Temporomandibular Disorder

Temporomandibular disorder (TMD) refers to persistent discomfort due to dysfunction of the temporomandibular joint (TMJ), surrounding muscles, and ligaments. Symptoms include TMJ noise and pain on movement, limited jaw movements, locking of the jaw on opening, bruxism, and tongue, lip, or cheek biting. Headache may be associated with TMD as well, but in patients with headache and bruxism, it is often not clear which is cause and which is effect. Patients with TMD can usually locate their pain...

Nifedipine

ACTIONS AND PHARMACOLOGY This dihydropyridine calcium-channel antagonist has been one of the most extensively studied agents for rapid control of blood pressure. Until the last few years when awareness of serious side effects became more widespread, it had been the most frequently used agent for acute blood pressure lowering in hospitalized patients. It is a coronary and peripheral arterial dilator, which causes a slight increase in heart rate but rarely causes postural hypotension. It can be...

Renal Colic

Intravenous pyelogram (IVP), spiral CT, and ultrasound are all used in evaluating patients thought to have renal colic. Bedside ultrasound often allows a much more rapid diagnosis and disposition of ED patients than either IVP or spiral CT, and there are situations where the use of contrast material or iodizing radiation is unwise (e.g., pregnancy, renal insufficiency, and volume depletion). False-negative ultrasound results occur, but the sonographic appearance of hydronephrosis in the...

Chest Pain Of Esophageal Origin

Most esophageal causes of chest pain are not immediate threats to life however, differentiating esophageal pain from ischemic chest pain can be impossible in the ED. Patients with esophageal pain can report spontaneous onset of pain or pain at night, regurgitation, odynophagia, dysphagia or meal-induced heartburn however, these symptoms are also found in patients with coronary artery disease (CAD), and there is no historical feature that is sensitive or specific enough to routinely make a...

After Care Instructions

Wounds should be kept clean and dry for 24 h after suturing. Thereafter, they may be cleaned with running water and covered with a clean, dry dressing. Discharged patients should return for suture or staple removal in 7 to 10 days for upper extremity lacerations, 10 to 14 days for lower extremity lacerations, and 14 days for lacerations over joints. This time can be extended a few days in patients over age 65 years because epithelialization and noncollagenous protein accumulation are delayed.8...

Magnetic Resonance Imaging Principles And Some Applications

MR ., in the Emergent Setting Chapter,, References The significant advances in imaging technology of recent years have dramatically expedited diagnosis and improved outcomes in emergency department patients. Magnetic resonance imaging (MRI) has been at the forefront. In just a short time, it has become a major adjunct for neurologic and musculoskeletal evaluation. This chapter briefly describes MRI and elucidates its role in emergency medicine Magnetic resonance imaging has the following major...

Clinical Features

Patients present with an area of swelling, tenderness, and erythema. Inspection of the area may reveal fluctuance, induration, or active drainage. Lymphadenitis, localized lymphadenopathy, or fever may indicate systemic involvement of the infection, but in otherwise healthy patients, cutaneous abscesses tend to remain localized. A careful history should be obtained, with special attention given to underlying immunocompromising illnesses, steroid or other immunosuppressive drug use, and...

Epidemiology Foodborne Disease

From 1988 to 1992, a total of 2423 outbreaks of foodborne diseases in the United States were reported to the CDC 77,373 persons developed predominantly diarrheal illness.3 This number represents only a small fraction of foodborne outbreaks. Most infections are undiagnosed or unreported. It has been estimated that foodborne illness affects 6 to 80 million people in the United States and causes 9000 deaths each year. 4 On a global scale, the prevalence of all diarrheal illnesses has been...

Noninvasive Positivepressure Ventilation

The widespread use of noninvasive positive-pressure ventilation (NIPPV) for chronic sleep apnea in the 1980s has prompted investigators to look at NIPPV in the acute setting today. NIPPV can be described as an application of a preset volume pressure of inspiratory air through a face or nasal mask. Inspiratory muscle fatigue is the final phase of ventilatory failure in patients with severe reactive airway disease, COPD, and end-state pulmonary edema pneumonia. The airway resistance overcomes the...

Fungal Infections

Candida albicans infection is the result of immunosuppression (especially from steroid use) causing overgrowth of an endogenous gut flora. Mucocutaneous disease affecting the oropharynx, esophagus, and vagina is the most common presentation. Candidal urinary tract infections, usually associated with indwelling catheters, can run a benign course with just cystitis or spread to pyelonephritis. Disseminated candidiasis often results in endocarditis, aortitis, osteomyelitis, meningitis, and brain...

Apnea

Apnea is the absence of respirations for a period of 20 s or if it is associated with a decrease in heart rate of 80 beats per minute and or accompanied by cyanosis or pallor. Apnea is categorized as central apnea when it is of CNS origin. There are no respiratory efforts and no gas flow in central apnea. In obstructive apnea, there is impaired gas flow in the presence of respiratory effort. In mixed apnea, there are components of both of the above. Periodic breathing is apnea of a few seconds'...

Automatic And Implantable Defibrillators

In 1933, William Kouwenhoven observed in dogs that closed-chest electrical shocks delivered within 30 s of inducing ventricular fibrillation (VF) were 98 percent effective in terminating the dysrhythmia. After 2 min of VF, the rate of resuscitation fell to 27 percent. He reported similar results in human subjects. 14 Modern research indicates that the likelihood for successful resuscitation decreases roughly 10 percent min after the onset of VF. Thus, the goal of emergency cardiac care is to...

