Clinical Features

One sees erythema with a peripheral annular slightly scaly edge in the groin and extending onto the inner thighs ( Fig 2.4.0.-1) and even the buttocks. The penis and scrotum are not affected. This feature is important in distinguishing tinea cruris from other eruptions in the groin as most other eruptions will affect the scrotum. FIG. 240-1. Tinea cruris. Erythema with a more prominent, arciform leading edge on the inner thighs is typical of tinea cruris. Other common disorders to be included...

Phase 1 Anxiety

The first level of behavior seen in a potentially violent patient is anxiety. This may not only occur with the patient. Family and visitors waiting long periods in the emergency department waiting room may also exhibit anxiety and should be dealt with before visiting the patient so as not to intensify the patient's behavior. In general, the signs of increasing anxiety are indicated by body language. Movements that seem to have no purpose other than to expend energy may be the first clue. These...

Breech Presentation

Breech presentations occur in 3 to 4 percent of term pregnancies and are associated with a morbidity rate three to four times greater than that of cephalad presentations. Breech presentations most frequently occur in premature infants, since final rotation in the pelvis may not have occurred. The major concern in breech deliveries is head entrapment. In a normal cephalic delivery, the larger head dilates the cervical canal, thus ensuring that the rest of the infant follows. With breech...

Diverticulitis

Diverticulitis is an acute inflammatory process caused by bacterial proliferation within an existing colonic diverticulum. Epidemiology Acquired diverticular disease of the colon has become an increasingly common disorder of industrialized nations. Diverticulosis coli was first described in the early 1700s by Littre but was not identified as a pathologic entity until the mid-nineteenth century by Cruveilhier. Radiologic studies have suggested that one-third of the population will have acquired...

Intravenous Contrast Enhancement

The IVP and CT use intravenous contrast material containing iodinated compounds that absorb x-rays. These agents allow the vessels and organs to be more easily differentiated from adjacent nonenhancing structures. A typical imaging protocol involves the administration of 150 mL of intravenous contrast by a power injector into an intravenous catheter of adequate size, typically an 18-gauge catheter in the antecubital vein. Intravenous contrast media are classified according to two...

TABLE 234 Etiology of Syndrome of Inappropriate Antidiuretic Hormone SIADH

Hypervolemic hyponatremia is described as TBW in great excess. These patients present with manifestations of volume overload, such as peripheral and or pulmonary edema. They usually have impaired ability to excrete a water load. This allows for water retention in excess of Na + retention. These patients can be further categorized into two groups (Iabje,,2 3. .3) The first of these is generalized edematous states without advanced renal insufficiency. These patients have urinary Na + of less than...

Clonidine

This centrally acting antihypertensive has long been a favorite for the acute management of hypertension. Two forms of clonidine are commonly prescribed, including an oral version and a transdermal patch. Clonidine has gained prominence in recent years because of its ability to mitigate opiate and alcohol withdrawal symptoms. Although it has not been approved by the Food and Drug Administration for this use, clonidine has been used as standard clinical practice for the treatment of narcotic...

Glossary Of Terms Abbreviations And Notations

It is important to understand the terms and abbreviations used in ophthalmology, not only to be more effective and precise when interacting with consultants but also to aid you in interpreting their written consultations. AC Anterior chamber, the first portion of the anterior segment Anisocoria Unequal pupil size under equal lighting conditions Anterior segment Consists of the anterior chamber and posterior chamber. Aqueous is produced in the posterior chamber of the anterior segment and...

Differential Diagnosis

The most important points to consider are those diagnoses arising as complications from sinusitis. These include any evidence of infectious extension from the sinus cavity, such as periorbital cellulitis, brain abscess, subdural empyema, meningitis, or cavernous sinus thrombosis. Such patients are febrile, extremely ill, may have unstable vital signs, can demonstrate altered mental status, meningismus, or focal neurologic findings. None of these symptoms are compatible with diagnosis of...

