Acute Pyelonephritis
Classically, acute pyelonephritis is characterized by shaking chills and fever, flank pain, and costovertebral angle tenderness following several days of dysuria and frequency.24 The urine often demonstrates WBC casts and clumps, as well as bacteria. Sometimes the presentation may not be dramatic, and it might be difficult to distinguish lower from upper UTI. Factors associated with an increased risk for pyelonephritis include pregnancy, prolonged symptoms prior to seeking care, three or more...
Hypertensive Encephalopathy
Although no specific blood pressure is pathognomic, the elevated pressure must exceed the limits of cerebral autoregulation of the small-resistance arteries, resulting in cerebral hyperperfusion with loss of integrity of the blood-brain barrier. In most cases, autoregulation usually cannot accommodate a constant cerebral blood flow above a MAP of 150 to 200 mmHg. Immediate reduction of blood pressure by 20 to 25 percent will help reverse the vasospasm that occurs at these pressures however,...
Approach To Low Probability Of Ischemia
After initial evaluation, early data collection, and interpretation, a high potential for the presence of an ACS will be recognized in many patients. The approach to further risk stratification and treatment of these patients is detailed in Chap.47. Many others can be classified as having a low probability of acute ischemia based on clinical information available at the time of their ED visit. However, there is currently no consensus in the literature on their optimal management or even a...
Esophageal Perforation
Perforation of the esophagus can occur secondary to a number of disparate processes 23 as noted in Table.71-3. Iatrogenic injury is the most frequent cause of esophageal injury, accounting for up to 75 percent of all perforations. Endoscopy, a prime offender, has a lesser rate of perforation when performed on an esophagus free of disease than does endoscopy of a diseased esophagus. Dilation of strictures increases the risk of perforation greatly. Other intraluminal procedures, such as variceal...
Class I Antidysrhythmic Agents
PROCAINAMIDE Procainamide is useful as an antidysrhythmic agent in the treatment of various ventricular and supraventricular dysrrhythmias. Procainamide was developed after the antidysrhythmic effects of the local anesthetic agent procaine were realized. However, procaine's short duration of action and its prominent central nervous system CNS effects rule it out for its clinical use. Like all class I agents, procainamide blocks sodium channels and depresses the speed of impulse conduction phase...
TABLE 1204 Classification of Asthma Severity Clinical Features before Treatment
Use in children below age 5 is limited by patient cooperation. In older children, the ability to perform deep inspiration and forced expiration may not be feasible during an acute exacerbation Table 1,20-5 . lw f T. Vf' Y Uh wi Vm,ji, LfcUiw fa' iiii'j fit'i ti ir purtlf t e jpin-K '51 .
Antidote Therapy
Digoxin specific Fab Digibind, Burroughs-Wellcome is derived from the IgG fragment of sheep antidigoxin antibodies. Fab fragments distribute widely throughout tissues and remove digitalis from tissue binding sites.12 In a series of 150 severely poisoned patients, 90 percent showed reversal or significant improvement in life-threatening dysrhythmias and hyperkalemia after Fab fragment administration. 12 In most cases, clinical improvement in cardiac rhythm occurs within one hour of antidote...
Plain Film Radiography
Plain films remain the workhorse imaging study for the emergency department evaluating a patient with abdominal pain. Plain films can be obtained quickly, cause no discomfort to the patient, and are relatively inexpensive compared to other gastrointestinal GI imaging modalities. The emergency physician can interpret plain films. Unlike the chest, where the organs have great differences in water and air content and therefore in radiodensity, the abdomen contains structures of similar...
Mortality And Morbidity Rates
The lethal triad in pregnancy has been hemorrhage, infection, and preeclampsia. In the United States, maternal mortality and morbidity rates have been significantly reduced, but these three diseases remain the most common complications of pregnancy. Direct maternal death includes the death of the mother due to obstetrical complications of pregnancy, labor, or the puerperium. Indirect maternal death includes death not directly due to obstetrical causes but resulting from previously existing...