Chapter References

Farrington PF Pediatric vulvovaginitis. Clin Obstet Gynecol 40 135, 1997. 2. Sobel J Vaginitis, in Pearlman MD, Tintinalli JE (eds) Emergency Care of the Woman. New York, McGraw-Hill, 1998, pp 535-549. 3. Centers for Disease Control and Prevention 1998 guidelines for treatment of sexually transmitted diseases Recommendations and reports. Morb Mortal Wkly Rep 47 1, 1997. 4. McCoy MC, Katz VL, Kuller JA Bacterial vaginosis in pregnancy An approach for the 1990s. Obstet Gynecol Survey 50 482,...

Cholecystitis And Biliary Colic

Brady Judith E. Tintinalli Pathophysiology Clinical Features Differential Diagnosis Diagnostic StM.dies Complications Treatment Chapter References Biliary tract emergencies result primarily from obstruction by biliary calculi in the gallbladder and bile ducts. The four major biliary tract emergencies related to gallstones include biliary colic, cholecystitis, gallstone pancreatitis, and ascending cholangitis. While gallstones are common, most are asymptomatic. The...

TABLE 2473 Intracranial Hematomas

Patients with tSAH can present with mild to severe TBI. Those with isolated tSAH often present with a headache and photophobia and mild meningeal signs. A CT scan is generally diagnostic but care must be taken on reports of delayed intracranial hematomas, especially subdural hematomas, exist in the literature for patients who exhibited nonfocal neurologic exams with negative initial CT scans.27 Unfortunately, delayed findings may not be detected for one to two months after initial insult....

Maternal And Fetal Physiologic Changes That Affect Cardiac Arrest

Uteroplacental blood flow is directly related to maternal blood volume and arterial pressure. Support of maternal blood volume and oxygenation is the best way to prevent fetal hypoxia. With this principle in mind, a detailed understanding of cardiac arrest physiology is important. A full discussion of fetomaternal physiology can be found in Chap 99, but several points are discussed and put in perspective here. The maternal cardiovascular system undergoes dramatic changes. Cardiac output...

Observation and Regional Back Examination

With the patient disrobed, the spine and pelvis should be observed for abnormal spinal curves, pelvic tilts, or the presence of spinal-pelvic lists, all suggesting splinting or guarding in response to pain. Each vertebra should be palpated to identify point tenderness that suggests bony involvement. The gait should be observed for a loss of normal, symmetric spinal-pelvic rhythm. Asymmetric posturing suggests pain or weakness to which the patient is biomechanically accommodating. Guarding or...

Consultation

Orthopedic consultation is required for joint capsule penetration, open fractures, nerve lacerations, lacerations of the EHL, TA, or Achilles tendon, and for suspected compartment syndrome. Hand surgery consultation must be obtained for all flexor tendon lacerations, as well as for extensor tendon lacerations distal to the MCP joint, and should be considered for extensor tendon lacerations proximal to the MCP joint. With peripheral nerve and tendon injuries, it is appropriate for the emergency...

End Points to Resuscitation

Perhaps one of the greatest challenges in shock management facing both clinicians and researchers today is the identification of valid and reliable shock parameters to assess the severity of hemorrhage and the adequacy of resuscitation. 213 In the past, gross physiologic indices such as heart rate, blood pressure, capillary refill, urine output, and central venous pressure have been used to assess the severity of hemorrhage. Despite a long history of frequent clinical use, these parameters have...

Radiography

The clinical examination should determine which radiographs are necessary to support the diagnosis. Standard views of the wrist include posteroanterior, lateral, and oblique views. Although these views are sufficient in the majority of cases, other projections may be necessary to profile specific carpal injuries. The key to interpreting the radiograph is to first assure proper positioning, then identify specific features on each projection. On a properly positioned posteroanterior view, the...

Rotator Cuff Tears

Tears in the rotator cuff muscles can occur from acute trauma, chronic overuse, or a combination of the two. Acute rotator cuff tears account for approximately 10 percent of all rotator cuff tears and usually occur as a result of significant trauma. Traumatic causes typically involve a fall on an outstretched arm, causing extreme hyperabduction or hyperextension. Lifting a heavy object or catching a heavy object as it falls can also cause acute rotator cuff tears. Chronic rotator cuff tears...

Gallbladder Disease

Ultrasound is generally accepted to be the modality of choice in the evaluation of biliary disease. 4 Greater than 90 percent of biliary disease is calculous in origin, and, regardless of composition, even the smallest of gallstones are visible sonographically. Conversely, only 15 percent of gallstones are visible with standard radiographs. SONOGRAPHIC CONSIDERATIONS The gallbladder is an ideal organ for sonographic evaluation. This cystic structure is typically filled with anechoic bile and...

Prader Willi Syndrome

Prader-Willi syndrome is a condition characterized by mental retardation, hypotonia, hypogonadism, and obesity. It is a sporadic multisystem disorder with an incidence of 1 in 10,000. It is due to a chromosomal deletion on the 15th chromosome. Presentation in infancy is of poor suck, hypotonia, developmental delay, and early failure to thrive. During childhood, the poor eating habits change to hyperphagia and obesity, which becomes a major problem for health and life. Consequences of obesity...

Heterocyclic Antidepressants Hcas

Although tricyclic antidepressants (named for their three-ring structure) were first synthesized in the nineteenth century, their antidepressant properties were not recognized until the late 1950s. Since that time, other cyclic antidepressant agents have been formulated thus creating need for the more general term heterocyclic (Table., .282-3). The therapeutic effect of HCAs is believed to be related to secondary downregulation of norepinephrine and serotonin postsynaptic receptors after...

TABLE 473 Short Term Risk of Death or Nonfatal Myocardial Infarction in Patients with Unstable Angina

Hypoxia is a reduction in oxygen supply to tissue despite adequate perfusion. Ischemia is oxygen deprivation accompanied by inadequate removal of metabolites due to reduced perfusion. Both ischemia and hypoxia must be discussed in relative terms, since conditions that result in ischemia in one patient may not result in ischemia in another. Ischemia occurs when there is an imbalance between oxygen demand and oxygen supply. Oxygen supply is influenced by the oxygen-carrying capacity of the blood...

