Other Causes of Lumbar Pain

Neurogenic pain in the low back region can be associated with herpes zoster as manifest in shingles or in femoral nerve mononeuropathy that is often associated with diabetes. Pain is due to loss of the pain inhibitory system in the central or peripheral nervous system. It is described as burning, tingling, or skin crawling. It is intensified by what would otherwise be nonpainful sensory stimulation, such as light touch (allodynia). It may persist after cessation of the provoking stimulus...

TABLE 1128 Differential Diagnosis of Acute Life Threatening Episodes

It is simply a description of a characteristic clinical presentation. The usual age of occurrence is 2 to 3 months, but ALTE can occur at any age. Approximately 1 to 3 percent of infants in the general population are reported to experience ALTEs. The incidence is increased among infants who die of sudden infant death syndrome (SIDS) to about 5 to 6 percent. It can be reassuring to families that only about 1 of 20 SIDS cases occurs in the population who experience ALTE...

Physiologic Changes Of Pregnancy

A normal pregnancy creates complex changes in maternal anatomy and physiology, many of which begin as early as the first trimester and continue throughout its term. Significant alterations to the maternal reproductive, cardiovascular, respiratory, and gastrointestinal systems as well as maternal anatomy make the evaluation of an acutely injured pregnant patient more difficult. An understanding of these physiologic changes is essential to the appropriate diagnosis and management in such cases....

TABLE 351 Tissue Growth Factors and Their Effects

Hemostasis is initiated at the time of injury. Tissue and vascular smooth muscle contraction compresses small bleeding vessels. Activation of platelets and the coagulation cascade produce a fibrin clot within the lumens of the severed vessels and within the exposed wound. Inflammation is stimulated by chemotactic factors released by activated platelets and the complement cascade, which initially attract neutrophils followed by macrophages. Neutrophils and macrophages phagocytose dead tissue,...

Emergency Treatment

The patient having an anaphylactic reaction, as defined by airway compromise or hypotension, is a true medical emergency and must be rapidly assessed and treated. Exposure to the causative agent, if identified, must be terminated if ongoing. Vital signs, intravenous (IV) access, oxygen, cardiac monitoring, and pulse oximetry measurements should be ordered immediately. Securing the airway is the first priority. The airway should be examined for angioedema. If angioedema is producing respiratory...

Selected Motor Lesions Causing Dysphagia

Neuromuscular disorders typically result in misdirection of the bolus, with repeated swallowing attempts. Liquids, especially at the extremes of temperature, are generally more difficult to handle than solids. Symptoms are often intermittent in nature. Cerebrovascular accident (CVA) is the most common cause in this category. Oropharyngeal muscle weakness is often the mechanism, though there can be poor function of the UES as well. Polymyositis and dermatomyositis are the second most common...

Laboratory

Laboratory studies may be helpful in diagnosing complications of cocaine or amphetamine abuse. Any patient with significant agitation or elevated temperature should have a chemistry panel and CPK obtained to screen for a metabolic acidosis, renal failure, or rhabdomyolysis. Hyponatremia of unknown etiology sometimes occurs following the use of hallucinogenic amphetamines (MDMA). Cardiac enzymes including CPK-MB or troponin are appropriate to screen for cardiac injury. A urine sample may be...

Nonpharmacologic Modalities

Cognitive behavioral and physical techniques are useful nonpharmacological adjuncts to pediatric acute pain management. 5 Several simple, age- and development-specific interventions can significantly decrease a child's anxiety and later pain perception. Cognitive behavioral modalities include reassurance and explanation, relaxation, distraction, music, psychoprophylaxis, biofeedback, and guided imagery. Environmental alterations, such as dimmed lights, a quiet room, or stereo headphones may...

Gastrointestinal

TOXIC EFFECTS OF THEOPHYLLINE Theophylline has a direct central nervous system effect, leading to nausea and vomiting. In addition, theophylline increases gastric acid secretion. Nausea and vomiting can be seen with therapeutic levels, although the incidence of nausea and vomiting increases markedly with levels above 15 Mg mL. Approximately 25 percent of patients with levels greater than 20 Mg mL have nausea or vomiting. Gastrointestinal bleeding, with epigastric pain, may also occur....

Chapter References

So AH Medical treatment of peptic ulcer disease Practice guidelines. JAMA 275 622, 1996. 2. Sontag SJ Guilty as charged Bugs and drugs in gastric ulcer. Am J Gastroenterol 92 1255, 199Z. 3. Rabeneck L, Graham DY H. pylori When to test, when to treat. Ann Intern Med 126 315, 199Z. 4. Talley NJ, Weaver AL, Tesmer DL, Zinsmeister AR Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy. Gastroenterology 105 1378, 1993. 5. Sonnenberg A, Everhart JE Health impact...

Complications Of Penile Prostheses

The use of urologic implantable prostheses has increased since the modern forms became available in the early 1970s. Penile prostheses are generally of two types semirigid penile prostheses (SRPPs) and inflatable penile prostheses (IPPs). SRPPs provide rigidity at all times. They are paired cylindrical devices, which are implanted within the corpus cavernosa. The devices are activated by means of a hinged segment or by repositioning a flexible metal core. Two types of SRPP commonly in use are...

Differential Diagnosis

The differential diagnosis of hypoglycemia differs in different age groups. Some disorders are only transiently seen in neonates, while others may start in the neonatal period but extend throughout childhood. Still others are not usually seen until after the neonatal period. For example, some inborn errors of metabolism always present in early infancy while others may not be clinically apparent until the child is a few years old. Table,.12.5 l lists some causes of hypoglycemia in childhood. A...