Effects of Status Grand

Experimental models in animals provide evidence of the neurologic effects of SGM. Selective permanent cell damage in the hippocampus, amygdala, cerebellum, thalamus, and middle cerebral cortical layers develops after 60 min of seizure activity. Even with artificial ventilation and correction of existing metabolic derangements, most changes still occur. This cell death results from the increased metabolic demands and the exhaustion of the continuously firing neurons. In addition, there are...

TABLE 2316 Some Common Topical Otic Preparations

Bacterial and fungal cultures may guide treatment of nonresponsive cases. Oral antibiotic therapy should be reserved for febrile patients and those with periauricular extension. All patients with OE should be taught to avoid predisposing factors in order to eliminate recurrences. Strategies include ear plugs while swimming or bathing (cotton wool impregnated with Vaseline or commercial ear plugs), occasional, brief use of a hair dryer to remove EAC water, and avoidance of cotton-tipped...

Orotracheal Intubation

Oral pharyngeal laryngeal axes. B. Sniffing position. The patient should be thoroughly preoxygenated prior to intubation if time permits. Begin with the laryngoscope in the left hand and an ET tube or suction apparatus in the right hand. After dentures and any obscuring blood, secretions, or vomitus are removed, the suction is exchanged for the ET tube and inserted during the same laryngoscopy. The blade is inserted into the right corner of the patient's mouth. If a curved...

Prodromes Of Violence

In most cases, violent behavior is not one of the presenting signs of the patient. Therefore, recognition of the prodromes of violence is necessary. The phases of escalation are generally agreed upon. The first is the anxiety phase, followed by defensiveness, and then physical aggression. 7 Each phase evokes a response that is proportionate to the patient's behavior. In general, verbal abuse is best handled by verbal response. Physical aggression is best handled by physical means. It is...

Cerebral Palsy

Cerebral palsy is a disorder of movement and posture due to static, nonprogressive injury sustained by the developing brain. The brain damage must occur by 5 years of age. It occurs in 2.5 to 3 per 1000 individuals. Diagnosis before 12 to 18 months of age can be confused with transient tonal problems or progressive degenerative disorders. The movement problems manifest in a variety of forms and can affect the head, trunk, and extremities in a variety of ways. Cerebral palsy is commonly...

Endometritis

EARLY POSTPARTUM 1ST 48 H (Note three drug therapy) 1. Cefoxitin (Mefoxin) 2 g IV q 6-8 h B 2. Ticarcillin clavulanic acid (Timentin) 3.1 g IV q6h B 3. Imipenem (Primaxin) 500-1000 mg IV q6h c 4. Ampicillin sulbactam (Unasyn) 3.0 g IV q6h B 5. Piperacillin tazobactam (Zosyn) 3.375 g IV q6h B PLUS 1. Doxycycline (Vibramycin) 100 mg IV or PO q12h D 2. Clindamycin (Cleocin) 450-900 mg IV q8h B PLUS 1. Gentamicin (Garamycin) 2 mg kg IV loading dose, then 1.7 mg kg IV q8h (monitor serum levels) D...

Sacroiliac Joint Disease

Mechanical dysfunction can occur within the sacroiliac (SI) joints. Sacroiliac joint pain is commonly referred to the inguinal and anterolateral thigh, as well as the lower abdominal quadrants, often simulating an acute appendicitis or ovarian cyst. Inflammatory processes can involve the SI joints, as in the seronegative spondyloarthropathies. Early in this process there may be little or no correlation between symptom severity and radiographic evidence of joint involvement. The pain is usually...

Chapter References

American Heart Association 1998 Heart and Stroke Facts Statistical Update. Dallas, American Heart Association, 1997. 2. Brott T, Adams HP, Olinger CP, et al Measurements of acute cerebral infarction A clinical examination scale. Stroke 20 864, 1989. 3. Brott T, Broderick JP Intracerebral hemorrhage. Heart Dis Stroke 2 59, 1993. 4. Reid CD, Charache S, Lubov B, et al (eds) Management and Therapy of Sickle Cell Disease. National Heart, Lung and Blood Institute NIH Publication 96-2117, revised...