Inconsistent Findings and Pain Behavior

The patient who embellishes a medical history, exaggerates pain perception, or provides responses on physical examination inconsistent with known physiology can be particularly challenging.15 This condition can be objectified in the physical exam with the use of Waddell's nonorganic physical signs. 20 Tests can be included in the flow of the general physical exam for the back. Testing includes tenderness to superficial skin rolling report of low back pain with axial loading or when the whole...

Modifications Of Cardiopulmonary Resuscitation

The etiology of cardiac arrest in pregnant patients is different from that in nonpregnant patients and includes pulmonary embolism, amniotic fluid embolism, eclampsia, drug toxicity (e.g., magnesium sulfate or epidural anesthetics), cardiomyopathy, aortic dissection, trauma, and hemorrhage. As always, one should address the potential underlying etiology as well as the cardiovascular collapse. Cardiopulmonary arrest in a pregnant patient must be considered under two scenarios prior to fetal...

Otitis Externa

Otitis externa includes infections and inflammation of the external auditory canal (EAC) and auricle. It may be divided into acute diffuse and malignant types. ACUTE DIFFUSE OTITIS EXTERNA Definition and Diagnosis Also known simply as otitis externa (OE) or swimmer's ear, this infection is characterized by pruritus, pain, and tenderness of the external ear. Physical signs include erythema and edema of the EAC, which may spread to the tragus and auricle. Other signs are clear or purulent...

Child Neglect

Child neglect includes both physical and emotional neglect. Nearly 1 million cases of neglect occur annually in the United States. Neglect results from failure of the child's caregiver to provide adequate clothing, shelter, food, health care, and or schooling. Children who are the victims of neglect may appear in the emergency department dirty, improperly clothed, and unimmunized. Their medical problems may not have been attended to in a timely manner. They may have suffered from burns or...

Airway Obstruction

Potential causes of upper airway obstruction are shown in Tibie 1.4.-1. Basic management of the obstructed airway is discussed in Chap.8. Most of these entities cause soft tissue swelling or themselves are soft tissue masses that compromise the upper airway, but a few need mentioning. Certain medical diseases like respiratory syncytial virus (RSV) and cystic fibrosis produce copious secretions in the upper airway that can lead to partial or complete occlusion. Angioedema may present with soft...

[NaJ tfHCOj [CI AG

The difference between the serum sodium (the contribution of potassium, largely an intracellular ion, is usually neglected) and the sum of serum chloride and bicarbonate, then, equals the concentration of the unmeasured anions. Correction of serum sodium for hyperglycemia is unnecessary because this condition similarly reduces chloride concentrations.4 The unmeasured anion concentration is commonly called the anion gap (AG), and in the past its normal value had been considered to be 12 4 meq L....

TABLE 2221 Common Etiologies of Acute Ataxia and Gait Disturbances

The summation and integration of proprioceptive information from the joints and tendons, visual information, and vestibular inputs while the head, body, or limbs are moving, and the production of a smooth, steady muscular movement is a complex process involving different areas of the central nervous system (CNS) and elements of the peripheral nervous system. Transmission of proprioceptive information from the peripheral nervous system into the CNS is required, as well as integration and...

Definition

Impetigo is a superficial bacterial infection of the skin confined to the epidermis. Deeper spread to the dermis leads to ecthyma. There are two varieties of impetigo impetigo contagiosa and bullous impetigo. Etiology Traditionally, group A b-hemolytic streptococcus (GABHS) was considered the major pathogen in impetigo contagiosa. However, recent studies have suggested that Staphylococcus aureus often can be the primary infecting agent and that therapy which does not include coverage for this...

Introduction and Definition

Consciousness has long been a perplexing subject for philosophers and physicians, and it may be argued that human consciousness is still poorly understood. However, emergency physicians need an operational definition for the disorders of consciousness that are frequently encountered in emergency departments. Dementia is a chronic state of reduced cognitive ability. The individual once was able to function but has lost intellectual skills and memory so that normal functioning has become...

TABLE 236 Clinical Manifestations of Hypernatremic States Related to Serum Osmolality

Virtually all hypernatremia encountered in the ED is related to volume loss, usually severe. There are two potential mechanisms seemingly opposed but having the same result. The first is the ADH response to low volume and hypertonicity. The renal response to ADH, conservation of free water, results in low urine output (less than 20 mL h) that has a high osmolality (usually greater than 1000 mosm kg H2O). The second mechanism is failure of ADH response, either central or peripheral (vide infra)....

TABLE 2712 Complications of Rhabdomyolysis

The serum potassium level is elevated in 10 to 40 percent of cases, due to release of potassium from injured skeletal muscle. -I3 Renal function, however, appears to be the most important determinant of the degree of elevation. Hyperkalemia can be a significant complication of rhabdomyolysis if acute renal failure occurs. Elevated uric acid levels can occur, especially in crush injures, due to release of muscle adenosine nucleotides and subsequent conversion to uric acid by the liver. Uric acid...

Step 1 Define the Problem

Population-based data on the incidence and impact of injury are essential to define the scope of the problem and mobilize the resources necessary to achieve change. Public health surveillance is needed to monitor patterns and trends, and to evaluate the impact of countermeasures. Several sources of information can be used for this purpose. Vital records or death certificates are useful to document the impact of injuries on overall rates of mortality, but they do not provide information about...

