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Written em Board Exam
Written em Board Exam
Emergency Medicine
Board Examination
Bobby Desai
Brandon R. Allen
Editors
123
Nailing the Written Emergency Medicine
Board Examination
Bobby Desai • Brandon R. Allen
Editors
Cardiovascular Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Bobby Desai
Pulmonary Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Michael R. Marchick and Bobby Desai
Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Brandon R. Allen and Bobby Desai
Nephrology and Urology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Bobby Desai
Hematologic and Oncologic Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Bobby Desai
Disorders Affecting the Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
Bobby Desai
Endocrine/Metabolic/Electrolytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
Bobby Desai
Ears, Nose, and Throat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
Bobby Desai
Environmental Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
Michael R. Marchick and Bobby Desai
Neurologic Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555
Michael R. Marchick and Bobby Desai
Obstetrics and Gynecology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617
Bobby Desai and Alpa Desai
Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 637
Bobby Desai
Toxicologic Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 675
Matthew Ryan and Bobby Desai
Orthopedic Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 735
Bobby Desai
Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 813
Henry Young II and Bobby Desai
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 869
vii
Contributors
ix
Cardiovascular Emergencies
Bobby Desai
Contents
Acute Coronary Syndrome 2
Other Causes of Acute Coronary Syndrome 4
Stable and Unstable Angina 6
Acute Myocardial Infarction 7
Arteries and Affected Areas 9
Inferior MI Specifics 13
Right Ventricular Infarction 15
Cardiac Markers 16
Reperfusion in AMI 18
Complications in AMI 22
Congestive Heart Failure 24
Valvular Emergencies 31
Mitral Regurgitation 33
Mitral Valve Prolapse 35
Aortic Stenosis 37
Causes of Aortic Regurgitation 39
Infective Endocarditis 42
Rheumatic Heart Disease 48
Cardiomyopathies (CM) 50
Myocarditis 56
Pericarditis 59
Cardiac Tamponade 62
Abdominal Aortic Aneurysm 64
Aortic Dissection 67
Hypertension 72
Pulmonary Hypertension 76
Syncope 77
Deep Venous Thrombosis and Pulmonary Embolism 79
Acute Limb Ischemia 87
Pacemakers 89
Left Ventricular Assist Devices (LVAD) 94
EKG Changes Related to Electrolytes and Metabolic Conditions 96
EKG Changes Related to Medications 100
Dysrhythmias 102
Heart Blocks 118
Miscellaneous 127
Description Radiation
Either
Pressure Crushing Squeezing Diffuse Chest Either Arm Either Hand
Shoulder
Sharp
Pleuritic
Cardiovascular Emergencies 3
Angina Pectoris
Angina
2–20
Can be minutes
Angina Pectoris Time
variable AMI
Can last
hours
B
u
t
N/V Sweats SOB
Can be at rest!
Prinzmetal’s HTN
Angina Hypercholesterolemia
Diabetes
Normal
Appearance may vary
Severe distress
Normal
Chronic Hypertension
Blood pressure varies Elevated
Anxiety
Extremes of BP can
be associated with
a worse prognosis Decreased Heart Failure
Decreased preload
RV infarction
Rales
May represent new
Ominous Physical Findings onset
CHF + Cardiogenic shock
S3
4 B. Desai
Pathophysiology
After
Vessel occlusion Hypoxia Cell death
aggregation
25–40 % loss
CHF
ventricular function
Affects
Affects pump
Cardiac output
function
>40 % loss Cardiogenic Blood pressure
ventricular function Shock
Effects of myocardial
cell death
Vasculitis or other
connective tissue
disease
Lupus
Kawasaki disease
Congenital
Drugs
anomalies
Cocaine
Other Causes of
Thrombotic Acute Coronary
Emboli
processes Syndrome
DIC, TTP + Bacteria
Infectious
diseases
HIV
Cardiovascular Emergencies 5
Potential coronary
Cocaine effects Vasospasm Due to a–agonism ischemia
Immune
Women Minorities Elderly Diabetics Lupus
compromised
HIV on HAART
Associated Sx in Nausea +
Jaw pain Neck pain Back pain
women? Vomiting
New-onset chest
Unstable angina
pain?
Greater than 20
Pain duration?
minutes
Prinzmetal’s Angina
Similar to STEMI
EKG
EKG
Cardiovascular Emergencies 7
ST elevation
Concave upwards
Convex upwards
May be difficult to
Transient
distinguish with STEMI
Minutes
Prinzmetal’s
Angina
Consider in No reciprocal ST
women depression
More common
No dynamic
changes
EKG’s in AMI
New ST- ≥ 1 mm elevation in two Positive predictive The elevation typically occurs
elevations anatomically contiguous leads* value for AMI >90 %! over the area of ischemia
Reciprocal ST depression over on ekg areas Predicts increased Predicts potentially larger
changes opposite areas of infarction mortality infarction
EKG
Identifies
Quickly shows who Conduction
Identifies the STEMI requires emergent Abnormalities Aids in localization
reperfusion of infarction
Dysrhythmias
vs.
May guide
specific
therapy
Non-diagnostic or
Continuous EKG
other “concerning”
monitoring may
findings
show evidence of
reperfusion after e.g., Avoidance
thrombolytic therapy of nitroglycerin
for Inferior MI
Right Ventricular
II, III, avF
(Inferior injury) Lateral
+ I, avL, V5, V6
1 mm ST elevation V4R
Anterior
V1–V4
Septal
V1, V2
Inferior
II, III, avF
Cardiovascular Emergencies 9
Acute MI
Ventricular wall
Early repolarization
aneurysm
Usually benign Post-MI
Pericarditis
Global ST elevation
Right Ventricular
Usually accompanies inf MI
4–5 % will be isolated
Anterior MI
Center image (Reprinted from Davies A, Scott A. Acute coronary syndromes. In: Davies A, Scott A, editors. Starting to read ECGs (The basics).
New York: Springer Science; 2013. p. 147–59. With permission from Springer Science + Business Media)
Hyperacute T Waves
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
II
Cardiovascular Emergencies 11
ST elevation
Horizontal
Convex upwards
ST depression
HyperacuteT waves
in reciprocal leads
Occurs early
Dynamic changes
Changes with time
ST elevation
Concave upwards
Precordial leads
J-point elevation
NOT specific for
No Q waves
coronary anatomy
Early
Repolarization
No reciprocal ST
Men, Young
depression
Muscular
No changes with
time
12 B. Desai
Anterior MI Specifics
Sinus Tachycardia
Left ventricular
Pericarditis Anxiety Pain Hypovolemia
failure
Emergent Reperfusion
Women = 1.5 mm
Men less than 40 = 2.5 mm
Men over 40 = 2 mm
Cardiovascular Emergencies 13
Sgarbossa Criteria
Sgarbossa’a Criteria
LBBB/Paced Rhythm V1, V2, V3
≥ 5 mm
Concordant ST Concordant ST
ST elevation > 5 mm in
elevation > 1 mm in depression > 1 mm in
leads with a (–) QRS
leads with a (+) QRS V1–V3
Center image (Reprinted from Allen B, Ganti L, Desai B. Cardiology. In: Allen B, Ganti L, Desai B, editors. Quick hits in emergency medicine.
New York: Springer Science; 2013. p. 71–82. With permission from Springer Science + Business Media)
Inferior MI Specifics
Inferior wall MI
complications
May have
Hypotension Bradycardia conduction
disturbances
Consider Atropine if
Increase preload with required Mobitz I (Wenkebach)
fluids
May need
transcutaneous or
transvenous pacing if
Usually will
refractory to Intermittent
NOT progress
atropine during the first
to higher
3 days
degree blocks
14 B. Desai
Inferior MI
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Inferior-Posterior MI
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
II
Cardiovascular Emergencies 15
Right ventricular Very preload Can develop severe hypotension in response Treated with
infarction sensitive to nitrates or other preload-reducing agents fluids
Other EKG ST elevation in Lead III is more “rightward facing” than lead II & more
Tidbits? lead III > lead II sensitive to the injury current produced by the right ventricle
Highly specific EKG If the magnitude of ST elevation in V1 If the ST segment in V1 is isoelectric and the
changes for RV MI? exceeds the magnitude of ST elevation in V2 ST segment in V2 is markedly depressed
Posterior Infarction
Posterior extension of an Implies a much larger area Increased risk of left ventricular
inferior or lateral infarct? of myocardial damage dysfunction and death
Isolated Posterior Indication for emergent Lack of obvious ST elevation in this condition
But…
infarction? coronary reperfusion means that the diagnosis is often missed
Cardiac Markers
Heart block
Tachy or
Stroke or SAH
Bradyarrhythmias
Aortic valve
CHF
disease
Infiltrative Pulmonary
diseases embolism
Drug toxicity
or toxins
Glycoprotein Iib/IIIa
Oxygen Aspirin Nitrates Morphine Heparins β-Blockers ACE Inhibitors P2Y12inhibitor
Inhibitors
>162–325 mg Sublingual Antiplatelet agent
Non-enteric Topical Consider for
Anti-arrhythmic
Reduce LV
persistent
When added to Indications
(Delays Intravenous ASA -Reduces dysfunction
absorption) pain (+) troponins
risk of AMI and Decreases onset
Anti-ischemic Pts getting PCI
death in of CHF Reduces
Unstable Angina platelet
Contraindicated if
Lowers BP aggregation
Reduces mortality by Phosphodiesterase-5 Use caution for
23 % inhibitors (eg Sildenafil) inferior MI’s! By 56 %! Mechanism Start within
within 24 hours Beware Can give if
24 hours
CHF Blocks binding aspirin
Hypotension of fibrinogen allergic!!
LMWH +ASA = Asthma at receptor
May cause fatal Better with Inferior/RV site that
hypotension! fibrinolysis infarction causes
ASA + Fibrinolytic Bradycardia aggregation In
Therapy reduces USA/NSTEMI
ischemic events Reduces:
Mechanism LWMH = Less Death
thrombocytopen Most AMI
Peripheral + Coronary ia Stroke
Effective
vasodilation Give orally Pts getting
within 24 PCI
LMWH = NOT hours
Decreased Reduces infarct
1st line for PCI
cardiac work size
42 % reduction in
mortality
LMWH = Do not Administer early in
use in renal patients along with
Decreased O2
Improves failure! (Use ASA regardless if
function Heparin) PCI or conservative
demand
management is
planned
Use LMWH in
Decreases
USA
complications
Afterload
reduction
CABG =
withhold for 12–
Decreases 24 hours
mortality by 35 %
Reperfusion in AMI
The longer the symptoms the better the benefit with PCI
For PCI
Use Glycoprotein IIb/IIIa
inhibitors! (In consultation
with cardiologist
Reduces death
Reduces MI
EKG findings
Fibrinolytics Indicated for 1 mm ST elevation
Act as Plasminogen activators in 2 or more
STEMI (if PCI contiguous leads
unavailable)
Known
Hx intracranial Known cerebral Ischemic stroke Active internal Aortic Dissection
intracranial
hemorrhage AVM in last 3 months bleed or Pericarditis
neoplasm
Relative Contraindications
Noncompressible
Recent trauma Prolonged CPR Major surgery Active Peptic
vascular Pregnancy
(last 2 weeks) (>10 min) (<3 weeks) Ulcer Disease
punctures
Conditions with
Recent internal
potential risk of
bleeding
bleeding
20 B. Desai
Beware
Elevated Blood Pressure
Older age >65
Early T-wave
Reperfusion Resolution of ST Resolution of chest inversions may be
Arrhythmias elevation pain highly specific for
reperfusion
Accelerated
idioventricular
rhythm
(highly specific)
Early T-wave
Reperfusion Resolution of ST Resolution of chest inversions may be
Arrhythmias elevation pain highly specific for
reperfusion
Accelerated
idioventricular
rhythm
(highly specific)
Cardiovascular Emergencies 21
Return of
Reperfusion phase spontaneous
post-MI circulation following
Most common cause cardiac arrest
Metabolic &
Electrolyte
derangements
3 or more
50–120 bpm Wide Regular ventricular
complexes
AIVR Treatment
AIVR
Complications in AMI
Pericarditis
2–7 days post event Ventricular aneurysm
Dressler’s Syndrome
Occurs in 20 % of MI’s formation
NSAID’s May take months to
Fever, friction rub
form
Associated with
Papillary muscle rupture Elevated WBC
chronic ST elevations
3–5 days post event Pericardial & pleural
effusions
Occurs in 1 % of patients
Treatment
Myocardial wall rupture
NSAID’s & steroids
1–5 days post event
Accounts for 10 % of
AMI deaths
Other complications
ST elevation
Concave upwards or
Convex upwards
Continued ST
elevation
Usually in anterior
leads
NO reciprocal ST
Q waves
Ventricular depression
Usually present Aneurysm
No dynamic changes
No change in old
EKG’s
Cardiovascular Emergencies 23
But
...
May be protective Does NOT increase mortality
Due to decrease in
myocardial O2 demand
Abnormal vagal
New Atrial Fibrillation tone
Atrial infarction Sustained atrial
Electrolyte
± increased atrial fibrillation =
Typically in 1st 24 hours derangements pressures
Usually transient Hypokalemia anticoagulation
Sinus &/or AV nodal
Marker of worse prognosis ischemia
Hypo-Mg Pericarditis 3-fold risk of embolization
Good prognosis
Type 1 second
3° AV Block
degree AV block
Wenckebach With INFERIOR MI
ONLY!
Poor prognosis
Death of
Anterior MI High grade blocks Pacemaker
conduction tissue
24 B. Desai
Heart Failure
Decompensated
CHF
Acute Acute MI
pulmonary
edema
Cardiogenic shock
Depends on
Myocardial
Hypertension Dysrhythmias “-itis’es” Aortic Dissection
ischemia
Acute & Chronic Pericarditis
Papillary muscle Myocarditis
rupture Cardiac tamponade Endocarditis
Chordae tendinae (infectious)
Pulmonary
rupture Mitral stenosis embolism
Mitral
Mitral regurgitation
Intrinsic myocardial
process Myxedema
Metabolic
Acquired Thyrotoxicosis
cardiomyopathy
Hypertrophic Toxic Cocaine
cardiomyopathy
Restrictive Alcohol
cardiomyopathy
Dilated
cardiomyopathy
High-Output Failure
Paget’s disease of
Anemia Beriberi Thyrotoxicosis A-V Fistula
bone
Normal ejection
60 %
fraction
Normal ejection
Contractility Normal
fraction
LV filling is decreased
Ventricular Left ventricle cannot C Atrial pressure
Impaired
relaxation receive blood
Preload dependent
Pulmonary congestion
Diastolic Systolic
May lead to
dysfunction dysfunction
Paroxysmal
Dyspnea Orthopnea JVD Cough Weakness
nocturnal dyspnea
Hepatojugular
Fatigue
reflex
Days
1 2 >7
Tachycardia
Hypotensive acute CHF
Dyspnea
Systolic BP < 90 mm Hg Rales
Altered mental status Symptoms Signs
Narrow pulse pressure
Decreased urine output
Pulmonary edema May have evidence of
end-organ damage Cool extremities
Tachycardia
Normotensive acute CHF
Less dyspnea
Symptoms Normal LV function Signs Rales
(may not be present)
Weight gain May have little edema on
CXR Peripheral edema
Tachycardia
Severe dyspnea Acute (Flash) Pulmonary
Edema
Symptoms Signs Significant rales & JVD
Usually pts are
Weight gain hypertensive
Cool, diaphoretic skin
28 B. Desai
CHF Diagnosis
Exam
Peripheral
Tachycardia ± Rales S3 JVD Orthopnea Dyspnea
edema
Specificity of Specificity of
99 % 94 % Hepato-jugular
RUQ pain
reflux
If present,
Liver
worse
engorgement
outcomes
Enlarged,
pulsatile liver
Supplemental Oxygen
Mild
Pt with CHF Maintain airway
Consider noninvasive Ventilation
exacerbation Moderate control
ventilation
Hemodynamically stable,
Se
ver cooperative pts
e
Endotracheal intubation
Hemodynamically unstable
IV Nitroglycerin
Nitrates Dobutamine
ACE inhibitors
Diuretics Dopamine
Nitroprusside
Increased mortality
Milrinone
Systolic
Hypotension? Inotropic agent Dobutamine
90–100 mm Hg
± Dopamine
Sx improve
Heart is sensitive to Titrate nitroglycerin
Start Nitroglycerin
Afterload rapidly
Until OR
SL first Until BP is
IV if needed BP improves controlled
Vasodilation Preload
contraindications dependent states
Amniotic fluid
emboli
Strangulation
Toxins
Non-Cardiogenic Salicylates
Pulmonary Phenobarbital
Edema
Carbon monoxide
Fat emboli Opioids
Environmental
High altitude
pulmonary edema
Thermal injury
Drowning
Cardiovascular Emergencies 31
Valvular Emergencies
New Murmur
Anemia Pregnancy
Systolic Murmur Normal Heart Consider High output state
Thyro-
Fever
toxicosis
Emergent
Echocardiogram Admission
ere Cardiology referral
Sev
Symptoms
No
t se
ver Outpatient
e
Symptoms are most referral
important to
consider, not the
murmur
New Systolic
Syncope Aortic Stenosis
Murmur
Until proven
otherwise New Aortic Surgical
Regurgitation? emergency
Pregnant New Murmur Mitral Stenosis
Until proven
otherwise
32 B. Desai
Mitral Stenosis
Tricuspid &
d to Pulmonary
May lea valve failure
Decreased
Left Atrial Pulmonary Pulmonary
flow out of the May lead to May lead to
Enlargement Congestion Hypertension May
left atria
lead Right sided
to
Failure
May lead to
May lead to
Ascites
Hepatomegaly
Atrial Pulmonary JVD
Fibrillation Edema Peripheral edema
Symptoms
Exam
Kerley B lines
Upper lung field
hyperemia
Atrial Fibrillation Overall increase
in vascular
markings
Cardiovascular Emergencies 33
Pulmonary
Diuretics
congestion?
Cardioversion
Atrial Other treatment depends
Anticoagulation
Fibrillation? on stability of patient
Medications
High risk of
Anticoagulation
embolism?
Depends on
Disposition
clinical condition
Mitral Regurgitation
MI
Retrograde
Left Ventricle Retrograde
blood flow Left Atrium
Blood to
(systole)
Acute retrograde Sudden increase in Sudden increase in Right Early Right sided
flow Left Atrial Pressure Ventricular Pressure Failure
Pulmonary edema
Dyspnea
Cardiogenic
shock
Acute Pulmonary May lead
Acute Symptoms Edema & CHF to
Cardiac Arrest
Right sided failure
Exertional dyspnea
1st symptom
May be
Compensated CHF prompted by
Chronic
Symptoms
± Atrial Fibrillation
Thromboembolism
Left atrial
Cardiomegaly Confirmatory
enlargement
Depends on
Treat Atrial
Chronic MR? Treat CHF Disposition clinical
Fibrillation
condition
High risk of
Anticoagulation
embolism?
During systole
Symptoms
Exam
Due to
Non-specific ST-
Usually normal Diagnostic
T waves changes
Ectopy
PSVT
β–Blockers may
Chest pain?
be helpful
β–Blockers may
Palpitations?
be helpful
β–Blockers may
Anxiety?
be helpful
Mitral Endocarditis
MVP
Regurgitation Prophylaxis
Depends on
Disposition
clinical condition
Cardiovascular Emergencies 37
Aortic Stenosis
Most common
Most common Second most
cause in
Pathophysiology younger
cause in common
patients adults cause
Maintain diminishing
Prevents
ejection fraction
systolic
ejection of
Women Men
blood
r to
rde
o
In
Decreased Increased
Left Ventricular Diastolic Ischemia on
flow out of the May lead to Leads to myocardial O2 May lead to
Enlargement dysfunction exertion
left ventricle requirements
Over time
As aortic Decreased
outflow Leads to cardiac
diminishes output
Symptoms
Classic Triad
Exam
Cardioversion
New-onset Atrial Anticoagulation Other treatment depends
Fibrillation? on stability of patient
Medications
Pulmonary
Consider Oxygen Diuretics
Edema
Biscuspid valves
Rheumatoid Symptoms
Arthritis Collagen-Vascular usually late in
disease disease Marfan’s
Reiter’s syndrome
syndrome
Prognosis worse
Conjunctivitis Appetite- once Sx start
Urethritis suppressant Calcific
Arthritis medications degeneration
Phentermine
Dexfenfluramine
Fenfluramine
Syphilitic Aortitis
Aortic Regurgitation
Volume Overload
Left ventricular
dilatation
Until proven
Acute MI AR Aortic Dissection
otherwise
Infective
Complications CHF Arrhythmias
Endocarditis
40 B. Desai
May Cardiogenic
Dyspnea Tachycardia Hypotension Cardiac Arrest
lead to shock
Most
common
presenting
Sx
M
lea ay
d to
Exam
CXR in Chronic
CXR in Acute AR AR
LVH
Acute Pulmonary Cardiac
enlargement Cardiomegaly
Edema
LAE
Kerley B lines
Upper lung field
hyperemia
Overall increase Aortic Dilatation
in vascular
markings
CHF
Displacement on
Widened Tracheal Apical pleural Loss of the aortic
Pleural effusion intimal
mediastinum deviation cap knob
calcification
Dobutamine
Augments forward blood Milrinone
Inotropic agents
flow & reduces LVEDP ±Dopamine
Pulmonary
Oxygen Airway control
Edema
Suspected
Antibiotics Surgery
endocarditis?
For Acute
Aortic Give Beta-blockers
Dissection
WANT to block
compensatory
tachycardia
42 B. Desai
Infective Endocarditis
Introduction
Infective Endocarditis
Prosthetic valves
HIV infection
Prior Hx of
Urban > Rural endocarditis
Pacemakers
IV drug use
Introduction (2)
Pathophysiology
Direct invasion
Valve defects
of endothelium
Pre-existing Intravenous
by virulent
defect drug use
organisms
Congenital
S.aureus
Injury due to
High flow Direct ischemia
Turbulent Endothelium Direct matter present in
strikes
blood flow endocardium damage effect injected material
Talc Cocaine
Sterile vegetations
Skin trauma
Mucosa of GI/GU
tracts
Periodontal disease
Strep. viridans
CNS Major
Gram negatives
cause of
Systemic
IV drug users death
Contaminated needles
S. pneumoniae
Pulmonary Less
Right sided S. aureus Emboli Less CHF
infarction mortality
IV drug users
Indwelling catheters
Organisms
DM
Enterococcal Underlying Underlying risk
endocarditis valvular disease factors
GI/GU procedures
Serratia
Cardiovascular Emergencies 45
Organisms (2)
Candida albicans
Mycotic
Large
prosthetic valve Large emboli
vegetations
endocarditis
Aspergillus
Clinical Findings
Embolic stroke
Nonspecific Sx N/V
Osler nodes Involving MCA is the
most common CNS Cx
Usually Valve
Malaise Tender nodules
regurgitant incompetence Rupture of
on tips of fingers
& toes mycotic aneurysm
Rupture of
papillary Subarachnoid
Fever
muscle hemorrhage
Janeway
Present in CHF? Rupture of lesions Retinal artery
almost all cases chordae embolism
tendinae Nontender
hemorrhagic plaques Acute monocular
Perforation of on palms & soles blindness
cardiac wall
Severe CHF?
GI embolic
complications
Abdominal pain
Bowel ischemia
46 B. Desai
Diagnosis
Observation High IE
Diagnosis Culture Echo Admission
over time suspicion
There are NO
useful Can evaluate
prediction 3 separate
valvular
rules for IE! sites
abnormalities
Transesophageal
has greater Risk Consider
Fever
sensitivity and Factors IE
There are NO 10 mL for specificity
definitive each bottle
laboratory
tests that can Recommended IV drug
Fever Admission
Dx IE in the for users
ED
Wait 1 hour
between 1st Prosthetic
and last valves Prosthetic
Fever Admission
culture valve
Inadequate
Transthoracic Evidence of
echo New
vasculitis or Admission
No antibiotics murmur
embolization
prior to
cultures High clinical
suspicion of IE
Evaluating
complications
Treatment
Penicillins
Vancomycin
Initial Antibiotic
stabilization therapy May include Surgery
combinations of:
Aminoglycosides
After blood
cultures
Definitive therapy
based on culture Rifampin
results
For prosthetic valve IE
4–6 weeks
Endocarditis Prophylaxis
High risk
conditions for IE
Prosthetic
Unrepaired
Prosthetic History of material used
congenital
valves prior IE for repair of
heart disease
valve
Repaired congenital
Repaired congenital heart disease with Cardiac
heart disease with residual defects at or transplantation with
prosthetic material adjacent to the site cardiac valve disease
or prosthetic device of a prosthetic patch or incompetence
or device
Mitral valve
prolapse
Endocarditis
Physiologic Patent ductus
Prophylaxis
murmurs arteriosus
NOT indicated
Hypertrophic
cardiomyopathy
48 B. Desai
Jones Criteria
Erythema Subcutaneous
Pyrexia Arthralgia
marginatum nodules
Evidence of
Diagnosis 2 major OR 1 major 2 minor preceding
Strep infection
Scarlet Fever
(+) Group A Strep
Rheumatic related valvular disease is the most common throat culture
cause of valvular disease overall Elevated ASO titer
Cardiovascular Emergencies 49
Streptococcal Appropriate
pharyngitis? antibiotics
Over 2 years of
age
NSAID’s or
Arthritis?