Corticosteroids

Urticaria, angioedema, and toxicodendron and other contact allergic dermatitides are potential indications for systemic corticosteroids. Other dermatologic syndromes, such as erythema multiforme, toxic epidermal necrolysis, and vasculitis, are best treated with systemic steroids only after consultation with a dermatologist. Eczema and psoriasis, both of which are chronic dermatologic conditions, are likely to rapidly improve after systemic steroid therapy. Both will also rebound as rapidly with...

Diagnosis And Treatment Of Contrast Reactions

The great majority of adverse effects from contrast agents are mild or moderate events that are not life-threatening and require only observation, reassurance, and general supportive measures. However, vigilance must be maintained because most severe contrast reactions begin with mild-to-moderate symptoms and signs. The vigilance need not be prolonged because essentially all life-threatening contrast reactions occur immediately or within 15 min of injection. 15 From a clinical perspective,...

Antiviral and Common HIV Medications

Current treatment for human immunodeficiency virus (HIV) and the resulting acquired immune deficiency syndrome (AIDS) requires patients to take multidrug regimens to prevent progression of their disease and to treat opportunistic infections. HIV therapy has grown complex over the past several years with the introduction of new therapeutic agents and evolving recommendations for prophylaxis against opportunistic infections. Drugs used to decrease the HIV load in the body include nucleoside...

Hobo Spider Tegenaria agrestis

The hobo spider is a venomous spider found in the Pacific Northwest and its bite is often misattributed to the brown recluse spider, which is not found in that region. 10 Originally native to Europe, the hobo spider entered the Pacific Northwest and has spread as far as central Utah and southern Alaksa. Hobo spiders are brown with gray markings and 7 to 14 mm in body size with 27- to 45-mm leg span. These spiders live in dark areas close to the ground in wood piles or basements. CLINICAL...

TABLE 1823 Treatment of Cyanide Poisoning

The initial rationale for using nitrites was based on their capacity to form methemoglobin. Methemoglobin binds avidly to cyanide and prevents its binding to cytochrome oxidase. Although the antidotal efficacy of nitrites is not disputed, their actual mechanism of action has been questioned recently. 4 The formation of methemoglobin is a slow process relative to the rapidity of the therapeutic response to nitrites. In addition, the reversal of cyanide toxicity in animals by nitrites has been...

The Referral Process

If a patient is ready to accept referral, a staff member who is familiar with treatment resources can assist the patient in making an appointment or plans to enter a treatment program. Each ED should provide a resource list for staff and a printed handout or brochure for patients with names, addresses, and phone numbers of treatment programs. The following resources should be available inpatient detoxification outpatient detoxification acupuncture methadone maintenance outpatient individual and...

Hospitalized Patients

The management of opioid dependent individuals hospitalized for medical or surgical reasons remains controversial. It is generally agreed that detoxification from opioids during the acute course of a medical illness is usually unsuccessful. Alleviation of withdrawal symptoms should be the goal of therapy. Daily administration of a verified dose of methadone orally (or half the verified dose intramuscularly if the patient is to take nothing by mouth) is recommended to inhibit withdrawal symptoms...

Specific Issues That Affect Evaluation And Treatment

Needle cricothyroidotomy is the preferred emergency surgical airway in children under the age of approximately 12 years who cannot be intubated orotracheally or nasotracheally. A 12- or 14-gauge catheter over a needle will support ventilation and oxygenation in a child until a tracheostomy can be performed in the operating room by a surgeon familiar with the anatomy of a child's neck. Surgical cricothyroidotomy should not be considered. The larynx is easily damaged by surgical...

Ants Formicidae

There are five known species of fire ants (Solenopsis) in the United States S. aurea, S. geminata, S. xyloni, and the two imported species, S. invicta and S. richteri. The two imported species entered the United States through Mobile, Alabama, in the 1930s and have now spread throughout the Gulf Coast states and are pushing westward.7 The fire ant inhabits a loose amount of dirt and breeds 9 to 10 months of the year. One mature nest can produce 200,000 ants during a 3-year period, which...

B Blockers

B-Adrenergic antagonists have antiarrhythmic, anti-ischemic, and antihypertensive properties. During AMI, they diminish myocardial oxygen demand by decreasing heart rate, systemic arterial pressure, and myocardial contractility. Prolongation of diastole may augment perfusion to ischemic myocardium. 32 Immediate b-antagonist administration in AMI reduces chest pain, wall stress, infarct size, incidence of cardiovascular complications, and mortality rate for patients not treated with...

Spinal Cord Injury

Pediatric spinal cord injury is an acute traumatic lesion of the spinal cord and roots resulting in motor and or sensory deficit occurring between birth and adolescence. About 1100 new pediatric cases occur each year secondary to motor vehicle accidents, sporting accidents, falls, gunshot wounds, and birth trauma. Spinal cord injury may result in complete or partial loss of neurologic function below the level of the lesion. Pain, heterotopic bone ossification, hypercalcemia, renal calculi, and...

Neurologic Complications

It is reported that between 19 and 47 percent of all adult liver transplant patients have a neurologic complication at some time during their posttransplant course. Neurologic complications in children, however, are much less common (8 percent).14 Common presenting problems include headache, seizure, and mental status changes. The etiology is more likely to be noninfectious than infectious. Common noninfectious etiologies are hemorrhage, immunosuppressive toxicity, and metabolic derangement....

Gastroesophageal Reflux

Gastroesophageal reflux is often present when tone is low. It may contribute to aspiration problems and can be associated with gastritis and esophagitis. Gastroesophageal reflux may present as emesis, nonspecific irritability, discomfort, or a lack of appetite and may contribute to failure to thrive. When the family complains about emesis, the physician needs to clarify their description they may be seeing clearing of secretions from the upper airways. In the severely impaired child, emesis may...