Rocky Mountain Spotted Fever

Rocky Mountain spotted fever (RMSF) is an infectious disease caused by Rickettsia rickettsii which is transmitted by ticks. The prominent clinical manifestations of RMSF can be directly related to the primary pathologic lesion in the endothelial cells lining small blood vessels where the rickettsia multiply. Rash, headache, mental confusion, terminal heart failure, and shock are manifestations of the generalized vasculitis. The incubation period is from 2 to 12 days with either a sudden or...

Pathophysiology

Monoamine oxidase (MAO) is an intracellular enzyme bound to the outer mitochondrial membrane.5 It has been identified in most human cells. A notable exception is erythrocytes, which do not contain mitochondria. MAO removes amine groups from both endogenous and exogenous biogenic amines. This oxidation deamination process is the primary mechanism by which endogenous biogenic amines such as norepinephrine (NE), dopamine (DA), and 5-hydroxytryptamine (serotonin or 5-HT) become inactivated. A...

Injuries to the Penis

Self-inflicted injuries of the penis include vacuum cleaner injuries and blade injuries. Vacuum cleaners cause extensive injury to the glans penis and some loss of the urethra, requiring debridement of devitalized tissue and reconstruction. Blade injuries range from superficial lacerations to complete amputation. Amputation of the penis is managed by reimplantation or local repair. Reimplantation is preferable if the distal penis is in satisfactory condition, and the ischemia time is less than...

Recognizing The Violent Patient

The only agreed upon predictors of violence are gender and alcohol abuse. Most perpetrators of violence are males with a history of substance abuse. The amount of education, ethnic background, marital status, or diagnosis are not reliable predictors, but they may be barriers to patient-staff interaction, which in itself may lead to frustration and anxiety for both the staff and patient. In turn, this subconscious conflict may precipitate a violent encounter. The most obvious predictor of...

Elbow Dislocation

The elbow is one of the most stable joints in the body. This stability is due to the adjacent muscular attachments, collateral ligaments, and inherent stability afforded by the hingelike articulation. Because of this stability, surgical repair for acute instability is usually not required, and chronic dislocations are unusual. Despite this, however, dislocations of the elbow are commonly seen, being third in large-joint dislocations, after glenohumeral and patellofemoral dislocations. There are...

Diagnostic Techniques

The potassium hydroxide preparation is used in patients with suspected molluscum contagiosum and dermatophytic infections. The test is performed on loose skin scales, nail pairings, subungual debris, short residual hairs, or small pearly globules (from a molluscum body). The material is placed on the microscope slide, gently crushed, and mixed with two drops of a 20 KOH solution. The specimen is then warmed boiling will produce artifactual change. Excess solution may be removed by placing a...

Complications Of Airway Devices

Hackeling Endotracheal .Tubes Tracheostomy Tubes Laryngeal Stents Sp.ee.c.h Devic.e.s Even with expertise and meticulous planning, complications of airway management are bound to occur. Most complications are due to many factors, including inadequate preparedness, inadequate assessment, failure to anticipate or recognize the complication, and inadequate skill during the airway crises. 1 This chapter focuses on complications of airway devices, including...

Open the Airway

Once unresponsiveness has been determined, assistance obtained, and a defibrillator requested, the next step is to assess the upper airway of the victim. This usually requires positioning the individual supine on a flat, firm surface with arms along the sides of the body, followed by opening the person's airway. Unless trauma can be definitely excluded, any movement of the victim must take into account the potential of a spine injury as the patient is placed supine, stabilize the cervical spine...

Syndrome Of Inappropriate

Primary and metastatic malignancy of the brain Small cell lung carcinoma Pancreatic adenocarcinoma Prostate carcinoma Ectopic secretion of antidiuretic hormone (ADH) may come from a variety of malignancies. In addition, excessive endogenous secretion of ADH may be caused by chemotherapy (Vinca alkaloids, cyclophosphamide), narcotics, phenothiazines, antidepressants, and head trauma. Regardless of etiology, the syndrome of inappropriate ADH (SIADH) consists of serum hyponatremia, less than...

TABLE 1372 Clinical Features of Genital Ulcers

GENITAL WARTS Human papillomaviruses (HPVs) are DNA viruses that cause genital warts by direct transmission. Different genotypes also have been implicated in cervical cancer, but the relationship is far from clear. The warts usually appear after an incubation period of 3 to 4 months and may coalesce to form condylomata acuminata. Although painless, their location or size may cause discomfort. Diagnosis Diagnosis is clinical, with care to exclude other STDs. Treatment Treatment decisions are...

Esophageal Bleeding

The general approach to upper gastrointestinal bleeding (UGIB) from an esophageal source does not differ from the approach for bleeding from other sources and is addressed in more depth in Chap. i70, Gastrointestinal Bleeding. Resuscitation proceeds concurrently with the diagnostic effort of history, physical examination, and laboratory evaluation. Gastric lavage through a nasogastric tube or larger-bore gastric tube is generally accepted, and early airway management should be considered....

Immediate Transfusion Reactions

ACUTE HEMOLYTIC TRANSFUSION REACTION This is a medical emergency that occurs when incompatible RBCs are transfused. Most often this is an intravascular event resulting from incompatibility in the ABO blood group system. Iable.215.-4 reviews compatibility in the ABO blood group system. An acute hemolytic reaction occurs when the incompatible transfused cells are immediately destroyed by antibodies. The overall incidence of acute hemolytic transfusion reactions is estimated at 1 in 21,000 to 1 in...

Diagnostic Peritoneal Lavage

Diagnostic peritoneal lavage (DPL) is used for the early recognition of intraabdominal injury requiring celiotomy. In many centers, the use of DPL has been supplanted by imaging techniques because of increased accessibility to improved computed tomography (CT) and ultrasonography. However, size and weight restrictions and transport difficulties may preclude the use of CT scanning in the obese trauma victim. Abdominal ultrasonography is also less reliable in the morbidly obese patient. Therefore...