Large Bowel Obstruction

A carcinoma is the leading cause of large bowel obstruction, while volvulus and diverticulitis account for most of the remaining cases. All of these precipitating conditions are more common in the elderly. The overall mortality rate approximates 40 percent. Distention is common, vomiting and constipation are reported in about half the patients. Importantly, a significant percentage (up to 20 percent) will report diarrhea. A history of rectal bleeding, altered bowel habits, or weight loss may be...

Zoonoses Transmitted From Animal Bites

Well recognized is that up to 1 percent of all emergency department visits are a result of an animal bite. 55 The vast majority of these bites (70 to 93 percent) are from dogs. Conversely, cats account for 3 to 15 percent of all animal bites but carry the highest risk of infection. 5 56 Infection acquired from either a dog bite or a cat bite is typically mixed flora. Staphylococcus and Streptococcus species predominate, followed by Corynebacterium species and Pasteurella multocida.56 Cat bites...

Acute Soft Tissue Injuries

Puncture Wounds are discussed in Chap 43. Complicated foot infections, gunshot wounds to the foot, and many lawn mower injuries require consultation and or operative debridement.34 The latter two open injuries require a careful search for associated vascular and tendon injuries, radiographs to document foreign-body presence and bony involvement, consideration of tetanus vaccine and immunoglobulin administration, aggressive wound irrigation, analgesics, and antibiotics in most cases. Do not rely...

TABLE 2204 Criteria for Intravenous Thrombolysis in Ischemic Stroke

DOSING, ADMISSION, AND COMPLICATIONS The total dose of rt-PA is 0.9 mg kg, with a maximum dose of 90 mg 10 percent of the dose is administered as a bolus, with the remaining amount infused over 60 min. Blood pressure and neurologic checks should be assessed every 15 min for 2 h after starting the infusion. Table 220-5 outlines the emergent management of hypertension following thrombolytic administration. No aspirin or heparin is given in the initial 24 h following treatment. Patients should be...

Tinea Capitis

Tinea capitis is a dermatophyte infection of the scalp. It is most commonly seen in children, particularly African-American children. CLINICAL FEATURES Clinically one sees areas of alopecia with broken-off hairs and scale at the periphery. The alopecia is patchy and usually nonscarring ( Fig. 238-4). Occasionally, tinea capitis is associated with an intense inflammatory response. This is manifested as a boggy, tender, indurated plaque with superficial pustules and overlying alopecia. This is...

Nausea Vomiting and Hyperemesis Gravidarum

Nausea and vomiting of pregnancy are generally seen in the first 12 weeks. Both are extremely common, with nausea seen in 70 percent of patients and vomiting in 50 percent, and symptoms are mild in most. Hyperemesis gravidarum is intractable vomiting with weight loss and laboratory values that show hypokalemia or ketonemia. The cause is not known. Women who lose more than 5 percent of prepregnancy body weight have an increased risk of intrauterine growth restriction and low-birth-weight...

Chronic Compensated COPD

The appropriate and optimal management of decompensated chronic airflow obstruction in an emergency department setting requires an appreciation of chronic day-to-day therapy. Specific management limits further insults to the respiratory system, treats reversible bronchospasm, and prevents or treats complications. HEALTHY LIFESTYLE Elements include regular exercise, weight control, and smoking cessation. Smoking cessation is the only therapeutic intervention that can reduce the accelerated...

Indications for Hospital Admission

All infants who appear toxic should be admitted. Patients with 10 percent dehydration, intractable vomiting, or altered consciousness should be given an infusion of normal saline or Ringer's lactate, regardless of the serum osmolality, and admitted. Infants who are less ill, but whose families may not be able to follow the guidelines for administering ORS, should also be admitted. Infants who are malnourished and have acute diarrhea require special attention. They more often need to be admitted...