TABLE 2551 Clinical Manifestations of Extremity Vascular Trauma

Algorithm for the evaluation of an injured extremity for vascular trauma. (Adapted from Frykberg Advances in diagnosis and treatment of extremity trauma. Surg Clin North Am 75 207, 1995. Duplex ultrasound has become a popular modality in the management of proximity injuries without evidence of arterial injury. Recent advances in duplex ultrasonography have shown highly accurate rates of detecting occult arterial injury (vide infra). Some clinicians use duplex ultrasound to...

History And Physical Examination

Obstetric and gynecologic history, including menstrual status and contraceptive use, should be obtained on every woman of reproductive age. Cessation of menses, as well as such symptoms as nausea, vomiting, fatigue, and urinary frequency, may be suggestive of pregnancy. The date of the last normal menstrual period aids in determination of gestational age (although it may be misleading if, for example, contraceptive use was recently discontinued). Quickening, the first maternal perception of...

Infections

Diabetics who achieve and maintain excellent glycemic control (HgbA 1c < 7 percent) are probably not at any greater risk from infection than the general population. A variety of factors, both those related to associated defects in immunity and disease-related effects, may account for the increased prevalence of certain infections in the diabetic population and poor wound healing in general. There are possible epidemiologic associations between diabetes and urinary tract infections, candidal...

Malignant Melanoma

The incidence of malignant melanoma is increasing, thus making consideration of this disease process important. Malignant melanoma of the foot accounts for up to 15 percent of all cutaneous melanomas. Melanomas can present as an atypical, pigmented, or nonhealing lesion of the foot, including the nail. These malignancies often imitate more common foot disorders such as fungal infections and plantar warts. Since prognosis is directly related to early diagnosis, a high index of suspicion must be...

Electrocardiography

The normal myocardium depolarizes from endocardium to epicardium and repolarizes in the opposite direction. When injured, the myocardium remains electrically more positive than the uninjured area at the end of depolarization. The relatively positive potential in this area will result in ST elevation of electrocardiogram leads over this area. Conversely, if the electrode is located over uninjured myocardium opposite the injured area, ST depression will be noted (reciprocal changes). If the...

Cutaneous Manifestations

Generalized cutaneous conditions, such as xerosis (dry skin), seborrheic eczema, and pruritus, are common and may be manifested prior to development of opportunistic infections. Treatment is with emollients and, if necessary, mild topical steroids. Pruritus may respond to oatmeal baths and antihistamines. Other infections, including S. aureus (manifested as bullous impetigo, ecthyma, or folliculitis), Pseudomonas aeruginosa (which may present with chronic ulcerations and macerations), and...

Enalaprilat

ACTIONS AND PHARMACOLOGY This agent, which is the first intravenous ACE inhibitor approved for clinical use, is the biologically active form of the oral ACE inhibitor enalapril that occurs after deesterification in the liver. It is effective in patients with chronic heart failure with left ventricular ejection fractions of 20 to 44 percent, because it causes coronary vasodilation and significant reduction in mean arterial blood pressure and pulmonary capillary wedge pressure. It also improves...

Preliminary Splinting

Effective splinting of the injured extremity is crucial for several reasons (1) it reduces the patient's pain (2) it reduces damage to nerves and vessels by preventing them from being repeatedly ground between the fragments or being stretched by increased angulation at the fracture site (3) it reduces the chance of inadvertently converting a closed fracture to an open one as a sharp bone fragment pokes its way through the skin (considered a mishap of severe consequence, because of the potential...

Posttransplant Lymphoproliferative Disease PTLD

PTLD can be a consequence of T-cell suppression with long-term cyclosporine use. The overall incidence in lung transplant patients is approximately 8 percent. The disease tends to occur with primary EBV infection following lung transplant. Because younger patients are more likely to be EBV-negative at the time of transplantation, they tend to develop EBV infection and PTLD at a higher rate. Presenting features include isolated lymphadenopathy, painful otitis media (secondary to tonsillar...

Candida Vaginitis

Candida species are a common cause of vaginitis. While there are no reliable figures as to prevalence of vulvovaginal candidiasis (VVC) because the disease is not reportable, it is estimated that 75 percent of women will experience at least one infection during their childbearing years (with the highest attack rate during the third trimester of pregnancy), making it the second commonest vaginal infection.2 A small subpopulation of women, less than 5 percent, have repeated episodes of disease...

Hydrocephalus

Hydrocephalus is present in 70 to 90 percent of children with thoracic or lumbar level defects and in substantial numbers of those with sacral level defects. It is routinely treated with shunt placement early in life. Concerns regarding shunt function are common in patients presenting to the acute care setting. Signs and symptoms of shunt malfunction are lethargy, irritability, nausea, vomiting, visual problems, cognitive changes, neck pain, headache, swelling along the shunt path, or seizure.9...

Uterine Cancer

Uterine cancer is the most common gynecologic malignancy. In 1997, 32,800 cases were diagnosed. The average age of incidence is 58 years of age. Endometrial cancer is the most common histologic type, and of these, the most common type is adenocarcinoma of the endometrium. Other histologic types of endometrial cancer that occur less frequently are papillary serous, clear cell, adenosquamous, and adenocanthoma. Sarcomas are malignancies of the uterine muscle. They behave very aggressively and...

Drug Allergy

Although adverse reactions to drugs are a common clinical problem, true immunologically mediated hypersensitivity reactions probably account for less than 10 percent of these problems. Since most drugs are small organic molecules, they are generally unable to stimulate the immune system alone. However, when a drug or metabolite becomes protein bound, either in serum or on cell surfaces, the drug-protein complex can become an allergen and stimulate immune system responses. Thus, the ability of a...