Constitutional Symptoms and Febrile Illnesses

OVERVIEW Systemic symptoms, such as fever, weight loss, and malaise, are common in HIV-infected patients and account for the majority of HIV-related emergency department presentations.12 In the emergency department, systemic infection and malignancy must be excluded. Appropriate laboratory investigation may include electrolyte determinations, complete blood count, blood cultures (aerobic, anaerobic, and fungal), urinalysis and culture, liver function tests, chest radiograph, and serologic...

Dentoalveolar Trauma

Dentoalveolar trauma is a very common reason for ED visits. Approximately 20 percent of all school-age children will experience oral trauma. The most common mechanism of injury is falls. Sporting injuries, fights, and motor vehicle collisions account for most of the remainder. Injury to the maxillary central incisors accounts for 70 percent of dental injuries.27 The management of dentoalveolar trauma depends on the extent of tooth and alveolar involvement, the degree of development of the apex...

Fractures and Dislocations

CLASSIFICATION SCHEMES There are multiple classifications of ankle fractures. The more complex utilize both the position of the foot at the time of injury and the deforming force. These classifications are useful in predicting associated injuries. In the Lauge-Hansen classification system, the first word refers to the position and the second word refers to the force. The Danis-Weber classification is based on the level of the fracture of the fibula. Proximal fractures of the fibula are...

Hypercalcemia Of Malignancy

Renal cell carcinoma Multiple myeloma Squamous cell lung carcinoma Breast carcinoma Lymphoma Mild elevations of serum calcium are well tolerated and produce little in the way of symptoms. However, when serum calcium levels rise rapidly or exceed ionic thresholds, cardiac, neural, and muscular electrophysiology may be greatly altered. A number of mechanisms have been identified that promote release of bony calcium into the circulation. Bony involvement with myeloma, carcinoma of the breast, or...

Hemodynamically Stable Asymptomatic Patients

This class of patients presents to the emergency department for reasons that are not referable to the heart and are discovered to have findings suggestive of cardiac disease. Some of the more common cardiac defects have already been mentioned including mildly affected tetralogy of Fallot, small to moderate-sized VSDs, and coarctation of the aorta. Several common structural defects warrant mention here. ATRIAL SEPTAL DEFECT Most children remain symptomatic throughout childhood until adolescence,...

Prolapse

The female pelvic organs, i.e., vagina, uterus, bladder, and rectum, are held in proper alignment by supporting ligaments, fascia, and the pelvic floor muscles. When any or all of these structures fail, the pelvic organs may prolapse within and occasionally protrude through the vagina. This prolapse or displacement may occur singly or more commonly combined. Prolapse can be divided into two broad categories, uterine and vaginal. Uterine prolapse is graded as first through third degree. 1. First...

Sulfonylureas

Sulfonylureas stimulate the b-islet cells of the pancreas to release insulin through inhibition of potassium channels and changes in membrane potential. 7 First-generation sulfonylureas, such as chlorpropamide, reduce hepatic clearance of insulin and have active metabolites. These agents are renally excreted, complicating glycemic control in diabetics with intrinsic renal disease. Second-generation sulfonylureas, such as glyburide and glipizide, have half-lives that exceed 24 h and are...

Emergency Department Recognition of Substance Abuse

The percentage of ED patients who test positive for blood alcohol at the time of the visit ranges from 6 to 34 percent for injured patients and 1 to 19 percent for the noninjured.8 At the time of an urban ED visit, 17 percent of patients were found to meet stringent criteria for alcohol abuse and 19 percent for alcohol dependency, while only 9 percent of the study group were breath alcohol positive, and only 14 percent reported a drinking problem. Among a 1-year sample of more than 7100...

Halo Devices

The Halo vest provides one of the most rigid types of cervical immobilization available. The Halo consists of a lightweight radiolucent ring attached to a lightweight adjustable vest. Current vests allow adjustment of the cervical spine in multiple planes. Titanium pins that do not interfere with MRI images, are stronger, lighter, and more expensive than older stainless steel pins. Pins are usually tightened to 6 to 8 in lb. 45 INDICATIONS Halo devices are indicated for stabilization of an...

Fluids

A prerequisite to the anatomy of body fluids and the physiologic principles that maintain normal fluid and electrolyte balance is a firm understanding of the extent and composition of the various body fluid compartments. Homeostasis is the maintenance of the composition of the internal environment that is essential for health. This includes consideration of the distribution of water in the body, along with appropriate maintenance of pH and electrolyte balance. Water is the major constituent of...

Molecular Pathophysiology of Sepsis

There is now compelling evidence that septic shock and its morbid consequences are the direct result of endogenous proteins and phospholipid mediators secreted by the infected individual. Molecular pathophysiology of sepsis can be divided into 3 phases induction of cytokine synthesis, cytokine synthesis and secretion, and cascade phase of sepsis. The induction of cytokine synthesis involves the interaction of certain microbial molecules that, when recognized by the host, results in the...

High Altitude Cerebral Edema

HACE is defined clinically as the presence of progressive neurologic deterioration in someone with AMS or HAPE. It is characterized by altered mental status, ataxia, stupor, and progression to coma if untreated. Headache, nausea, and vomiting are not always present. Because of raised intracranial pressure, focal neurologic signs such as third and sixth cranial nerve palsies may result from distortion of brain structures or by extraxial compression. HACE is usually associated with pulmonary...

