Other Antidysrhythmic Agents

ADENOSINE Adenosine (Adenocard) is an endogenous nucleoside produced by the dephosphorylation of adenosine triphosphate (ATP) and is contained in every cell of the body. Cardiac adenosine receptors are concentrated in the coronary arteries, the SA node, the AV node, and the atrial myocytes. 9 A1 adenosine receptor stimulation alters potassium channels. The increase in K + conductance hyperpolarizes the cell membrane and shortens the action potential of supraventricular cells. Therefore, the...

TABLE 2312 Symptoms and Signs of Hypocalcemia

The severity of signs and symptoms depends greatly on the rapidity of the fall in calcium. The more acute the drop in the serum calcium, the more likely are significant pathophysiologic changes. As serum calcium levels fall, neuronal membranes become increasingly more permeable to sodium, enhancing excitation. Potassium and magnesium have an antagonizing effect on this excitation. Decreased ionized calcium levels reduce the strength of myocardial contraction primarily by inhibiting relaxation....

Psilocybin

Psilocybin and the related compound psilocin are hallucinogens of the indole alkylamine class, and are structurally related to LSD. Psilocybin and psilocin are believed to act as 5-HT2 agonists in a manner similar to LSD. They occur naturally in mushrooms of the Psilocybe genus, most notably P. semilanceata (liberty cap), and P. cubensis. Psilocybin-containing mushrooms grow naturally in many areas of the United States and Europe, and kits containing spores and the ingredients necessary for...

Clinical Features

Clinical presentation of acute liver disease is variable. Symptoms of hepatocellular necrosis accompanying viral hepatitis include anorexia, nausea, vomiting, and low-grade fever. Cholestatic disease is accompanied by jaundice of varying degree, pruritus, clay-colored stools, and dark urine. Biliary colic implies acute obstructive cholestasis of extrahepatic or mechanical etiology, as in common duct gallstones or rapidly growing tumors. Cholestasis resulting from intrahepatic processes and...

TABLE 3211 Suggested Dosages for Regional Blocks for Adults and Children 40 kg

HAND BLOCKS ANATOMY Median Nerve The median nerve provides sensation to the lateral two-thirds of the palm of the hand, palmar surfaces of the lateral three and one-half digits and their finger tips. The palmar branches of the median digital nerves extend dorsally over the digit to supply the dorsum of the thumb, the index, the middle finger and lateral half of the ring finger distal to the interphalangeal joint and including the nail and the nail bed. The median nerve enters the hand through...

Radiographic Views of the Face

The Waters or occipital-mental view is the single most valuable study of the midface. It evaluates continuity of orbital rims, provides an initial diagnosis of blowout fractures, and will demonstrate air fluid levels in maxillary sinus. The posterior-anterior (PA or Caldwell) view, which best details the bones of the upper face, confirms ethmoidal and frontal sinus fractures, as well as lateral orbital injuries. The cross-table or upright laterals are difficult to read and are not very helpful....

TABLE 518 Cardiac Tamponade in Medical Nontrauma Patients

CLINICAL FEATURES AND DIAGNOSIS Symptoms are nonspecific, and patients most commonly complain of dyspnea and profound exertional intolerance. Additional complaints may be present due to the underlying disease (e.g., uremia) or if the pericardial effusion has developed gradually (e.g., tuberculous pericarditis). Such symptoms may include weight loss, pedal edema, ascites, and so on. Physical examination most commonly reveals tachycardia and low systolic arterial blood pressure with a narrow...

Intubation In Cervical Spine Injury

Airway management of patients with the potential to have an unstable injury of the cervical spine challenges clinical judgment. There is no single best algorithm. Cervical spine radiography without a thorough and reliable neurologic examination does not clear the neck. From 20 to 30 percent of cervical spine injuries are not appreciated on a single cross-table lateral view. In addition, patients with blunt major trauma requiring tracheal intubation have associated unstable cervical spine...

Fetal Sonographic Evaluation

Ultrasound can be used to assist in the initial evaluation of the fetus after maternal trauma.1 First, ultrasound can aid in making a quick estimate of gestational age. Knowledge of the gestational age is important, since subsequent management decisions will be based on it. Next, a sonographic determination of immediate fetal viability can be made. If the fetus is dead (no cardiac activity and no fetal movement), the management of the mother will become the sole priority. Gross injury to the...

Obtain Meaningful Vital Signs

Normal ranges for heart rate, respiratory rate, and blood pressure vary significantly with age and must be interpreted in the context of a child's activity at the time (Table 111-1). Anxiety, pain, fever, and crying will increase all values, and these states should be documented if present. Optimal vital signs are obtained without eliciting an adverse reaction to the examiner (e.g., respiratory rate taken by observing abdominal movements, and heart rate auscultated through clothing). If fever...