Investigations

Pregnancy tests should be ordered routinely in women of childbearing age to rule out pregnancy as a cause of pain and bleeding. A complete blood count is essential in most cases of vaginal bleeding and or pelvic pain. Coagulation studies are ordered only when indicated by the history and physical examination. In individuals with suspected endocrine disorders, determination of thyroid-stimulating hormone and prolactin levels may be helpful, but the levels are rarely available for ED evaluation....

Latex Allergy

Latex allergy is a concern in children and adults with meningomyelocele. It occurs in 24 to 67 percent of children with meningomyelocele. Increasingly severe allergic-type reactions are being reported related to latex and latex-containing products. Reactions vary from mild local reactions to anaphylaxis. Children may present with local or generalized swelling, hives or edema, itching, or a rash. Runny nose or eyes, coughing, sneezing, wheezing, stridor, and difficulty swallowing or breathing...

Food Allergy

Hypersensitivity reactions to ingested foods are generally due to IgE-mediated reactions to food components or additives. IgE-coated mast cells lining the gastrointestinal tract react to presented allergens in ingested foods and produce clinical findings associated with the release of biologic mediators, as previously described. Non-IgE-mediated food allergy reactions have also been described. Dairy products, eggs, and nuts are some of the most commonly implicated foods. A detailed history will...

Insect Sting Allergy

Insect stings can produce significant and sometimes fatal reactions, particularly in sensitized patients. Approximately 100 patients die annually from insect sting reactions, making insect sting the second most common cause of fatal anaphylaxis. True stinging insects belong to the order Hymenoptera, which includes three families Apoidea (honeybee), Formicoidea (fire ants), and Vespidae (wasps, yellow jackets, and hornets). The venoms of each family are unique, although all have similar types of...

Captopril

ACTIONS AND PHARMACOLOGY This is an angiotensin-I-converting enzyme inhibitor that is rapidly absorbed orally, with an onset of action within 15 to 30 min, peak effects of blood pressure reduction between 50 and 90 min, and duration of antihypertensive effect of 4 to 6 h. It causes no change in cardiac output, heart rate, or cerebral blood flow. Since captopril is renally metabolized, its dosing must be decreased in patients with renal insufficiency. Postural hypotension is a rare problem,...

Apnea And Home Apnea Monitors

Most infants resolve apnea of prematurity before discharge and do not require apnea monitoring at home. 15 However, home monitoring is sometimes utilized for premature infants with severe apnea or if apnea persists beyond 38 weeks' postconceptional age.11Z Infants may be brought to an emergency department because of an actual apneic episode or because the parents are not sure of the significance of an alarm. Studies have demonstrated that the majority of alarms at home are not associated with a...

Adnexal Masses

Developing ovarian follicles may measure up to 2 cm at midcycle. Functional ovarian cysts measure greater than 2.5 cm and are well defined, thin walled, and anechoic. Most simple ovarian cysts resolve spontaneously, and serial sonographic exams are helpful to follow their progression. In postmenopausal patients, even well-defined anechoic ovarian cysts require further workup, especially if they are greater then 5 cm in diameter. Sonographically, polycystic ovary disease appears as bilaterally...

Ovarian Torsion

Doppler ultrasound is commonly used for the evaluation of suspected ovarian torsion however, the diagnostic accuracy of Doppler studies for ovarian torsion is poor. When torsion is present, the lack of internal ovarian blood flow on Doppler examination probably indicates that an ovary is beyond salvage. Also, the absence of blood flow to the ovary can be seen in a variety of cystic ovarian lesions when torsion is not present. Massive ovarian edema is an entity caused by intermittent or partial...

Otitis Media

Otitis media, or inflammation of the middle ear, is one of the most common pediatric diagnoses. Each year there are 24.5 million office visits and over 3.7 million emergency department visits, with direct and indirect costs of 5.7 billion a year.12 and3 Acute otitis media (AOM) (acute suppurative, purulent, or bacterial) is associated with signs and symptoms of inflammation of the middle ear, such as otalgia, otorrhea, fever, irritability, anorexia, or vomiting. 4 Otitis media with effusion...

History of Allergy

A history of asthma or severe allergy (e.g., anaphylaxis) to one or more allergens is associated with an increased risk of a contrast reaction. Patients with a history of asthma may have a fivefold greater risk of an adverse reaction than in the general population, and a history of allergy may double the risk. 1 A history of reaction during a previous contrast administration is associated with a three- to eightfold greater risk of a subsequent adverse reaction than in the general population. 1

Back Pain

Epidural abscess is characterized by a chronic course of 1 to 15 months in most patients. However, a more acute course with pain, paraplegia, and urinary incontinence developing over several hours to days can occur. The earliest and most prominent symptom is localized pain, which may develop a radicular component. Cerebrospinal fluid (CSF) analysis often demonstrates a mononuclear pleocytosis and increased protein. Myelography, computed tomography (CT), and magnetic resonance imaging (MRI) can...

Emergency Department Management

Most cases of bronchiolitis are treated on an outpatient basis, for which close follow-up with a private pediatrician is essential. During RSV epidemics, the emergency physician will be exposed to a broad spectrum of patients at varying stages of disease and must be able to identify those who need admission and who are at risk for apnea. Infants in respiratory failure will require emergent intubation and admission to the ICU. Treatment is mainly supportive and consists of oxygen, fluid...

Other Infectious Diseases Of The Face

In addition to the infections mentioned above, numerous other infections can occur on the face. In children, impetigo on the face is common, as is dermatophyte infections (tinea faciei and tinea barbae). Staphylococcal folliculitis is also seen on the face. The face and scalp are also a common site of involvement in secondary syphilis in which individuals develop moth-eaten alopecia, scaly or moist papules around the nose and at the angles of the mouth. Flat warts are frequently seen in males...