TABLE 238 Etiology of Hyperkalemia

Clinical manifestations of hyperkalemia usually result from derangement in membrane polarization. Cardiac manifestations are the most serious. They include ECG 6.5 to 7.5 meq L tall peaked T waves, short QT interval, and prolonged PR interval 7.5 to 8.0 meq L QRS widening, and flattening of the P wave 10 to 12 meq L the QRS complex may degrade into a sine wave pattern Ventricular fibrillation, complete heart block, and asystole may occur. Death from hyperkalemia is usually the result of...

TABLE 1206 Differential Diagnosis of Asthma

INFECTION Fever and focal wheezing implicate infectious etiologies such as pneumonia or bronchiolitis. Nocturnal wheezing, nocturnal cough, and poor exercise tolerance may be clues of more chronic illness. Sinusitis can exacerbate asthma symptoms a history of nasal congestion and nocturnal cough or snoring should be treated with at least a 2-week course of antibiotics and nasal steroids. Recurrent attacks, failure to thrive, and a history of sinusitis and chronic ear infections should raise...

Acquired Immunodeficiency Syndrome

There are numerous oral manifestations of HIV infection. Primary HIV infection, occurring from 1 to 6 weeks after contact, is an acute viral syndrome but may have associated intraoral findings such as a sore throat, mucosal erythema, and focal ulceration. Persistent generalized lymphadenopathy, particularly of the cervical lymph nodes, is present in 70 percent of otherwise asymptomatic HIV-infected patients. The presentation of acquired immunodeficiency syndrome (AIDS) is highly variable, and...

Renal Cortical Scintigraphy RCS

RCS, using dimercaptosuccinic acid (DMSA), is a radionuclear study that evaluates kidney function. RCS is most commonly used in the evaluation of children with suspected pyelonephritis and, occasionally, assessment of a renal transplant. Two hours after administration of Tc99m-DMSA, scanning is performed using a gamma camera. DMSA binds to the renal tubules and accumulates in the functioning renal cortex. Intrarenal blood flow and proximal tubular cell membrane transport determine cortical...

Common Parasitic Infections

Pathophysiology Clinical.Features Diagnosis Helminths Nematodes, (Roundworms) TrematodesiFlukes) Ce.stodes jfiatworms) Protozoa Amebas Protozoan .jnfe.ctions.in ,immunocompromised H.o.sts Respiratory Tract Treatment Disposition Chapter References Despite significant advances in medical knowledge and technology over the last half century, parasitic disease remains prevalent world-wide. It is estimated by the World Health Organization that 200 million people, living mostly in the rural tropics,...

TABLE 1992 Types of Radiation

The biological effect of these forms of radiation is a function of the mass, charge, and energy that the type of radiation possesses. Linear Energy Transfer (LET) describes the rate at which radiation deposits its energy as it travels through matter. In general, particulate radiation has a high LET and electromagnetic radiation has a low LET. High LET radiation interacts readily with matter, creating a dense number of ionizations in the matter through which it passes. Thus, high LET radiation...

Central Venous Pressure Catheterization And Monitoring

Central venous catheterization should be performed (1) when rapid delivery of cardiac medications to the coronary circulation is required during cardiopulmonary resuscitation (CPR) 15 (2) for access when peripheral veins are inadequate and (3) when measurement of central venous pressure is desired. Hypovolemic shock by itself is not, however, an indication for central venous catheterization. Many patients who require large-volume infusions or transfusion with multiple units of blood can be...

Hip Dislocations

Hip dislocations can be classified as anterior, posterior, and central. Acetabular fracture with central hip dislocation has been discussed under acetabular fractures. ANTERIOR DISLOCATIONS About 10 percent of hip dislocations are anterior (Fjg SS O i and Fjg BS Oe), and the majority are secondary to automobile accidents, but they may also result from a fall, or a blow to the back while squatting. In anterior dislocations, the femoral head rests anterior to the coronal plane of the acetabulum....

Caterpillars And Moths Lepidoptera

There are at least 10 families of venomous caterpillars and moths. Stinging moths are found in the southern United States that can cause an illness termed lepidoterism. Some caterpillars possess hollow spines among their hairs that contain urticating poisons that can cause symptoms ranging from local dermatitis to generalized systemic reactions. The puss caterpillar or woolly slug, larval stage of the moth Megalopyge opercularis, is perhaps the most toxic variety in the United States and is...

Specific Hernia Types

INDIRECT INGUINAL HERNIA The inguinal canal is the tract in the abdominal wall through which pass the gubernaculum, testis, and spermatic cord in males or the round ligament in females. The canal is defined by an internal ring defect in the transversalis fascia and transversus abdominis aponeurosis, lateral to the inferior epigastric vessels, and a more medial external ring defect in the external oblique aponeurosis ( Fig 7,6,-1 and Fig 7,6-2.). Normal passage through the inguinal canal is...

Exotic Animal Bites

Extensive clinical data and treatment recommendations pertaining to bite wounds made by exotic animals and resulting infection are based on anecdotal case reports. In general, it is best to adhere to the dictum that the bacteriology of the bite wound will reflect the normal oral flora of the inflicting animal as opposed to the normal skin flora of the patient. General principles of local wound care including irrigation and surgical debridement, wound cultures as appropriate, and tetanus and...

Neurologic Problems

SEIZURES Thirty to 50 percent of all developmentally delayed individuals have seizure disorders. Often, an individual experiences several different types of seizures, which may have complicated presentations such as Lennox-Gastaut seizures. Occasionally, patients, particularly those who are verbal, also have pseudoseizures. As with any other patient, the priorities are to insure adequate oxygenation and to stop the seizure. Subsequently, one must determine the precipitants for the seizure,...

Ballistic Properties And The Wound Produced

Animal experiments using military-rifle bullets9 have clearly disproved the assertion that all tissue exposed to temporary cavitation is destroyed. Not only does the 14-cm diameter temporary cavity produced by the AK-74 not destroy a great amount of muscle, but the sizable stellate exit wound it causes in the uncomplicated thigh wound ensures excellent wound drainage, which assists healing. 916 A history that the wound was caused by a high-velocity bullet does not mandate radical excision of...