TABLE 344 Common Fraudulent Techniques Used by Drug Seekers and Their Management

Patients should be examined for signs of intravenous drug addiction, including needle marks and healed or active superficial cutaneous abscesses, and the heart should be examined for evidence of a new murmur and other signs of endocarditis. Patients attempting to simulate nephrolithiasis can falsify hematuria by biting their buccal mucosa and spitting into the urine sample or by pricking their finger and dipping it into the urine sample. Patients who are suspected of factitious hematuria should...

Endocrine Abnormalities

THYROID HORMONE The most common findings of hypothyroidism include lethargy, fatigue, dry coarse skin, facial and extremity swelling, hoarseness, constipation, and weakness. Oral manifestations are related to the accumulation of glycosaminoglycans in the oral tissues, causing macroglossia and thickened lips. If hypothyroidism occurs in childhood, teeth may fail to erupt, although tooth formation is unimpaired. 19 Grave's disease is the most common type of hyperthyroidism and is associated with...

The Examination

The dermatologic physical examination must be performed on the disrobed patient in a room with adequate lighting. All skin and mucosal surfaces must be inspected, including hair, nails, scalp, and mucous membranes. Then, the specific skin lesions must be inspected. A magnifying lens and a portable lamp are helpful for conducting the examination. The skin should be examined in a systematic, methodical, orderly process. The distribution, pattern, arrangement, morphology, extent, and evolutionary...

Acute Abdomen

Intravenous contrast enhancement is indicated for all CT examinations performed for the evaluation of acute abdomen. Acute abdominal conditions for which CT is commonly performed include appendicitis, diverticulitis, intraabdominal abscess, and bowel obstruction. While intravenous contrast material enhances the visualization of all of these conditions, its role is not as great as in CT for abdominal trauma. For example, mesenteric inflammation is detectable in the absence of intravenous...

Portal Hypertension

Portal hypertension is rare in children in the United States, but is one of the common causes of major upper GI hemorrhage. Extrahepatic portal thrombosis, parenchymal liver disease associated with fibrocystic disease, and biliary cirrhosis in youngsters with congenital biliary atresia surviving as a result of portal enterostomy are examples of conditions that can result in portal hypertension and esophagogastric varices. In two-thirds of cases, no specific cause is found. Massive hematemesis...

Emergency Management

In the prehospital phase, personnel should be directed to immobilize the limb, establish intravenous access in another limb, administer oxygen, and transport the victim to a medical facility. Previously placed tourniquets and constriction bands should not be removed until intravenous access is established. As in any emergency, initial snakebite management should include advanced life support. If the patient is hypotensive, initial treatment should include rapid intravenous isotonic fluid...

Sinus Arrest Pause

Sinus pause is a failure of impulse formation within the sinus node. In sinus arrest, the P-P interval has no mathematical relation to the basic sinus node discharge rate (Fig 24-24). CLINICAL SIGNIFICANCE The same conditions that produce SA block can also produce sinus arrest, especially digoxin toxicity and aging disease of the SA node, as in sick sinus syndrome, discussed below. The combination of digoxin and carotid sinus massage is well known to be able to produce prolonged sinus arrest....

Disorders of the Neuromuscular Junction

Myasthenia gravis is discussed in Chap 226. Botulism Ingestion of foods contaminated with Clostridium botulinum toxin causes botulism, an acute disease marked by weakness and gastrointestinal slowing. Adults whose disease is caused not by bacterial infestation but by ingestion of botulinum toxin may report exposure to foods such as home-canned vegetables in the preceding 1 to 2 days. Unlike adults, infants, whose guts are not colonized fully, are susceptible to infection with viable bacteria...

TABLE 681 Conceptual Framework Undifferentiated Acute Abdominal Pain

Broadening the scope of abdominal pain beyond the intraabdominal reminds us that the clinical focus of the ED physician is quite different from that of his or her surgical colleagues. Surgeons, quite appropriately, approach abdominal pain seeking a binary answer to the question Does this patient need an operation ED physicians, in contrast, must first identify sick or possibly sick patients as early as possible in the course of their illness. Once this determination is made clinically, the ED...

Cervical Cancer

Currently, 15,800 new cases of cervical cancer are diagnosed per year. The average age at the time of diagnosis is 54. Risk factors include early coitus, multiple sexual partners, high-risk male partners, smoking, human papillomavirus, and HIV infection (or other immunosuppressive states). The diagnosis of cervical cancer in an HIV-positive patient is now considered an AIDS-identifying illness. Smoking increases the risk of cervical cancer in women by 3.5 times, and even passive smoke increases...