Salicylates
NSAID’s or
Mild carditis?
Salicylates
Moderate to
3° heart block Cardiomegaly CHF Prednisone
severe carditis?
Chorea? Benzodiazepines
50 B. Desai
Cardiomyopathies (CM)
Cardiomyopathy: General
Impairs Electrical
Diseases that Cardiac
Cardiomyopathy myocardial properties of the
directly alter structure
function myocardium
Cardiomyopathy
Primary Secondary
Primary
Hypertrophic Dilated Toxins Amyloid Metabolic
restrictive
Thiamine
EtOH
deficiency
Cocaine Diabetes
Myocarditis Peripartum mellitus
Hypo-&
Hyperthyroidism
Acquired Neuromuscular
disorders
Dilated Cardiomyopathy
Systolic Diastolic LV RV
dysfunction dysfunction contractility contractility
¯ ¯
Low cardiac End End
output systolic pressure diastolic pressure
¯ Ventricular
compliance
Intracavitary
Pressures
Peripheral Peripheral
Murmurs Rales PND Orthopnea Dyspnea
edema embolization
Due to poor
closure of CP usually due to lack of vascular reserve
valves, not
necessarily Sudden death is possible
valvular issues
CXR EKG
Echo
Ventricular
ectopy? Amiodarone AICD
Ultimate Cardiac
treatment? transplantation
Depends on
Disposition clinical condition Exacerbation? Admit
Hypertrophic Cardiomyopathy
¯ LV diastolic LV filling
LV hypertrophy ¯ LV compliance
function pressure
End-systolic End-diastolic
Cardiac output Ejection fraction Normal
volume volume
¯ Preload
Murmur Volume
Squatting Hand grip α–agonists Trendelenburg
decreased expansion
Afterload
Surgical Surgical
treatment? myomectomy
Depends on
Disposition Exacerbation? Admit
clinical condition
Cardiovascular Emergencies 55
Restrictive Cardiomyopathy
Sarcoid
Amyloid
Most common cause May be familial Multiple other
Idiopathic
of Restrictive CM? Autosomal dominant causes
Scleroderma
Hemochromatosis
Restrictive CM LV end diastolic RV end diastolic Normal LV Early diastolic pressure has a decrease
pressure pressure systolic function followed by a rapid rise & plateau
EF ≥ 50 %
Peripheral
JVD Rales PND Orthopnea Dyspnea Right sided CHF
edema
Hepatomegaly
CP uncommon
RUQ pain
Except in amyloidosis
Ascites
CXR EKG
Pulmonary Normal heart Nonspecific ST-T Low voltage may A. Fib may be
congestion size changes be seen seen
CHF
Kerley B lines
Upper lung field
hyperemia
Overall increase
in vascular
markings
Echo
Confirmatory
56 B. Desai
Medical
Diuretics ACE inhibitors
management
Less effective
Sarcoid? Steroids
Chelation
Hemochromatosis?
therapy
Depends on
Disposition Exacerbation? Admit
clinical condition
Myocarditis
Introduction
Causes of Connective
Idiopathic Infectious Chemotherapy
Myocarditis tissue disorders
Coxsackie B
Enteroviruses
Parainfluenza Influenza
Viral
Echovirus EBV
Hepatitis B HIV
Lyme Disease
Mycoplasma
Rheumatic fever
pneumoniae
Bacterial
Corynebacterium Neisseria
diphtheriae meningitidis
58 B. Desai
Sinus
Flu-like illness Fever Myalgias Headache CHF Dysrhythmias
tachycardia
Severe cases Out of
proportion to
fever
Pericardial
Emboli
friction rub
CXR EKG
Severe cases
Severe cases
Labs
Myocarditis: Treatment
Treatment is largely
supportive
Myocarditis from
Antibiotics
Rheumatic fever?
Myocarditis from
Antibiotics
Diphtheria?
Myocarditis from
Antibiotics
Meningococcus?
Medical
CHF?
management
Depends on CHF
Disposition Admit
clinical condition Exacerbation?
Cardiovascular Emergencies 59
Pericarditis
Causes of Pericarditis
Myxedema Idiopathic
Post-MI Radiation-induced
Dressler’s
syndrome
Malignancy
Drug Induced
Melanoma
Pericarditis
Leukemia
Metastatic lung
cancer
Lymphoma Infectious
Metastatic
breast cancer
Rheumatic
Uremia
diseases
SLE
RA
Polyarteritis nodosa
Dermatomyositis
Scleroderma
Echovirus
Staph
Streptococcus
pneumoniae
Bacterial Rheumatic fever
Tuberculosis
Histoplasma
Fungal
capsulatum
60 B. Desai
Pericardial Pulsus
CP common Fever Dyspnea Dysphagia Malaise
friction rub paradoxus
Sharp/Stabbing Due to pain on Due to BP lowers on
Sinus
inspiration esophageal inspiration &
Retrosternal or Tachycardia
irritation increases on
Precordial
expiration
Radiates to back, neck, Especially left
L arm or shoulder trapezium ridge
Worse on inspiration or
movement
Worse when supine
Relief on sittingup &
Rub heard better
bending forward
Only present in
15% of cases
Labs
CT sensitivity? Echo sensitivity
ST amplitude: T wave
Stage PR Segment ST Segment T wave
amplitude >0.25
Diffuse elevation
Depression,
1 (does not correlate
especially in II, N/A
with coronary
aVF& V4–V6
distribution)
2 Returns to Returns to
baseline baseline N/A
Inversions,
3 N/A Isoelectric especially in I,
V5, V6
Pericarditis: Treatment
Treatment depends on
cause
Viral
NSAID’s Course is benign
pericarditis?
Poor prognostic
signs
Cardiac Tamponade
Introduction
↑ Fluid in ↑ Pericardial
Pathophysiology
pericardial sac pressure
Myxedema Uremia
Hemorrhage Radiation-induced
Anticoagulant use
Idiopathic
Acute
Drug Induced Chronic
Cardiac
Tamponade Infectious
Tuberculosis
Trauma Bacterial
Rheumatic
Malignancy
diseases
SLE Melanoma
Leukemia
Metastatic lung cancer
Lymphoma
Metastatic breast
cancer
Other metastatic
cancer
Cardiovascular Emergencies 63
CXR EKG
Cardiac Volume
Pericardiocentesis Admit
Tamponade? expansion
Definitive treatment
Introduction
All layers of
True Aneurysms
vessel wall
Connective
Risk Factors Atherosclerosis Hypertension
tissue diseases
Symptomatic Abdominal
Emergent repair
Aortic Aneurysm of any size?
Extremity
GI Bleeding Sudden death Flank pain Shock Tachycardia Tachycardia
ischemia
Aortoenteric Due to Most common
embolization From rupture
fistula misdiagnosis =
from of aneurysm
Renal Colic
aneursymal
thrombus
Physical Exam in
Unreliable
AAA? Unusual
Presentations
Abdominal &/or
Classic Triad Pulsatile mass Hypotension
back pain Partial bowel
obstruction
IVC Erosion
AAA Signs
Scrotal or vulvar Inguinal Dissection of May irritate psoas muscle = Psoas sign
hematomas masses retroperitoneal blood May irritate femoral nerve = Femoral neuropathy
Periumbilical
Cullen’s sign
ecchymosis
Flank
Grey-Turner sign
ecchymosis
Presence of
< 50 %!
pulsatile mass?
Abdominal or Decreased
Other signs?
femoral bruits femoral pulses
Diagnosis
Radiologic Evaluation
Computed
Plain radiography Ultrasound MRI
Tomography
65 % with symptomatic
AAA Absence does not rule
out AAA rupture
Can define
Cannott ass
assess for anatomic detail
retroperitoneal
hemorrhage
Lateral AP
Won’t Arch of
Can id
identify
overlie calcification
retroperitoneal
vertebrae to the left
hemorrhage
Pt away
Risk
from ED
Treatment
Asymptomatic
Elective repair
AAA >5 cm
Cardiovascular Emergencies 67
Aortic Dissection
Introduction
Mortality without 25 % in 75 % in
treatment 1st 24 hours 1st 2 weeks
Prompt Increases
diagnosis? survival to 90 %
Anatomy
Major structural
Tunica Media
component?
68 B. Desai
Hypertension
Most common
Coarctation of Bicuspid aortic
risk factor
the aorta valve
Parainfluenza Male
Congenital
Acquired
May reenter
through the
intima
Ascending 60 %
Aortic arch 10 %
10 %
60 %
Descending 30 %
Type I
Anatomy and Classification of Aortic Dissection
False lumen
True lumen
30%
Intimal tears
Type II
DeBakey I II III
A B
Stanford
A = 62 % B = 38 %
History
Feeling of
Others Diaphoresis Syncope N/V
impending doom
Neurologic Hyper-or
Myocardial Infarction Stroke Syncope Limb Ischemia
findings hypotension
CXR
EKG
Ascending AD
31 % are normal involving RCA
Inferior wall MI
Will have same
signs &
symptoms
Almost always
requires further
imaging
Transesophageal
Echocardiography CAN Pericardial Valvular
Diagnostic test of identify effusions abnormalities
choice in the MRI Labs
unstable patient Limited use in the
Of little value
Sensitivity 98 % ED
Identifies the mobile
Highest Sensitivity
intimal flap that Do not use D-
Specificity 95 % 98 %
separates the true & dimer to exclude
Highest
Can image most false lumen dissection
specificity 98 %
of the thoracic
aorta Type & cross if
going to OR
Cardiovascular Emergencies 71
Acute
management
Decrease Minimize
Initial Pain control
the blood the shear
stabilization as needed
pressure pressure
Fentanyl Target
Target heart
preferred with systolic BP is
rate is £ 60
labile blood 100–120 mm
BPM
pressures Hg
Has both a & b May be used as a single Has a longer Hypotension & bradycardia
Labetalol
properties agent for BP & HR control half-life may be prologed
Hypertension
Systolic BP Diastolic BP
mm Hg mm Hg
Arbitrary BP ³
180/120
No specific BP
level!!
Hypertensive Emergencies
Cocaine
± Mental
Drugs Amphetamines Tachycardia Diaphoresis Hypertension
status changes
PCP
Benzodiazepines
Nitroglycerin
Labetalol
Phentolamine
Nicardipine
a+b-blocker is
ideal No b-blocker Unopposed
alone a effect
Labetalol +
Phentolamine
74 B. Desai
Catecholamine
Adrenals Pheochromocytoma
crisis
Labetalol +
Phentolamine
a+b-blocker is
ideal
Alternating periods of
Pheochromocytoma Headache Flushing
hypertension and normal BP
Treat associated
Eyes Exudates Hemorrhages
syndromes
Onset = immediate
Reflex tachycardia
Arterial & venous Use with b-blocker
Nitroprusside
vasodilator ↑ Increased ICP
Long term use
Onset = 1-2 min Cyanide toxicity
No reflex tachycardia
Labetalol a+b-blocker Do not use in AV blocks, CHF,
or bronchospasm
Onset = 2-5 min
Onset = immediate
Cardiovascular Emergencies 75
Cerebrovascular occlusion
Phentolamine a1 & a2 blocker
MI
Avoid in pregnancy
Enalaprilat ACE Inhibitor Dizziness
Headache
Onset = 5–10 min
Arteriolar vasodilator
May be used in Reflex tachycardia
Hydralazine Pediatric nephritis Chronic use = “Lupus-like”
Not recommended syndrome
Pregnancy-induced
hypertension
Onset = 10 min
Basic
EKG metabolic CXR Urinalysis
panel
Depends on
Disposition clinical condition
76 B. Desai
Pulmonary Hypertension
Introduction
Pulmonary Dx cannot be
Hypertension made in the ED!
Symptoms
Sx of underlying Peripheral
Dyspnea Chest pain Fatigue Syncope
disease edema
Most common Poor coronary Poor cardiac
RV failure
Sx blood flow output
On rest or
exertion
Diagnostic Studies
CXR EKG
Use to show any signs Incomplete RBBB with right
of pulmonary disease RVH
RBBB axis deviation
Confirmatory
Transthoracic Cardiac
PFT’s
echocardiography catheterization
Goal of Treatment
Syncope
Introduction
Causes of Syncope
Cardiac Medications
Structural – 4 % 3%
Dysrhythmias –
14 %
Unknown Orthostatic
hypotension
34 % 8%
Syncope
Breath Neurally
holding mediated
Neurologic Psychiatric
10 % 2%
78 B. Desai
Cardiac Syncope
Until proven
Elderly? Aortic Stenosis Syncope Angina Dyspnea
otherwise!
Until proven
Young? HOCM
otherwise!
Brady-
Dysrhythmias Tachy-rhythms OR Usually sudden No prodrome
rhythms
Depends on Continued
Disposition Admit
clinical condition syncope?
Evaluation of Syncope
Depends on
Disposition
clinical condition
Introduction
Popliteal
Superficial
Pelvic
Femoral
Veins in which
clots can form
Jugular
Pulmonary vessels
PE symptoms
20–30 % occluded
Hypoxemia in Shunting of
Unpredictable Due to
PE? blood flow
80 B. Desai
Conditions that
allow the Virchow’s Venous Damage Hypercoagulable
formation of Triad stasis of tissue states
clots
Immobilization Trauma Thrombophilic states
Venous
Smoking Cancer
catheters
CHF Post-op Lupus
COPD HIV
Nephrotic Syndrome
Hormonal
Pregnancy
Age Contraceptives
Signs
Wheezes or Sinus
Tachycardia Tachypnea Low PO2 ± Fever Dysrhythmias
rales tachycardia
Most have Atrial Out of
Shock DVT’s clear lungs fibrillation proportion to
Pulmonary fever
infarction has
rales over the
affected area
Cardiovascular Emergencies 81
Symptoms
Unilateral
Signs
Venous
Erythema U/L swelling ± Fever Homan’s sign
insufficiency
Not sensitive
Hyperpigmentation
or specific
Skin ulcers Calf pain
when
passively
dorsiflexing
the affected
foot
Diagnosis
Well’s Score
Low < 2
PE Unlikely < 4 Moderate = 2–6
OR
PE Likely > 4 High > 6
PE is leading
Signs and
diagnosis or equally HR > 100 bpm Prior PE or DVT
symptoms of DVT
likely
3 points 3 points 1.5 points 1.5 points
Immobilization
Active malignancy Hemoptysis
within 4 weeks
No recent trauma or
Age < 50
surgery
ABG EKG
Most commonly
abnormal Usually abnormal Sinus Incomplete
S1-Q3-T3
but not specific tachycardia RBBB
Nonspecific ST-T
changes
Hypoxemia ↑ A-a gradient
Right axis T-wave inversions
P pulmonale
↑ A-a deviation V1–V4
gradient?
PE more likely
CXR
Westermark
Cardiomegaly Atelectasis Hampton hump
sign
Oligemia distal Wedge shaped
Pleural to infarct pulmonary
Infiltrates
effusions infarction
Cardiovascular Emergencies 83
D-Dimer
Qualitative
Break down of Fibrin D-dimer protein Measured by
containing clots into blood Quantitative Qualitative
Quantitative Sensitivity
Usually high for 94–98 %
3 days after (–) D-Dimer + High risk?
NOT sensitive
DVT/PE Imaging
enough
Specificity
50–60 %
NOT specific (+) D-Dimer?
ALL risk factors for
thromboembolism enough Imaging
D-dimer!
Inflammatory
Recent surgery
disease
SLE Within past week
Rheumatoid Also indwelling
arthritis catheters
PE Imaging: CT Angiography
Filling defect in contrasted Exactly like Pulmonary
PE
pulmonary arteries angiography
64 slice > 32 slice Better resolution with Filling defects can be seen in
More detectors
32 slice > 1 slice multi-head scanners Subsegmental pulmonary arteries
Sensitivity 90 %
Specificity 90 %
Not sensitive enough to rule out
PE in high risk patients
Angiography Direct treatment Can measure pulmonary Can see filling defects
benefits of PE artery pressures in ³ 3 mm vessels
Lysis of clots
IVC filter
placement
PE Imaging: VQ Scanning
Sensitive enough
Normal V/Q
to rule out PE
Even in high
risk patients!
Venous Ultrasound
Non-compressible
DVT diagnosis?
veins
Venography
Treatment: Anticoagulation
Unfractionated
DVT or PE Renal Failure
Heparin
PE Tidbits
Ultrasound in
RV hypokinesis RV dilation
massive PE
Ultrasound in Normal RV
Normal RV size
less severe PE systolic function
Treatment: Fibrinolysis
Hypotension
Respiratory
Right sided strain Criteria for
Failure
Fibrinolysis
On Echo Hypoxia <90 %
Elevated Fibrinolytic Increased work
Troponin agent + Heparin of breathing
or LMWH
Metastatic cancer
Cardiac arrest
Intracranial Fibrinolysis
Uncontrolled HTN
disease Contraindications
Recent major
surgery or trauma
Within 3 weeks
86 B. Desai
Treatment: Embolectomy
Large proximal
Embolectomy Young patient Hypotension
PE
For most severe
cases
Mortality rate =
30 %
Disposition
PE? Admission
Extensive
iliofemoral DVT
Contraindication
Bleeding risks
to LMWH
Complicating
Features
Cardiac disease Concurrent PE
Introduction
Acute Limb Lack of blood flow to With passage of time have Usually within 6 hours but can occur
Ischemia an affected extremity irreversible cell death sooner due to lack of collateral flow
Typically due to
Thrombosis? Most common Has a slow onset
atherosclerosis
Usually cardiac in
Embolism? Atrial fibrillation Rapid onset
origin
Reperfusion Peripheral
Related to time Myoglobinemia Renal Failure
injury muscle infarction
Clinical Features
Muscle
Pain Paralysis Pallor Pulselessness Paresthesias Polar
weakness
Severe & With Early Severe cases
Constant continued
Later =
Earliest Sx ischemia
Mottled
Latest =
Necrosis
Ischemic
Hypoesthesia OR Hyperesthesia
neuropathy
Preservation of Tissue is
light touch? probably viable
Clinical Diagnosis
Otherwise normal
Known source Rapid onset Embolism
opposite limb
Diagnosis
Echo Intracardiac
thrombus
Treatment
Pacemakers
Emergency Pacing
Types
Transcutaneous Transvenous
AMI Asystole
Symptomatic
AMI bradycardia
Hypotension
New Bifascicular
AMI block
Mobitz type II 2°
AMI
heart block
Drug-resistant
tachyarrhythmia
Drug overdose
Digoxin, b-blocker, Ca
channel blocker
90 B. Desai
Pacemaker Nomenclature
Response
Chamber Chamber Arrhythmia
to electrical Programming
Paced Sensed control
activity
Programmable rate
A trium Inhibits or output Pacing
Unipolar vs Asynchronous
Bipolar vs. Synchronous
NOne NOne
Pacemaker Bipolar
Due to
functions electrodes
92 B. Desai
Battery or Electromagnetic
Failure to pace Lead problems Oversensing
component failure interference
Pacemaker Dislodgement
does not fire
Wire fracture
when it should
No visible pacing
EKG
spikes
Pacemaker Failure
Signs
Slowing of pacer
Rapid rhythm
rate
Internal
malfunction
Looks like
Ventricular
tachycardia
CXR EKG
Introduction
May have no
Stable patients
pulse at baseline!
Aorta
LVAD Emergencies
Pt in extremis
Use manual BP
Check MAP Ideally >65
or Doppler
May dislodge
MAP present No CPR!
the pump
LVAD Complications
Pump Failure
Echo Findings
EKG in LVAD
MI Catheterization
But…
No pads over
Arrhythmia Standard ACLS
device!
96 B. Desai
Sinus
V. Fib
Bradycardia +
Prolonged Prolonged Prolonged +
Other
Asystole
Arrhythmias
J-waves Other
Slow A. fib
May be present Muscle tremor
artifact
Early
Flat May be
Prominent May widen Depression
Later present
Inversion
Intervals Other
PR
PVC’s
Prolonged
V.Tach
QT
Torsades
Prolonged
Cardiovascular Emergencies 97
Early
Hyperacute”
“
Flat or May be
Wide Later
Absent elevated
QRS + T = Sine
wave
PR
Prolonged Bradycardia
V. Fib AV Blocks
QT Sine Wave
Shortened
Ventricular
dysrhythmias
QT
Inversions
Prolonged
Torsades
98 B. Desai
PR
May be May be Prolonged
wide depressed QT
Shortened
PR PVC’s
Prolonged Flat or V.Tach
Wide Not normal
QT inverted Torsades
Prolonged V. fib
QT
QT prolongation
Hypokalemia
Hypocalcemia
Hypomagnesemia
Hyperphosphatemia
Hypomagnesemia
Usually in association with
hypokalemia + hypocalcemia
Cardiovascular Emergencies 99
Torsades De Pointes
Electrolyte
Causes Medications
abnormalities
Overdrive pacing
Cardioversion or
Medications
Defibrillation
NO
Depending on Treatment Lidocaine Amiodarone or
patient condition Isoproterenol Procainamide!
Phenytoin
Magnesium
Shortens QT
Give infusion post
conversion
100 B. Desai
Rhythms &
Intervals ST Segment T wave
Blocks
PR Sagging,
Prolonged Concave
Flat or PVC’s (most common)
QT upwards
inverted AV dissociation
Shortened (dig effect and
PAT with blocks
may be normal)
Sinus bradycardia
SA blocks
AV blocks
Bidirectional V.tach
Slow A. Fib
Junctional tachycardia
Sinus Arrest
Right axis
Sinus
deviation Wide May be
Prolonged tachycardia
>100 ms present
Terminal R wave (most common)
>3mm in aVR
R/S ratio >0.7 in
aVR
I aVR V1 V4
Quinine
II aVL V2 V5 Propranolol
Antimalarials
(Chloroquine)
Local anesthestics
III aVF V3 V6 (Bupivacaine)
Type 1a antiarrhythmics
(Quinidine, Procainamide)
Type 1c antiarrhythmics
II
(Flecainide, Encainide)
102 B. Desai
Dysrhythmias
Severe
Blocks
Metabolic
derangements
Electrolyte
disturbances
Hypo- or
Hyperkalemia
Shortened if P
Absent Usually
wave precedes Regular
May be inverted narrow Atria = <60 bpm
QRS
Ventricle =
20–40 bpm
Accelerated
Junctional Rhythm
Retrograde P
waves
Rate =
60–100 bpm
Cardiovascular Emergencies 103
JER Treatment
Hemodynamically Transvenous or
Atropine
Unstable Transcutaneous pacing
JER Treatment
Stable patient
Atropine to speed
Usually none
up rate
SVT
MAT
Pre-excitation
Hyperthyroidism
syndromes
WPW
Rheumatic Heart
Mitral disease
Disease
Stenosis
Tobacco
Alcohol
Acute MI
Digitalis toxicity
Pericarditis
104 B. Desai
May be absent
Narrow Regular
May be
retrograde
SVT Treatment
Hemodynamically Synchronized
Unstable cardioversion
Methylxanthines
(Theophylline)=
MORE
Carbamazepine = LESS
Vagal maneuvers Adenosine
Most effective mg
Valsalva 6 12 12
CP, dyspnea, feeling
of doom
Calcium Channel
b-blockers
Blocker
Diltiazem Esmolol
Verapamil Propranolol
Cardiovascular Emergencies 105
SVT 2°
Propranolol
Thyrotoxicosis?
Depends on
Disposition
clinical condition
Most common
AF
supraventricular arrhythmia
Pre-excitation
Thyrotoxicosis
syndromes
WPW
Heart Disease
Acute MI
Pulmonary Embolism
Rheumatic HD ±
Valvular HD
Hypertension
Dilated
Causes of AF/AFl cardiomyopathy
HOCM
Drugs & Medications
Digitalis toxicity
COPD
Sympathomimetics
Metabolic
Pericarditis
derangements
Electrolyte
disturbances
Acid-base
disturbance
106 B. Desai
Aberrantly
conducted beats
usually of RBBB
morphology
Due to long
refractory period
of the preceding
RR interval
Usually
blocked
AF/AFL Treatment
Hemodynamically Synchronized
Unstable cardioversion
Diltiazem
Stable patient
Digoxin
Slow in onset
Depends on
Disposition
clinical condition
108 B. Desai
COPD
Sepsis
At least 3 different
P wave Usually Irregularly PP, PR, & RR
morphologies narrow irregular intervals vary
Other
Isoelectric baseline
No single dominant
atrial pacemaker
Cardiovascular Emergencies 109
MAT Treatment
Oxygen
MAT
Treatment
Stable patient
Drug of choice
Iatrogenic Hyperthyroidism
Sympathomimetics CHF
Alcohol Myocardial
Causes of PVC’s contusion
Caffeine
Cardiomyopathy
Tobacco
Beta agonists
Hypoxia
Hypokalemia
Hypomagnesemia
Acid-Base disturbance
110 B. Desai
Compensatory
pause
Absent Wide Varies
Unifocal or
Multifocal
PVC Treatment
Magnesium
Stable
DEPENDS ON
CLINICAL
SCENARIO!!