TABLE 1932 Hospital Care of Near Drowning Victims

Although patient survival in a persistent vegetative state is a concern, substantial numbers of patients, predominantly children, requiring CPR on emergency department arrival have survived with good outcomes, and physicians should err on the side of providing resuscitation. 45 and 6 The physician should gather sufficient history to allow an estimate of prognosis and gauge the patient's response to resuscitative efforts. On the victim's arrival in the emergency department, adequate oxygenation...

Skin and Soft Tissue Infections

Unique features of skin infections in the IVDU29,30 are (1) a high rate of skin and pharyngeal colonization with S. aureus and streptococcal species, (2) the high frequency with which cutaneous abscesses are due to oral flora,31 and (3) the fact that infection with HIV also confers an additional risk for the development of skin abscesses.10 The IVDU will self-inject, often multiple times a day, with unsterile needles, which may be licked prior to injection. Tap or toilet water or saliva often...

Classification

Diabetes can be grouped into four major categories (T.a,bl.e ,2Q.9.-1).1 Type 1 diabetes older terminology insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes mellitus (JODM) is characterized by an absolute deficiency of insulin secretion. The disease is believed to be primarily autoimmune in nature with a genetic predisposition and a possible link with viral infections or other environmental factors (such as absence of breast-feeding, diet, and factors related to low...

Vulvovaginitis

Normal VulyovaqinalEnyironment Bacterial Vaqinosis Candida Vaginitis Trichomonas Vaginalis Contact Vulvovaginitis Vaginal Foreign Bodies Pinworms Atrophic Vaginitis Chapter References Vulvovaginitis is inflammation of the vulva and vaginal tissues. It is usually characterized by a vaginal discharge and or vulvar itching and irritation. A vaginal odor may be present. It accounts for 10 million visits to physicians per year in the United States, and is the most common gynecologic complaint in...

TABLE 1018 Physical Findings Cause and Treatment of Postpartum Hemorrhage

Management plan for postpartum hemorrhage. (From American College of Obstetricians and Gynecologists Postpartum Hemorrhage. Washington, 1998, The management of postpartum hemorrhage is dependent on stabilization of the patient and diagnosis of the cause of bleeding (see Table 101 8). If bleeding is massive, two large-bore intravenous lines should be started, CBC and clotting studies performed, and the patient typed and crossmatched for blood. A red-top tube should be kept by the...

Class II Antidysrhythmic Agents b Blockers

There are numerous b blockers, each being an effective antidysrhythmic because it prevents circulating catecholamines from binding to beta receptors. However, specific to each drug is its degree of cardioselectivity, intrinsic sympathomimetic activity, a-adrenergic blockade, and quinidine-like membrane stabilization. The metabolic effects (such as alterations in glycogen metabolism) and pharmacokinetics (relative potency, route of elimination, distribution in fat and brain, and duration of...

Pain of Odontogenic Origin

TOOTH ERUPTION Discomfort is commonly associated with the eruption of primary or deciduous teeth in infants. Irritability, drooling, and decreased intake are commonly associated findings. An associated low-grade fever (37.9 C) and diarrhea are more controversial findings. No scientific data support an association of teething, fever, and diarrhea. It is plausible that mild dehydration from excessive salivary production or a decrease in intake may result in a low-grade fever, and changes in...

Three Joint Complex Degeneration

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

Thoracic Spine

Although spine pain complaints are more common at cervical and lumbar levels, thoracic complaints can be as disabling. This region of the spine is comparatively stable and protected both by the rib cage and the orientation of the facet joints. In this region, the spinal cord and paired segmental nerves traverse the narrowest of bony canals and any compromise of the available space can result in rapid and profound neurologic deficits. Thoracic spine fractures occur most commonly at the T10-L2...

Burn Depth

The depth of a burn has been historically described in degrees first, second and third. 9 However, a classification of burn depth according to the need for surgical intervention has become the accepted approach in burn treatment centers superficial partial-thickness, deep partial-thickness, and full-thickness burns. 3 Determination of burn depth requires judgment, using the commonly seen clinical features there is no objective method of measuring burn depth, and burn wound biopsy has not become...

Sickle Cell Hemoglobin C Disease HbSC Disease

This heterozygous sickle cell variant results when the gene for HbS is inherited from one parent and the gene for HbC is inherited from the other parent. Hemoglobin C results from a single point mutation in the beta-chain gene lysine is substituted for glutamic acid at the sixth position. About 2.4 percent of US African-Americans carry the gene for HbC. This gene frequency is one-fourth that for HbS, but the prevalence among adults of SC and SS disease is almost the same because those with HbC...

TABLE 2472 Agents for Rapid Sequence Intubation of Patients with Severe TBI

CIRCULATION Once the airway is secured, aggressive fluid resuscitation may be required to prevent hypotension and the resulting secondary brain injury. Studies have shown an increase in mortality from 27 to 50 percent for patients with isolated TBI who had a single episode of systolic blood pressure of less than 90 mmHg. Adequate fluid resuscitation has not been shown to increase ICP. Guidelines recommend that the MAP be maintained at 90 mmHg (systolic blood pressure of 120 to 140 mmHg) to...

TABLE 1191 Common Causes of Pneumonia

NEWBORNS BIRTH TO 1 MONTH The newborn age group is the only developmental period when bacterial infections are more common than viral agents as the leading cause of pneumonia. The majority of infections in this age group are caused by aspiration of the maternal genital organisms present during labor and delivery. The predominant pathogen is group B streptococcus, followed by Escherichia coli, Klebsiella species, and other gram-negative enteric bacilli from the Enterobacteriaceae family. Other,...