Chest Xray 1
The chest x-ray is often the first imaging test obtained for patients with suspected cardiovascular disease. Ideally, lateral and posteroanterior PA views of the chest are obtained, with film exposure at a distance of 6 ft 1.8 m . Patients should be upright and have a moderately deep inspiration. For patients who are too ill to stand, semierect x-rays are obtained with an anteroposterior AP film exposure. The AP film has two disadvantages the heart demonstrates magnification, and the pulmonary...
Procedures
If greater accuracy for the diagnosis of PID is desirable, a number of procedures can be performed. These procedures are not necessary, nor are they indicated, in every case of presumptive PID. In fact, transvaginal pelvic ultrasound is the only procedure that may be considered part of routine evaluation whenever PID is considered within the differential diagnosis. Transvaginal pelvic ultrasound may demonstrate thickened, fluid-filled fallopian tubes or free pelvic fluid in acute, severe PID....
Genital Herpes
Genital herpes is a sexually transmitted infection caused by a DNA-containing virus specific to human beings. Sexual transmission can occur during asymptomatic periods. Usually, genital herpes is the most frequently encountered of the diseases causing genital ulcers and is thought to be associated with an increased risk for HIV infection.3 There are two antigenic groups herpes simplex virus 1 HSV-1 and herpes simplex virus 2 HSV-2 . Initially, HSV-1 caused oral lesions and HSV-2 genital...
Treatment Imx
Treatment consists of four main phases 1. Resuscitation should begin in the emergency department ED immediately on making a presumptive diagnosis. Aggressive fluid resuscitation using crystalloid, plasma, and packed cells is usually needed to replace red blood cells lost due to hemolysis and to correct hypotension due to shock. Volume status should be closely monitored using urine output and central venous pressure readings. Avoid the use of vasoconstrictors when possible due to the possibility...
Pathophysiology And Epidemiology
Fertilization of the oocyte usually occurs in the ampullary segment of the fallopian tube. In normal pregnancy, the zygote passes along the fallopian tube and implants into the endometrium of the uterus, with subsequent development of the placenta. An EP occurs when the zygote is implanted in any location other than the uterus 95 percent of ectopic pregnancies occur in the fallopian tube. Extratubal sites include the abdominal cavity, cervix, and ovary. Abdominal ectopic pregnancies most...
Skin Disorders Affecting The Nipple And Breast
Any disorder of the skin can affect the breast. Some of the more important ones specific to the breast and nipple are discussed below. Colonization of the nipples or the lactiferous ducts by Candida albicans may cause chronically sore nipples during or after lactation. The appearance of the nipple may be normal however, more commonly, scaling, fissuring, and erythema are present. Predisposing factors for candidal colonization include antibiotic use, vaginal candidiasis, mastitis, and nipple...
Treatment Lil
b2-RECEPTOR AGONISTS Albuterol salbutamol is the treatment of choice. Dosage is as follows unit dose 0.5 percent solution by nebulizer, O 2 flow at 6 to 7 L min up to 2.5 mg 20 min or three unit doses by continuous nebulizer over 1 h. This may be repeated to a total of six unit doses. Continuous cardiac monitoring is required. b2 receptors are widely distributed on bronchial smooth muscle and airway epithelial cells. b 2-receptor agonists activate adenylate cyclase, increase cyclic adenosine...
Apnea and Periodic Breathing
Periodic breathing, which may occur in normal neonates, should be differentiated from apnea. However, periodic breathing may precede apnea, and both may occur in the same patient. Apnea is a cessation of respiration for 10 to 20 s with or without bradycardia and cyanosis. It signifies critical illness and warrants prompt investigation and admission for monitoring and therapy. Apnea may be precipitated by any of the disease conditions listed in Tab. e ll2. 4 and usually indicates respiratory...