Hemodynamic Cardioversion or
Sustained PVC’s VT > 30 sec
instability Defibrillation
Cardiovascular Emergencies 111
Anterograde
Pre-excitation syndrome due to
WPW Pathways Retrograde
abnormal accessory pathway
Bi-directional Majority
Bundle of Kent
Orthodromic Antidromic
pathway pathway
SA AV SA AV
RA LA RA LA AV node cannot
slow down
conduction
ST segment & T
Slurred initial
wave may show
Shortened Wide upstroke of QRS
discordant
may be present
changes
Pseudo-
Infarction
Pseudo Q waves
Prominent R waves
in V1–3
Mimicks posterior
infarction
During
tachyarrhythmias
pre-excitation features
are lost
Direction of reentry
determines shape of
QRS
AVRT with
orthodromic (left) &
antidromic (right)
AV nodal conduction
Cardiovascular Emergencies 113
Orthodromic
Buried in Normal May be
QRS or Depression 200–300
inverted
Retrograde
Andromic
Wide
< 120 ms
Orthodromic
Andromic
Irregular
>200 bpm A. Flutter = Wide Stable
Regular
May change in
shape
114 B. Desai
Amiodarone
Procainamide Treatment
Preferred for CHF or
Slow in onset
low EF
Calcium Channel
β-blockers
Blocker
Diltiazem Esmolol
Verapamil Propranolol
Hemodynamically Synchronized
Unstable cardioversion
WPW + Wide
Procainamide OR Amiodarone
Complex
Preferred for
CHF or low EF
Digitalis
Adenosine
Do NOT Block AV node ↑ Conduction down ↑ Ventricular May lead
USE β-blockers conduction accessory pathway rate to V. Fib
Ca-Channel blockers
Cardiovascular Emergencies 115
Family Hx of Sudden
Hypoxia
Cardiac Death
Rate >120
Absent Wide Regular Usually > 150
Unifocal or
Multifocal
Monomorphic
Polymorphic VT
VT
No LBBB or RBBB
QRS > 150 ms
morphology
Concordance
AV dissociation
throughout
P’s and QRS
complexes at
different rates
VT Treatment
Hemodynamically Synchronized
Pulse
Unstable cardioversion
Hemodynamically
Pulse Defibrillation
Unstable
Amiodarone
Low EF
Lidocaine Procainamide
VT
Stable patient
Magnesium
Torsades
150–500 per
Absent Absent Absent Chaotic
minute
Other
Amplitude
decreases with
duration
Coarse to Fine
Heart Blocks
Ischemic Heart
Aortic stenosis
disease
Digitalis toxicity
Causes of LBBB
Primary cardiac
fibrosis of the
Hypertension
conducting system
Dilated Electrolyte
Cardiomyopathy derangements
Hyperkalemia
Hypermagnesemia
Cardiovascular Emergencies 119
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
II
Rheumatic heart
Cor Pulmonale
disease
Causes of RBBB
Primary cardiac
fibrosis of the Congenital heart
conducting system disease
Cardiomyopathy Myocarditis
120 B. Desai
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
II
Age-related
Increased vagal tone
degeneration
Heart Disease
Acute Inferior MI
Myocarditis
Drugs & Medications Endocarditis
Mitral valve surgery
Digitalis toxicity
1oHB Congenital
β -blockers Causes of
Ca-channel blockers
Amiodarone
Hypothermia
Electrolyte
Athletic training
derangements
Hypo-or
Hyperkalemia
Hypermagnesemia
Cardiovascular Emergencies 121
Block at level of
AV node
1° HB Treatment
Transcutaneous
Symptomatic? Atropine
pacing
1oHB Treatment
Stable
Age-related
Increased vagal tone
degeneration
Heart Disease
Acute Inferior MI
Myocarditis
Drugs & Medications Endocarditis
Mitral valve surgery
Digitalis toxicity
Causes of 2o Congenital
β -blockers Type 1 HB
Ca-channel blockers
Similar to 1° HB
Amiodarone
Hypothermia
Electrolyte
Athletic training
derangements
Hypo-or
Hyperkalemia
Hypermagnesemia
PR & RR
P waves QRS Complex Rhythm Other
Intervals
PR
Progressively “Marked” 1°HB
Usually
Normal lengthens Regular if PR > 300 ms
narrow
RR 1:1 relationship
Progressively of P & QRS
shortens
Block at level of
Until a beat is AV node
dropped
Cardiovascular Emergencies 123
2° Type 1 HB Treatment
2° Type 1
Treatment
Transcutaneous
Atropine
pacing
Permanent pacing
is rarely required
Sarcoid
Amyloidosis
Heart Disease
Hemachromatosis
Acute Anterior MI
Due to infarction of
the bundle branches
Drugs & Medications
Mitral valve surgery
Ca-channel blockers
Autoimmune
Amiodarone disorders
Lupus
Systemic sclerosis
Inflammatory Electrolyte
conditions derangements
2° Type 2 HB Treatment
2° Type 2
Treatment
Transcutaneous Transvenous +
Bridge to
pacing Permanent pacing
Permanent pacing
may be required
Cardiovascular Emergencies 125
Severe
Hemodynamic Progression to
2° Type 2 HB 2° Type 1 HB In producing
compromise
symptomatic
3° Heart Block
bradycardia
Insertion of permanent
Disposition ADMISSION
pacemaker
Sarcoid
Amyloidosis
Heart Disease
Hemochromatosis
Acute MI
Due to infarction of the
bundle branches
Causes of 3° HB
b-blockers
Ca-channel blockers
Essentially the same Autoimmune
Amiodarone as 2° Type 2 HB disorders
Lupus
Systemic sclerosis
Inflammatory Electrolyte
conditions derangements
Junctional Block at AV
Changes node, bundle of
Normal escape beats Usually severe
randomly His or bundle
Narrow QRS bradycardia branches
with
independent
Ventricular atrial &
ventricular rates No relationship
escape beats between P and
Wide QRS QRS
Rate Other
3° HB Treatment
3° HB Treatment
R
No Atropine
x
Transcutaneous
Atropine
pacing
Cardiovascular Emergencies 127
Miscellaneous
Brugada Ventricular
Sudden death Syncope Due to
syndrome fibrillation
Fever
Infectious &
Non-infectious
causes
Drugs & Electrolyte
Medications derangements
Cocaine Hypo-&
Hyperkalemia
Alcohol
Brugada Hypercalcemia
a-agonists
Syndrome Hypercalcemia
b-blockers
Factors that may
Nitrates precipitate Vagal maneuvers
dysrhythmias
Na channel blockers
TCA’s Heart Disease
Hypothermia
128 B. Desai
Brugada Sign
ST segments Type 2 Type 3
Type 1
Elevated in
V1 & V2
Coved ST segment
elevation > 2mm ST elevation Morphology of
in V1-3 (only need resembling a Type 1 or 2, but <2
1 lead) followed by saddle > 2mm mm ST elevation
a (-) T wave
“Pseudo RBBB”
V1 V1
V1
V2 V2 V2
V3 V3 V3
Cardiovascular Emergencies 129
Tetralogy of Fallot
PEDIATRICS
Pulmonary stenosis
Dyspnea Syncope
Usually precipitated
“Tet Spell” Hemoptysis
by feeding or crying
Hypercyanosis Seizures
Propranolol Supplemental O2
Potential
treatments for
Tet Spell
Can decrease
Increases systemic
Phenylephrine Morphine sulfate hyperpnea, but can
vascular resistance
decrease BP
Bicarbonate
Decreases acidosis
induced respiratory
drive
Pulmonary Emergencies
Contents
Definitions and Clinical Presentations ............................................................................................................................................................ 132
Pneumothorax ................................................................................................................................................................................................... 135
Asthma ............................................................................................................................................................................................................... 138
Chronic Obstructive Pulmonary Disease ........................................................................................................................................................ 143
Bronchiolitis....................................................................................................................................................................................................... 150
Pertussis ............................................................................................................................................................................................................. 152
Pneumonia ......................................................................................................................................................................................................... 153
Tuberculosis ....................................................................................................................................................................................................... 168
Lung Abscess ..................................................................................................................................................................................................... 172
Acute Respiratory Distress Syndrome ............................................................................................................................................................ 172
Pleural Effusions ............................................................................................................................................................................................... 173
The Airway ........................................................................................................................................................................................................ 179
General Pediatrics ............................................................................................................................................................................................. 181
M.R. Marchick, MD
Department of Emergency Medicine,
University of Florida College of Medicine,
Gainesville, FL, USA
B. Desai, MD, MEd (*)
Department of Emergency Medicine,
University of Florida, Gainesville, FL, USA
e-mail: [email protected]
Hypoxemia
Low arterial
Hypoxemia PaO2 < 60 mmHg OR SaO2 < 90 mmHg PaO2 < 60 mmHg
oxygen content
Hypoventilation
Right->Left
shunting
Does not reverse Causes
with supplemental
O2
Vascular
malformations V/Q mismatch
Cyanotic
congenital PE
heart disease Infection
Atelectasis Asthma
Consolidation COPD
Hypoxia
Insufficient tissue
Hypoxia oxygen delivery
Hypoxemia
#1 cause
Abnormal
hemoglobin Causes Anemia
Methemoglobinemia
Low cardiac
output
Pulmonary Emergencies 133
Hypercapnia
Arterial-Alveolar Gradient
Arterial-Alveolar
Measured PaO2 Calculated PaO2
Gradient
Decrease in
diffusion
Interstitial disease
V/Q Mismatch
Shunt Causes of Pulmonary
increased A-a embolism
AV Fistula gradient Pneumonia
Atrial septal defect COPD
134 M.R. Marchick and B. Desai
Cyanosis
Obtain formal
Cyanosis present?
ABG
Hemoptysis
Bronchitis
#1 cause
Pulmonary
Bronchiectasis
embolism
Common Causes
Pulmonary
Malignancy
embolism
Tuberculosis
Arterio-bronchial
Angiodysplasia
fistula
Will miss 20 % of
Imaging CXR
neoplasms
Pneumothorax
Spontaneous Pneumothorax
Male
Smoking
COPD
#1 cause
Sarcoidosis Asthma
Secondary Risk
Factors
Thoracic P. jiroveci
endometriosis infection
Needle 16 gauge or larger long 2nd (or 3rd) Midclavicular Subsequent tube
decompression needle / Angiocath intercostal space line thoracostomy
Iatrogenic PTX
Similar to
Treatment
spontaneous PTX
Pulmonary Emergencies 137
Pneumomediastinum
Pulmonary
barotrauma
Forceful valsalva
Pulmonary
barotrauma
Endoscopy
Intubation
Mechanical
ventilation
Treat underlying
Treatment cause
Tension
Pneumomediastinum Rare Treatment Pericardiocentesis
138 M.R. Marchick and B. Desai
Asthma
Introduction
50 % of cases Initial 2:1 predominance
Affects ~ 5 % of Higher in Blacks
Asthma develop among of M:F & equalizes over
US population children < 10 subsequent decades & Puerto-Ricans
Triggering agent
Recruitment of
Air trapping
inflammatory cells
Eosinophils
Neutrophils
Pathophysiology
Mast cells
Lymphocytes
Triggering Agents
Viral Pregnancy
Menses
Thyroid disease
Allergens Exercise
Pollutant
Emotional stress
Triggering Agents
Irritants
Food Smoke
preservatives
Dust mites
Clinical Features
Prolonged
Typical S&S Tachypnea Tachycardia Chest tightness Wheezing Cough
expiratory phase
Severe exacerbations – May indicate Poor Paradoxical Altered mental
No wheezing Hypercapnia
impending respiratory arrest respirations respirations status
140 M.R. Marchick and B. Desai
> 2 hospitalizations
in prior year
Prior psychiatric
disease
Risk Factors for
Death Hospitalization or
ED visit for asthma
Prior pulmonary in past month
disease
Current use or
Recreational drug Low socio- recent
use economic status discontinuation of
systemic steroids
Peak Flow
Compare to Personal
Peak Flow Age Sex Height
predicted value best
<40 %
Generally requires admission Short course of
predicted
systemic
steroids
Pulmonary Emergencies 141
β-2 adrenergic Primarily dilate small, Short acting agents Long acting agents Not indicated for
agonists peripheral airways have rapid onset have slow onset acute sx
Rare
Tremor
Side effects Tachycardia HTN Anxiety arrhythmias,
(#1) e.g., MAT
Seen with
theophylline
Occasionally used
Bronchodilatory Anti-inflammatory
Methylxanthines Theophylline for chronic
effects effects
management
Modulate
Leukotriene Useful for chronic Not indicated for
inflammatory
modifiers management ED use
response
25–75 mg/kg up
Relaxes bronchial Stabilizes mast cells & Indicated only in
Magnesium severe to 2 g IV over 30
smooth muscle T-lymphocytes exacerbations minutes
Introduction
Increasing Only major cause Insidious onset
4th leading cause
COPD prevalence in of death which is typically over
of death in US women increasing decades
FEV 1 FVC
Clinical FEV1/FVC< 70 % FEV1 < 80 %
Forced expiratory Forced vital
definition predicted volume in 1 sec capacity
Emphysema Pathologic
Destruction of small pulmonary airspaces
“pink puffer” diagnosis
Long-term
Cigarette Indoor air Occupational α-1 antitrypsin
Risk factors passive
smoking pollutants dust exposure deficiency
smoking
#1 risk factor Very rare
Interventions which
Smoking Long-term O2 Consider pneumococcal
improve disease
cessation therapy vaccination for all COPD patients
progression
144 M.R. Marchick and B. Desai
COPD Pathophysiology
Irritants
Arterial
Failed gas constriction Increased
exchange inflammatory
pCO2 cells
T cells
pO2
Polycythemia
Neutrophils
Pathophysiology
Macrophages
Blockage of small
airways
Release of
Tissue destruction inflammatory
mediators
Decreased lung Diminished cross
elasticity sectional area of TNF
vascular bed
Proteases
Leukotriene B4
Mucus secretion
Diminished cross
Arterial Pulmonary Right heart
sectional area of Cor pulmonale
constriction hypertension failure
vascular bed
Pulmonary Emergencies 145
Infection
Viral
Bacterial
#1 cause
Idiopathic PE
CHF
Acute COPD
Beta blockers Exacerbation Environmental
Causes changes
Temperature
Humidity
Spontaneous PTX Pollutants
Medication
noncompliance
PNA, CHF
Diagnostics
Evaluate for
CXR treatable cause of Pneumonia PTX CHF
exacerbation
Chronic HCO3 ≠ 3.5 mmol/l for Acute HCO3 ≠ 1mmol/l for each
Hypercapnia
each 10 mm Hg ≠ in pCO2 Hypercapnia 10 mm Hg ≠ in pCO2
ECG Findings
Right axis Multifocal atrial Atrial Right ventricular S1Q3T3 pattern as result of
Low voltage
deviation tachycardia enlargement hypertrophy right ventricular strain
146 M.R. Marchick and B. Desai
Improved dyspnea
Antibiotics Acute COPD Hyperglycemia
Exacerbation most common
Indicated in patients Management
with evidence of side effect
infection
≠ Sputum
purulence
≠ Dyspnea Bronchodilators
≠ Sputum See asthma
volume section
Respiratory
Organisms S. pneumoniae M. catarrhalis H. influenzae Azithromycin
fluoroquinolones
Respiratory arrest
Hemodynamic
Craniofacial trauma
instability
Respiratory arrest
Contraindication to
¯ Mental status
NIPPV
despite otherwise
maximal treatment
Severe Indications for
hypercapnia Intubation
Obstructed airways
Diminished
subsequent Incomplete
delivered tidal exhalation of
volumes tidal volume
“Air trapping”
Airway effects
Barotrauma
Increased airway
PTX pressures
Avoid
hyperventilation!
↑ Risk of
Dysrhythmias barotrauma Respiratory
alkalosis
Hyperventilation
effects
Seizures
Further metabolic
derangement in
setting of chronic
metabolic alkalosis
148 M.R. Marchick and B. Desai
Permissive Hypercapnia
Improved V/Q
matching
Permissive
Less barotrauma Increased cardiac
hypercapnia
from autoPEEP output
benefits
Increased oxygen
unloading
Increased ICP
Permissive
hypercapnia
harms
Decreased
seizure threshold
Significantly
worsened
symptoms from
baseline
New oxygen
requirement
Poor social
situation or ADMIT
follow-up
Worsened hypercapnia
Inadequate
Significant
response to ED
comorbidities
treatment
Patient already
taking oral
steroids
³ 5 ED and clinic
HIGH RISK OF
Initial RR > 20 visits for COPD in
RELAPSE
prior year
Pulmonary Emergencies 149
Acute Bronchitis
Viruses
Most common
cause
Atypical bacteria
Influenza
<10 % cases
Acute Bronchitis
Rhinovirus Close quarter
Inflammation of outbreaks
Most common cause the large airways
of common cold of the lungs Chlamydophila
pneumoniae
Coronavirus Cough ± Mycoplasma
phlegm pneumoniae
Adenovirus
Bordetella
pertussis
RSV
Parainfluenza
virus
Clinically Wheezing?
± CXR Albuterol
Suspect
Sx > 3 weeks?
pertussis?
Consider Azithromycin or
alternative Clarithromycin
diagnoses
Acute Bronchitis Reduces
GERD Management transmission of
B. pertussis
Asthma
Minimal effect on
Chronic symptoms, which
bronchitis often last > 3
weeks
Suspect
influenza?
Oseltamivir
Bronchiolitis
Bronchiolitis
PEDIATRICS
Acute
inflammation of
bronchioles
Pathophysiology
Edema
Airway resistance
Mucous
production
Atelectasis
Parainfluenza
Organisms RSV Influenza Adenovirus Rhinovirus
virus
#1 cause
RSV Management
PEDIATRICS
Bronchiolitis Disposition
PEDIATRICS
Witnessed apnea
Gestational age
Underlying <37 weeks
cardiopulmonary ADMIT
disease
Age < 3 months
Marked
Immunodeficiency
tachypnea
Inability to clear
airway secretions
Bronchopulmonary Dysplasia
PEDIATRICS
Pertussis
Introduction
PEDIATRICS
Immunization
Bordetella Gram negative Highly Incubation 1–3
efficacy wanes from
pertussis coccobacillus contagious weeks
late adolescence
Culture on
Diagnosis? NP swab Bordet-Gengou PCR also useful
medium
Paroxysmal Convalescent
Stages of disease Catarrhal Stage
stage stage
Sx Sx Sx
Paroxysmal coughing
Congestion
40–50 per day
Pertussis Complications
PEDIATRICS
Pneumonia
#1 complication
Encephalitis Aspiration
Pertussis
Seizures Apnea
Complications
Subconjunctival
Pneumothorax
hemorrhage
Epistaxis Pneumomediastinum
Pulmonary Emergencies 153
Pertussis Treatment
PEDIATRICS
Consider
Close contacts?
treatment
Highest
Severe respiratory
Admission Age < 1 year mortality in
distress
those < 1 month
Pneumonia
Pneumonia Classification
New infection ³ 2
Hospitalized ³ 2 Hospital
days after
days in past 90 acquired PNA
admission
days
New infection ³ 2
Ventilator
days after
Patients receiving associated PNA
Long-term care intubation
chronic wound
residents
care
Healthcare- Resistant Lower risk in
associated PNA organisms? CAP patients
(HCAP)
Patients receiving
home IV Hemodialysis
antibiotics patients
Immuno
Patients receiving
compromised
chemotherapy
patients
Pneumonia Pathophysiology
Impaired Chronic
Diminished host Impaired
mucociliary underlying OR Immune disease
defenses cough/gag
transport disease
Impaired
cough/gag AMS Seizure CVA
Impaired
Pre-existing viral
mucociliary Smoking COPD infection
transport
Hematogenous Otherwise
seeding Pseudomonas S. aureus uncommon
Pneumonia Treatment
S. pneumoniae
Outpatient Macrolide (preferred)
H. influenza
Previously healthy or
Mycoplasma pneumonia
No Abx within 3 months Doxycycline
Chlamydophila pneumoniae
Comorbidities
Chronic heart, lung, liver, renal Respiratory fluoroquinolone
disease, DM, Alcoholism, Same as above or
Malignancies, Immune disease β-lactam + Macrolide
Special Considerations
Pseudomonas a consideration?
Antipneumococcal, Respiratory
antipseudomonal b-lactam fluoroquinolone
OR
Antipneumococcal,
antipseudomonal b-lactam Aminoglycoside Azithromycin
OR
Antipneumococcal, Antipneumococcal
antipseudomonal b-lactam Aminoglycoside fluoroquinolone
PEDIATRICS
S. pneumoniae
Bordetella pertussis Erythromycin
3 weeks – 3 months Chlamydia trachomatis or
H. influenza Cefotaxime
Viral – RSV/Parainfluenza
Viruses
4 months – 4 years S. pneumoniae Same as above
Mycoplasma pneumoniae
Erythromycin
Mycoplasma pneumonia (Doxycyline if >8)
5 years – 15 years
S. pneumoniae or
Cefotaxime
Streptococcus pneumoniae
Parapneumonic
CXR Lobar infiltrate
effusion
Potential rapid
Functional or Immunosuppressed
OR development of
surgical asplenia patients
septic shock
158 M.R. Marchick and B. Desai
Haemophilus influenzae
Type b causes Less common in
Haemophilus Gram negative
majority of children due to
influenzae rod infections immunization
Patchy alveolar
CXR Effusion
infiltrates
Complication Bacteremia
Pseudomonas aeruginosa
Severe
Systemic illness Fever Chills Chest pain Vomiting AMS
presentation
Cyanosis
Empyema
Bilateral lower
CXR formation
lobe infiltrates common
Consider double
Complication High resistance
coverage
Pulmonary Emergencies 159
Klebsiella pneumoniae
Abscess
CXR Lobar pattern
formation
Common producer of
Necrotizing extended spectrum
Antibiotic
Complication Due to
infection β-lactamases resistance
Staphylococcus aureus
Large gram (+) High association
Staphylococcus Uncommon Incidence
cocci in pairs with concomitant
aureus cause of CAP increasing (MRSA)
and clusters influenza infection
Hematogenous
Complication
spread
160 M.R. Marchick and B. Desai
Non-productive
Gradual onset Sore throat Headache Flu-like Sx Vomiting AMS
cough
Cyanosis
Associated with
Mycoplasma
bullous myringitis
Legionella
Observed more Transmitted via inhalation of
Intracellular No person-
Legionella frequently during aqueous aerosols from
organism summer contaminated source to-person
Watery Relative
Flu-like Sx N/V Classic Hx Transaminitis
diarrhea bradycardia
Patchy infiltrates
Pleural effusion Can progress to
CXR predominantly
lower lobe in up to 1/3 ARDS
Immune
High risk groups Alcoholism Age > 50 Smokers DM COPD
disease
General Non-productive
Dyspnea Fever Weight loss Night sweats
malaise cough
Pathogens in HIV
CD4
CAP TB PCP
<200
Most common
CD4 Mycobacterium
CAP TB PCP CMV Fungi
<50 avium complex
Hilar
CXR Granulomas
adenopathy
Acute &
No treatment
Asymptomatic
Treatment
Evidence of 1st line
Symptomatic OR
chronic infection Itraconazole
Pulmonary Emergencies 163
Disposition
2 or more CURB-
Admit
65 factors?
Class II Outpatient Rx
Class IV or V Admit
164 M.R. Marchick and B. Desai
If indicated, obtain
Cultures
prior to antibiotics
Respiratory
Inpatient CAP? OR Ceftriaxone Azithromycin
fluoroquinolone
or Aminoglycoside or Linezolid
Organisms within
3 months of K. pneumoniae E. coli S. aureus Pseudomonas Legionella Fungi
transplant
Poor prognosis
Organisms within
Especially
6 months of CMV P. jirovecii Fungi
transplant Aspergillus
Organisms > 6
Ordinary CAP
months of Better prognosis
transplant pathogens
Pulmonary Emergencies 165
Cystic Fibrosis
PEDIATRICS
Pulmonary Respiratory
Hemoptysis Pneumothorax Cor pulmonale
emergencies failure
Pneumonia in
S. aureus Haemophilus
early life
Aspiration
High gastric
Stroke
pressures
Gastric tube
Seizure
placement
Emergent
Head Trauma
intubation
Pulmonary Emergencies 167
Aspiration Management
Wheezing? Bronchodilators
Tuberculosis
TB Tidbits
Calcified, necrotic
Ghon focus
granuloma
Associated calcified
Ghon complex Ghon focus
hilar lymph node(s)
TB Pathophysiology
Latent reactivation
Immunocompetent Rapidly
progressive
Primary infection
primary active TB
+/- disseminated
Bacilli inhaled spread
into alveoli
Primarily of
Latent infection lower lobes
Reactivation TB
Occurs in up to
5 % within 2 years 5 % subsequent
Reactivation TB 10 % of general
of initial infection lifetime risk
population
AIDS
Steroids
DM ESRD
TB Presentation
Primary infection
Asymptomatic
contained?
Primary Active TB
Reactivation TB
Exposure to non-
False positive Prior BCG
tuberculous
PPD vaccination
mycobacteria
Immune
False negative Very recent Improper
compromised
PPD infection administration
patients
TB Diagnosis
Seizures Thrombocytopenia
Concern for
Admit
active infection?