History And Physical Examination

The most common reasons for emergency department visits during the postoperative period following gynecologic procedures are pain, fever, and vaginal bleeding. A focused but thorough evaluation should be performed. The history should include the surgical procedure performed (abdominal versus vaginal), the reason for it, time of symptom onset and its proximity to the surgery, complications already experienced, patient's postsurgical history, and medications prescribed. The interval between the...

Alopecia Areata

Alopecia areata (Fig 2.3.8 5.) is disease of unknown etiology that results in nonscarring alopecia. Clinically, one will loose round patches of hair leaving behind smooth bald skin. Inflammation or scale is not present. Any hair-bearing area may be affected, but the scalp is the most common site of involvement. Rarely, patients loose all of their scalp or body hair these are referred to as alopecia totalis and alopecia universalis, respectively. Diagnosis is based on clinical examination....

Bronchiolitis

Bronchiolitis is acute wheezing-associated respiratory illness in early life preceded by signs and symptoms of an upper respiratory infection. Bronchiolitis is a highly seasonal disease, with comparatively few cases seen during summer months and activity peaks during winter months. Serious cases of bronchiolitis occur most commonly in infants younger than 1 year of age, particularly in the first 3 months of life. In the general population of the United States, the incidence of bronchiolitis is...

Gastroesophageal Reflux Disease GERD

Reflux of gastric contents into the esophagus causes a wide array of symptoms and long-term effects. It affects up to 25 percent of the adult population, possibly with even higher rates in elderly populations.14 Classically, a weak LES has been the mechanism held responsible for reflux, and this is seen in some patients. However, it is now accepted that transient relaxation of the LES complex (with normal tone in between periods of relaxation) is a primary mechanism causing reflux. Patients...

DeQuervains Stenosing Tenosynovitis

DeQueirvain's tenosynovitis is a common condition that occurs in patients who have experienced excessive use of the thumb. Often no good cause can be found. This is a tenosynovitis of the extensor pollicis brevis and abductor pollicis tendons, where they lie in the groove of the radial styloid. The patient presents with pain along the radial aspect of the wrist that extends into the forearm. The definitive examination that confirms the diagnosis is Finkelstein's test (Fig. 277 7), in which the...

TABLE 1254 Treatment of Hypoglycemia

Boluses in neonates should be given with 10 D W. Infants should receive 10 D W whenever possible, although 25 D W is acceptable as well. In older children, 25 D W may be used. 25 D W and especially 50 D W are very hyperosmolar and may cause phlebitis or tissue necrosis, if they extravasate. Even without extravasation, patients commonly complain of pain at the injection site for 1 to 2 weeks. The risk of extravasation is increased when smaller veins, such as those found in infants, are used. In...

TABLE 2132 Clinical Emergencies in Patients with Sickle Cell Anemia

Patients with SCD have a chronic hemolytic anemia with a baseline hemoglobin of 6 to 9 g dL and a reticulocyte count of 5 to 15 percent. These patients commonly have cardiopulmonary disease, including decreased pulmonary function and reserve, decreased resting arterial oxygen tension, systolic and diastolic flow murmurs, congestive heart failure, cardiomegaly, and cor pulmonale. Myocardial infarction is rare in patients with SCD. Icterus is the rule as a result of chronic hemolysis. Bilirubin...

TABLE 1205 Predicted Average Peak Expiratory Flow for Normal Children and Adolescents Male and Female

Arterial blood gas analysis should be obtained to determine Pa co2 in children with impending respiratory failure, if the patient is hypoventilating, if PEFR is less than 30 percent of predicted, or if the patient is not responding as expected to treatment. It may also be helpful in determining which children should potentially be admitted to an intensive care unit versus a regular floor. Complete blood count and chemistries are usually unnecessary unless there is a concurrent febrile illness...

Pathophysiology

Orellanine and ortinarin A and B are nephrotoxic compounds found in species of Cortinarius (C. orellanus, C. speciosissimus, and C. gentilis). These toxins are heat stable, and their mechanisms of action are unknown. Mushrooms of this species are found primarily in Europe and do not represent a significant problem in the United States. Recently, a similar delayed onset of renal toxicity was reported following the ingestion of Amanita smithiana14 This mushroom is commonly mistaken for pine...

