for more than half of deaths in diabetics.16 Factors contributing to the diabetic cardiac dysfunction are increased incidence of atherosclerosis of the coronary arteries, autonomic neuropathy, and microvascular disease (associated with hypertension and renal disease). Diabetics are prone to silent myocardial...

Failure to Thrive

The establishment of consistent weight gain with oral feedings is a standard criterion for discharge from the hospital for most premature infants. However, this does not ensure that the pattern of weight gain will continue following discharge. Failure to thrive may occur either because of an ongoing chronic disease (e.g., bronchopulmonary dysplasia, malabsorption, or central nervous system disease) or because of dysfunctional parenting. NICU graduates should be consuming at least 150 mL kg day...

Bleeding Complications

The vast majority of postoperative bleeding complications in patients will occur in the first week and will not be seen in the ED. More likely is gastrointestinal bleeding, which should be managed in the usual fashion but may signal graft dysfunction and be accompanied by profound hypoglycemia and progressive coagulopathy. 3 Portal hypertension is reversed by liver transplantation and gastrointestinal (GI) bleeding from varices postoperatively may be indicative of portal vein thrombosis....

TABLE 54 Triage Categories

WOUND CARE AND CRUSH SYNDROME This section addresses some concepts of care that are not found in the routine management of emergency patients. Wound infections may occur in virtually all types of disasters. Infected wounds and gangrene were major problems following an earthquake in Armenia (1988) and tornadoes in Illinois (1991).5 58 In hurricanes or tornadoes, persons may be cut by flying glass and other, potentially highly contaminated material. Because of this, all wounds should be copiously...

Initial Interventions

Patients may be unresponsive or have an altered mental status for many reasons. Four possible diagnoses (hypoxia, opioid intoxication, hypoglycemia, and Wernicke encephalopathy) may be easily overlooked, but are readily treated by the administration of specific antidotes. Within the first few minutes after the patient's arrival, the administration of empiric antidotes supplemental oxygen, 1.0 to 2.0 mg intravenous naloxone in adults and 0.01 mg kg in children, 50 mL 50 dextrose in water (50 D...

Frostbite And Other Localized Coldrelated Injuries

Nonfreezing, Cold Injuries ., Chil.b.la.i.ns .and , IrenchFoot F,re,eZing Cold.n Throughout history the most celebrated and extreme reports of cold-related injuries have been in the field of military endeavor. From Hannibal's losing half his 46,000-man army crossing the Pyrenean Alps to frostbite and hypothermia, to the tens of thousands of cases of trench foot during World War I, we have learned much. Perhaps the most famous cold-injury mass-casualty incident was Napoleon's retreat from Moscow...

TABLE 474 Some Nonatherosclerotic Etiologies of Acute Myocardial Ischemia

Plaque formation occurs through repetitive injury to the vessel wall. Macrophages and smooth muscle cells are the main cellular elements in plaque development, whereas lipids are the predominant in the extracellular milieu. Plaque fissuring and rupture is affected by features inherent to the plaque, such as its composition and shape, as well as local factors such as shear forces, coronary arterial tone, coronary arterial perfusion pressure, and movements of the artery in response to myocardial...

Scrum Crdefcifl 20 of ihc kxly vch total body Vdefkit

The total body Cl - should be repleted by giving 25 percent of the calculated Cl- deficit as KCl and 75 percent as NaCl. In the setting of renal insufficiency or failure, treatment options are more complicated in that NaCl administration may lead to volume problems and KCl may lead to hyperkalemia. The replacement method of choice, amino acid hydrochlorides or 0.1 N HCl, will lead to a non-anion-gap acidosis, worsening the underlying wide-anion-gap acidosis associated with renal failure.

Sources Of Assistance

Emergency department personnel should be familiar with authorities that can provide advice and assistance when radiation accidents occur. Radiation emergency call lists may be prepared in advance and include the following contacts 1. Local facilities which staff medical and health physics professionals trained in radiation accidents. 2. Local civil defense or disaster offices. 3. State radiological health office (title may vary by state). 4. Federal Emergency Management Agency (FEMA) 5. US...

Internally Contaminated Patients

Radioactive material gains entry into the body by three principal routes inhalation, ingestion, or absorption from contaminated mucous membranes or abraded skin. Misadministration of a radiopharmaceutical is a potential source of internal contamination that can occur in the hospital setting. Internal contamination becomes a major concern of the population if large amounts of radioactive material are released into the atmosphere as a result of nuclear weapon detonation, large-scale nuclear power...

TABLE 1998 Commonly Treated Forms of Internal Contamination

RADIOIODINE Inhalation or ingestion of radioiodine is particularly hazardous to the thyroid with a potential risk of causing hypothyroidism or thyroid cancer. I-131 is the predominant internal contaminate resulting from incidents that involve the release of nuclear fission products such as a nuclear reactor accident or nuclear weapons test. Studies on the health effects of the Chernobyl accident have shown that populations in heavily contaminated areas have an increase in thyroid cancer...

Pathophysiology

Repetitive impingement of the bursa, rotator cuff, and biceps tendon produces pathologic changes in these structures that progress in a predictable pattern. Early on, repetitive motion produces mechanical inflammation of the subacromial bursa and underlying rotator cuff. As activities that cause impingement continue, inflammation of the rotator cuff tendons worsens. Chronic inflammation in time leads to degeneration and eventual tearing of the rotator cuff. Degeneration of the rotator cuff...