172 M.R. Marchick and B. Desai
Lung Abscess
Incidence
Lung Abscess declining as PNA
Rx improves
Inflammatory
Lung Abscess
disorders, e.g., Malignancy
Causes
Wegener’s,
Sarcoidosis
Pulmonary
Fungal infection
infarction
Include anaerobic
coverage!
ARDS Causes
Subarachnoid
Pancreatitis
hemorrhage
Toxin/Smoke
Aspiration
inhalation
ASA, opioids,
TCAs, cocaine High altitude
PE Transfusion
Pleural Effusions
Introduction
Low-protein
↑ Hydrostatic ↓ Oncotic
Transudate OR plasma
pressure pressure
ultrafiltrate
Pleural protein Pleural
Light’s Criteria Pleural LDH>2/3 upper
level/serum OR LDH/serum LDH OR
for Exudates protein >0.5 > 0.6 normal limit serum LDH
Labs for
Culture/ AFB
Evaluation of Glucose Cytology pH Amylase
Gram Stain smear
Exudate
<6 = esophageal
rupture
Post-expansion
Complications Pneumo/ Lung Transient
Infection pulmonary
Hemothorax laceration hypoxia edema
Due to V/Q Especially
mismatch with >1500 ml
fluid removal
Transudates
CHF
#1 cause in US
Peritoneal Nephrotic
dialysis Transudates syndrome
Constrictive
Hypoalbuminemia
pericarditis
PE Myxedema
Exudates
Infection
Bacterial pneumonia
Tuberculosis
Viral illness
Recent abdominal Lung abscess
Malignancy
surgery
Subphrenic abscess PE
Pulmonary infarction
Exudates
Pancreatitis Malignancy
Connective tissue
Chylothorax disease ARDS
Pulmonary Emergencies 175
Empyema
Pus in the
Empyema
pleural space
Pleuritic chest
Other Sx Fever Chills Dyspnea
pain
Pipercillin- Vancomycin
Antibiotics Cefepime OR
Tazobactam (if MRSA suspected)
Causes of Empyema
Hematogenous or
lymphatic spread
from pneumonia
#1 cause
Other infected Aspiration
fluids pneumonia
Hemothorax
Chylothorax
Hydrothorax Transudates Esophageal rupture
Direct extension of
Mediastinitis
osteomyelitis
Extension from
retropharyngeal Post-procedure
abscess
Thoracotomy
Thoracostomy
Thoracentesis
176 M.R. Marchick and B. Desai
Mediastinitis
Post cardiac
surgery
#1 cause in US
S. aureus
S. epidermidis
Esophageal
Trauma
perforation
Acute Causes
Surgical
Acute Treatment IV antibiotics consultation
TB
Histoplasmosis
Hiccups
Chlorpromazine
Treatment 25–50 mg IM
Pulmonary Emergencies 177
Pneumoconioses
Coal Worker’s
Due to Coal dust
Pneumoconioses
Diagnosis CXR
Sarcoid
Fatigue Lack of energy Weight loss Arthralgias Arthritis Dry eyes Blurry vision
Radiation +
Treatment May need stenting
chemotherapy
Mediastinal Masses
Most common Bronchogenic
mass in
mediastinum carcinoma
Thyroid
“Terrible”
(Carcinoma) Thymoma
Anterior
mediastinal
masses
Five “T”’s
The Airway
Pre-oxygenation
Pretreatment
Paralysis with
induction
Protection &
Time Zero Positioning
Placement with
Proof
Post-intubation
t + 90 seconds management
180 M.R. Marchick and B. Desai
Airway Tidbits
3-3-2 Rule
Opening of mouth = 3 fingers
Hyoid-chin distance = 3 fingers
Distance from thyroid cartilage to floor of mouth = 2 fingers
M allampati Score
O bstruction
N eck mobility
Definitive
ENT evaluation
treatment
(Reprinted from Ramachandran SK, Kheterpal S. The expected diffi- New York: Springer Science; 2013. p. 11–32. With permission from
cult airway. In: Glick DB, Cooper RM, Ovassapian A, editors. The diffi- Springer Science + Business Media)
cult airway: an atlas of tools and techniques for clinical management.
Pulmonary Emergencies 181
Definitive Interventional
ENT evaluation
treatment radiology
General Pediatrics
PEDIATRICS
Choking or Change in
Color change Apnea gagging muscle tone
Cyanotic Limp
Pale
Occurred during
sleep period
Hx of abuse or Witnessed
other trauma seizure activity
Hypotonic tone
182 M.R. Marchick and B. Desai
PEDIATRICS
Idiopathic
Congenital heart
Increased ICP
disease
Intracranial
Arrhythmias
hemorrhage
Airway
Cardiomyopathy
obstruction
Meningitis Munchausen
Gastroesophageal
Hypoglycemia
reflux
Pneumonia Hypocalcemia
Sepsis
Pulmonary Emergencies 183
PEDIATRICS
High maternal
parity
Higher Risk of
SIDS
Higher risk if
Prematurity sibling had SIDS
Higher risk if
infant had ALTE
Infant should sleep Higher risk for prone Upper airway Hypercarbia from
Sleeping position
on back or sides sleeping infants obstruction rebreathing expired air
Lower risk
Gastroenterology
Contents
Pediatric Gastroenterology 186
Constipation 187
Diarrhea 189
Esophageal Emergencies 199
Esophageal Perforation 204
Esophageal Foreign Bodies 207
GERD 210
Peptic Ulcer Disease 212
GI Bleeding 214
Liver and Gallbladder 219
Pancreatitis 229
Ileus 233
Bowel Obstruction 234
Intussusception 236
Volvulus 240
Hernias 242
Bowel Perforation 245
Acute Appendicitis 246
Acute Diverticulitis 248
Mesenteric Ischemia 251
Crohn’s Disease 253
Ulcerative Colitis 256
Irritable Bowel Syndrome 257
Miscellaneous Anorectal Emergencies 257
Pediatric Gastroenterology
PEDIATRICS
Forceful Regurgitation
Vomiting vs spitting up
Infections
Sepsis
Incarcerated
Gastroenteritis Increased ICP
hernia
UTI Shaken baby
syndrome
Inborn errors of
metabolism
Intussusception
Hypoglycemia
Metabolic
Etiologies of Acute acidosis
Constipation
Gut malrotation
Pyloric stenosis Bilious vomiting
Projectile vomiting 50 % Dx in 1st
at end of feeding month of life
Hepatic disease
Necrotizing Enterocolitis
Pneumatosis
Imaging Late finding
intestinalis
Abdominal Fluids
Treatment IV antibiotics
decompression (Pressors if needed)
Gastroenterology 187
Constipation
Introduction
Most common GI
Constipation
complaint in US
Increases with
Constipation
age
Rectal Examination
GI Causes
Tumors
Volvulus
Neurologic Obstruction Medications
Etiologies of Acute
Electrolyte Constipation
Hypomagnesemia
Hypercalcemia Endocrine
Hypokalemia Hypothyroidism
Common reason Hyperparathyroidism
for ileus mimicking
SBO DM
Amyloidosis Iron
Scleroderma Lead
188 B.R. Allen and B. Desai
GI Causes
Tumors
Dysmotility
Medications
Narcotics
Anal Pathology
Etiologies of Acute Anticholinergics
Hemorrhoids Constipation
Antipsychotics
Fissures
Antihistamines
Foreign bodies
Other
Lack of exercise
Lack of fiber
Lack of fluid intake
Diagnosis
Labs for
Depends on DDx
Constipation?
No specific labs!
If normal plain
film & high
suspicion
Treatment
Diarrhea
Introduction
Infectious Non-infectious
Diarrhea
85 % 15 %
Infectious Viruses
Bacterial Parasitic
diarrhea (Vast majority)
PEDIATRICS
2nd most
Viral causes Rotavirus Most common Adenovirus
common
Viral Diarrhea
Increased incidence
Winter & Spring Children Daycare
of viral diarrhea
Bacterial Diarrhea
Traveler’s
E. coli C. jejuni Shigella Salmonella
Diarrhea
Consider bacterial
Abdominal pain Fever Bloody stool
diarrhea
Consider bacterial
(+) stool WBC Bleeding
diarrhea
Also (+) stool Depending on
lactoferrin pathogen
Invasive E. coli
Bloody stools Shigella Campylobacter Yersinia
pathogens O157:H7
Enterohemorrhagic
E. coli O157:H7 Bloody stool WBC in stools
E. coli
Traveler’s Enterotoxogenic
Diarrhea E. coli
Treatment Ciprofloxacin
Reservoirs of Undercooked
Eggs Chicken Amphibians
Salmonella food
Complications of
Osteomyelitis
Salmonella
Sickle cell disease
Treatment Ciprofloxacin
192 B.R. Allen and B. Desai
Campylobacter
symptoms Fever Bloody diarrhea
Campylobacter
mimics IBD Appendicitis
Adults Children
Can mimic
Yersinia
appendicitis
May persist up
Yersinia
to 2 weeks
Ciprofloxacin or
Treatment OR Supportive
TMP-SMX
Complicated Uncomplicated
Salmonella
Reiter’s Shigella
Arthritis Conjunctivitis Urethritis
syndrome
Yersinia
Campylobacter
Gastroenterology 193
V.
Raw oysters Clams Shrimp
parahaemolyticus
V. 6–24 hour
parahaemolyticus incubation
WHO
Treatment Ciprofloxacin rehydration
Or TMP-SMX
Treatment No antibiotics!
194 B.R. Allen and B. Desai
Sx within 6–24
C. perfringens Large outbreaks hours
Spores survive
C. perfringens cooking process Toxins produced
C. perfringens
Watery diarrhea Vomiting Fever
symptoms
C. perfringens
No Fecal WBC’s No RBC’s
stool
Treatment Fluids
Anaerobic spore
B. cereus forming organism
Supportive due to
Treatment
self-limited nature
Gastroenterology 195
Treatment Antihistamines
1–4 week
Giardia incubation
Treatment Metronidazole
Fecal-oral
E. histolytica
contact
Treatment Metronidazole
Gastroenterology 197
1 week
Cryptospordium
incubation
Cryptospordium
Abdominal pain Watery diarrhea
symptoms
Antibiotic-Associated Diarrhea
Stop offending
Treatment
antibiotic
198 B.R. Allen and B. Desai
Pseudomembranous Antibiotic
Types Neonatal Post-operative
enterocolitis associated
Colonic
Complications Toxic megacolon
perforation
Severe disease
Stop offending
Treatment Metronidazole OR Vancomycin
antibiotic
Gastroenterology 199
Esophageal Emergencies
Dysphagia
Transfer Transport
Dysphagia OR dysphagia
dysphagia
Stroke
Other Mechanical
Functional dysphagia OR dysphagia
classifications
Progressive
Intermittent
Solids then
liquids
Usually made
Diagnosis outside of ED
Transfer Dysphagia
Symptoms
Signs
CNS Processes
CVA
Most common
cause in this Rheumatologic
Toxic & Poison Processes
category
Lead toxicity Parkinson’s Polymyositis 2nd most
common cause
Tetanus Dermatomyositis in this category
Botulism Scleroderma
Neuromuscular
causes of Transfer
Dysphagia
80 %
Endocrine
disorders
Thyroid Disease
Gastroenterology 201
Cancer
Tongue
Pharynx
Zenker’s
Diverticulum
Localized causes of
Halitosis Transfer Dysphagia
Acquired disease 20 %
Above upper
sphincter
Pts present with Sx Pharyngitis
of neck mass
Candidal
infection Cervical disease
Causes
odynophagia
Immunocompromised
202 B.R. Allen and B. Desai
Transport Dysphagia
Symptoms
Signs
Cancer
Large vessel
Strictures
abnormalities
GERD
Diverticula
Occur in distal
esophagus
Occur in middle or
Near GE junction
proximal esophagus
“Steakhouse Non-progressive
syndrome” dysphagia
Thyroid
enlargement
204 B.R. Allen and B. Desai
Nutcracker
esophagus
Common motility
disorder in pts with
noncardiac chest
pain
Achalasia
Esophageal spasm Most common
Motor causes of motility disorder
Sx = chest pain Transport Dysphagia causing dysphagia
May cause chest
pain, regurgitation,
15 % weight loss and
airway Sx
Other inflammatory
Scleroderma
processes
Esophageal Perforation
Mallory-Weiss
Hiatal hernia Alcohol
risk factors
Iatrogenic
Endoscopy
Boerhaave
Infection Risk higher in Syndrome
diseased esophagus
Rare Dilation increases Spontaneous
risk Increase in
Most at pharyngo- intraluminal
esophageal junction pressure
Zollinger-Ellison
Syndrome Gastric Sudden forceful
intubation emesis
Treatment of
varices 10–15 % of
Cancer perforations
Left distal esophagus
Causes of
Esophageal Full thickness tear
Aortic pathology Perforation
Aortic aneurysm
Trauma
Penetrating
Barrett’s 10 % of
Esophagus perforations
Alkaline
206 B.R. Allen and B. Desai
Symptoms
Abdominal
Chest pain Neck pain Back pain Dyspnea Dysphagia Hematemesis
pain
Mallory-Weiss
Non-toxic patient
Signs
Abdominal Subcutaneous
Cyanosis Hypotension Fever Tachycardia Tachypnea emphysema
rigidity
In cervical
perforations
Swallowing Mediastinal Hamman’s
Pleural effusion
exacerbates pain emphysema crunch
Takes time to Air in In thoracic
develop mediastinum perforations
Absence does moving with the
not rule out heart
perforation
Ultimate Dx of Gastrografin
CT scan OR
Esophageal perforation? Upper GI series
Center bottom image (Reprinted without modification from James Heilman https://commons.wikimedia.org/wiki/
File:CoinAP.jpg. With permission from the Creative Commons License https://creativecommons.org/licenses/by-sa/3.0/
deed.en)
Choking or
Chest pain Dysphagia Vomiting Coughing Dysphagia
gagging
Button battery lodged Emergent Broad spectrum Burns and perforation Lithium battery =
in esophagus? endoscopy antibiotics in 6 hours worse outcome
Double density
appearance on X-ray
Caustic Ingestions
Esophageal
Oral findings
findings
Caustic
Endoscopy
ingestion?
Caustic Gastric
ingestion? decontamination
Coagulation
Acid ingestion? Less damage
necrosis
Liquefaction
Alkali ingestion? More damage
necrosis
Dilution with
Solid alkali?
water or milk
Supportive
Treatment GI consultation
therapy
Early Perforation of
Edema of airway
complications esophagus
GERD
Transient relaxation of
Mechanism
lower esophageal sphincter
Risk factors Pregnancy Alcohol use Tobacco use High fat diet
Anticholinergics
Estrogens
Premalignant
condition
Predisposes to
adenocarcinoma
pain
GERD Treatment
Ultimate Dx of Gastrografin
CT scan OR
Esophageal perforation? Upper GI series
Esophagitis
Esophagitis
Odynophagia Chest pain
symptoms
Causes of Esophagitis
GERD
Aggressive
treatment with
acid-blocking Immunosuppression
agents
Medications Candida
Mycobacteria
212 B.R. Allen and B. Desai
Introduction
Ulcerations in Ulcerations in
PUD Due to OR
stomach proximal duodenum
Helicobacter
PUD Causes NSAID use
pylori infection
Inflammation of
Gastritis
gastric mucosa
Pathophysiology
Mucosa Mucosa
destructors protectors
Almost all PUD caused
by
Mucosa
HCl acid Pepsin H. Pylori
destructors
NSAID’s
Destroyed by
H. pylori
Gastritis
Chronic renal
Autoimmune failure
Pernicious
anemia
Renal
Transplantation
Causes of PUD
Medications
H. pylori
NSAID’s
Steroids
Have direct toxic
Cirrhosis
effect in gastritis
Zollinger-Ellison
Emotional stress
syndrome
Gastroenterology 213
Suspicion of Endoscopy is
PUD? gold standard
NO NSAID’s!
Fluids
Blood
PUD Complications
GI Bleeding
Terminology
Bleeding proximal to
UGI Bleed Hematemesis
Ligament of Treitz
Other causes of
black stool
Black coloration Bismuth
Melena UGI Bleed from digestion Beets
Sigmoid
Anus Will be
May be
accompanied hemodynamically
by unstable
hematemesis
Maroon colored
Right colon OR Transverse colon
stool
Gastroenterology 215
Bleeding proximal to
UGI Bleed More common Males Elderly
Ligament of Treitz
Aortoenteric
Other causes AVM Cancer
Fistula
Preexisting
aortic graft
“Herald” bleed
then massive
bleed
Palmar erythema
Ascites
Abdominal Change in
Weight loss Hepatosplenomegaly
pain bowel habits
Malignancy
216 B.R. Allen and B. Desai
Stabilize Replacement of
Massive Volume Emergent Blood
ABC’s as Medications coagulation
UGIB? Replacement endoscopy indications
needed factors as needed
Protect airway Crystalloids Continued
active bleed
2 large bore IV
Shock states
No change
after several
boluses of
fluid
Disposition
Image just left of center (Reprinted from Allen B, Ganti L, Desai B. GI bleeding/hemorrhage. In: Allen B, Ganti L, Desai
B, editors. Quick hits in emergency medicine. New York: Springer Science; 2013. p. 83–5. With permission from Springer
Science + Business Media)
Systolic BP (+) Bloody NG Low Hematocrit
Significant UGIB? Hx of liver failure
< 100 mm Hg lavage (<30)
Admit OR (+)
hematemesis
Low risk =
Score of 0
Glasgow-Blatchford
Bleeding Score Any score higher than 0 is "high risk" & may need a medical
intervention of transfusion, endoscopy, or surgery
Gastroenterology 217
Bleeding distal to
LGI Bleed
Ligament of Treitz
Most common
UGIB
cause of LGIB
Multiple bouts of
hematochezia
High Morbidity in
LGIB
Multiple
Syncope
comorbid factors
Use of
anticoagulants
UGI Bleed
Most common
overall
Cancer
Mesenteric Inflammatory
ischemia bowel disease
Hemorrhoids
Most common Trauma
source of anorectal
bleeding
Ulcers Foreign body
Aortoenteric
Endometriosis
fistula
Inflammatory
Angiodysplasia
bowel disease
Disposition
LOW RISK
Healthy patient
Introduction: Liver
Injury to Hepatocyte
Hepatitis Leads to Scarring in liver
hepatocytes death
Especially in
chronic disease
Bilirubin Evaluation
Prehepatic
Unconjugated Hepatic causes
causes
Posthepatic
Conjugated causes
Hemolysis
Drug-induced
Mass/Tumor Conjugated
hepatitis
Stone Cirrhosis
Obstruction of
Sepsis
biliary ducts
Gastroenterology 221
Neonatal Jaundice
PEDIATRICS
Breast feeding Bilirubin inhibitors Peaks at 10–27 Cessation of breast feeding causes a
related jaundice
(5–10% of cases) present in breast milk mg/dL by days 10–21 decrease in levels, but not recommended
Unlikely to cause kernicterus
UV light
Treatment
treatment
UV light Levels
2–3 days old
treatment ³18 mg/dL
Levels
> 3 days old
³20 mg/dL
Direct
Admission
hyperbilirubinemia?
Palmar erythema
Ascites
Hepatosplenomegaly
Tea-colored Dupuytren’s
Pruritis White Stools Presyncope Muscle atrophy
urine contracture
Acholic
Chronic
222 B.R. Allen and B. Desai
Acute Hepatitis
Encephalopathy
Severe Immunocompromised
electrolyte
abnormalities
Concomitant
significant renal
Sepsis
impairment
Hepatitis A
Incubation of
Hepatitis A
15–50 days
Hepatitis A
Prophylaxis
vaccine
Hepatitis B
Hepatitis C
Usually
Hepatitis C aymptomatic
acutely
Higher incidence
Hepatitis C in pts with HIV
No vaccine
Hepatitis C available
Hepatitis D
Most commonly
Requires Hepatitis B surface
Hepatitis D from injection drug
antigen for co-infection
use
Hepatitis E and G
Toxic Hepatitis
Multiple other
Toxic Hepatitis Acetaminophen prescription Mushrooms Alcohol
medications
Most common Amanita
Acetaminophen
N-acetylcysteine
overdose?
Severe hepatic
Carbon
necrosis with Consider Acetaminophen OR Mushrooms OR
tetrachloride
AST/ALT > 1000?
Hepatic Encephalopathy
Hepatic
Dehydration or Electrolyte
encephalopathy Sedatives Infection GI bleeding
volume loss imbalances
precipitants
Sleep during
Early sign Sleep inversion day, not night
“Liver flap”
Pitfall? Hypoglycemia
Treat Decreased
Treatment precipitants Lactulose Neomycin dietary protein
226 B.R. Allen and B. Desai
Enterococcus
E. coli
Abdominal Increased
Encephalopathy Fever Hypotension Sepsis
pain ascites
May be shock
May be absent
state
Introduction: Gallbladder
Due to gallstone
Biliary colic RUQ pain Vomiting But… No inflammation
obstruction
E. coli
Stones in common Klebsiella
Choledocholithiasis
bile duct
Calcification
Biliary–duodenal fistula
RUQ pain
Ascending
Ascending Bile duct
infection through Charcot’s triad Fever
cholangitis obstruction
biliary tree
Jaundice
Gastroenterology 227
Acalculous Cholecystitis
Acalculous Beware
cholecystitis perforation!
Ascending Cholangitis
RUQ pain
Ascending
Ascending Bile duct
infection through Charcot’s triad Fever
cholangitis obstruction
biliary tree
Jaundice
Pathophysiology
Pure (20%)
Types of Cholesterol stones Pigmented stones
gallstones (70%) (30%)
Mixed (10%)
Radiolucent Radiopaque
Obesity
Pts on TPN
From reflux
of intestinal Inflammatory
contents into mediators
the biliary
tree
Most
commonly
Gram (-)
Can be
mixed
228 B.R. Allen and B. Desai
Diagnosis
No specific labs!
Increased
Sonographic signs Sonographic Pericholecystic
thickness of GB
of cholecystitis Murphy’s sign fluid
wall
Presence of Most cholecystitis Specific for
tenderness over has wall thickness > cholecystitis
the GB 5 mm
Positive if GB is Obstruction of
Negative U/S? HIDA Scan not seen cystic duct
Identifies biliary
dyskinesia
Stones in bile
ducts? ERCP
Potential for
Gallstone ileus? CT or US
Gastroenterology 229
Treatment
Asymptomatic No specific
Refer to surgeon
gallstones treatment
Symptomatic
Biliary colic?
treatment
Surgical or
Ascending Broad spectrum
Admission Endoscopic GB
cholangitis? antibiotics
decompression
Pancreatitis
Gallstones
Most common
Infection Alcohol
Bacterial Acute
Viral Chronic
Drugs and
Autoimmune
Medications
disease
Pancreatitis
Posterior penetrating
Cancer peptic ulcer
Inflammation of
the pancreas Hypertriglyceridemia
Iatrogenic May involve other
surrounding areas
ERCP Hyperparathyroidism
Post-op
Ischemia
Toxins
Organophosphate Trauma
poisoning
Scorpion venom Penetrating
Hypercalcemia
Complications of Pancreatitis
Pancreatic
necrosis
Cardiovascular
effects Abscess
Hypotension
Pseudocyst
Pericardial effusion
+ Hemorrhage
Pulmonary
effects Ascites
Hypoxemia
PUD Hyperglycemia
GI perforation
Hypocalcemia
GI Bleed
Hypertriglyceridemia
Bowel obstruction
Biliary obstruction
Gastroenterology 231
Ecchymosis in
Cullen’s Sign
Umbilical area
Severe necrotizing
Late findings Hemorrhage
pancreatitis
Grey-Turner’s Ecchymosis in
Sign flank area Intraabdominal
Retroperitoneal
Diagnosis
Labs for suspicion
Liver function Electrolyes +
of Pancreatic CBC Lipase
tests BUN/Cr
disease?
3x upper limit
Imaging Pleural or
Sentinel Generalized
considerations for Plain films Identify Free air OR OR OR pericardial
loop ileus
pancreatitis? effusions
Age > 55
Decrease in
hematocrit > 10%
Ranson’s Criteria at
48 hours
Rapid fluid
Calcium < 8 mg/dL
sequestration > 6L
PaO2 < 60 mm Hg
Treatment
Monitor
Acute Fluid Correction of Pain & nausea
hemodynamic and
Pancreatitis? resuscitation electrolytes control
volume status
Abscess or
CT guided
potentially infected Antibiotics
drainage
pseudocyst?
Retained common
ERCP
bile duct stone?
Gastroenterology 233
Ileus
Cessation of
Ileus NO obstruction
normal peristalsis
Medications
Electrolyte
abnormalities
Usually self-
Treatment? NPO Supportive care
limited
234 B.R. Allen and B. Desai
Bowel Obstruction
Cancer
Adhesions
Most common
Most common
Pseudo-
Ulcerative colitis
Small Bowel Obstruction
Strictures Hernias Large Bowel
Obstruction
Obstruction
Intussusception Fecal impaction
Cancer Intussusception
Abscess
Incarcerated
inguinal hernia
Duplication cyst of
intestine
Gastroenterology 235
Continued
accumulation of
Development of secretions from Bowel becomes
obstruction stomach, pancreas congested
and liver
Increase in
Bowel becomes
Distention of bowel intraluminal
ischemic
pressure
Septicemia + Bowel
necrosis
High Mortality
Diagnosis
Center bottom image (Reprinted from Pelaez CA, Agarwal N. The surgical abdomen. In: Pitchumoni CS, Dharmarajan
TS, editors. Geriatric gastroenterology. New York: Springer Science; 2012. 607–13. With permission from Springer Science
+ Business Media)
236 B.R. Allen and B. Desai
Traverse the
SBO X-ray Step Ladder or Plicae circulares
entire width of the
Appearance? “String of pearls” are seen
bowel
CT is diagnostic
DO NOT traverse
LBO X-ray
Distended colon Haustra are seen the entire width
Appearance?
of the bowel
“Coffee Bean”
Closed loop bowel Competent High risk of
appearance on
obstruction ileocecal valve perforation
plain film?