NonDeflating Retention Balloon
A number of factors can lead to a frustrating inability to deflate the retention balloon on a Foley catheter. Mechanical obstruction, which is the most common cause of a non-deflating balloon, can occur as a result of clamping or crushing the inflation channel or can be due to a faulty balloon port valve. Also, filling of the balloon with a fluid other than water can lead to crystal formation with resultant blockage of the inflation channel. Several techniques have been advanced to deflate...
TABLE 785 Pruritus Ani
In Iable78 5 anorectal disease includes the various categories that have been discussed in this chapter. The pruritus that accompanies such conditions as fissures, fistulas, hemorrhoids, and prolapses occurs as a result of the perianal skin's being exposed to and macerated by constant mucous and purulent discharge. It is probably the increased perianal moisture caused by these conditions that results in itching. The itching triggers a vicious cycle of scratching, excoriation, and more itching....
Chest Xray Interpretation
On the PA view of the chest, there are three visible cardiac segments Fig 57 1a . The lowermost segment, adjacent to the diaphragm, is the lateral and apical walls of the left ventricle. A small rounded density may be lateral to the cardiac apex this represents the epicardial fat pad. Superior to the left ventricle is a rounded short segment that varies considerably in size. This is the pulmonary artery and its left main branch. Prominence of the pulmonary artery is normal in young women. Just...
Ventilationperfusion Scans
The ventilation-perfusion V Q scan is performed on patients with suspected pulmonary embolism PE . The study has a low incidence of adverse reactions, is noninvasive, and requires no advance preparation.3 However, it is performed outside of the ED, limiting its use in unstable patients. The V Q scan is a two-step process. First, the ventilation portion of the examination is performed with the patient breathing an aerosolized solution of technetium 99m 99mTc diethylenetriaminepentaacetic acid...
TABLE 2311 Drugs that Can Cause Hypocalcemia
Postoperative Hypocalcemia HYPOPARATHYROIDISM Currently, more than 10 percent of postparathyroidectomy patients may have hypoparathyroidism as defined by a fasting calcium level of less than 8.5 mg dL and a simultaneous inorganic phosphorus level of greater than 4.5 mg dL. Postoperative hypocalcemia can be due to hypoparathyroidism from the permanent surgical removal of parathyroid tissue, from transient ischemia of the parathyroid glands in patients who have extensive bilateral neck surgery,...
Cardiac Dysrhythmias 1
Outpatient continuous portable ECG monitoring Holter monitoring only identifies the cause of syncope in 3 percent of pediatric patients. 4 A cardiac dysrhythmia should be suspected if the syncope is associated with an intense sympathetic stimulus such as fright, anger, surprise, or physical exertion. 16 The event will usually start and end abruptly, contrary to nonarrhythmogenic causes such as hypoglycemia or seizures, which are more gradual. Associated symptoms may include palpitations or...
Electrocardiography Qyn
The most common ECG abnormality in PE is nonspecific ST-T wave changes, seen in more than 40 percent of patients. T-wave inversions in the precordial leads mimicking subendocardial infarction may be seen in massive PE. Other ECG changes include new right bundle branch block, p-pulmonale, S1Q3T3 pattern, and clockwise axis rotation. Sinus tachycardia is the most common rhythm disturbance, although atrial fibrillation or flutter may occur. 7 There is no diagnostic pattern of PE on the ECG. The...
Labetalol
ACTIONS AND PHARMACOLOGY This antihypertensive agent is a competitive, selective a1 blocker and a competitive, nonselective b blocker, with the b-blocking action being 4 to 8 times the a-blocking action. It can be given either orally or intravenously. It lowers blood pressure by blocking a 1 adrenoreceptors in vascular smooth muscle but, because of the simultaneous b blockade, causes no reflex tachycardia. When given intravenously, the distribution to peripheral tissues is rapid, with a large...