Clinical Features

Scabies tends to be an extremely pruritic eruption, often disturbing sleep (except Norwegian scabies, which tends to have minimal associated pruritus). Ihe most common sites of involvement include the hands, feet, flexural surfaces of the elbows and knees, umbilicus, groin, and genitals. Facial involvement is usually seen only in infants. Ihe pathognomonic lesion, or burrow, is a fine erythematous linear or curved lesion with central scale ( Fig 2.4.2.-1). Burrows are most often visible in the...

Sonography and Ectopic Pregnancy

Sonography plays an essential role in the diagnosis of EP. The primary goal of sonography in suspected EP is to determine if an IUP is present. Sonographic findings may also be useful in planning therapy when an EP is discovered. Noninvasive therapies are often reserved for EPs in which no cardiac activity is seen or those in which the mass is less than a specified size, though this area is undergoing rapid change. In addition, sonography provides information regarding fetal age and viability...

Lice Anoplura

Body lice concentrate about the waist, shoulders, axillae, and neck. The lice and their eggs often can be found in the seams of clothing. The lesions produced from bites of these arthropods begin as small, noninflammatory red spots that quickly become papular wheals. They are so intensely pruritic that their linear scratch marks are diagnostically suggestive of infestation. The white ova of head lice can be mistaken for dandruff, but unlike dandruff, they cannot be brushed out because they are...

TABLE 2211 Features of Delirium Dementia and Psychiatric Psychosis

One useful scheme is to divide consciousness into arousal and content functions. Arousal functions include wakefulness and basic eyes-open alerting functions. Anatomically, neurons responsible for these arousal functions reside in the reticular activating system, a collection of neurons scattered through the midbrain, pons, and medulla. The neuronal structures responsible for the content of consciousness reside in the cerebral cortex. Content of consciousness includes self-awareness, language,...

Evidentiary Concerns

Physicians must be aware of the importance of preserving evidence in patients being resuscitated after penetrating trauma. Do not cut through bullet holes or knife holes in clothing when removing it. Do not incise through skin wounds unless absolutely necessary. To preserve powder marks, do not scrub wounds unless necessary. Emergency departments must have a protocol for collecting clothing and other evidence so that it can be documented that it was always under surveillance or otherwise kept...

TABLE 3021 Medical Problems Associated with Specific Mental Retardation Syndromes

It is estimated that between 1 and 2.5 percent of the population has mental retardation thus 3 to 6 million individuals in the United States and 61 to 150 million in the world are affected. In recent decades, the reduction in the number of children born with mental retardation, coupled with the markedly improved survival of mentally retarded adults, has shifted the age distribution of persons with mental retardation. The largest age group with mental retardation is the 10- to 20-year-old group....

TABLE 2802 Behavioral Characteristics that Suqqest Various Clusters of Personality Disorders

The personality disorder that constitutes a disproportionate share of emergency visits is antisocial personality disorder. The patient shows a continuous pattern of maladaptive behavior displaying disregard for the rights of others in a variety of ways criminal behavior, fighting, lying, abuse and neglect of dependents and spouses, financial irresponsibility, recklessness, and inability to sustain enduring attachments to others. The sociopathic behavior begins before the age of 15, but the...

TABLE 833 Laboratory Utilization in Suspected Acute Pancreatitis

Amylase This digestive enzyme, used to cleave starch into smaller carbohydrates, is primarily found in the pancreas and salivary glands. Low levels of amylase can also be found in numerous other tissues, including the fallopian tubes, ovaries, testes, adipose tissue, small bowel, lung, thyroid, skeletal muscle, and certain neoplasms. As a result, serum amylase can be elevated in many conditions, making this test relatively nonspecific. Amylase levels are expressed in either Somogyi units (SU)...

Laboratory Tests and Ectopic Pregnancy

The final diagnosis of EP is made either by ultrasound (US) or direct visualization via the laparoscope or at surgery. Laboratory tests are used as part of an overall diagnostic and management scheme to either raise or lower the level of suspicion for EP. All laboratory tests must be interpreted in light of the clinical picture and findings from US. No single diagnostic test or combination of laboratory tests is currently considered to have sufficient negative predictive value to completely...

TABLE 902 Guidelines to Outpatient Management of Uncomplicated UTI

Trimethoprim alone or in combination with sulfamethoxazole (cotrimoxazole or TMP SMX) is generally recommended because these are cheap and effective ( Table 90-3). Nitrofurantoin is also effective though compliance with frequent dosing is a problem and nitrofurantoin is not effective against S. saprophyticus. Because of increased bacterial resistance, extended-spectrum penicillins (e.g., amoxicillin) and cephalosporins have become less-acceptable alternatives. In cases of treatment failure, or...

Skin and Soft Tissue Complications

Several cutaneous disorders and infections are more common in diabetics (Iable,,2.09-8). Serious infections usually develop due to the combination of poorly controlled serum glucose, vascular insufficiency, and tissue hypoxia. These infections may spread rapidly with dramatic skin changes. The most common sites are lower extremities, but such infections may occur on the peritoneum, scrotum, and abdominal wall (especially at sites of penetrating trauma or surgery). They all require emergent,...

Falls

Falls are the most common accidental injury in patients over 75 years of age and the second most common injury in the 65 to 74 age group. Fifty percent of elderly persons who fall do so repeatedly. Most individuals who fall will do so on a level surface, and most will suffer an isolated orthopedic injury. 14 Falls are reported as the underlying cause of 9500 deaths each year in patients over the age of 65 years. Many falls in the elderly population occur in residential institutions such as...