Diagnostic
method of choice? CT scan
SBO
Treatment
Monitor
Bowel Fluid Correction of Pain & nausea
hemodynamic and
obstruction? resuscitation electrolytes control
volume status
Consider NG
tube placement
Prophylactic
True mechanical
Surgery broad spectrum
obstruction?
antibiotics
Intussusception
(a) Top right image (Reprinted from Yoo S-Y. Non-neonatal gastrointestinal diseases. In: Kim I-O, editor. Radiology
illustrated: pediatric radiology. Heidelberg: Springer Verlag; 2014. p. 629–63. With permission from Springer Verlag).
(b) Bottom right image (Reprinted from Gilger MA, Nazer HM. Gastrointestinal bleeding. In: Elzouki AY, Harfi HA, Nazer
HM, Stapleton FB, Oh W, Whitley RJ, editors. Textbook of clinical pediatrics. Heidelberg: Springer Verlag; 2012. p. 1937–
49. With permission from Springer Verlag)
Gastroenterology 237
Uncommon > 3
Intussusception Rare < 3 months
years
Abdominal
N/V Heme(+)stools
pain
Diagnosis
No specific labs!
Imaging
Plain films Ultrasound Barium Enema
modalities?
Treatment
No relief with
Surgery
enema?
Pyloric Stenosis
Image just right of center (Reprinted from Yoo S-Y. Non-neonatal gastrointestinal diseases. In: Kim I-O, editors. Radiology
illustrated: pediatric radiology. Heidelberg: Springer Verlag; 2014. p. 629–63 (With permission from Springer Verlag)
PEDIATRICS
“Olive-shaped” mass in
Pyloric stenosis
right upper quadrant
Abdominal
N/V Dehydration Heme(+) stools
pain
Non-bilious Intermittent Currant jelly
Classic
stool is late
hypochloremic
Child appears well finding
metabolic
between
alkalosis
paroxysms of pain
Gastroenterology 239
Diagnosis
Imaging for
Ultrasound OR Upper GI Series
Pyloric Stenosis?
Appearance on
“String sign”
Upper GI series?
Treatment
Monitor
Fluid Correction of Pain & nausea
Pyloric stenosis? hemodynamic and
resuscitation electrolytes control
volume status
Hirschsprung’s Disease
PEDIATRICS
Hirschsprung’s
Complication Enterocolitis Potentially fatal
Disease
240 B.R. Allen and B. Desai
Volvulus
Introduction
Bottom left image (Reprinted from Pelaez CA, Agarwal N. The surgical abdomen. In: Pitchumoni CS, Dharmarajan TS,
editors. Geriatric gastroenterology. New York: Springer Science; 2012. p. 607–13. With permission from Springer Science
+ Business Media)
Bottom right image (Reprinted from Hellinger MD, Steinhagen RM. Colonic volvulus. In: Wolff BG, Fleshman JW, Beck
DE, Pemberton JH, Wexner SD, Church JM, Garcia-Aguilar J, Roberts PL, Saclarides TJ, Stamos MJ, editors. The ASCRS
textbook of colon and rectal surgery. New York: Springer Science; 2007. p. 286–98. With permission from Springer Science
+ Business Media)
Chronic motility
disorders Most common
cause of bowel
obstruction in
Rx pregnancy
Sigmoidoscopy
decompression
Rx
Surgery
Inverted “U” or “Bent Inner Tube”
Loops project to RUQ
Kidney shape loop in LUQ
Loops project to LUQ
Gastroenterology 241
PEDIATRICS
Bilious Rigid
Sudden onset
Diagnosis
No specific labs!
Air-fluid levels in
Appearance on “Double bubble
stomach & in
Imaging? sign”
distended duodenum
242 B.R. Allen and B. Desai
Treatment
Monitor
Malrotation with Correction of Pain & nausea
hemodynamic and Fluid resuscitation
Volvulus? electrolytes control
volume status
Consider NG
tube placement
Prophylactic
Malrotation with broad spectrum
Surgery
Volvulus? antibiotics
Prophylactic
Surgical
Other Volvulus? broad spectrum
consultation
antibiotics
Hernias
Introduction
Inguinal Hernias
Most common
Inguinal Hernia type of hernia for 2/3 are Indirect
males & females
Common in boys
Common in older
men
Direct and
Pantaloon
Indirect at the
Hernia
same time
Gastroenterology 243
Ventral Hernias
Epigastric
Incisional
Older age
Obesity
Ascites
Adult form is Increased tension Strangulation is
Umbilical Hernia usually acquired Due to on the abdominal Obesity
uncommon
wall
Pregnancy
Other Hernias
Hernia protrudes More likely to have
Mass below the More common in
Femoral Hernia through femoral incarceration &
inguinal ring women
canal strangulation
Increased tension
Lateral ventral Have high rates of
Spigelian Hernia Acquired Due to on the abdominal
hernia incarceration
wall
Diagnosis
Can identify
“Best” imaging
CT scan uncommon hernia
for hernias?
types
Treatment
Toxicity
Systemic signs Potential for
Tender hernia Obstruction Antibiotics Surgery
or symptoms Strangulation
Peritonitis Do not attempt ED
reduction!
Incarcerated hernia
(NO Attempt reduction
strangulation)? in ED
Gastroenterology 245
Bowel Perforation
Introduction
Most common
Cecum
site
Most common
Ulcers cause of
perforation
Inflammation
Appendicitis
Diverticulitis
Colitis
Obstruction Ulceration
Ischemia Trauma
Abdominal Septic
N/V Fever
pain appearance
246 B.R. Allen and B. Desai
Diagnosis
No specific labs!
Diagnostic
CT scan
method of choice?
Treatment
Monitor
Bowel Fluid
hemodynamic and Antibiotics Surgery
perforation? resuscitation
volume status
Prophylactic
True bowel
Surgery broad spectrum
perforation?
antibiotics
Acute Appendicitis
Introduction
Obstruction by fecalith of
Appendicitis
the vermiform appendix
Other causes of
Parasites OR Tumor OR Lymphatic tissue OR Gallstones
Appendicitis
Appendicitis Confounders
Pregnancy
Displacement by
gravid uterus
RUQ tenderness
Most common is
still RLQ
Malrotation of Retrocecal
colon appendix
LUQ tenderness Right flank or
Appendicitis
pelvic pain
Confounders
Suprapubic pain
Testicular pain
Sudden
improvement in Consider perforation
pain?
Palpation of LLQ
Rovsing’s sign
worsens RLQ pain
Diagnosis
Imaging for
Ultrasound OR CT
Appendicitis?
Treatment
Monitor
Fluid Pain & nausea
Appendicitis? hemodynamic and
resuscitation control
volume status
Prophylactic
Appendicitis? broad spectrum Surgery
antibiotics
Acute Diverticulitis
Introduction: Diverticulitis
Outpouchings through the colonic Increased
Weakening of
Diverticula wall near where vasa recta Due to intraluminal
colonic wall
penetrate bowel wall pressure
Involve only mucosal & submucosal Sigmoid = highest
layers pressures
Sigmoid
Western diet
High fat
Low fiber
High carb
Potential links
Alcohol
Caffeine
Ingestion of nuts &
seeds
Smoking
Abdominal Alterations in
pain Anorexia bowel function N/V Fever Urinary Sx
May be
suprapubic
Colicky or
constant
250 B.R. Allen and B. Desai
Diagnosis
Imaging for CT
OR Ultrasound
Diverticulitis? (Preferred)
Fluid
collections
Treatment
Uncomplicated
Oral antibiotics High fiber diet Discharge
Diverticulitis?
-Non-toxic
-Pain controlled
-Healthy
Broad spectrum
-Toxic appearing
including
-Vomiting
anaerobic
-Comorbidities
coverage
Mesenteric Ischemia
Introduction
Mesenteric
Arterial OR Venous OR Nonocclusive
ischemia
SMA thrombosis
Continued
Nonocclusive
decrease in e.g., Shock states
(20%)
cardiac output
Hypercoagulable
states
Dysrhythmias
A. fib
Venous
Use of
vasoconstrictors
Most common
Nonocclusive
Prolonged
CHF
hypotension
Shock states
252 B.R. Allen and B. Desai
Abdominal
Anorexia Diarrhea N/V Fever Tachycardia
pain
“Out of May be grossly
Food fear
proportion” bloody
Abdominal
Sudden = Peritoneal signs
distention
embolic
Insidious =
thrombotic or
Late findings
nonocclusive
Diagnosis
Labs for suspicion
Electrolytes +
of Mesenteric CBC Lactate ABG
BUN/Cr
ischemia?
Usually elevated May show
Elevated Acidosis
WBC hyperphosphatemia
Mesenteric
Plain films CT
ischemia
Treatment
Monitor
Mesenteric Fluid Prophylactic Early surgical
hemodynamic and
ischemia? resuscitation antibiotics consultation
volume status
Gastroenterology 253
Crohn’s Disease
Introduction
Chronic
Involves any part Ileum usually Segmental
Crohn’s Disease granulomatous
of GI tract involved involvement
inflammatory disease
Involves all layers of From mouth to “Skip lesions”
the bowel wall anus
Crohn’s Disease
Remission Exacerbation
pattern
Perianal Toxic
Abscesses Fistulas Rectal prolapse Hematochezia
fissures megacolon
Colonic
involvement
254 B.R. Allen and B. Desai
Extraintestinal Manifestations
Arthritic
Sacroiliitis
Hyperoxaluria Episcleritis
Malnutrition
Hematologic
Extraintestinal
Chronic anemia Manifestations Vascular
Seen in 50 % Vasculitis
Hypercoagulable
state
Skin
DVT
Erythema
Venous
nodosum
thromboembolism
Pyoderma
gangrenosum Arteritis
Hepatobiliary
Cholelithiasis
Hepatitis
Pancreatitis
Cholangiocarcinoma
Pericholangitis
Primary sclerosing
cholangitis
Diagnosis
If needed
Visualization of
Appearance on Mesenteric Thickened bowel
Local abscesses extra-intestinal
CT? edema wall
manifestations
Gastroenterology 255
Treatment
Prevention of Nutritional
Crohn’s disease? Symptom relief
complications maintenance
Mild to moderate
Crohn’s disease? Sulfasalazine
Acute
exacerbation of Glucocorticoids
Crohn’s disease?
Ciprofloxacin
Perianal
complications & Metronidazole
Fistulas
Ulcerative Colitis
Introduction
Mucosal Epithelial
Ulcerative Colitis Lead to Ulcerations Crypt abscesses
inflammation necrosis
Ulcerative Colitis
Remission Exacerbation
pattern
Same extraintestinal
Similar GI Sx as Similar laboratory
Ulcerative Colitis manifestations as
Crohn’s evaluation as Crohn’s
Crohn’s
30 fold increased
Ulcerative Colitis
risk of carcinoma
Toxic Megacolon
Disease process
Ulcerative Colitis Loss of muscular Dilated transverse
Toxic megacolon through all layers
complication of colon tone in colon colon > 6 cm
Continued Risk of
dilation perforation
Laboratory Electrolyte
Leukocytosis Anemia Hypoalbuminemia
evaluation abnormalities
Irritable bowel
Abdominal pain Bloating Constipation OR Diarrhea
syndrome
Usually concomitant
Irritable bowel
psychiatric
syndrome
conditions
Depending on
complaints
Hemorrhoids
Engorgement, prolapse,
Hemorrhoids or thrombosis of
hemorrhoidal veins
Tender to
External Distal to the Seen on external
palpation if
hemorrhoids dentate line examination
thrombosed
Thrombosed
Clot excision
hemorrhoid?
Constipation
Straining with
defecation
Ascites Tumors
Anal Fissures
Superficial linear tear Most common
Usually midline
Anal Fissures of the anal canal below cause of painful
& posterior
the dentate line rectal bleeding
Children &
Adults
Until proven
TB
otherwise
Syphilis, GC,
Chlamydia
Non-healing Surgical
fissure? consultation
Gastroenterology 259
Anorectal Abscesses
Associated with
Can be treated Surgery
Perianal abscess Unless deeper periectal
in ED
abscesses
Rectal Prolapse
Hemorrhoidal
mucosal folds
radiate out like
wheel spokes
Treatment Reduction
Bobby Desai
Contents
Acute Renal Failure 262
Rhabdomyolysis 274
Chronic Renal Failure 277
Hemodialysis 283
Urinary Tract Infections 288
Hematuria 292
Kidney Stones 293
Renal Transplant 295
Male Genital Emergencies 295
Sexually Transmitted Diseases 301
Introduction
Decrease in renal
Acute Renal
function over Due to Prerenal causes OR Renal causes OR Postrenal causes
Failure
hours to days
Decrease in
Prerenal causes perfusion of
normal kidney
Intrinsic renal
Renal causes pathology
Obstruction to
Postrenal causes urinary tract
Sx of underlying
Confusion N/V Fatigue Lethargy Weakness
process
RIFLE Criteria
Risk
GFR decrease by
25 % OR
ESRD
Urine output Injury
Complete loss of
<0.5 mL/kg/hr x
kidney function
6 hr 2 fold increase in
for more than 3
creatinine OR
months
GFR decrease by
50 % OR
RIFLE Criteria
Loss
Urine output
<0.5 mL/kg/hr x
Complete loss of 12 hr
kidney function
for more than 4
weeks
Failure
3 fold increase in
creatinine OR
GFR decrease by
75 % OR
Urine output
<0.5 mL/kg/hr x
24 hr OR
Anuria x 12 hr
PEDIATRICS
Glomerulonephritis
Common Causes of
Postoperative Hemolytic
Acute Renal Failure
complications Uremic Syndrome
in Children
Sepsis
264 B. Desai
Prerenal Failure
Decrease in Renal artery or
Prerenal Acute
perfusion of Due to Hypovolemia OR Cardiogenic shock OR small vessel
Renal Failure
normal kidney disease
Related to
Symptoms
underlying cause
Hypovolemia
GI loss
3rd spacing
Hypoaldosteronism
Medications Hypotension
Medications
Renal artery
disease
Electrolyte Embolism from any
cause
Hypercalcemia Thrombosis from
any cause
Dissection
Nephrology and Urology 265
Related to
Symptoms
underlying cause
Interstitial
Treat underlying
Treatment disease
cause
Antibiotics
NSAIDs
Antifungals
Small vessel + Other non- Glomerular
disease medication causes disease
HSP
Glomerulonephritis
Tumor lysis
syndrome General Causes of Nephrotic syndrome
Intrinsic Renal
Failure
Hemoglobinuria Myoglobinuria
Tubular disease
ATN
Contrast
Chemotherapy
266 B. Desai
Infiltrative
processes
Lymphoma
Sarcoid
Acute interstitial
nephritis Urine
Immune mediated Pyuria Treatment
Features Treat underlying
Usually from a drug
Rash process
reaction
Fever WBC Casts
Most commonly
Eosinophilia
NSAIDs & Antibiotics Antibiotics for
(PCN, Sulfa) Eosinophils in infection
May be infectious urine
as well
Nephrology and Urology 267
Malignant
hypertension
Goodpasture
Lupus
syndrome
Infection
Usually NOT
Toxin derived
oliguric
Radiocontrast
agents
Aminoglycosides
Rhabdomyolysis
Hemolysis
Multiple myeloma
Ethylene glycol
Nephrology and Urology 269
Age >70
Risk reduction
Scleroderma
Vascular or Related
Disease
Malignant Transplant-related
hypertension thrombosis
270 B. Desai
Causes of Microthrombosis
Hemolytic-uremic
syndrome
Postrenal Failure
Obstruction of
Postrenal Failure
outflow tract
Treat underlying
Treatment
cause
Nephrology and Urology 271
Phimosis
Neurogenic bladder
Meatal stenosis
Urethral calculus
Prostatic
hypertrophy Most common
Anatomic
Retroperitoneal Causes of Postrenal
malformation of
tumor or clot Failure
ureter
Vesicoureteral
reflux
Bilateral ureteral
Papillary necrosis GU Tract trauma
stones
Diabetes mellitus
Sickle cell
Pyelonephritis
272 B. Desai
Fractional
Prerenal Failure BUN/Cr Urine Na
excretion of Na
Urinalysis Mandatory
Nephrotic Proteinuria
syndrome alone
Probable
WBC Bacteria
infection
Macroscopic Urine
Renal /
Microscopic Nephritic Renal
Gross Hematuria OR Ureteral OR Tumor OR
Hematuria syndrome Trauma
calculus
Urinalysis
Granular casts
Bowman’s
Proximal
capsule
Red cell casts convoluted Tubules
tubule
Nephritic syndrome
Descending
White cell casts
Limb of Distal
Loop of convoluted
Interstitium Henle tubule
Collection duct
Acute interstitial nephritis
Ascending
Pyelonephritis Limb of Loop
Loop of Henle of Henle
Eosinophiluria
Interstitium
Acute interstitial
nephritis
Center image (Adapted from Kidney Nephron: https://commons.wikimedia.org/wiki/File:Kidney_Nephron.png. Artwork by Holly Fischer with
permission from Creative Commons License: https://creativecommons.org/licenses/by/3.0/deed.en)
Glomerulus
Nephritic syndrome
Interstitium Tubules
Acute interstitial nephritis Acute tubular necrosis
Pyelonephritis
Eosinophiluria
Interstitium
Acute interstitial
nephritis
274 B. Desai
Rhabdomyolysis
Introduction
Caused by acute Leakage of muscle
Rhabdomyolysis necrosis of skeletal contents into
muscle circulation
Creatine
Muscle contents Myoglobin LDH Potassium
kinase
Causes of Rhabdomyolysis
Alcohol
Electrolyte
abnormalities
present in
Neuroleptic alcoholics Prolonged
malignant syndrome contributes to immobility
rhabdomyolysis
Tumor lysis
Intrinsic muscle syndrome
diseases
Diagnosis of Rhabdomyolysis
Failure of CK to
Ongoing muscle
decrease over
necrosis
time
Acute rise in
Other marker
creatinine
RBC on
Urine (+) dip for heme
microscopy
Serum
Other labs electrolytes Calcium Phosphorus Uric acid Baseline CBC
with BUN/Cr
Complications of Rhabdomyolysis
Oliguric
Most common
Early Metabolic
Complications
Hyperkalemia
Hyperphosphatemia
Hyperuricemia
Hypocalcemia Musculoskeletal
complications
Complications of Compartment
Rhabdomyolysis syndrome
Late Metabolic
Complications Neuropathy
Hypophosphatemia
Hypercalcemia
DIC
Usually
spontaneously
resolves
Treatment of Rhabdomyolysis
Treatment of Treatment of
Urine output
Rhabdomyolysis IV hydration electrolyte
2 cc/kg/hr
derangements
No significant benefit
Mannitol OR Bicarbonate over aggressive
hydration alone
Hypocalcemia? No treatment
Oral phosphate
Hyperphosphatemia? binders if >
7 mg/dL
Treat if <1
Hypophosphatemia?
mg/dL
Nephrology and Urology 277
PEDIATRICS
Build up of toxins
End Stage Renal Irreversible loss of 10 % of normal for
GFR & loss of
Disease (ESRD) renal function age
homeostasis
Accumulation of
Clinical syndrome Fatal without
Uremia Azotemia nitrogen in the
of ESRD therapy
blood
Clinical
syndrome
4 stages of
Chronic Renal Stage 1 Stage 2 Stage 3 Stage 4
Failure
GFR 50–75% of GFR 25–50 % of GFR 10–25 % of GFR <10 % of
normal for age normal for age normal for age normal for age
Elevated urine Chronic renal
failure ESRD
protein
Elevated
Anemia
BUN/Cr
Acidosis
Rickets in
children
Most common
Congenital renal Reflux
cause of CRF in Older children Glomerulonephritis
disease nephropathy
younger children
278 B. Desai
Nephrotic Syndrome
PEDIATRICS
Permeability
Nephrotic Chronic disease Loss of protein in
changes in
syndrome in children urine
glomerular wall
Nephrotic
Proteinuria Edema Hypoalbuminemia Hyperlipidemia
syndrome
Thromboembolic
Complications Infection
events
PEDIATRICS
Minimal change
disease
Primary
Proliferative Membranous
nephritis nephropathy
DM
Gold
HSP
Mercury
Secondary
Sickle cell disease Cancer
HIV Lupus
Syphilis
PEDIATRICS
Sequelae of potassium
ED visits Urinary Tract
Failure to thrive derangements (High & Rickets
prompted by Stones
Low)
Depends on
Treatment underlying
condition
280 B. Desai
Renal failure on
Flank pain Hematuria
lab evaluation
Most commonly
Consider uremic AV fistula high
CHF due to Fluid overload
cardiomyopathy output failure
hypertension
Similar treatment
Pulmonary
to non-dialysis Nitrates Diuretics ACE Inhibitors
edema
patients
Pulmonary
vasodilation
Typical EKG
Usually due to Loud pericardial
Pericarditis changes may be
uremia friction rubs
absent
Fails to respond
Dialysis Nonspecific CNS
Progressive with dialysis or Ultimately fatal
dementia Sx
transplant
Frequent Autonomic
Peripheral
manifestation of Lower > Upper dysfunction may
neuropathy
ESRD occur
Impaired
Paresthesias Decreased DTR Weakness
vibration sense
Anemia caused Dialysis blood Decreased red cell Decreased Usually normocytic,
by loss survival time erythropoietin normochromic
Anorexia
Gastrointestinal
Complications of
Uremia
Chronic
Gastritis
constipation
Dialysis related
UGI Bleeding
ascites
Idiopathic Higher mortality
Hyperkalemia
Hypermagnesemia Hypokalemia
In dialysed patients
Electrolyte
Complications of
ESRD
Hypomagnesemia Hypocalcemia
Hyperphosphatemia
Nephrology and Urology 283
Hemodialysis
Refractive
Hyperkalemia &
Hypercalcemia
Metabolic Refractive
acidosis volume overload
Indications for
Emergency Dialysis
Severe sodium
Imbalance Toxic overdose
Symptomatic
Uremia
Pericarditis
Bleeding
Encephalopathy
Severe acidosis
Hyperkalemia BUN >100
or alkalosis
284 B. Desai
Complications of Hemodialysis
Infectious
Dialysis site
infection
Bacteremia
High output CHF Thrombosis
Hemorrhage
Vascular Vascular
insufficiency aneurysms
“Steal From repeated
syndrome” punctures
Cool, pulseless
digits
Rx with
Gram negative
Organisms Staph aureus Vancomycin ±
organisms
Gentamicin
Most common
Multiple
Hypotension complication of
differentials
hemodialysis
Rx with
Hypotension Hypovolemia that Gram negative
Vancomycin ±
early in dialysis is preexisting organisms
Gentamicin
Volume depletion
before HD
Nausea &
Tachycardia Dizziness Syncope Anxiety
Vomiting
286 B. Desai
Dialysis Disequilibrium
Dialysis
N/V Hypertension Leads to Seizure Coma Death
Dysequilibrium
Especially SDH
Increase serum
osmolality
Hypotension
Dialysis
Hypoglycemia
dysequilibrium
Intracranial
Hypercalcemia
hemorrhage
“Psychic moans” SDH
Peritoneal Dialysis
Peritonitis cell
> 100 WBC/mm3
count
>50% neutrophils
Antibiotics in
Treatment
dialysate
288 B. Desai
UTI
Kidney
Significant Described by Bladder
UTI Symptoms
bacteriuria location
Urethra
Most risk of
Older men Neonates Girls Young women
infection
STD
Males <50 With Dysuria OR Frequency (until proven
otherwise) Consider
prostatitis
Males >50 With Dysuria OR Frequency UTI
More likely to
Abnormal GU Essentially have resistant
Complicated UTI Comorbities everyone else
tract organisms
Pseudomonas
Staphylococcus Proteus
Pathogens
Enterobacter
Perinephric Emphysematous
UTI Complications
abscess pyelonephritis
From contiguous Especially in
spread diabetics
290 B. Desai
Pain in
Dysuria Frequency Hematuria CVA tenderness Hesitancy Fever
suprapubic area
Urethritis in a Urethral
Dysuria
male discharge
Gonococcal Gram-(-)
intracellular
urethritis diplococci
UTI Diagnosis
Enterococcus
Nitrite >90% specificity Coliform bacteria Nitrite (-) Pseudomonas
Acinetobacter
Unnecessary in
Imaging
uncomplicated infections
Hematuria
Infections
Any age
Any location in
GU tract
Glomerulonephritis Nephrolithiasis
<20 years > 20 years
Hematuria
IgA nephropathy Sickle cell anemia
Microscopic
hematuria = >5
Schistosomiasis WBC/HPF Medication
related
Most common >20 years
cause worldwide
Prostatic
hypertrophy Cancer
On start of
Urethra OR Bladder
urination
May have clot
formation
End of urination Prostate
Kidney Stones
Diseases that
Causes of calcium Inflammatory Small bowel
increase calcium Hyperparathyroidism
oxalate stones Bowel disease resection
excretion
Urea-splitting
Struvite stones Chronic infection organisms Proteus Pseudomonas
25 % of patients
Radiolucent
Uric acid stones with gout will Low urinary pH
stones
develop stones
Medications Carbonic
Indinivir Prolonged abuse
predisposing to anhydrase
stone formation (Radiolucent) of laxatives
inhibitors
Ureterovesicular
Common sites of Ureteropelvic
Renal calyx Pelvic brim junction
impaction junction
(most common)
Spontaneous Depends on
Amount of urinary
Size Shape Location
stone passage obstruction
<5 mm = 98 % pass rate
294 B. Desai
Absent in 10-
Hematuria?