TABLE 335 Dose Equivalents and Pharmacokinetics of Analgesics

Agents in common use for ED CS include morphine, fentanyl, and meperidine. Meperidine may be a poor choice for ED analgesia in general. It causes more histamine release than either morphine or fentanyl. Its primary metabolite, normeperidine, is bioactive and toxic. Normeperidine causes CNS excitation, including tremors, myoclonus, and seizures, effects that are not antagonized by naloxone. Because normeperidine is excreted by the kidneys, it accumulates in renal insufficiency and with repeated...

Cocaine Associated Myocardial Ischemia

Management of patients with cocaine associated myocardial ischemia focuses on reversal of coronary vasoconstriction, hypertension, tachycardia, and predisposition to thrombus formation.31 Central nervous system protection and decreased sympathetic outflow should be accomplished with the administration of benzodiazepines. Multiple animal experiments and widespread anecdotal experience in humans support the use of diazepam as the initial agent for the management of cocaine intoxicated patients....

TABLE 2062 Signs and Symptoms of Symptoms of Hyperthyroidism

Palliative treatment for mild hyperthyroidism can be accomplished by using various b-blocker medications, the most common of which is propranolol. The goals of therapy include decreased heart rate, decreased tremor, increased muscle strength, and overall improvement in the patient's sense of well-being. 5 Treatment of Graves' disease may include long-term antithyroid medication, propylthiouracil or methimazole (MMI), radioiodine (iodine 131), or surgical ablation (subtotal thyroidectomy). Toxic...

Treatment

Treatment in the emergency department depends on the severity of the hemoptysis and the likelihood of a malignant cause. All patients with massive hemoptysis, and some patients with minor hemoptysis due to tuberculosis, mycetoma, or bronchiectasis, who are at significant risk of developing massive hemoptysis in the near future, require urgent management and hospitalization. All such patients require intravenous access, supplemental oxygen to ensure adequate arterial saturation, and typing and...

Ultrasound Findings

The first sonographic finding in early pregnancy is the gestational sac. This is a hypoechoic structure that is slightly eccentric in its location within the uterine cavity. The decidua capsularis and decidua vera are seen as two distinct hypoechoic layers surrounding the early gestational sac this is known as the double decidual sac sign (Fig 109-8). The yolk sac is the next embryonic structure to be visualized. It appears as a small ringlike structure within the gestational sac. Finally, the...

Longterm Outlook For Alcoholics

Alcoholic patients should be referred for counseling when possible. A fifth or more may achieve permanent abstinence with the aid of Alcoholics Anonymous or other self-help groups. Unfortunately, the rate of recidivism is related to socioeconomic status and availability of family and social support systems. Thus, while 60 percent of middle-class alcoholics remain ethanol free for at least 1 year after completing a rehabilitation program, the outlook is considerably bleaker for those who are...

Urinary Retention

Obstructive uropathy causes a wide expanse of signs and symptoms. Overt urinary retention represents one end of the spectrum, while symptoms of insidious overflow incontinence will often fool an unsuspecting examiner. Prior to acquiring a detailed genitourinary history, questions regarding chronic systemic medical illnesses or carcinomas that have as sequelae sensory or motor neurogenic side effects or complications must be addressed. A detailed medication history, including over-the-counter...

Periodontal Pathology

PERIODONTAL DISEASE Gingival inflammation and bleeding, or gingivitis, results from the accumulation of plaque along the gingival margins. Hormonal variations of puberty, adolescence, and pregnancy, as well as many medications such as phenytoin, also may result in gingival inflammation. As the inflammatory process progresses, destruction of the attachment apparatus occurs, and the gingival sulcus deepens, resulting in periodontal pockets and periodontitis. Periodontal pockets create a favorable...

TABLE 1564 Grading of Lithium Toxicity

In addition to neurologic changes, renal dysfunction is common. Due to diabetes insipidus, patients complain of polyuria and polydipsia. Fluid losses may exacerbate toxicity. Acute renal failure may develop, particularly in patients with preexisting renal impairment, advanced age, diabetes, hypertension, or dehydration. GI symptoms are common in both acute and chronic toxicity. Patients present with gastroenteritis, nausea, vomiting, diarrhea, bloating, or generalized abdominal pain....

Plantar Fasciitis

Plantar fasciitis is an inflammation of the plantar aponeurosis. The plantar fascia's main function is to anchor the plantar skin to the bone, thus protecting the longitudinal arch of the foot. The cause of plantar fasciitis is usually overuse in the physically active patient or in the patient unaccustomed to activity. Other causes include abnormal joint mechanics, tightness of the Achilles tendon, shoes with poor cushioning, abnormal foot position and anatomy, and obesity. In the younger...

Disease Management

Although currently available therapies do not change the underlying pathology of PD, their use can significantly reduce symptoms. These drugs include anticholinergics such as trihexyphenidyl and benztropine drugs that increase central dopamine levels such as amantadine, levodopa, and carbidopa and dopamine receptor drugs such as bromocriptine and pergolide. When PD symptoms cause severe motor dysfunction, the monoamine oxidase (MAO) inhibitor selegiline HCl and the COMT inhibitors entacapone...

Injury to the Chest Wall

SOFT TISSUE INJURIES Bleeding Probing of a penetrating chest wound to determine its depth or direction can be dangerous because it can damage underlying structures and cause severe recurrent bleeding or a pneumothorax or air leak. Bleeding from chest wall muscles can be rather brisk at times and is best controlled initially by local pressure. Later, one can inspect the depths of the wound in the operating room and use ligatures to control the bleeding and carefully close the wound. Open...