Vitamin B6 Pyridoxine

Vitamin B6 is a complex of three physiologically active compounds, the most active being pyridoxine. Pyridoxine is converted to pyridoxal-5-phosphate, which is a coenzyme in the transamination of amino acids that is required for the utilization of most amino acids for energy and for the synthesis of nonessential amino acids. A deficiency in vitamin B6 in infants results in convulsive seizures (due to a reduced synthesis of g-aminobutyric acid), anemia (due to impaired synthesis of heme),...

Schizophrenia and Other Psychotic Disorders

Mood Disorder Children Decision Tree

Schizophrenia and related disorders are marked by the presence of psychotic symptoms, primarily delusions and hallucinations. Delusions are defined as fixed false beliefs that are not amenable to arguments or facts to the contrary and that are not shared by others of similar cultural background. Common delusions are of several types. Persecutory delusions are those in which one believes that one is being attacked, followed, harassed, or conspired against. Grandiose delusions are those that...

Adhesive Capsulitis

Adhesive capsulitis, commonly referred to as the frozen shoulder syndrome, causes significant discomfort and dysfunction. It is characterized by markedly restricted joint motion and pain. This condition usually occurs in middle-aged patients and is uncommon in patients younger than 40 years of age and in those older than 70 years. It is more common in women, particularly postmenopausal women. The incidence in the general population is 2 to 5 percent this increases to 10 to 20 percent in...

Common Neonatal Problems

Normal .Vegetative Functions Feeding,, Patterns Crying,,, Irritabilityiand,, Lethargy IntestinalColjc Abuse ,andMJrauma Infections Surgical Lesions Improper ,Feedin,g,,,Pra,c,tice,s Diarrhea ,,a,nd,,,D,e,,h,yd,ra,t,io,n liness nyolying ,Othe,r,,,Q,rg,a,,n Systems Congenital,, Diseases Neuromuscular, Disease Couflh,,,and,,Nasaln, Congestion Noisy,,Breathing,, and, Stridor Apnea and.Eeriodlc Breathing Cyanosis, ,and Biue ,Spel s Jaundice Eye Discharge,,,, Re,d,n.e.s.s.,,,,an.d,, Conjunctivitis...

Staphylococcal Scalded Skin Syndrome

Staphylococcal scalded skin syndrome develops in patients with clinically inapparent staph infections caused by an exotoxin produced by Staphylococcus aureus. It occurs primarily in infants and young children, and also in immunosuppressed adults or those with renal insufficiency. The exotoxins involved, collectively known as exfoliatin, are elaborated by the bacteria, released into the circulation, and cause acantholysis and intraepidermal cleavage of the skin. 14 An episode of SSSS frequently...

Nerve Blocks

Peripheral nerve blocks are advantageous in the ED environment, particularly for procedures on the digits or penis. They require less total LA medication, and the site of drug delivery is often less painful than for local infiltration. It is important to document neurovascular status prior to application of the block, to prevent masking a primary traumatic neurovascular injury. The onset of anesthesia is more delayed than by direct infiltration and may be up to 15 min. The duration depends on...

Granulocytopenia Immunosuppression And Infection

Overwhelming infection is a common cause of death in the immunocompromised host. A variety of factors may contribute to increased susceptibility to infection in cancer patients. Important factors include 4. Impaired humoral immunity and antibody production, as in chronic lymphocytic leukemia or multiple myeloma 5. Altered cellular immunity, as in Hodgkin and other lymphomas 6. Postsplenectomy susceptibility to serious pneumococcal infections 7. Reactivation tuberculosis with concurrent...

Scabies

Scabies is a highly contagious, pruritic skin disorder caused by an arachnid, Sarcoptes scabiei var. hominis. The human scabies mite is endemic in many developing countries, where the prevalence ranges from 20 to 100 percent. In some areas of Central and South America, the scabies infestation rate among young children is close to 100 percent.85 Human scabies is transmitted primarily by direct personal or sexual contact with infected individuals. Although less common, transmission may occur by...

Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy is characterized by LV and or RV hypertrophy that is usually asymmetrical and involves primarily the interventricular septum. The diagnostic hallmarks of the disease are echocardiographic asymmetical septal hypertrophy and histologic hypertrophy associated with myocardial fiber disarray surrounding areas of increased loose connective tissue. 8 In approximately 50 percent of cases, it is a familial disease with autosomal dominant inheritance. In the rest, it is...