20 %
Confirmatory Noncontrast
94–97 % sensitive 96–99 % specific
imaging helical CT
98 % sensitive for
Confirmatory Ultrasound (if CT detecting 64–90 % sensitive 94–100 % specific
imaging contraindicated) hydronephrosis
Except in Opioids as
Treatment Pain control NSAID’s
congenital stones needed
Urologic
Infected stones? Antibiotics Admission
consultation
Stone Admission
Criteria
Intractable
vomiting Intractable pain
Solitary kidney
with severe
obstruction
Nephrology and Urology 295
Renal Transplant
Most common
Renal Transplant solid organ Location = pelvis
transplant
Antirejection
Cyclosporine Is nephrotoxic
meds
Scrotal Disorders
Usually from
Antibiotics for
Scrotal abscess infected hair Simple I&D
complicated cases
follicle
Risk of
Diabetics Alcohol abusers IV Drug Users
Fournier’s
Immunocompromised
Center right image (Reprinted from Wessells H, Sorensen MD. Fournier’s gangrene. In: Wessells H, editor. Urological emergencies: a practical
approach. New York: Humana Press; 2013. p. 141–50. With permission from Springer Science + Business Media)
296 B. Desai
Balanoposthitis is
Inflammation of Inflammation of
Balanitis Posthitis inflammation of
glans penis foreskin both
Antifungal creams
Treatment Proper cleansing
or oral
Inability to Urinary
Phimosis Complication Treatment Circumcision
retract foreskin retention
PEDIATRICS
Rupture of tunica
Direct trauma to
Penis fracture albuginea of
erect penis
corpus cavernosa
Urological
Treatment
evaluation
Priapism
Sickle cell
In children
disease
Consider
Sickle cell disease? exchange
transfusion
Testicular Torsion
Results from abnormal fixation Bell clapper Free movement Rotation and
Torsion
of testis in tunica vaginalis deformity of testes swinging of testes
Most torsion
Torsion can Periods of Most are aligned
Minor trauma But… occurs without a
occur with testicular growth horizontally
preceding event!
Severe pain in May have pain in Horizontal lie of Testicle is firm & Absent Absent Prehn’s
N/V
testicle abdominal or inguinal area testes elevated Cremasteric reflex sign
Elevation of the
Blue dot sign for appendix scrotum with
testis torsion improvement of pain
Emergent urologic
Radionuclide Salvage rates
Diagnosis Doppler U/S OR But… consultation if high
scintigraphy decline >6 hours
suspicion
88 % sensitive;
100 % sensitive
90 % specific
If unsuccessful, try
Bilateral opposite direction
Treatment
orchidopexy “Opening a
book”
Treatment of
appendix testes Pain control
torsion
Nephrology and Urology 299
Most commonly
Urine reflux Mumps or other
Epididymitis due to bacterial Orchitis
(Inflammation) viral illnesses
infection
Mumps =
Unilateral then
bilateral
involvement
Sexually active
STD’s GC OR Chlamydia
males
Prostatic Urethral
Older males OR E. coli Klebsiella
enlargement stricture
Associated with
Bacterial orchitis
epididymitis
Gradual onset of pain May have pain in Testicle may be (+) Cremasteric Progression may cause
(+) Prehn’s sign
in scrotum or testicle abdominal or inguinal area firm reflex epididymo-orchitis
Prostatitis
Lower urinary
Epididymitis Foley Rectal
Risk factors Phimosis tract
or urethritis catheter intercourse obstruction
E. coli (most
Causative agents Klebsiella Pseudomonas Serratia Staph
common)
Evaluate for
Diagnosis U/A
GC/Chlamydia
Antibiotics (long
Treatment Analgesics Foley
term = 30 days)
Suprapubic
Severe? IV antibiotics
catheter
Especially for
retention
Urethritis
Purulent urethral
Urethritis
discharge
Ceftriaxone Azithromycin
Treatment Treat partners
250 mg IM 1 g po
Nephrology and Urology 301
Urinary Retention
Drugs &
Other causes
medications
Opioids
Sympathomimetics TCA
Cold remedies
Drugs &
medications
Antihypertensives Anticholingerics
D/C with
Treatment Foley catheter
catheter
Ulcer-Forming Processes
Syphilis
Lymphogranuloma
Chancroid Ulcer Forming
venerum
Processes
Molluscum
Yeast infections contagiosum
Granuloma
Genital warts inguinale
302 B. Desai
Non-ulcer-Forming Processes
Gonorrhea
Non-ulcer Forming
Processes
2º & 3º syphilis PID/Cervicitis
Bacterial
vaginosis Trichomonas
Chlamydia
Types of Reiter’s
Urethritis Epididymitis Proctitis
infections in males syndrome
Types of
Sterile pyuria
infections in Cervicitis Urethritis PID
females (Males as well)
Complications in Fitz-Hugh-Curtis
PID Ectopic pregnancy Infertility
females syndrome
Azithromycin No intercourse
Doxycycline Refer partner for
Treatment OR until 7 days after
(single dose) (7 days) therapy treatment
Gonorrhea
Types of
Urethritis Epididymitis Prostatitis Proctitis
infections in males
Types of PID
infections in Cervicitis Urethritis (20% of untreated
females females get PID)
Gram stain of
Diagnosis DNA amplification
urethral swab
Trichomoniasis
High prevalence
Protozoan Infections mostly 3 days to 4 weeks
T.vaginalis of coinfection
infection in women incubation period
with other STD
Males
Motile organisms
Diagnosis
on microscopy
Syphilis
Enters through
Spirochete Consists of three Still sensitive to
Syphilis mucous membranes
disease phases or damaged skin Penicillin
Painless chancre
Incubation Lesions resolve
Primary syphilis with indurated Symptoms
borders period 21 days after 3–6 weeks
Involvement of nervous
Seen in 33 % of 3–20 years after
Tertiary syphilis and cardiovascular
patients initial infection systems
Neuropathy
Widespread Thoracic Charcot’s
Tertiary syphilis Meningitis (Tabes Dementia
gummas aneurysm joint
dorsalis)
Benzathine Benzathine
Treatment Treatment of Treatment
penicillin IM x 1 penicillin weekly x
1º and 2º dose partners 3º 3 weeks
Fever
Complication of Jarisch-Herxheimer Most frequently In 1st 24 hours of
HA
treatment reaction in early syphilis Myalgias therapy
Due to organism
Jarisch-Herxheimer Lasts a few 50 % Primary Pretreat with
death & release of
reaction hours 90 % Secondary acetaminophen
endotoxins
Nephrology and Urology 305
Herpes Simplex
Exposure of Most genital
Lifelong
HSV infections mucosal surfaces infections caused
infection or nonintact skin by HSV-2
Painful
Burning Tingling Pain in area Headache Fever Malaise
adenopathy
Prodrome Constitutional
2–24 hours Sx in 75%
Urethral
Shaft of penis Glans of penis Labia Perineum
meatus
Recurrent
Usually milder
outbreak?
C-section if
Treatment Antivirals
pregnant Neonatal herpes
Acquired at birth
Treatment Antivirals with
recurrent
High mortality
reduced dosages
infections
Aseptic Urinary retention due
meningitis Erythema Transverse
Complications to sacral root ganglia Hepatitis Encephalitis multiforme myelitis
(HSV-2) inflammation
306 B. Desai
Chancroid
H. ducreyi is
Haemophilus If present search
Chancroid Due to cofactor for HIV
ducreyi for other infections
transmission
Culture medium
Exclude herpes
Diagnosis Clinical grounds Swab for culture not universally
& syphilis available
I&D of
Treatment Ceftriaxone OR Azithromycin OR Ciprofloxacin OR Erythromycin
buboes
Chlamydia
LGV Due to Serotypes L1,L2, L3
trachomatis
Buboes
Erythema Meningoencephalitis
Fever Chills Arthralgias
nodosum (Rare)
Culture of Complement
Diagnosis Clinical
aspirate fixation titers
Doxycycline for 3
Treatment
weeks
Nephrology and Urology 307
Granuloma Inguinale
Granuloma Calymmatobacterium
Due to Donovaniasis Rare in US
Inguinale granulomatis
Diagnosis Biopsy
Doxycycline for 3
Treatment
weeks
Lesions
Syphilis
Granuloma
inguinale Painless lesions LGV
Genital Warts
Flesh colored
1–3 month
Genital warts cauliflower like
incubation period projections
Seen in external
In females Perianal region
genitalia Usually painless
Depending on
Nonhealing Urethral
In males Pruritis location may be
penile ulcers discharge painful
Diagnosis Clinical
Bobby Desai
Contents
Anemia 310
Transfusion Therapy 314
Complications of Transfusion Therapy 317
Dyshemoglobinemias 321
Hemostasis Tests 323
Sickle Cell Anemia 325
Hereditary Hemolytic Anemias 329
Specific Labs for Hemolytic Anemia 330
Platelet Disorders 333
Hemophilia 338
Von Willebrand’s Disease 339
Anticoagulants 339
Absolute and Relative Contraindications to Thrombolysis 342
Complications of Malignancy 343
Anemia
Introduction
Reduced Increased
Decrease in Increase in RBC
Anemia concentration of Due to
production
OR loss
OR destruction of
RBC from baseline RBC
Decrease in
Response to Increase in Stimulation of
Tachycardia systemic vascular
acute anemia cardiac output erythropoietin
resistance
Causes of Anemia
Increased
destruction
Sickle cell
Splenic sequestration
Thalessemia
Hemolytic anemia
Impaired
production
Dilutional
Hematologic and Oncologic Emergencies 311
Dyspnea on Palpitations +
Fatigue Weakness Orthostasis Lethargy
exertion Chest pain
Chronic anemia
Pallor of skin & Wide pulse Systolic ejection
Tachycardia Hepatosplenomegaly Jaundice
mucosal surfaces pressure murmur
Hemolytic
anemia
Decreased
Anemia Hemoglobin & Decreased RBCs
Hematocrit
Reticulocyte
RBC production
count
Classification of Anemia
Iron deficiency
Low MCV Low ferritin
anemia
Anemia of
Renal failure
chronic disease
Sideroblastic
Low MCV Normal ferritin Hypothyroidism
anemia
Vitamin C
Thalessemia
deficiency
Normal
Normal MCV Iron deficiency B12 deficiency
reticulocyte count
Folate deficiency
Hereditary
Sickle cell disease
spherocytosis
High reticulocyte Negative Coomb’s
Normal MCV
count test
Microangiopathic
G6PD deficiency
hemolysis
Treatment
Depends on
Treatment
etiology of anemia
Iron deficiency
Elemental iron
anemia
B12 or Folate IM
OR PO Folate
deficiency anemia Cyanocobalamin
Anemia of Transfusion as
Supportive care
chronic disease needed
314 B. Desai
Transfusion Therapy
Total blood 5L in 70 kg
volume in adult person
For plasma
Washed RBCs
hypersensitivity
Bottom figure image (Reprinted from Allen B, Ganti L, Desai B. Trauma and ATLS. In: Allen B, Ganti L, Desai B, editors. Quick hits in
emergency medicine. New York: Springer; 2013. p. 37–44. With permission from Springer Science + Business Media)
ARDS from
Complications Hypothermia microaggregate Citrate toxicity
debris
TRALI = Transfusion
related acute lung injury
Use blood
Hypothermia
warmer
Platelet Transfusion
Prophylaxis when
ED transfusion Active bleeding
clinically indicated
< 10,000
Asymptomatic
<50,000 <20,000
General surgery
Usually 4 units in
Volume of One unit of each 2 mg of fibrinogen
One unit FFP adults, 15 mL/kg
250 cc coagulation factor per mL
in children
Massive Bleeding
Warfarin
FFP Uses Liver failure transfusion (to DIC from factor TTP
overdose
provide clotting) deficiency
Cryoprecipitate
Insoluble protein
Cryoprecipitate
fraction of FFP
Destruction of Release of
DIC
RBC vasoactive amines
Pain at
Acute stages Fever Chills Low back pain Dyspnea Tachycardia
transfusion site
Repeat cross
Evaluation Retype
match
Proportional to
Morbidity amount of blood
given
318 B. Desai
CBC
Coagulation
Indirect bilirubin
parameters
Hemoglobinuria Haptoglobin
Laboratory
Investigation for
Haptoglobin Acute Hemolytic Electrolytes
Transfusion Reaction
LDH BUN/Cr
Plasma free
hemoglobin
Consider
Stop Evaluate for
Treatment Treat fever IV hydration infectious
transfusion! hemolysis
evaluation
May be life-threatening
Natural history Usually mild But… in patients with poor
cardiovascular reserve
Hematologic and Oncologic Emergencies 319
Delayed
7–10 days after Antigen-antibody
Transfusion Delayed reaction Due to
transfusion reaction
Reaction
Otherwise
Low grade fever
asymptomatic
Hemolysis
Treatment Stop transfusion!
evaluation
Vasomotor
Severe Bronchospasm Dyspnea Tachycardia Shock
instability
May restart
Treatment for Stop No further
Diphenhydramine transfusion if
mild reaction transfusion! workup
symptoms resolve
Risk of
1:2,000,000
Hepatitis C or HIV
Risk of
1:200,000
Hepatitis B
Risk of
1:10,000
Parvovirus B19
Usually self
Treatment Supportive But… Can be fatal
resolves
Electrolyte
Uncommon Hypokalemia OR Hyperkalemia OR Hypocalcemia
disturbances
2–4 mL/kg/hr
Hematologic and Oncologic Emergencies 321
Dyshemoglobinemias
Limited by enzyme
Normal amounts 1–2 % of circulating NADH -> NAD
reduction of ferric to
of methemoglobin hemoglobin reaction
ferrous iron
Antimalarials
Common
Benzocaine
Most common
Lidocaine
Nitrates/Nitrites
Amyl nitrite
Silver nitrate
Nitroglycerin
Pyridium Rare
Sulfonamides
322 B. Desai
Types of Methemoglobinemia
Clinical Features
No effects until
Healthy patients
MHb >20 %
Generalized
Headache Weakness Lightheadedness Tachycardia Tachypnea Cyanosis
weakness
Myocardial Metabolic
AMS Coma Seizures Arrhythmias
ischemia acidosis
Treatment
Clinical
Use in Asymptomatic pts
Antidote Methylene blue improvement in
symptomatic pts with Mhb > 25 %
20 minutes
Pt on Dapsone? Cimetidine
Hematologic and Oncologic Emergencies 323
Hemostasis Tests
Bleeding Time
Uremia
Prolonged
Von Willebrand’s
NSAID
disease
Bleeding Time
Prolonged Prolonged
Replaced by platelet
function test
Aspirin
Prolonged
324 B. Desai
Prothrombin Time
Warfarin
Prolonged
Prothrombin Time
(Reported as INR)
Measures common
pathway
Prothrombin>Thrombin
>Fibrinogen>Fibrin
Deficiency of
Vitamin K
Prolonged
Heparin
Prolonged
Activated Partial
Von Willebrand’s Thromboplastin Time
Hemophilia
disease
Measures common
pathway
Lupus
anticoagulant
Prolonged
Hematologic and Oncologic Emergencies 325
Introduction
Under certain
Sickle cell Genetically Due to abnormal
Hemoglobin S conditions causes
disease based Hb molecule
RBC sickling
Cannot pass
Sickled cells through Leads to Ischemia Infarction
microcirculation
Higher rate of
Chronic hereditary
Sickled cells hemolysis than May be icteric
hemolytic anemia
normal RBC
Vaso-occlusive
Usually May Spontaneous
Sickle cell Trait have crisis under
asymptomatic bleeding
extreme conditions
PEDIATRICS
Marrow infarction
Early sign of sickle Hand-foot
Dactylitis in bones of hands
cell in children syndrome
& feet
Consider
Hip pain in sickle 30 % of patients
avascular necrosis
cell disease will have this
of femoral head
Vaso-occlusive Crisis
Vaso-occlusive Increased
Leads to Ischemia Infarction
Crisis viscosity of blood
Precipitants or Changes in
Infection Dehydration Cold weather
stressors altitude
Evidence of
Elevated WBC Antibiotics
infection?
May be a
Acute Chest May occur during
combination of
Syndrome hospitalization
factors
Aplastic Crisis
PEDIATRICS
Most common
Especially with
cause of Aplastic Infection
Parvovirus B19
Crisis
Bone marrow
Other causes Folate deficiency
infarction
Generalized
Pallor Fatigue
weakness
Transfusions may be
Self-limiting
Treatment But… required for severe
process
symptoms
Splenic Sequestration
PEDIATRICS
Generalized + LUQ
Pallor Lethargy Hypotension Tachycardia Tachypnea
weakness abdominal pain
Splenic Recurrence is
Sequestration common
328 B. Desai
Ischemic in Hemorrhagic in
Strokes adults
children
Exchange
Treatment
transfusion
Neurologic Recurrence is
sequelae common
Osteomyelitis in Salmonella
Staph aureus E. coli
SCD typhimurum
Infectious
Fever OR Early antibiotics
symptoms
Especially
Need
SCD pneumococcal
immunizations vaccine
Hematologic and Oncologic Emergencies 329
G6PD Deficiency
Most common Some may have
X-linked inherited Most patients are
G6PD Deficiency enzyme disease of anemia or chronic
disorder asymptomatic
RBC’s worldwide hemolysis
Likelihood of hemolysis
G6PD Deficiency depends on amount of enzyme
deficiency
Hereditary Spherocytosis
Unable to pass Increased
Hereditary Autosomal RBCs are
easily through destruction in
Spherocytosis dominant spherical
spleen spleen
Aplastic or Neonatal
Acute hemolytic Cholelithiasis &
Complications megaloblastic hemolysis with
anemia Cholecystitis
crisis jaundice
Fragmented Intravascular
Schistocytes
RBCs hemolysis
Peripheral smear
Extravascular
Spherocytes Spheroid RBCs
hemolysis
Lactate
Elevated RBC destruction
dehydrogenase
Intravascular
Haptoglobin Decreased
hemolysis
Free Intravascular
Elevated
Hemoglobin hemolysis
Hemoglobinuria Present
Reticulocyte Production of
Elevated
count RBCs
Total Increased
Bilirubin
Indirect Increased
Urine
Present
Urobilinogen
Hematologic and Oncologic Emergencies 331
Thrombotic
Hemolytic uremic
Two syndromes thrombocytopenic purpura
syndrome (HUS)
(TTP)
Neurologic
More common Wider deposition of
TTP symptoms
in adults platelet aggregates
predominate
Causes consumptive
TTP
thrombocytopenia
CNS Renal
TTP Fever MAHA Thrombocytopenia
dysfunction dysfunction
Platelet
Treatment Plasmapheresis Steroids Supportive care
transfusion
90 % mortality if
May relapse
TTP not treated in 1st
within 2 years
24 hours
332 B. Desai
PEDIATRICS
May be bloody
Pathophysiology Infectious
Due to (Hemorrhagic Usually no fever
of HUS diarrhea
colitis)
Ingestion of
2–14 days after
Onset Due to contaminated
diarrhea develops
food or water
Laboratory Evidence of
Hyperglycemia Stool studies Urine studies
investigations hemolytic anemia
Treat renal
dysfunction
Hematologic and Oncologic Emergencies 333
Platelet Disorders
Introduction
More common
Platelet Decreased Decreased Nonpalpable
Petechiae in lower
disorders number function purpura
extremities
Drugs DIC
Radiation Heparin
B12 / Folate
Some drugs Sulfa
Thiazide
causing Ethanol Aspirin Heparin containing
diuretics
thrombocytopenia antibiotics
Gingival
Epistaxis Hemoptysis Hematochezia Menorrhagia Hematuria
bleeding
Normal except
ITP Laboratories
platelets
IV Platelet
Treatment Prednisone Rhogam
Immunoglobulin transfusion
For very low If needed, after 1st
50–75 % remission For Rh+ patients
platelets & dose of steroids or
by 3 wks
bleeding IVIG
Extremes of
Trauma Crush injury Brain injury Rhabdomyolysis Fat embolism
temperature
Activation of
Pancreatitis/ Hepatocyte
Liver Pancreatitis coagulation
Liver Failure release of TF
cascade
Post incompatible
Bleeding Shock
tranfusion
336 B. Desai
Infectious
Sepsis Bleeding Thrombosis
etiology
Adenocarcinoma
Lymphoma
except Prostate Thrombosis Bleeding
Adenocarcinoma
cancer
Pancreatitis
Bleeding Thrombosis
Liver Failure
Adult respiratory
Bleeding Thrombosis
distress syndrome
Post incompatible
Bleeding Thrombosis
tranfusion
Widespread
Wide range of
Bleeding Petechiae bleeding from
bleeding
multiple sites
Prothrombin
Time
Prolonged
Prolonged Decreased
Fibrinogen
Schistocytes
Low
May be present
Laboratory Findings in
DIC
Fibrin degradation
D-dimer
products
Elevated Elevated
Factor assays
Depend on factor
Treatment of DIC
Depends on Mostly
Treatment
underlying disease supportive
Platelets Replace
Bleeding
<50,000 platelets
Platelets Replace
<20,000 platelets
DIC associated
FFP Vitamin K Folate
bleeding
Hemophilia
Introduction
Deficiency in Usually appear
Factor VIII & IX is
Hemophilia Bleeding disorder Due to clotting cascade early in life
most common
factor (Males only)
Most common
Deficiency of Deficiency of
Hemophilia A cause of Hemophilia B
Factor VIII Factor IX
hemophilia in US
May have
Moderate Activity levels Usually bleed
spontaneous
hemophilia 1–5% with trauma
bleeding
PTT may be
Laboratory Unless factor
Abnormal PTT normal in this
abnormalities levels >30–40 %
case
Treatment
Evaluation for
Hemophilia with Factor No major interventions (central lines,
major
bleeding? replacement etc) without factor replacement
complications
Factor Recombinant
replacement factor Plasma derived
Introduction: VWD
Most common Deficiency in von Made & stored in
VWD congenital Due to Willebrand factor vascular
bleeding disorder (VWF) endothelial cells
Von Willebrand Cofactor for Carrier protein Leads to platelet activation &
Factor platelet adhesion for factor VIII adhesion to other platelets
GI/GU Gingival
Clinical features Easy bruising Epistaxis Heavy menses
(GIB/hematuria) bleeding
Unless severe
Clinical features NO Hemarthosis
disease
Prolonged
Prolonged Decreased
depending on
severity
Treatment for
Desmopressin
Mild disease
Anticoagulants
Introduction: Warfarin
Disrupts synthesis II, VII, IX, X Extrinsic pathway blocked
Blocks action of
Warfarin of Vitamin K (Has mild thrombotic effect
vitamin K (Also Proteins C&S)
dependent factors through Protein C&S blockade)
Multiple Change in
Drugs or Albumin
Warfarin interfering hepatic
Medications binding
factors metabolism
NOT in
Warfarin Teratogenic
Pregnancy
Major Warfarin
Bleeding Skin necrosis
complications
340 B. Desai
Prothrombin
Other Concentrates of Works Less volume
complex
considerations II, VII, IX & X immediately than FFP
concentrates
Protein C
Skin necrosis Due to Not exclusively
deficiency
Use another
Screen for Protein
Treatment Stop Warfarin anticoagulant as Vitamin K
C & S deficiency
needed
Hematologic and Oncologic Emergencies 341
Introduction: Heparin
Thrombin & Unfractionated Unfractionated
Binds to
Heparin Factor Xa heparin must be heparin is given in a
Antithrombin
inhibition given parenterally weight based dosing
Therapeutic range =
Unfractionated Requires frequent
Guided by PTT 1.5–2.5 times the
heparin monitoring
normal value
More predictable
Low molecular Allows for b.i.d.