Anticoagulation Problems
Some children with congenital heart disease are on anticoagulant therapy to prevent shunt occlusion or thrombosis of surgically implanted valves or grafts. The risk of serious bleeding is small with routine emergency department visits, but must be considered for any elective repair of fractures or lacerations. Prothrombin time and the international normalized ratio INR must be monitored. Reversal of anticoagulation with the administration of either vitamin K or fresh-frozen plasma should be...
Septic Pelvic Thrombophlebitis
CLINICAL FEATURES Septic pelvic thrombophlebitis SPT is a diagnosis of exclusion complicating 0.1 to 0.5 percent of gynecologic procedures. The diagnosis is made when a patient with a postoperative fever does not respond to appropriate antibiotics in the absence of an undrained abscess or infected hematoma. Patients with SPT rarely present to the emergency department, since the complication typically presents in the hospital and delays discharge. There are two forms of SPT. The classic form...
Sequence of Spinal Immobilization
Prehospital personnel are taught to have a high index of suspicion for spine trauma. If the patient is sitting in a car after an accident and is stable from respiratory and circulatory standpoints, the short spine board and rigid cervical collar or KED are first used to safely get the patient onto a long spine board and out of the vehicle in a orderly manner. If time is critical because of the patient's condition or the threat of hazards such as chemicals, fire, or water, the patient can be...
Urinary Alkalinization
Urinary alkalinization will promote the excretion of long-acting barbiturates only, as explained earlier. The reasons for this singular application are pharmacologically based. Long-acting barbiturates tend to be weaker acids lower p Ka values , less lipid soluble, less protein bound, and are appreciably excreted in the urine compared with shorter-acting barbiturates. In basic solutions, long-acting barbiturates weak acids are relatively more ionized. Since only nonionized drug forms can cross...
Intraabdominal Masses
Every child should have a careful abdominal examination because intraabdominal masses grow silently at first until they cause obstruction, bleeding, or hemorrhage into the tumor or until a parent sees a mass protruding in the abdomen. The child should be supine with his or her head turned toward the parent, and one should carefully palpate all quadrants of the abdomen. If a mass is palpated, the child should be referred to a pediatric surgeon and diagnostic imaging studies obtained. A careful...
Clinical History
The symptoms of ischemic heart disease that should be sought and characterized include chest discomfort, severity, location, radiation, duration, and quality. In addition, the presence of associated symptoms such as nausea, vomiting, diaphoresis, dyspnea, light-headedness, syncope, and palpitations may be helpful. A detailed history regarding the onset and duration of symptoms, activities that precipitate symptoms, and prior evaluations for similar symptoms should be ascertained. Cardiac...
Digital Intubation
Digital intubation is an underutilized noninvasive technique for ET tube insertion. The performance of this maneuver requires tactile recognition of the epiglottis. Visual landmarks may be impossible to identify with a laryngoscope because of patient positioning, anatomic disruption, or significant hemorrhage. Tactile digital intubation can avert cricothyrotomy when direct laryngoscopy has failed following neuromuscular blockade. Patients with micrognathia or temporomandibular immobility are...
Epidemiology Lba
Pneumonia is defined pathologically as an inflammation of lower tract lung tissue. Clinically, pneumonia is defined by the presence of pulmonary infiltrates on a chest radiograph, usually associated with a combination of clinical signs, such as cough, fever, chest pain, tachypnea, and a variety of abnormal auscultatory findings. Most commonly, pneumonia is caused by an infectious agent, although aspiration of irritants and interstitial inflammation are also referred to as such. Pneumonia...
UShaped Flaps and Jagged Lacerations
A U-shaped skin flap is often caused by compressive forces on skin overlying bone. The flap usually has abraded skin and extends deep with attached subcutaneous tissues. The edges of the flap are usually irregular and fit together with adjacent wound edges, like a jigsaw puzzle. The survival of a rectangular-shaped flap is dependent on the blood supply from vessels that enter the flap at its base. Survival of a flap is more dependent on its length and not the width of the base wide and...