Toenails

Terbinafine (Lamisil) 250 mg PO qd for 12 weeks B 2. Itraconazole (Sporanox) 200 mg PO qd for 3 months C 1. Fluconazole (Diflucan) 400 mg PO single dose C 2. Ketoconazole (Nizoral) 400 mg PO single dose OR 200 mg PO QD for 7 days (monitor for hepatotoxicity not FDA approved for this use) C 3. Ketoconazole 2 cream (Nizoral) apply to rash qd for 2 weeks C 4. Itraconazole (Sporanox) 400 mg PO qd for 3-7 days C 5. Selenium sulfide (Selsun) 2.5 lotion apply as lather, leave for 10 minutes, then wash...

Microbiology

The bacterial etiology of hand infections depends on the source of the offending inoculum. Since Staphylococcus and Streptococcus species routinely colonize the skin, they are the bacteria most frequently isolated from hand infections.1,6 Polymicrobial infections, including anaerobes, are the rule rather than the exception, and antibiotic coverage must be chosen accordingly. Intravenous drug abusers typically present with abscesses or deep space infections secondary to Staphylococcus aureus....

Sleep Deprivation

Shift work and scheduling difficulties are the most common sources of stress, career dissatisfaction, and attrition in emergency medicine. People who work swing shifts have a shortened life expectancy. Circadian principles acknowledge the body's natural rhythms and can help in integrating one's work schedule with one's personal life and promote quality sleep and, thus, health. SLEEP PHYSIOLOGY Sleep occurs in discrete stages. The bulk of delta sleep or slow wave sleep (SWS) occurs early in the...

TABLE 1045 Treatment of Genital Herpes

The safety of acyclovir and valacyclovir during pregnancy has not been established. In pregnant patients with life-threatening disease, such as encephalitis, pneumonitis, or hepatitis, intravenous acyclovir should be used. It should not be used for recurrent episodes or as suppressive therapy. Pregnant women treated with the drug should be reported to the Glaxo-Wellcome registry, which is kept in cooperation with the CDC (1-800-722-9292, extension 38465). Current registry findings do not...

Streptococcal Pharyngitis

GABHS pharyngitis is the most common treatable cause of pharyngitis in children. The peak months of infection are January to May, but, because of the high frequency of occurrence in school-age children, the beginning of school in the fall is also associated with GABHS pharyngitis in many areas. The peak ages are 4 to 11 years, with GABHS infection being uncommon under the age of 3 years. DIAGNOSIS No set of symptoms or signs is completely specific for GABHS. Nonetheless, there are findings that...

Menopause

Menopause results from ovarian burnout and, on average, occurs at age 51.6 During the transition phase, or perimenopausal period, there is lengthening or marked variation in the intermenstrual intervals. By age 45, only a few primordial cells remain, and the production of estrogen decreases. As a result, the pituitary continuously produces large quantities of FSH and LH. Ihere is no midcycle rise in estrogen to trigger a further surge of pituitary hormones for ovulation. Estrogens continue to...

Scabies Sarcoptes scabiei

Scabies infestation resembles that of lice but is generally concentrated around the hands and feet, especially in the web spaces between the fingers and toes. In children, the face and scalp may be infested as well. In adults, scabies frequently affect the nipples in females and the penis in males. The scabies mite is a universal pest that appears to follow a 30-year cycle of proliferation. During the past several years, there has been an epidemic of scabies infestation in the United States....

Down Syndrome

Congenital heart defects occur in 40 to 60 percent of children with Down syndrome. Atrioventricular canal defects, ventricular septal defects, atrial septal defects, tetralogy of Fallot, and patent ductus arteriosus are all reported in this population. Pulmonary hypertension may develop in these children, associated with chronic upper airway obstruction and left-to-right shunts. Congestive heart failure has been described even in children without known heart lesions. Mitral valve prolapse and...

TABLE 1173 Differential Diagnosis of Allergic and Infectious Conjunctivitis

In approaching infectious conjunctivitis (Fig 11.7-1), the physician must decide whether the ocular disorder is one manifestation of a systemic illness such as measles or is occurring in relative isolation. Isolated conjunctivitis may be due to various viruses and bacteria, of which herpes simplex and N. gonorrhoeae are particularly severe, or to C. trachomatis, especially in the first 3 months of life. FIG. 117-1. Approach to the child with an isolated, infectious conjunctivitis. Abbreviations...

Heavy Metal Intoxication

Ingestions of one of several heavy metals can lead to systemic manifestations. Lead poisoning, or plumbism, is the most common heavy metal poisoning. Systemic signs of lead poisoning are highly variable depending on the age of the patient and the amount of lead ingested. Symptoms range from colic, iritability, fatigue, and anemia to encephalopathy. Intraorally, lead poisoning presents as an ulcerative stomatitis or a bluish hue to the buccal mucosa. The classic bluish lead line on the ginigiva,...

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

Appendix Testis Torsion

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...

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...