anticoagulant
weight heparin or daily dosing
effect
1 mg Protamine
50 mg in 10
Other treatment Protamine neutralizes 100 units of Give slowly
minutes
unfractionated heparin
Skin
5-10 days after Arteries
HIT
starting heparin
Veins
Platelets return to
Monitor for
Treatment Stop heparin normal 4 -6 days after
thrombosis
stopping heparin
342 B. Desai
Active bleeding
Uncontrolled HTN
from any site
(DBP >120)
Pregnancy or < 10
Hx of GI bleed
days postpartum
Relative
Significant trauma Known active
Contraindications to
< 4 weeks cavitary lung lesion
Thrombolysis
Complications of Malignancy
Introduction
Due to therapy
N/V
Related
electrolyte
derangements
Metabolic
Hematologic
Hypercalcemia
Complications of Neuropenia &
Hyponatremia Malignancy related
complications
SIADH
Thromboembolism
Adrenal
insufficiency Hyperviscosity
Tumor lysis
syndrome
Local effects
SVC syndrome
Pathologic
fractures
Airway obstruction
Tamponade
Spinal cord
compression
Symptomatic improvement
Position patient O2
ED Management Heliox of upper airway
for comfort
obstruction due to cancer
Definitive Radiation
management therapy
344 B. Desai
Benign
Severe localized
Symptoms appearance of
pain
affected limb
Radiation
Treatment Pain control Surgery
therapy
Diagnosis Echocardiogram
MRI of entire
Diagnosis CT Endoscopy
spine
Radiation
ED Management Steroids Surgery
therapy
Central Other
Other causes Goiter Radiation TB
lines thrombosis
Face edema Arm edema Head Neck & upper Face plethora &
Headache Papilledema
(80 %) (50 %) congestion chest congestion telangiectasia
Voice Mediastinal
Dyspnea Cough Sentinel node
hoarseness enlargement on CXR
Diagnosis CT
Most common
Multiple Squamous cell
associated Breast cancer
myeloma carcinoma of Lung
malignancies
Altered mental
Lethargy Dehydration Constipation Weakness Abdominal pain Short QT
status
IV hydration
ED Management Bisphosphonates Calcitonin Steroids Furosemide
2–4 L as tolerated
Not
recommended
for malignancy
related
hypercalcemia
Symptoms depend
SIADH due to Ectopic Normovolemic
Due to on rapidity of
Malignancy secretion of ADH hyponatremia
development
Less than
Normovolemic Elevated urinary
Diagnosis Low osmolality maximally dilute
hyponatremia Na excretion
urine
Adrenal
Insufficiency due Due to Dehydration OR Infection OR Surgery OR Trauma
to Malignancy
Consider in
Fever Hypotension Shock Dehydration
cancer patients
Common
Eosinophilia Hypoglycemia Hyponatremia Hyperkalemia
findings
Most life-
Potassium
Hyperkalemia threatening Arrhythmias
release
complication
Abrupt
Phosphorus May combine Precipate in Acute
hypocalcemia &
release with calcium renal tubules nephropathy
its complications
Treat electrolyte
Maintain
ED Management abnormalities as
hydration
usual
348 B. Desai
Febrile Neutropenia
Pts may not manifest Most common
Increased risk of Impaired
Neutropenia Due to symptoms due to lack due to bacterial
infection immunity
of neutrophils infection
Absolute Absolute
Severe
Neutropenia neutrophil 1000/mm3 neutropenia
neutrophil 5000/mm3
count count
Neutropenia in
Due to Chemotherapy
cancer patients
Chronic
Waldenstrom Multiple
Causes OR OR myelocytic OR Polycythemia
macroglobulinemia myeloma
leukemia
Altered mental
Fatigue Headache Abdominal pain Blurred vision Anorexia Somnolence
status
Hyponatremia with
Laboratory Rouleaux
Anemia Hypercalcemia low osmolality &
abnormalities formation
normovolemia
Bobby Desai
Contents
Generalized Skin Rashes and Disorders 350
Allergic Processes 363
Skin Cancers 365
Infectious Diseases and Associated Skin Lesions 366
Viral Infections 372
Malaria 376
Pediatric Rashes 376
Miscellaneous Skin-Related Disorders 385
Erythema Multiforme
Erythema
Young adults M>F
Multiforme
Precipitating causes
(50 % idiopathic) Mycoplasma Herpes Malignancies Antibiotics Anticonvulsants
Hypersensitivity
reaction in all
Bottom center image (Reprinted from Zaidi Z, Lanigan SW. Vasculitis, common erythemas, and lymphatic disorders. In: Zaidi Z, Lanigan SW,
editors. Dermatology in clinical practice. London: Springer; 2010. p. 253–70. With permission from Springer Verlag)
Disorders Affecting the Skin 351
Affects > 30 % of
TEN
body surface area
Precipitating causes
Mycoplasma Herpes Malignancies Antibiotics Anticonvulsants
(50 % idiopathic)
Hypersensitivity
reaction in all
Bullous
SJS cutaneous lesions
Stomatitis Conjunctivitis Mucositis Nikolsky’s sign
Very large Severe Skin peels off with
TEN Hypotension Shock Tachycardia light pressure
bullae mucositis
Increased Secondary
Older age Dehydration
mortality infection
Primary causes
Sepsis Pneumonia
of death
PEDIATRICS
Right side image (Reprinted from Zaidi Z, Lanigan SW. Exanthems and Hypersensitivity Syndromes. In: Zaidi Z, Lanigan SW, editors. Dermatology
in clinical practice. London: Springer; 2010. p. 271–80. With permission from Springer Verlag)
352 B. Desai
PEDIATRICS
Mucous membranes
SSSS are spared
Electrolyte Vancomycin
Treatment Fluids replacement Antibiotics (Does not alter skin process)
Bottom center image (Reprinted from Zaidi Z, Lanigan SW. Exanthems and hypersensitivity syndromes. In: Zaidi Z, Lanigan SW, editors.
Dermatology in clinical practice. London: Springer; 2010. p. 271–80. With permission from Springer Verlag)
Disorders Affecting the Skin 353
Pemphigus Vulgaris
Pemphigus Vesicles or Bullae May appear on 1st affect mucous Bullae break easily,
Vulgaris < 1cm to several cm normal skin membranes, head, trunk leave painful areas
Increased Secondary
mortality Older age Dehydration infection
Right side image (Reprinted from Zaidi Z, Lanigan SW. Bullous disorders: autoimmune and childhood bullous dermatoses. In: Zaidi Z, Lanigan
SW, editors. Dermatology in clinical practice. London: Springer; 2010. p. 233–52. With permission from Springer Verlag)
354 B. Desai
Bullous Pemphigoid
Precipitating Medications
Malignancy
causes (Sulfa)
Right side image (Reprinted from Cashman MW, Doshi D, New York: Springer; 2013. p. 147–73. With permission from Springer
Krishnamurthy K. Vesiculobullous dermatoses. In: Buka B, Uliasz A, Science + Business Media)
Krishnamurthy K, editors. Buka’s emergencies in dermatology.
Disorders Affecting the Skin 355
Precipitating
Medications Systemic disease Chemicals Malignancy
causes
Precipitating
Penicillin Sulfa drugs Cephalosporins
causes
Stevens-Johnson
Complications
syndrome
Discontinue
Treatment Antihistamines Steroids
medication
Disorders Affecting the Skin 357
Erythema Nodosum
Bottom center image (Reprinted from Vázquez-Roque MI, De Jesús- New York: Springer; 2012. p. 41–51. With permission from Springer
Monge WE. Cutaneous manifestations of gastrointestinal diseases. In: Science + Business Media)
Sánchez NP, editors. Atlas of dermatology in internal medicine.
358 B. Desai
Eczema
Chronic & itchy
Has association with Allergic rhinitis
Eczema Nasal Polyps (+) Family hx
multiple processes Asthma
Worse in winter
Right center image (Reprinted from Silverberg NB. Eczematous dis- New York: Springer; 2012. p. 69–88. With permission from Springer
eases. In: Silverberg NB, editor. Atlas of pediatric cutaneous biodiver- Science + Business Media)
sity: comparative dermatologic atlas of pediatric skin of all colors.
May be limited to
Erythema Pruritis Vesicles Bullae
area of contact
Treatment Steroids
Disorders Affecting the Skin 359
Psoriasis
May be accompanied by
Psoriasis
psoriatic arthritis
Bottom center image (Reprinted from Norman RA, Young, Jr. EM. Psoriasis. In: Norman RA, Young EM Jr, editors. Atlas of geriatric dermatology.
London: Springer; 2014. p. 83–95. With permission from Springer Verlag)
360 B. Desai
Seborrheic Dermatitis
PEDIATRICS
Ketaconazole Selenium
Treatment
shampoo shampoos
Bottom center image (Reprinted from Silverberg NB. Eczematous dis- New York: Springer; 2012. p. 69–88. With permission from Springer
eases. In: Silverberg NB, editor. Atlas of pediatric cutaneous biodiver- Science + Business Media)
sity: comparative dermatologic atlas of pediatric skin of all colors.
Disorders Affecting the Skin 361
Pityriasis Rosea
PEDIATRICS
Antihistamines
Treatment Symptomatic
for pruritis
Left side image (Reprinted from Zaidi Z, Lanigan SW. Keratinizing and Right side image (Reprinted from Silverberg NB. Papulosquamous
papulosquamous disorders. In: Zaidi Z, Lanigan SW, editors. disorders. In: Silverberg NB, editor. Atlas of pediatric cutaneous biodi-
Dermatology in clinical practice. London: Springer; 2010. p. 179–209. versity: comparative dermatologic atlas of pediatric skin of all colors.
With permission from Springer Verlag) New York: Springer; 2012. p. 53–60. With permission from Springer
Science + Business Media)
362 B. Desai
Dermatophyte Infections
Scaly patch on
Tinea capitis Affects scalp
head
Large edematous
Kerion DO NOT I&D!
nodule & pustule
Right side image (Reprinted from Zaidi Z, Lanigan SW. Superficial fungal infections. In: Zaidi Z, Lanigan SW, editors. Dermatology in clinical
practice. London: Springer; 2010. p. 73–99. With permission from Springer Verlag)
Disorders Affecting the Skin 363
Tinea Versicolor
PEDIATRICS
Selenium Ketoconazole
Treatment
shampoo cream or shampoo
Bottom center image (Reprinted from Silverberg NB. Cutaneous New York: Springer; 2012. p. 113–25. With permission from Springer
infections. In: Silverberg NB, editor. Atlas of pediatric cutaneous biodi- Science + Business Media)
versity: comparative dermatologic atlas of pediatric skin of all colors.
Allergic Processes
Urticaria
Epinephrine for
Treatment H1& H2blockers Steroids
severe cases
364 B. Desai
Angioedema
Skin Cancers
Malignant Affects ages Affects sun Head, neck, Most common cause of skin
melanoma 30–60 exposed areas truncal areas cancer related deaths
Congenital or Exposure to UV
Risk factors dysplastic nevi Family Hx Fair skin radiation
Basal cell Most common Does not Affects head & Seen where there
carcinoma skin cancer metastasize neck are hair follicles
Exposure to UV
Risk factors Elderly males Fair skin
radiation
Meningococcemia
PEDIATRICS
Sepsis
Neisseria Encapsulated gram Causes a spectrum
Meningococcemia Meningitis
meningitidis negative diplococcus of diseases
Bacteremia
Petechiae Coalesce to
Rash
1–2 mm purpura
Waterhouse- Adrenal
Shock Petechiae
Friderichsen syndrome infarction
Rifampin or
Prophylaxis? Close contacts
Ciprofloxacin
Laboratory workup
Diagnosis CSF serology Blood serology
as indicated
Penicillin
Chloramphenicol ICU for shock
Treatment IV antibiotics Isolation
rd states
3 generation
cephalosporin
Right side image (Reprinted from Stamell E, Krishnamurthy New York: Springer; 2013. p. 19–41. With permission from Springer
K. Infectious emergencies in dermatology. In: Buka B, Uliasz A, Science + Business Media)
Krishnamurthy K, editors. Buka’s emergencies in dermatology.
Disorders Affecting the Skin 367
Gonorrhea
Neiserria Gram negative Also causes
Gonococcemia gonorrheae diplococcus multiple disorders Arthritis
Synovitis
Cefoxitin with
Treatment Ceftriaxone OR Cefotaxime OR
probenecid
Lyme Disease
Right side image (Reprinted from Miró EM, Sánchez NP. Cutaneous manifestations of infectious diseases. In: Sánchez NP, editor. Atlas of derma-
tology in internal medicine. New York: Springer; 2012. p. 77–119. With permission from Springer Science + Business Media)
Disorders Affecting the Skin 369
Leptospirosis
Mild
Leptospirosis Fever & chills Myalgias Headache
Diagnosis Serology
Altered mental
Fever Myalgias Headache Vomiting Rash Encephalitis
status
Relative
Myocarditis Arrhythmias Pneumonitis
bradycardia
Gangrene of
Complications CNS issues DIC Renal failure Liver failure
digits
Delirium Azotemia Elevated LFT’s Due to
Seizures vasculitis
Bottom right image (Reprinted from Morgan MB, Smoller BR, Somach clinicopathologic atlas and text. New York: Springer; 2007. p. 125–8.
SC. Rocky mountain spotted fever and the rickettsioses. In: Morgan With permission from Springer Science + Business Media)
MB, Smoller BR, Somach SC, editors. Deadly dermatologic diseases:
Disorders Affecting the Skin 371
Ehrlichiosis
Rash Maculopapular
Sx very similar
Fever Myalgias Headache Rash
to RMSF
Diagnosis Clinical
Babesiosis
Viral Infections
TORCHES
PEDIATRICS
TO Toxoplasmosis
R Rubella
C CMV
H Herpes/HIV
E Epstein-Barr Virus
S Syphilis
Cytomegalovirus (CMV)
PEDIATRICS
Congenital
Most common Member of Herpes 3 disease
CMV Acquired
of the TORCHES virus family processes
Immunocompromised
CMV effects on
Nephritis Pneumonitis Retinitis Colitis
immunocompromised pts?
Immune
CMV High mortality
compromised
Atypical lymphocytes
Diagnosis ELISA
on peripheral smear
PEDIATRICS
Exudative
Fever Splenomegaly Lymphadenopathy
pharyngitis
Atypical lymphoctyes
Diagnosis Monospot Serology
on peripheral smear
Instructions for no
Treatment Rest Supportive care
contact sports
374 B. Desai
Disseminated Post-herpetic
Complications Meningitis Pneumonia
VZV neuralgia
Bottom center image (Reprinted from Zaidi Z, Lanigan SW. Viral infections. In: Zaidi Z, Lanigan SW, editors. Dermatology in clinical practice.
London: Springer; 2010. p. 101–23. With permission from Springer Verlag)
Complications of AIDS
Post exposure Start meds within 1–2 Multiple drugs Reverse transcriptase Protease
prophylaxis hours, continue for 4 weeks are standard inhibitors inhibitors
Disorders Affecting the Skin 375
Molluscum Contagiosum
PEDIATRICS
Face Groin
Autoinoculation Trunk Children Adults
Extremities Genitalia
Bottom center image (Reprinted from Silverberg NB. Cutaneous New York: Springer; 2012. p. 113–25. With permission from Springer
infections. In: Silverberg NB, editor. Atlas of pediatric cutaneous biodi- Science + Business Media)
versity: comparative dermatologic atlas of pediatric skin of all colors.
376 B. Desai
Malaria
“ Blackwater
Fever & Chills Splenomegaly Headache Malaise Joint pain N/V
fever”
Cerebral Abnormal Massive
AMS Seizures posturing Opisthotonus hemolysis
malaria
Pediatric Rashes
Erythema Infectiosum
PEDIATRICS
Erythema
Parvovirus B19 Fifth Disease
Infectiosum
Rash follows
Fever Headache Myalgias URI/Flu Sx Diarrhea
these Sx
Treatment NSAID’s
Fetal anemia if
Complications Arthritis Aplastic crisis
acquired in pregnancy
Sickle cell
Disorders Affecting the Skin 377
Rubella
PEDIATRICS
Acute viral
Rubella
illness
Spread from
Rash Pink macules
head to feet
Treatment Supportive
Congenital
Complications Arthritis Encephalitis
defects
Immune complex If acquired during
1st trimester
378 B. Desai
Measles (Rubeola)
PEDIATRICS
Acute viral
Measles
illness
Morbilliform
Fever Cough Coryza Conjunctivitis Koplik spots
rash
“The 3 C’s”
Treatment Supportive
Roseola Infantum
PEDIATRICS
Treatment Supportive
PEDIATRICS
Varicella Zoster
Chicken Pox
virus
“Dew drop on a
Rash Macules Papules Vesicles
rose petal”
Secondary
Complications Pneumonia Encephalitis Otitis media
infection
Avoid salicylates!
May precipitate Reye
syndrome
Disorders Affecting the Skin 381
Hand-Foot-Mouth Disease
PEDIATRICS
1–2 mm oral
High fever Sore throat URI Sx Malaise Dysphagia Vomiting
vesicles
Vesicles
Buccal mucosa Tongue Soft palate Gingiva
intraorally
Vesicles also
Hands Feet Soles
present on
Change to gray
Skin lesions Red papules Palms & Soles Buttocks
vesicles
Aseptic
Complications? Rare Myocarditis Encephalitis
meningitis
382 B. Desai
PEDIATRICS
Palpable
Abdominal pain Hematuria GI Bleeding
purpura
No Consider checking
Laboratory
thrombocytopenia renal function
Right side image (Reprinted from Zaidi Z, Lanigan SW. Vasculitis, common erythemas, and lymphatic disorders. In: Zaidi Z, Lanigan SW, editors.
Dermatology in clinical practice. London: Springer; 2010. p. 253–70. With permission from Springer Verlag
Disorders Affecting the Skin 383
Kawasaki’s Disease
PEDIATRICS
Increased
Laboratory Increased WBC Elevated ESR
platelets
IV
Treatment Aspirin
immunoglobulin
Coronary artery
Complication
aneurysm
384 B. Desai
Scarlet Fever
PEDIATRICS
Strawberry
Fever Headache Sore throat N/V Lymphadenopathy Rash
tongue
Skin peeling
(palms & soles)
Increasing ASO
Diagnosis Throat swab
titer
Treatment Penicillin
Strep
Complications Otitis media Glomerulonephritis Rheumatic fever
pneumonia
Disorders Affecting the Skin 385
Venous Stasis Result from chronic Caused by episodes of Poor venous return from LE leading
Ulcers venous insufficiency phlebitis or varicose veins to edema & stasis dermatitis
Prolonged Tall
Risk Factors Older age Female Pregnancy Genetic
standing person
Medial distal legs & pretibial areas Honey crusted Secondary Cellulitis or
Tidbits
most affected for dermatitis lesions or pustules? infection lymphangitis
Ulcers – medial & lateral malleolus
Diagnosis Clinical
Located along These sinuses are lined with Sinuses can get blocked &
Pilonidal Cysts
the gluteal fold squamous epithelium & hair lead to bacterial infection
Most common
Diagnosis Clinical
Decubitus Ulcers
Areas commonly
Sacrum Posterior scalp Heels
affected
Stages of
Stage 1 Stage 2 Stage 3 Stage 4
decubitus ulcers
Intact skin with Shallow open Full thickness Exposure of
erythema sore, pink base No exposure of muscle, tendon,
muscle, tendon, or bone
or bone
Diagnosis Clinical
Lipoma
Diagnosis Clinical
Treatment Excision
Disorders Affecting the Skin 387
Hemangiomas
PEDIATRICS
Diagnosis CT or MRI
PEDIATRICS
Bobby Desai
Contents
Hypoglycemia 390
Diabetes Mellitus 393
Diabetic Ketoacidosis 395
Alcoholic Ketoacidosis 401
Hyperosmolar Hyperglycemic Nonketotic Syndrome 404
Thyroid Disorders 407
Hypothyroidism and Myxedema Coma 408
Hyperthyroidism and Thyroid Storm 415
Adrenal Insufficiency and Crisis 423
Pheochromocytoma 429
ADH-Related Diseases 430
Electrolytes and Acid-Base 437
The Osmolal Gap 466
Hypoglycemia
Agents causing
hypoglycemia Sulfonylureas
Long duration Chlorpropamide
Stimulate the Chlorpropamine of action Can cause SIADH
pancreas to Glyburide
OD can cause profound
release insulin
Glipizide hypoglycemia
α-glucosidase
inhibitors
Thiazolodenediones
Hypoglycemia
Hepatic disease
Extrapancreatic
neoplasm
Medications Insulinoma
Insulin
Oral hypoglycemics
Causes of
Hypoglycemia Artifactual
(Laboratory)
Alcohol
Salicylates Leukemia
Barbituates Polycythemia
Hypothermia Infection
Dumping
syndrome AMI
Endocrine
disorders
Hypothyroidism
Adrenal
insufficiency
Pituitary
insufficiency
Endocrine/Metabolic/Electrolytes 391
Neuroglycopenic Symptoms
Concentration
Confusion Drowsiness Dizziness Tiredness
difficulty
Can have severe
Psychosis obtundation
Coma
Tidbits of Hypoglycemia
Primary energy
Glucose source for brain
Glucagon
Norepinephrine
Role of multiple Cause the
Glucose
counterregulatory Growth Hormone release of liver
control hormones glycogen stores
Epinephrine
Glucocorticoids
Psychosis Depression
Hypoglycemia
Sympathomimetic Altered mental
Mimics
drug ingestion status
Traumatic brain
injury Multiple sclerosis
Other neurologic
deficits
Treatment of Hypoglycemia
Awake &
Hypoglycemia Oral glucose
alert
15–20 g Disposition
depends on clinical
D 50 Adults condition and
effectiveness of
Standard treatment
treatment D 25 Pediatric use
D 10 Infant use
Sulfonylurea Glucose
Hypoglycemia overdose Octreotide infusion Admit
Inhibits insulin
secretion
Prevents rebound
hypoglycemia
Continued D10
hypoglycemia Infusion
Endocrine/Metabolic/Electrolytes 393
Diabetes Mellitus
Insulin
DM Hyperglycemia Defects in production
Insulin action
Type I Dx
No circulating B-cell
Children
DM 5–10 % insulin dysfunction Teens
Causes ketoacidosis Insulin is required Immune mediated
in untreated cases
90 %
Type II
80–90 % Has circulating Fails to act on Relative insulin Dx
insulin but tissues deficiency Older
Ketoacidosis during
stress Insulin resistance
Skeletal muscle
Insulin
Glucose Stimulates Fat tissue
release
Liver
Glycogen Gluconeogenesis
Worsens
Primary hormone hyperglycemia
Counterregulatory Glycogenolysis Acetoacetate
hormones Cortisone
Free fatty acid + Convert to
Catecholamines β-hydroxybutyrate
glycerol production ketones
Renin-
Volume Angiotensin- Potassium
Activates
Aldosterone
Exacerbates
depletion
system
loss
394 B. Desai
Types of Insulin
Insulin Administration
Insulin Pump
Catheter problem
Endocrine/Metabolic/Electrolytes 395
Diabetic Ketoacidosis
Noncompliance
with insulin regimen
Pregnancy CVA
Pulmonary
Medications & Embolism
Drugs
Cocaine
Most GI Bleed
Steroids
common
Causes of DKA
Thiazides
Sympathomimetics
Critical Illness
Antipsychotics
Errors in insulin
administration
Infection
Heat stroke
Trauma AMI
Endocrine organ
dysfunction
Pancreatitis
Hyperthyroidism
Diabetic Ketoacidosis
Effects of Hyperglycemia
Osmotic Leading
Hyperglycemia Causes Dehydration Due to Polydipsia
diuresis to
Osmotic Leading
Causes Polyuria to Hypovolemia Electrolyte Loss
diuresis
Electrolytes Lost
Severe
Hypovolemia Leads to Leads to Shock
Dehydration
Systemic &
Intracellular
Worsened by
vomiting that Also ketonuria
accompanies DKA
Endocrine/Metabolic/Electrolytes 397
Production of Leading
Lipolysis Causes to Ketonemia Acidosis
ketoacids
Anion gap
Ketoacidosis Causes Vomiting Ketonuria
metabolic acidosis
Increased
Anion gap ventilation to
Leads to Tachypnea Leads to
metabolic acidosis decrease CO2
Altered mental
Vomiting Leads to Dehydration Leads to Shock
status
Directly related to
Common in
children
Neuroglycopenic Symptoms
Concentration
Confusion Drowsiness Dizziness Tiredness difficulty
Can have
Psychosis
severe
obtundation
Coma
398 B. Desai
Diagnosis: DKA
Venous pH
is 0.03 lower
CBC +
Basic Labs EKG ABG/VBG Lactate U/A Ketones
‘Lytes
Glucose Look for ± Culture
Calculate hyper-K+
anion gap changes
And K+ may be normal or
Mg + PO4
ischemia elevated
Consider other
studies depending Cardiac LFT’s + Thyroid Head CT
on underlying evaluation Lipase studies + LP
medical conditions Cardiac
enzymes
CXR Looking for DKA
precipitants
DKA Precipitants
ANY acute
Noncompliance
stressor
Psychosis Infection
Precipitants of
Drug or Other
DKA Hyperthyroidism
Ingestion
Myocardial
Traumatic injuries
Infarction
High mortality
Neurologic
Pancreatitis
deficits
Endocrine/Metabolic/Electrolytes 399
Other alcohol
ingestion Drug Ingestion
Methanol Salicylates
Ethylene glycol
DKA Treatment
Immediate
Suspicion Fluid Bedside Appropriate
Hx DM Glucose of DKA resuscitation glucose
Urine dip +
Labs
EKG
Anion gap?