Testes and Epididymis

TESTICULAR TORSION The differential diagnosis of acute scrotal pain includes testicular torsion, torsion of the appendix testis, appendix epididymis, and epididymitis. Testicular torsion must be the primary consideration ( Fig, 91-7). While the peak incidence of intravaginal torsion occurs at puberty in conjunction with maximal hormonal stimulation, it may occur at any age. FIG. 91-7. Diagrams of testicular torsion and torsion of the appendix testis. FIG. 91-7. Diagrams of testicular torsion...

Anterior Nasal Packing

Anterior nasal packing should be performed on any patient in which direct pressure and vasoconstrictors are unsuccessful in controlling epistaxis. The use of nasal tampons, or sponges, is a very quick and effective method for controlling epistaxis. Nasal tampons, which are initially rigid, are inserted along the floor of the nasal cavity against the septum. They are made of synthetic, sponge-like material that expands to many times its original size after installation of saline or the...

TABLE 771 Extraintestinal Manifestations of Inflammatory Bowel Disease

Dermatologic complications include erythema nodosum and pyoderma gangrenosum. Ocular manifestations include episcleritis and uveitis. Hepatobiliary disease is common in patients with inflammatory bowel disease and includes pericholangitis, chronic active hepatitis, primary sclerosing cholangitis, and cholangiocarcinoma. Gallstones are detected in up to 33 percent of patients with Crohn's disease. Ihe incidence of acute and chronic pancreatitis is increased in patients with Crohn's disease and...

Vitamin K

Vitamin K is represented by several compounds that have antihemorrhagic activity the parent compound called menadione vitamin K1, which is a naturally occurring phylloquinone from plant sources and vitamin K2, which is a naturally occurring menaquinone from microbial sources. Vitamin K forms are generally heat resistant but are broken down by alkali, strong acids, light, and some oxidizing agents. High levels of dietary vitamin A inhibit the absorption of vitamin K. Vitamin E at high levels...

Diagnosis

PHYSICAL EXAMINATION Special attention should be given to the abdominal and cardiovascular portions so that potential catastrophes mimicking acute renal colic are excluded. The vital signs should be carefully noted. There may be elevations of blood pressure and pulse secondary to extreme discomfort. The presence of fever or hypotension should suggest the possibility of concurrent infection or a diagnosis other than renal colic. The abdominal examination is extremely important. It should...

Acute Respiratory Deterioration In Infants With Bronchopulmonary Dysplasia

Although acute respiratory deterioration can occur in any NICU graduate, this discussion focuses on those infants with ongoing pulmonary disease, such as bronchopulmonary dysplasia (BPD). BPD is usually a sequela of prematurity, hyaline membrane disease, and mechanical ventilation, although it may be associated with other conditions.11 Features of BPD include tachypnea, hypercarbia, suboptimal oxygenation, and sometimes reactive airway disease. In more severe cases, pulmonary hypertension,...

TABLE 801 Causes of Jaundice

Depending on whether the defect occurs before or after the conjugation phase in the hepatocyte, two types of hyperbilirubinemia can be produced unconjugated and conjugated. If increased production of bilirubin exceeds the ability of the liver to process it or if there is a defect in bilirubin uptake or conjugation, then levels of the unconjugated form will rise, producing unconjugated hyperbilirubinemia. Causes include hemolysis from hemoglobinopathies, hemolytic anemias, or transfusion...

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...

Lead Fragments And Lead Poisoning

Lead fragments in soft tissue usually become encapsulated with fibrous tissue and do not cause problems. Bullet-induced lead poisoning is most common with intraarticular, disk space, and bursal locations of bullet fragments because of the solubility of lead is synovial fluid. 2 35 Lead fragments in the brain are usually relatively benign unless they are copper plated (as are many civilian .22 caliber bullets). 31 Copper-plated lead pellets produced a sterile abscess or granuloma in the brain of...

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

Scrotal Edema Penis Disappeared

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...

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...

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...