Therapeutic Implications

All of the medical management provided to children with heart disease is directed toward increasing cardiac output in low-output states by alteration of the heart rate, preload, afterload, or inherent contractility. As mentioned previously, some of these parameters may be rather fixed due to the inherent limitations of the neonatal ventricular noncompliance.3 Heart rate is the most malleable of the cardiac physiologic parameters. Symptomatic bradycardias of all types are treated with...

TABLE 2291 Considerations for Nonenhanced Head CT for Headache

Axial CT demonstrates areas of increased density compatible with subarachnoid hemorrhage (SAH) (straight arrows). There is also early hydrocephalus with the temporal horns dilated (curved arrow). Headache associated with unexplained fever is also an indication for neuroimaging, particularly when there is associated meningismus and photophobia. Although diagnosis is made by lumbar puncture, imaging is typically recommended to exclude hydrocephalus. Despite the absence of scientific...

Primary Headache Syndromes

The term primary headache includes all forms of migraine, tension-type, and cluster headaches. There is considerable clinical overlap in primary headache syndromes, and it has been suggested that they share a pathophysiology and represent different ends of a clinical spectrum. 7 MIGRAINE Epidemiology Migraine headaches are common, with onset usually in the early teens or even younger. Prevalence is estimated at approximately 5 percent for males and 15 to 17 percent for females.2 Prevalence...

Troubleshooting a Persistently Hypotensive Patient

Treatment of a persistently hypotensive patient after maximal therapy can be a harrowing experience in the ED. The patient who has obvious trauma with ongoing hemorrhage, the reason is usually apparent, and the outcome is dismal if uncorrected. In medical cases of shock or in cases without ongoing hemorrhage, potential pitfalls should be rapidly reviewed. Is the patient appropriately monitored Is there malfunctioning arterial blood pressure monitoring, such as dampening of the arterial line or...

TABLE 1125 Causes of Jaundice in Neonates

Physiologic jaundice is due to the breakdown of fetal red blood cells, and bilirubin rises at a rate of less than 5 mg dL per 24 h, with a peak of 5 to 6 mg dL during the second to the fourth day of life, returning to < 2 mg dL by 5 to 7 days. Septic infants with hyperbilirubinemia also have other features of sepsis, such as vomiting, abdominal distention, respiratory distress, and poor feeding. Jaundice associated with breast-feeding is thought to be due to the presence of substances that...

Encephalitis Arboviral

Arboviral encephalitis is characterized by a febrile illness associated with any of the following neurologic signs and symptoms headache, confusion, altered sensorium, nausea and vomiting, meningismus, cranial nerve palsy, paresis or paralysis, sensory deficit, altered reflexes, seizures, abnormal movements, or coma. The illness may be of varying severity and cannot be distinguished clinically from other central nervous system infections. The diagnosis is made based on laboratory detection of...

Bone Marrow Transplants

Emergency physicians can expect to care for increasing numbers of bone marrow transplant patients due to the rising prevalence and survivability of this procedure. Bone marrow transplants are currently performed for malignant conditions such as leukemia, lymphoma, and selected solid tumors as well as for nonmalignant conditions such as aplastic anemia, thalassemia, and sickle cell anemia. Bone marrow transplants can be categorized as either allogeneic or autologous. In an allogeneic transplant,...

Hantavirus Pulmonary Syndrome

Hantavirus pulmonary syndrome is a febrile illness characterized by bilateral interstitial pulmonary infiltrates and respiratory compromise resembling adult respiratory distress syndrome. There is typically a prodrome of fever, chills, myalgias, headache, and gastrointestinal distress. Common laboratory findings include one or more of the following hemoconcentration, left shift in white blood cell count, neutrophilic leukocytosis, thrombocytopenia, or circulating immunoblasts. Hantavirus should...

Prostate Surgical Procedures

Prostate surgery is usually performed for either benign prostatic hyperplasia (BPH) or prostate cancer. Common surgical techniques employed include transurethral resection of prostate (IURP), transurethral incision of prostate (IUIP), transurethral laser vaporization, and transurethral microwave thermotherapy. Surgical procedures of the prostate typically involve direct manipulation of the urinary outflow tract. Iherefore, common complications include hematuria, clots with subsequent urinary...

Investigation of the ED Headache Patient

COMPUTED TOMOGRAPHY SCANNING The ED patient whose headache requires emergent investigation usually begins with a noncontrast computed tomography (CT) scan.4 The use of contrast material increases the time, expense, and risk of adverse effects (minor 10 percent, severe 0.1 percent), 5 and the noncontrast CT scan usually adequately excludes critical lesions or mass effects requiring emergent interventions. In particular, the noncontrast CT scan is the best neuro imaging test for diagnosing an...

TABLE 53 Hospital Disaster Areas

DISASTER COMMAND Disaster command provides overall direction and coordination of the hospital disaster response activities. These activities include activation of the plan, coordination of hospital activities with those at the disaster site, opening up additional hospital wards or clinics, obtaining outside assistance, evacuation of endangered patients, assignment of staff to treatment areas, and adjustment of the plan as necessary. Good, reliable communication is essential. TRIAGE Entry of all...

Oral Candidiasis

Candidiasis commonly affects the oral cavity. Nearly 60 percent of healthy adults harbor candidal microorganisms. Concurrent histologic evidence of tissue invasion and clinical manifestations of candidal infections are the primary means for diagnosing oral candidiasis. Many predisposing factors influence the development of oral candidiasis. These include the extremes of age, intraoral prosthetic devices such as dentures, malnourished states, associated mucosal disorders, concurrent infections,...