TABLE 731 Traditional Drugs for Peptic Ulcers

Although NSAIDs should be stopped in patients with peptic ulcer disease whenever possible, misoprostol may prevent ulcer formation in those on concurrant NSAID therapy. Misoprostol is a prostaglandin analogue that may act by increasing mucous and bicarbonate production and by increasing mucosal blood flow. If H. pylori infection is diagnosed in the presence of peptic ulcer disease, eradication is clearly indicated. 1 15 Multiple regimens have been proposed and studied mainly using combinations...

The Kidney

Most systemic rheumatic diseases may affect kidney function. Glomerulonephritis is a major determinant of morbidity in patients with lupus and Wegener's granulomatosis. Urinalysis abnormalities (hematuria, proteinuria) and hypertension are apparent before serum creatinine rises. Patients with lupus and nephrotic syndrome can develop renal vein thrombosis due to urinary loss of antithrombin III they present with flank pain and proteinuria. In diffuse scleroderma, renal dysfunction secondary to...

Empiric Antimicrobial Therapy

All patients with septic shock should receive empiric antimicrobial therapy as soon as possible. Whenever possible, samples of blood or fluids from potential sites of infection should be obtained prior to the initiation of antimicrobial therapy. Selection of antibiotics should be based upon the adequate coverage of all potential pathogens of the potential infection sites as well as the anticipated antimicrobial susceptibility patterns of the bacterial isolate(s). Empiric therapy should be...

Changing Role of Emergency Department Physicians

In light of the enormous impact of alcohol and other drug abuse on society and individuals, it is no longer sufficient to treat only the emergency condition and the medical complications of substance abuse without providing proper screening, brief counseling, and referral to further treatment when appropriate. Connecticut State Law 472 mandates universal screening in the health care setting and requires documentation of training in intervention for all personnel working in health care...

Mechanical Ventilation

When in spite of the emergency physician's best effort to treat an acute asthma exacerbation, when the patient begins to exhibit signs of acute ventilatory failure, noninvasive positive-pressure ventilation may be attempted.30 However, if the patient manifests progressive hypercarbia and acidosis or becomes exhausted or confused, intubation and mechanical ventilation are necessary to prevent respiratory arrest. Mechanical ventilation does not relieve the airflow obstruction it merely eliminates...

Gastrointestinal Emergencies in Children 2 Years and Older

APPENDICITIS Clinical Features Although appendicitis can occur in children younger than age 2, the presentation is usually one of peritonitis or sepsis because of the delay in diagnosis.10 Over age 2, appendicitis becomes a more important part of the differential diagnoses of abdominal pain. The classic progression of symptoms associated with appendicitis applies equally to children and adults. The events involve early anorexia followed by the development of mild to moderate periumbilical pain...

Grief Reaction

Individual responses to the death of a loved one vary greatly. The initial response has been described as a psychic pain spike. Although it lasts only a brief amount of time, usually 5 to 15 min, it occurs. During this period, the family can make no decisions. Once this period of acute grief has ended, the family members will progress through other reactions denial, anger, and or guilt.13 Denial is one of the more frequent reactions to the news of death. The bereaved family may express...

Lipolysis in adipose tissue5 Clinical Features

Ihe typical patient with HHNS is usually elderly, who is often referred by a caretaker for abnormalities in vital signs and or mental status with complaints which include weakness, anorexia, or fatigue. Many will have either undiagnosed or poorly controlled type 2 diabetes. Ihese patients often have some level of baseline cognitive impairment, and self-referral for medical treatment is rare. In general, any patient with hyperglycemia, an impaired means of communication, and limited access to...

TABLE 583 Causes of Wheezing

The duration of wheezing, or, more precisely, that portion of the expiratory phase occupied by wheezing, has been used to quantify the severity of airflow obstruction in moderate-to-severe acute asthma. As noted above, patients with the most profound obstruction may not wheeze, but their condition can be detected by noting markedly decreased lung sounds. Most patients with bronchospastic disease (either asthma or COPD) relate a history of previous attacks and response to bronchodilators. The...

AGlucosidase Inhibitors

Acarbose acts to decrease postprandial glucose concentrations by decreasing gastrointestinal absorption of carbohydrates. Acarbose inhibits the brush-border enzyme a-glucosidase, thereby preventing the metabolism of polysaccharides into smaller units for absorption. By itself, acarbose does not cause hypoglycemia. To date, experience with acarbose overdose is limited. However, flatulence, bloating, and malabsorption can complicate use of this medication and should be expected in overdose.

TABLE 1234 Causes of Diarrhea

Treatment of diarrhea will vary depending on cause. A suspicion of Hirschsprung or Crohn's disease warrants surgical consultation. Malabsorption, hemolytic-uremic syndrome, cystic fibrosis, or persistent diarrhea with weight loss and failure to thrive warrants pediatric consultation. Other causes may only require 24 h of rehydration solution and avoiding fatty or high-carbohydrate-containing foods for 2 or 3 days. Stool cultures are warranted in children with bloody diarrhea, diarrhea for more...

Postoperative Bleeding

Postextraction bleeding is not uncommon. Dislodgment of the clot may result in recurrent or continued bleeding. Generally, firm pressure applied to the extraction site is adequate to control bleeding. This is best accomplished by neatly folding a 2 * 2 gauze pad and placing it over the extraction site, applying firm pressure by clenching firmly with the opposing teeth. This pressure must be held firmly, not a chewing action, for 20 min or until hemostasis is complete. Also, pressure with a used...