Refrigerant Anesthetic Sprays
Refrigerant anesthetic sprays such as Ethyl Chloride chloroethane and Fluori-Methane dichlorodifluoromethane, trichloromonofluoromethane offer another effective and convenient alternative for topical anesthesia. Ethyl Chloride has been used as a local anesthetic for over 100 years. Vaporization of the liquid spray on the skin lowers its temperature to -20 C, thereby temporarily freezing it. Anesthesia is almost immediate, providing a distinct advantage in a busy outpatient clinic or ED over...
Treatment Lcg
All patients should be evaluated immediately for alterations of consciousness, hemodynamic instability, and respiratory impairment. Every patient requires an intravenous line, continuous ED cardiac monitoring, and an ECG. Serial ECGs will be required in most patients. Suggested laboratory studies include determinations of serum electrolyte, creatinine, and glucose levels. A quantitative serum acetaminophen level is recommended in all overdose patients. Most symptomatic patients will require...
Unexplained Heart Failure And Cardiomegaly Differential Diagnosis And Evaluation
Symptoms of CHF and associated cardiomegaly or evidence of cardiomegaly in an asymptomatic patient necessitates a directed evaluation. In the vast majority of instances, one of the following five disease entities will eventually be diagnosed. Where appropriate, recognized diagnostic clues are noted. 1. Hypertensive heart disease. Systemic arterial hypertension affects 10 to 20 percent of the adult population. This is a disease with a high prevalence that may be diagnosed at a number of stages....
Injuries Involving the Perionychium
The nail, nail bed, and surrounding soft tissue make up the perionychium see Fig 3.9 1 . The nail bed is made up of the germinal and sterile matrix. The germinal matrix begins 3 to 5 mm proximal and deep to the eponychium and extends distally to the lunula. From there, the sterile matrix responsible for producing the majority of the nail extends distally to the hyponychium. Injury to the perionychium is most commonly due to closure of the fingertip in a door and often occurs in the distal...
Emergency Cardiac Care
While it is clear that ALS saves lives after sudden cardiac arrest, the number of lives saved and the cost are often debated. 56 Since sudden cardiac death SCD is the number one cause of out-of-hospital death in the United States, the potential benefit of treatment is enormous. Some have argued that the successful treatment of out-of-hospital cardiac arrest alone by EMS systems justifies their existence.6 Population studies with an age distribution of the entire US population find that the...
TABLE 1554 Pearls and Pitfalls
1. Andersson C, Chakos M, Mailman R, Lieberman J Emerging roles for novel antipsychotic medications in the treatment of schizophrenia. Psychiatr Clin North Am 21 151, 1998. 2. Kane JM Schizophrenia. N Engl J Med 334 34, 1996. 3. Dubin WR, Feld JA Rapid tranquilization of the violent patient. Am J Emerg Med 7 313, 1989. 4. Levien T, Baker DE Quetiapine. Hosp Pharm 33 556, 1998. 5. Fines RE, Brady WJ, DeBehnke DJ Cocaine-associated dystonic reaction. Am J Emerg Med 15 513, 1997. 6. Egan MF, Apud...
Specific Diagnoses
Table 68-2 is drawn from a combined series of over 10,000 cases of acute lt 1 week duration abdominal pain presenting to over 200 EDs in 17 countries during a 10-year period. The data were collected on a highly standardized instrument. In virtually all large series of acute abdominal pain, the substantial majority of final diagnoses include nonspecific abdominal pain NSAP , appendicitis, and biliary tract disease usually cholecystitis , in that order, accounting for nearly 75 percent of all...
TABLE 1782 Clinical Effects of Inorganic Lead Toxicity
DIAGNOSIS History of an exposure occupational, hobby, environmental, or related to retained lead bullets is the most important clue to making the diagnosis. The physician should focus on symptoms, developmental and dietary histories in children , pica, any house or day-care remodeling, previous serum iron and blood lead levels, and possible lead toxicity in other family members. Occupational and hobby histories should be elicited, both for adults being evaluated and for children who may be...