TABLE 478 Frequency of Occurrence of Arrhythmias during Acute Myocardial Infarction

Early in the course of AMI, patients frequently exhibit evidence of increased autonomic nervous system activity. Sinus bradycardia, atrioventricular block, and hypotension may occur from increased vagal tone. Activation of atrial and ventricular receptors in the myocardium may result in enhanced efferent sympathetic activity, increased circulating catecholamines, and increased local catecholamine release. These increased catecholamines in the setting of a sensitive myocardium form the substrate...

TABLE 11B5 Antibiotic Dosages for Bacteremia and Meningitis

The treatment of febrile infants 3 to 36 months of age remains a subject of considerable controversy. As for all infants, an ill-appearing febrile child should be stabilized with supportive care and fully evaluated for sepsis, and broad-spectrum intravenous antibiotics such as cefotaxime or ceftriaxone should be administered in the ED. Fortunately, most penicillin- and cephalosporin-resistant strains of S. pneumoniae demonstrate only intermediate resistance at this time and may be adequately...

Autonomic Dysreflexia

Patients with spinal cord injuries at or above the T6 level are at risk for developing autonomic dysreflexia (also called autonomic hyperreflexia). 1 This reflex is initiated by a noxious stimulus from below the level of the patient's spinal cord lesion. Intact sensory neurons below the level of the lesion transmit a message up the spinal thalamic tract and posterior columns, where interconnections stimulate the intermediolateral gray matter neurons, producing sympathetic outflow from spinal...

Miscellaneous

Another cause of primary adrenal failure is bilateral adrenalectomy for metastatic breast or prostate cancer or for Cushing's syndrome. Following such a procedure, the patient is totally dependent upon replacement corticosteroids for life. Chemotherapeutic agents such as mitotane ( o,p'-DDD) used in treatment of Cushing's disease can produce adrenal failure. Other drugs such as methadone, rifampin, and ketoconazole have been reported to cause adrenal insufficiency. Finally, rare congenital and...

TABLE 4711 Likelihood of Significant Coronary Artery Disease in Patients with Symptoms Suggesting Unstable Angina

Patients at high risk of coronary artery disease, AMI, or death should be admitted to an intensive care unit (ICU). Moderate risk patients should be admitted to a non-ICU monitored setting. Patients at low risk can be treated in a non-ICU monitored setting or can be observed in an ED observation unit. Both ED observation units and non-ICU monitored settings are safe and cost-effective for patients with normal ECGs and other low-risk clinical features. Prior invasive and noninvasive assessments...

Sepsis

Sepsis occurs at a rate of about one case per 1000 live births, and one-third of septic newborn babies develop meningitis. Factors associated with perinatal infection are either maternal or perinatal. Premature rupture of membranes, prolonged rupture of membranes, and maternal infection presenting as chorioamnionitis or urinary tract infection increase the likelihood of newborn disease. Low birth weight is the single most important risk factor for the infant. Group B b-hemolytic Streptococcus...

Etiology and Pathogenesis

Environmental, genetic, infectious, and host factors have all been implicated as a cause of both Crohn's disease and ulcerative colitis. Among the environmental factors, smoking has been associated with an increased recurrence rate of Crohn's disease. Mycobacterium paratuberculosis and the measles virus have received recent attention and have also been considered as possible etiologies of Crohn's disease. There are few data to support a primary causative role of psychogenic factors. Immunologic...

Acute Cystitis

The selection of antibiotics depends on the suspected bacteriology of the infection, the patient's compliance, potential drug toxicity, and cost. 12 In uncomplicated UTIs, E. coli is the offending microorganism in the vast majority of cases, and this and other typical coliform pathogens remain susceptible to a variety of agents trimethoprim, co-trimoxazole, nitrofurantoin macrocrystals, and the fluoroquinolones ( Ta.b e,.9.0.-2).

Acute Asthma In Adults

Epidemiology Pathophysioloqy ClinicalFeature.s Diagnosis Treatment Adrenergic Agents HeHoxJnKetam,in,e, , ,,a.nd Ma. oSh.a.n.P Leukotriene, Modifiers Mechanical, .Ventilation Specific Issues that Impact Diagnosis, Evaluation, and Treatment Asthma is a chronic inflammatory disorder characterized by increased responsiveness of the airways to multiple stimuli. Many cells and cellular elements, such as mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells, play a...

Steroids

A water-soluble glucocorticoid should be administered promptly. As soon as the diagnosis of adrenal crisis is entertained, 100 mg of hydrocortisone sodium succinate (Solu-Cortef) or phosphate should be given in an intravenous bolus. In addition, 100 mg of hydrocortisone should be added to the intravenous solution. Usually, 200 mg of hydrocortisone is given every 6 h during the first 24 h of therapy. Glucocorticoid therapy acts to correct hypotension, hyponatremia, hyperkalemia, and...

TABLE 1702 Key Diagnostic Features of Calcium Channel Antagonist Overdose

Other clinical manifestations of CCB toxicity stem from multiorgan hypoperfusion and inhibition of metabolic processes and may indicate impending severe shock. Physical examination (and intuition) may provide the best initial evidence of incipient severe toxicity. Most patients with significant toxicity are drowsy and asthenic. However, muscular weakness does not occur from a direct effect of CCBs on skeletal muscle excitation contraction even with massive overdoses. Mydriasis is not a key...

TABLE 11S1 Clinical Presentation of Pediatric Heart Disease

Children with previously undiagnosed heart disease can be broadly classified into three categories unstable, stable but symptomatic, and stable and asymptomatic. Unstable infants usually require immediate and decisive stabilization and aggressive management before diagnostic studies or tertiary referral can be made. Pediatric cardiology consultation should be emergently sought from the regional tertiary care center before pharmacologic intervention, if at all possible. Stable and symptomatic...