Class III Antidysrhythmic Agents
The Cardiac Arrhythmia Suppression Trial illustrated the prodysrhythmic effects and increased mortality of certain Class I sodium channel blocking agents. Class III antidysrhythmics serve as an alternative to the sodium channel blocking drugs.3 They are a heterogenous group of antifibrillatory agents that lack negative hemodynamic effects. Class III drugs are characterized by prolongation of the effective refractory period by a mechanism other than or in addition to sodium blockade. Amiodarone,...
Anemia and Polycythemia with Cyanotic Congenital Heart Disease
Children with this problem require an increase in hemoglobin concentration to compensate for hypoxemia. Children develop tachycardia, feeding difficulty, or congestive heart failure when hemoglobin concentrations fall to normal. Often, anemia will be compensated for by polycythemia, which will cause increased viscosity and the potential for cerebrovascular complications. Iron supplementation is important for prevention of anemia. When polycythemia occurs, therapeutic phlebotomy may be...
Thyroid Storm
Patients with thyroid storm present with fever, volume depletion, cardiac decompensation. Thyroid storm has been associated with a mortality rate of up to 25 percent. Patients are treated with intravenous fluids, oxygen, antipyretic agents, as well as PTU 400 mg PO q8 h and sodium iodide 1 gm IV in 500 mL of intravenous fluid each day. Long-term use gt 10 days of sodium iodide results in a high incidence of fetal goiter and hypothyroidism. Propranolol 40 mg PO q6 h is administered unless...
High Toxicity
Highly toxic compounds include sodium monofluoroacetate SMFA and its derivatives, fluoroacetamide compound 1081 and or MNFA. SMFA is a white crystalline, odorless, tasteless, water-soluble powder licensed only by commercial exterminators. It is toxic when absorbed through broken skin, ingested, or inhaled. The active component, fluoroacetate, is converted to fluorocitrate, which interferes with the Krebs cycle. Aerobic glycolysis is thus blocked. As a result, glucose metabolism, cellular...
Normal Pediatric Airway Anatomy
The normal airway of a pediatric patient has important anatomic differences from that of the adult. These differences are most apparent in infants and become relatively insignificant by age 8. They include the size of the occiput and the tongue in the infant, the high position of the larynx, the configuration of the larynx, and the position of the vocal cords. The infant has a large occiput. Positioning of the head to obtain the optimum orientation for laryngoscopy, or the sniffing position, is...
TABLE 311 Treatment of Neurogenic Shock
It is impossible to separate the initial evaluation and management of the patient with neurogenic shock from that of the general trauma patient. In essence, the diagnosis of neurogenic shock should be one of exclusion. Certain clues such as bradycardia and warm, dry skin may be evident, but hypotension in the trauma patient can never be presumed to be due to neurogenic shock until all other possible sources of hypotension have been eliminated. 1 Again, a difference has been noted between blunt...
Testes
Ihe testes usually lie in an upright position with the superior portion tipped slightly forward and outward. Ihe average size is between 4 and 5 cm in length, and approximately 3 cm in width and depth. Ihe overall volume is about 25 mL. Each testis is encased in a thick fibrous tunica albuginea except posterolaterally, where it is in tight apposition with the epididymis. Ihe enveloping tunica vaginalis anchors each testis and epididymis to the posterior scrotal wall. Inferiorly, the testis is...
Minoxidil
Minoxidil is a direct-acting peripheral vasodilator that lowers systolic and diastolic blood pressure without much affect on the CNS. It also has the advantage of not interfering with vasomotor reflexes and therefore does not induce orthostatic hypotension. Minoxidil, in tablet form, is usually reserved for the treatment of severe or refractory hypertension, and reported toxicity has been rare. A common side effect of minoxidil is hirsuitism. In 1988, a 2 topical solution of minoxidil was...