Breast Cancer

The report by the American Cancer Society that one in eight women will develop breast cancer is actually misleading, in that the risk is cumulative, with half of the risk occurring after the age of 65. The risk for African-American women is only 7 to 8 percent. Such statistics contribute to the anxiety experienced by patients with a breast mass. While the specifics of diagnostics, treatment, and prognosis in breast carcinoma are beyond the scope of this chapter and beyond the purview of...

Gallbladder and Biliary Tract Disease

Gallstones are the most common cause of biliary tract disease in the United States. Gallstones occur in 20 to 35 percent of the population by age 75 years but in the majority are asymptomatic. Acute colicky pain localizing to the right upper quadrant accompanied by nausea and vomiting, sometimes with a finding of a palpable and tender gallbladder, characterizes gallstone obstruction of the cholecystic duct. The acutely ill patient frequently will give a history of past episodes of postprandial...

Renal And Urologic Syndromes

Renal insufficiency in the cancer patient often has multiple etiologies. Prerenal azotemia is common due to vomiting, anorexia, or diuretic use. Hepatic and peritoneal disease also may cause sequestration of fluid in the peritoneal cavity, leading to intravascular volume depletion. Multiple myeloma and lymphoma can cause rapidly progressive renal failure by intraglomerular amyloid deposition. In addition, several chemotherapeutic agents (i.e., carmustine, cisplatin, and mitomycin) are directly...

Sd Urinary Tract Infections

Urinary tract infection (UTI) is defined as significant bacteriuria in the presence of symptoms. It affects an estimated 20 percent of women at some point in their lifetime, and accounts for a significant number of emergency department visits. In the elderly, UTI is a major cause of nosocomial gram-negative sepsis with a significant mortality.

Complications Of Myocardial Infarction And Ischemia

Myocardial perfusion and cardiac function affect blood flow to the entire body. As a result, any end organ can be damaged when cardiac pump function is decreased. In this section, discussion of the complications of acute coronary syndromes is limited to the direct effects on the heart. The systemic effects of cardiac function are discussed in organ-appropriate chapters of this book. The treatment of these complications is discussed in the following chapter. The genesis, diagnosis, and treatment...

Pathophysiology And Pharmacology

Intracellular calcium is the primary stimulus for smooth and cardiac muscle contraction and for impulse formation in sinoatrial pacemaker cells. At therapeutic concentrations, organic CCBs bind to the alpha subunit of the L-type calcium channel, causing the channel to favor the closed state and thereby decreasing calcium entry during phase II depolarization. At very high concentrations, some CCBs (verapamil) may occupy the channel canal and completely block calcium entry through the L-channel....

Clinical Presentation

Patients who ingest b blockers manifest a spectrum of clinical presentations ranging from minimal symptoms to profound bradycardia, hypotension, and cardiogenic shock. The majority of serious cases result from ingestion of propranolol. 3 Symptoms typically develop within 1 to 3 h after acute ingestion, but the onset may range from 15 min to 10 h. Delays are expected following ingestion of sustained-release formulations. Systemic toxicity has been reported following instillation of ophthalmic...

TABLE 3022 Frequently Used Medications and Side Effects

Next it is important to determine the patient's living situation. Even relatively minor changes in routine or caretakers can have a dramatic impact on the functioning of some developmentally disabled individuals, particularly those with autism. It is also essential to determine the patient's resources for appropriate follow-up care within the community. The provision of routine and preventative care is particularly important in the developmentally disabled population because of the higher...

Urinary Tract Infection

A urinary tract infection should be suspected when a spinal-cord-injured patient presents with fever, discomfort over the kidney or bladder, change in spasticity, development of urinary incontinence, an episode of autonomic dysreflexia, cloudy or foul-smelling urine, a change in energy level, or a feeling of apprehension. 67 Unless there are confounding factors, the urinalysis shows pyuria and significant bacteruria. In a patient with the abovementioned symptoms and signs and pyuria, empiric...

Complications And Mortality

Complications can be categorized as those occurring secondary to the acute disease, early complications related to therapy, and late complications. A critically ill, lethargic patient is at risk for aspiration, and airway protection and evacuation of gastric contents may be indicated. In general, the greater the presenting serum osmolarity, blood urea nitrogen, and blood glucose concentration, the greater the mortality. There is also increased mortality for patients presenting with a serum...

Laboratory Assessment

Serum iron levels have been used to determine toxicity and to direct management, but this use is limited, since excess iron is toxic intracellularly and not in the blood. In general, serum iron levels between 300 and 500 pg dL correlate with significant GI toxicity, and mild systemic toxicity and serum iron levels between 500 and 1000 pg dL correlate with moderate systemic toxicity. Levels greater than 1000 pg dL are associated with significant morbidity. Although high serum iron levels support...

TABLE 1043 Treatment Regimens for Vulvovaginal Candidiasis

Self-medication should only be advised in women with previously diagnosed VVC and recurrence of similar symptoms. If symptoms persist or recur within 2 months, the patient should be seen so that vaginal and microscopic examinations can be performed. Cultures should be considered for patients with frequent recurrences. All possible precipitating factors, such as high blood glucose levels, should be controlled. However, the majority of women with recurrences do not have obvious precipitating...

Assessment Of Children Suspected Of Having Heart Disease

The initial evaluation of ill children begins with the process of assessment and triage. Often, children present with symptoms unrelated to the underlying disease, and careful neurologic, pulmonary, and cardiac assessment must be performed to determine the stability of patients and the need for supportive care. From a cardiovascular perspective, this assessment determines whether the cardiac output is low, normal, or hyperdynamic. Concurrent conditions often exist, making definition of physical...