Correct Treat
Replace
DKA? fluids
metabolic reversible
derangements causes Other electrolytes
Over 24–36
hours Na = Pseudohyponatremia
(correction = 1.6 mEq/L
for every 100 mg/dL
Treatment Replace Correct glucose over 100)
potassium Insulin
order fluids derangements PO4 = Emergent
May need to replacement when level
give K+ even <1 mg/dL (Sx= respiratory
with normal
depression, muscle
levels
weakness, CHF, AMS)
SQ insulin once
Insulin Continue Anion gap Ketonemia
DKA Normal K+
therapy until closes has resolved
Switch to IV insulin has
stopped
IV drip
400 B. Desai
Bicarbonate in DKA
Rarely
HCO3
indicated!
Impaired
Potential Cerebral Electrolyte Sodium oxygen– Paradoxical
complications edema problems overload hemoglobin CSF acidosis
dissociation
Especially in Curve shifts to Also worsening
Hypo-K+ left intracellular
children acidosis
Hypo-PO4
DKA Complications
Precipitating
factors with
highest MI Infection
mortality
Over- Acute
Respiratory
aggressive Distress
fluids? Syndrome
Cerebral New-onset
Young persons
edema DM
High mortality
Cerebral Edema
Symptoms/Signs
Fluid
Treatment Intubation Mannitol
restriction
High mortality
Endocrine/Metabolic/Electrolytes 401
Disposition
Alcoholic Ketoacidosis
Introduction
Abrupt cessation
Alcoholic Wide anion
Due to of alcohol use Causes
ketoacidosis gap acidosis
after chronic use
Can be followed by
vomiting
Nicotinamide Conversion to
Metabolism Alcohol
adenine Alcohol Acetyl
of alcohol dehydrogenase
dinucleotide coenzyme A
NAD
Pathophysiology
Due to ethanol
metabolism
Growth hormone
Reduction Decreased
Addition of Stimulation
of glycogen insulin Catecholamines
stress of
stores section
Dehydration Glucagon
Illness
Anaerobic metabolism
Abdominal
Nausea Vomiting pain
Tremors Hematemesis
Most common
Signs
Most common
Diagnosis
Ca Usually
low or
Mg negative
PO4
Inability of
During recovery
Initial ketone nitroprusside
Low Due to Recovery acetoacetate
level reagent to detect b -
increases
HB
Tests become
positive
Treatment
Stops
Insulin
Glucose Stimulates Glucagon
production
production
Endogenous Ketone
Stops Lipolysis
Insulin production
Not
exogenous!
404 B. Desai
Disposition
Other Persistent
AKA Admission
illness acidosis
Introduction
Hyperosmolar
hyperglycemic Hyperglycemia Hyperosmolarity Usually in Type II Diabetics
state
Hyperosmolar
Higher mortality
hyperglycemic No ketoacidosis Insidious onset
than DKA
state
Pathophysiology
Abdominal Neurologic
pain deficits
Signs
Diabetes
Often the initial
presentation of
Pulmonary NIDDM
GI Bleed
embolism
Medications
β-and Ca channel Uremia
blockers
Lithium
Phenytoin UTI/Pyelonephritis
Neuroleptics Pneumonia
Cimetidine
Pancreatitis SDH
Diagnosis
Serum
Basic Labs glucose
‘Lytes Osmolality Lactate CBC Ketones
Mg Calculated
&
Calculate Measured
anion gap
Consider other
studies depending Cardiac LFT’s+ Thyroid Head CT
U/A ABG
on underlying evaluation Lipase studies + LP
medical conditions Cardiac + Culture
enzymes
EKG
CXR
Treatment
50 % of fluid
Volume Improves Decreases Remainder over
Fluids deficit over the
depletion perfusion glucose the next 24 hours
first 12 hours
Replace Average
volume before deficit 8-12 L
insulin
Initial 1 L
boluses as
indicated Cerebral edema not as
common as in DKA, but can
occur with rapid fluid
replacement
HypoK+ = HypoMg+
Disposition
HHS Admission
Endocrine/Metabolic/Electrolytes 407
Thyroid Disorders
Thyroid Hormones
Feedback TRH
inhibition of Hypothalamus
TSH
TSH
Pituitary
Depends on
Thyroid gland
iodine intake
Excess Iodine
blocks hormone
release
T3 Converted to T4
20 % 80 %
4x more
biologically
active than T4
Protein Cell
synthesis metabolism
408 B. Desai
Introduction: Hypothyroidism
Primary
Thyroid
Hypothyroidism hormone Metabolism 2 types
production
Females Males
TSH administration
Primary
will not be
Hypothyroidism
effective
Autoimmune
Hashimoto’s
Thyroiditis
Infection
Medications &
Drugs Surgical ablation
Amiodarone
After radiation
Panhypopituitarism
Treatment of
Infiltrative disease Idiopathic
Graves’ disease
Lymphoma
Sarcoid
410 B. Desai
Symptoms
Signs
Cardiopulmonary
Dermatologic
Non-pitting Periorbital
Dry skin Hair loss Macroglossia Facial swelling Ptosis
edema edema
Neuropsychiatric
Myxedema Coma
Mental
Myxedema Preexisting Some type of
status Hypothermia
Coma hypothyroidism stress
changes
Or coma <35.5oC
AMS or
Signs Bradycardia Hypotension Hypoventilation Hypothermia
Coma
Poor prognostic
Persistent
factors for The elderly Bradycardia
hypotension
Myxedema Coma
412 B. Desai
Infection MI
Medications &
Drugs
Trauma
Amiodarone
β-blockers
Phenothiazines
Sedatives
CHF
GI bleed
CVA
Burns
Metabolic
Surgery
conditions
Hyponatremia,
hypoxia,
hypoglycemia,
hypercapnia
Endocrine/Metabolic/Electrolytes 413
Sepsis
DDx
Infection-
Meningitis
Florid depression
Cold exposure-
CVA Hypothermia
Hypoglycemia CHF
Myxedema Diagnosis
Looking for
Free T4 Free T3 Other laboratories and
Consider TSH precipitating
imaging as needed
factors
Other common
May have
laboratory Hyponatremia Anemia
elevated lipids
findings
414 B. Desai
Treatment
Treatment of
Consideration of Thyroid hormone
Supportive care precipitating
Myxedema Coma? replacement
factors
IV T4 IV T3 and large
doses of IV T4 in
Beware of large
the elderly
doses in the elderly
may cause
arrhythmias
More aggressive
measures may be
Passive Warm
Hypothermia Warmed fluids needed for
rewarming Blankets profound
hypothermia
Disposition
Myxedema
Admission
coma
Endocrine/Metabolic/Electrolytes 415
Introduction: Hyperthyroidism
Circulating Circulating
Hyperthyroidism Thyroid Thyrotoxicosis Thyroid
hormone hormone
From thyroid
From any cause
overproduction
Altered
Life-threatening Adrenergic Presence of
Thyroid Caused peripheral OR
state of hyperactivity With one or more
storm by response to
thyrotoxicosis precipitants
thyroid hormone
Other
Hyperthyroidism
Female > Male autoimmune Family history
risk factors
disease
Excess production
Primary of thyroid
Hyperthyroidism hormone from the
thyroid
Graves disease
Most common
form (85%)
Primary
Hyperthyroidism
Graves’ Disease
Thyrotropin receptor
immunoglobulins stimulate both
Graves disease thyroid hormone synthesis and
secretion
Pre-tibial
myxedema
Rare
Bilateral
Pre-tibial Accumulation of
elevated dermal Waxy skin
myxedema mucopolysaccharides
nodules
Endocrine/Metabolic/Electrolytes 417
Causes of Hyperthyroidism
Thyroiditis
Hashimoto
Drug overdose thyroiditis
Thyroid hormone Initially hyperthyroid
followed by
hypothyroidism
Secondary and
Other Causes of
Drugs & Pituitary
Medications Hyperthyroidism adenoma
Iodine
Amiodarone
Radiation
thyroiditis
Metastatic
Teratoma thyroid cancer
Symptoms
Signs
Cardiopulmonary
Constitutional
Fever
May have
hyperthermia
Neuropsychiatric
Medications &
DKA
Drugs
Withdrawal of
thyroid meds
Intentional ingestion
of thyroid meds Thyroid storm
MI
precipitants
Iodine
administration
Eclampsia CVA
Idiopathic PE Surgery
Up to 25%
Endocrine/Metabolic/Electrolytes 419
Infection and
Sepsis
DDx
Malignant
Psychosis
hyperthermia
Organophosphate Neuroleptic
poisoning malignant syndrome
Amphetamines
Cocaine
420 B. Desai
If considering Thyroid
Graves disease antibody titers
Primary
High TSH
hyperthyroidism
Secondary
Low TSH
hyperthyroidism
Normal T3
Low TSH OR Free T3
Free T4 Thyrotoxicosis
Other common
May have low
laboratory Hypercalcemia Hyperglycemia Elevated LFT’s
cholesterol
findings
Endocrine/Metabolic/Electrolytes 421
Treatment
Consideration Block peripheral Block thyroid Block thyroid Treatment of
Supportive
of Thyroid thyroid hormone hormone precipitating
care
Storm? hormone effects synthesis release factors
Correction of
Supportive care Fluids Steroids electrolyte
imbalances
Decrease
conversion of T4
to T3
Block peripheral
Beware β-blocker
thyroid hormone Propranolol
contraindications!
effects
Also inhibits
peripheral
conversion of T4
toT3
Block thyroid
hormone PTU OR Methimazole
synthesis
Also inhibits
peripheral
conversion of T4
toT3
Block thyroid
Iodine
hormone release
Disposition
Thyroid
Admission
storm
422 B. Desai
Apathetic Thyrotoxicosis
Hallmarks of
Slowed Lethargy and Apathy and
Apathetic
mentation weakness depression
Thyrotoxicosis
Adrenal Hormones
Feedback
inhibition
Gonadcorticoids
Estrogen & Testosterone
Corticotropin
releasing factor
(Hypothalamus) Renin-
Angiotensin Serum K+
system
Responds to
Hyperkalemia
changes in
increases
volume,
ACTH Diurnal secretion
posture,Na
Pituitary rhythm intake
Higher in am
Lower in pm
Adrenal
Adrenal gland gland
Cortisol Aldosterone
424 B. Desai
Primary
Adrenal gland
Adrenal
hormone 2 types
Insufficiency
production
Secondary
Primary Cortisol
Dysfunction of
Adrenal Addison disease and
adrenal gland
Insufficiency Aldosterone
Adrenal hemorrhage
Idiopathic
or infarction
Meningococcal sepsis
Infiltrative
Infection
Most common diseases
TB infectious cause Amyloid
worldwide
Fungal Sarcoid
Bacterial sepsis Lymphoma
Most common
HIV infectious cause Hemachromatosis
in the US Causes of Metastasis
Primary Adrenal
Insufficiency
Medications
Etomidate
Autoimmune
Congenital
Congenital adrenal
hypoplasia
Endocrine/Metabolic/Electrolytes 425
Infection Infiltrative
diseases
TB
Amyloid
Fungal
Sarcoid
Meningitis
Lymphoma
HIV
Hemachromatosis
Causes of Metastasis
Secondary Adrenal
Medications Insufficiency
Most common
Steroids cause overall
Causes adrenal
“Tertiary” atrophy
Pituitary Pituitary
Hypothalamic
Trauma to head
426 B. Desai
Primary
Cortisol deficiency
May be marked
Aldosterone deficiency
No aldosterone
Secondary
deficiency symptoms
Diagnosis of Adrenal High index of Especially in those with Those with predisposing
Insufficiency suspicion unexplained hypotension features
Primary adrenal
Hyperkalemia Hyponatremia Hypoglycemia
insufficiency
Other common
Metabolic
laboratory Hypoglycemia Eosinophilia
acidosis
findings
Due to cortisol Due to hypotension Chronic
deficiency & hypovolemia insufficiency
Looking for
Cortisol ACTH Other laboratories and
Consider precipitating
level stimulation test imaging as needed
factors
Treatment
Consideration of Treatment of
Supportive
Adrenal Steroids precipitating
care
Insufficiency? factors
IVF = D5NS Hydrocortisone Dexamethasone
Hypotension or Consider
Steroids
shock? Vasopressors
Due to underlying
High mortality Dysrhythmias Shock
precipitant
Hyperkalemia
428 B. Desai
Disposition
Adrenal
Admission
crisis
Cushing’s
Cortisol
Syndrome
Prolonged steroid
use
Most common
Pituitary
adenoma
Hypertension Hirsuitism Truncal obesity Buffalo hump Purple striae Moon facies Edema
On abdomen
Endocrine/Metabolic/Electrolytes 429
Common
laboratory Hypernatremia Hyperglycemia Glucosuria
findings
Due to cortisol Due to hypotension Chronic
deficiency & hypovolemia insufficiency
Treatment
Disposition
Depends on
Hyperadrenalism
clinical scenario
Pheochromocytoma
Introduction
Diagnosis
Consideration of
24 hour urine Catecholamines VMA
Pheochromocytoma?
Metabolites
Depends on
Disposition
clinical condition
ADH-Related Diseases
Antidiuretic Hormone
Feedback
inhibition
Brain
Heart
ADH produced
(Hypothalamus)
Well hydrated?
Pituitary
secretes ADH
Restoration of
plasma volume and
tonicity
Increases renal
water absorption
Endocrine/Metabolic/Electrolytes 431
Inappropriately
SIADH concentrated Hyponatremia Normovolemia
urine
Low serum
osmolality
CNS disease
Trauma
CVA
Infection
CNS
Pneumonia TB or Fungal
Malignancy
Medications &
Some causes of
Drugs CNS
SIADH
Chlorpropramide Hypothalamic
Diuretics
Vasopressin
Vincristine
Cyclophosphamide
Thioridazine
Cisplatin
Stress
432 B. Desai
Consideration of Treatment of
SIADH? Supportive care precipitating
factors
Hyponatremia
Central Pontine
corrected too
Myelinolysis
rapidly
Other
Other risk factors
Alcoholism electrolyte Malnutrition
for CPM
imbalances
Failure of central
Diabetes Urine
or peripheral ADH
Insipidus response production
Diabetes
Insipidus
Nephrogenic Kidneys are unresponsive to ADH
CNS disease
Neoplasms
Head Trauma
Granulomas
Endocrine/Metabolic/Electrolytes 435
Renal disease
Hematologic
Malnutrition
disorders
Electrolyte
Disturbances
Hypercalcemia
Hypokalemia
Hypocalcemia is frequently
seen in patients with
hypernatremia
Sodium
Introduction: Hyponatremia
Primarily Concentration
Sodium
extracellular 140 mEq/L
Concentration
Hyponatremia <135 mEq/L
Hyponatremia
These Sx can be
Late seen with an acute
(<24 h) drop in Na+
Chronic
Diagnosis + Treatment
Most
Movement of Intracellular Extracellular common
Osmolality From To
water space space cause is
Hyperglycemia
>295
Normal No treatment
Pseudohyponatremia
Osmolality required
275–295
Replace fluids
Hypovolemic Small boluses
with NS
Assess Volume Correct Water
Osmolality Euvolemic Furosemide
Status underlying cause restriction
If Na <120
<275 Measure urine Salt & Water
Hypervolemic sodium restriction
Causes of Hyponatremia
Hypertonic
hyponatremia
Osm > 295
Hyperglycemia Hyperglycemia
Glycerol therapy For every 100
mg/dL increase in
Mannitol therapy glucose, the Na+
decreases by 1.6–1.8
mEq/L
Some causes of
Hyponatremia
Isotonic
hyponatremia
Osm 275–295
Hyperlipidemia
Hyperproteinemia
Endocrine/Metabolic/Electrolytes 439
Hypovolemic
Renal
Diuretics
Nephropathy
Osmotic diuresis
Aldosterone
deficiency
Extra-Renal
GI loss Hypervolemic
3rd spacing
Urine Na+ > 20
Sweating mEq/L
Euvolemic
Renal Failure
SIADH
Urine Na+ < 20
Hypothyroidism mEq/L
Water intoxication Nephrotic syndrome
Medications Cirrhosis
CHF
Introduction: Hypernatremia
Concentration
Hypernatremia >150 mEq/L Increases Thirst
Decrease in Decreased
Increased intake
Hypernatremia Due to total body OR excretion of
of sodium
water sodium
Volume loss a
common etiology
440 B. Desai
Inadequate water
intake
Ingestion of large
amount of Na+
Burns
Iatrogenic
Essential
hypernatremia
Mineralocorticoid
Causes of excess
Hypernatremia
Medications &
Drugs Glucocorticoid
excess
Renal disease
Nephrogenic
Diabetes Insipidus
Central Diabetes
Insipidus
Hypernatremia Symptoms
Treatment
Potassium
Introduction: Hypokalemia
Most located in
Potassium muscle tissue
Serum levels
Concentration
Hypokalemia determine
<3.5 mEq/L
complications
Causes of Hypokalemia
Decreased
dietary intake
Alkalosis Vomiting
β-agonists Malabsorption
NG suctioning
Causes of
Medications &
Drugs Hypokalemia
Renal loss
Lithium
Diuretic therapy
Penicillin
1°& 2°
Aldosteronism
Osmotic diuresis
Hypo-Mg
Renal tubular
acidosis
Heat stroke /
Sweat loss
Diagnosis + Treatment
Intravenous
Hypokalemia? Oral replacement
replacement
Introduction: Hyperkalemia
Causes of Hyperkalemia
Pseudohyperkalemia
Hemolysis
Extracellular
shifts Potassium load
Acidosis Supplementation
b-blockers GI bleed
Rhabdomyolysis
Causes of
Medications &
Drugs Hyperkalemia
Succinylcholine
Leukocytosis
Renal tubular
Lupus
acidosis
Low Aldosterone
444 B. Desai
Diagnosis + Treatment
Continuous
Hyperkalemia? EKG cardiac Recheck sample
monitoring
Assess for If no EKG changes
dysrhythmias and pt is stable
Ca Chloride 3 times as
Cell membrane Calcium gluconate
Beware Digitalis potent as Ca Gluconate
stabilization or chloride
Ca Potentiates
digoxin’s toxic Consider administering Ca
cardiac effects Chloride via central venous
access
Albuterol
Intracellular shift Insulin + Glucose Bicarbonate
(b-agonist)
Sodium
Removal of excess
polystyrene Furosemide Hemodialysis
K+
sulfonate
Endocrine/Metabolic/Electrolytes 445
Calcium
Introduction: Calcium
Maintained Parathyroid
Calcium Calcitonin Vitamin D
by hormone
Increased Increased
PTH Increased GI
Hypocalcemia? bone resorption
secretion absorption
resorption by kidney
Acidosis
Also affected
Calcium Acid Base status Increases
by
ionized fraction
446 B. Desai
Introduction: Hypocalcemia
Normal ionized
Ionized level
Hypocalcemia level = 2.1–2.6
<2.0 mEq/L
mEq/L
Depends on the
Hypocalcemia < 1.4 –1.6
Start at rapidity of the
Symptoms mEq/L
decrease in Ca
Mouth twitch
Chvostek’s sign after tapping
the facial nerve
Causes of Hypocalcemia
Sepsis
Increased Decreased
excretion absorption
Renal failure Vitamin D deficiency
Diuretics
Endocrine
Medications & disorders
Drugs Hypoparathyroidism
Phosphates Causes of Pseudo
Phenytoin & Hypocalcemia hypoparathyroidism
Phenobarbital
Cimetidine
Acute
Heparin Pancreatitis
Glucagon
Norepinephrine
Hypomagnesemia
Glucocorticoids
Sodium
nitroprusside
Magnesium sulfate Rhabdomyolysis
Low Aldosterone
Diagnosis + Treatment
Mild or
Asymptomatic Oral calcium Vitamin D
Hypocalcemia?
IV calcium should
Severe Causes be used with
IV calcium
Hypocalcemia? vasoconstriction caution in patients
taking digitalis
Potentiates
digitalis toxicity
Replace Mg
Hypocalcemia Hypomagnesemia before or with
calcium
Introduction: Hypercalcemia
More common in
ED
Endocrine/Metabolic/Electrolytes 449
Causes of Hypercalcemia
Malignancy
Squamous cell-
Lung
Fungal Infection Endocrine
Breast 1°
Histoplasmosis
Hyperparathyroidism
Kidney
Coccidioidomycosis Pheochromocytoma
Leukemia
Hyperthyroidism
Myeloma
Thiazides
Lithium
Paget disease of
Sarcoidosis
bone
Tuberculosis
Weakness &
Polydipsia Stupor & apathy Headache EKG changes Reflexes & tone Confusion
malaise
Shortened QT
Abdominal
Anorexia N/V Constipation
pain
Peptic ulcer
Pancreatitis Renal failure
disease
Diagnosis + Treatment
Severe
Dialysis
Hypercalcemia?
Magnesium
Introduction
Introduction: Hypomagnesemia
Level <1.5
Hypomagnesemia
mEq/L
Severe
Frequently With With
Hypomagnesemia Alcoholics Malnourished vomiting or
seen in pancreatitis cirrhosis diarrhea
Endocrine/Metabolic/Electrolytes 451
Causes of Hypomagnesemia
Sepsis
Potassium
Severe Diarrhea
depletion
Medications &
Drugs Severe burns
Loop diuretics
Causes of
Alcohol Hypomagnesemia Acute
Pancreatitis
Aminoglycosides
Ketoacidosis Alcoholism
1° or 2°
Malnutrition
Aldosteronism
Hyperparathyroidism Malabsorption
Hyperthyroidism
Diagnosis + Treatment
Severe
IV/IM magnesium
Hypomagnesemia?
Introduction: Hypermagnesemia
Ingestion of
Most common Magnesium
Hypermagnesemia Renal failure
cause containing
medications
Causes of Hypermagnesemia
Renal Failure
Acute or chronic
Other Hypercalcemic
Untreated DKA
states
Treatment of
preeclampsia or
eclampsia
Medications &
Drugs
Mg - containing Rhabdomyolysis
Causes of
medications
Hypermagnesemia
Lithium ingestion
Adrenal
insufficiency
Hyperparathyroidism Malnutrition
Hypothyroidism
Endocrine/Metabolic/Electrolytes 453
Respiratory
Nausea Drowsiness Hypotension Heart Block reflexes Cardiac arrest
depression
Diagnosis + Treatment
Hyperkalemia Hypercalcemia
If no renal failure
Phosphorus
Introduction
Measured serum
Intracellular Hydroxyapatite
Phosphorus level
(15 %) (85 %) 2.5–5.0 mg/dL
Inversely 30 – 40
Phosphorus Calcium Calcium Phosphorus
proportional mg/dL
Proportional
Phosphorus Dietary intake
to
Lowers PO4 by
increasing renal
excretion
454 B. Desai
Introduction: Hypophosphatemia
Normal ionized
Hypophosphatemia Unusual level = 2.1 – 2.6
mEq/L
Specifically 12–
Hypophosphatemia
Start at < 1.0 mEq/L 24 hours after
Symptoms
DKA treatment
Causes of Hypophosphatemia
Redistribution Decreased GI
with glucose absorption
infusion
Alkalosis
Medications & Causes of
Metabolic
Drugs Hypophosphatemia
Respiratory
Antacids
Hyperalimentation
DKA treatment
Increased renal
excretion
Renal tubular
Hyperparathyroidism
defects
Malignancy
associated with
hypercalcemia
Hemolytic Impaired
Tremors Rhabdomyolysis CHF
anemia platelets
Endocrine/Metabolic/Electrolytes 455
Diagnosis + Treatment
Oral
Severe
IV Phosphate
Hypophosphatemia?
Lower total
Hypercalcemia Hypophosphatemia replacement of
Phosphate
Introduction: Hyperphosphatemia
Usually seen in
Hyperphosphatemia patients with
renal failure
Hyperphosphatemia Concomitant
Due to Hypomagnesemia Hypocalcemia
Symptoms renal failure
Causes of Hyperphosphatemia
Hypoparathyroidism
Increased Increased
phosphorus intake Vitamin D
Problems
associated with
hypercalcemia
456 B. Desai
Diagnosis + Treatment
Oral
Oral phosphate
Hyperphosphatemia? IV Fluids Acetazolamide binders
Severe
Hyperphosphatemia? Dialysis
Metabolic Derangements
Introduction
pH changes 0.01
Plasma H+ 40 nmol/L pH of 7.4 Thus
of 0.01 nmol /L H+
Increased production
Acidosis Increase in H+
H+ addition
Decreased excretion
Alkalosis Decrease in H+
Will have
Acid-Base compensatory
Respiratory OR Metabolic
Disorders mechanisms to limit
pH changes
1° changes in Will NOT return pH
1° changes in PCO2
HCO3 to normal
Endocrine/Metabolic/Electrolytes 457
Medications
Vomiting
Liver
Evaluate specific
organs involved in
Kidneys
maintaining acid-
base status
Lungs
Laboratory Investigations
Sodium
There is a good
“Chem 7” Arterial
Potassium correlation
or (or venous) blood between pH/CO2
Basic metabolic gases
Specific chemistry Chloride in arterial &
panel
laboratories venous samples
Bicarbonate Except in
Lactate level severe shock
Serum osmolality
Potassium and pH
Low or normal K+
For every 0.1 decrease in
In acidosis Severe intracellular K+
pH, K+ increases by 0.5
depletion
mEq/L
Metabolic Acidosis
Anion Gap
Relies on principal of
electrical neutrality
Chloride
Chloride
Bicarbonate
Lactic
Anion Gap 30 Usually OR DKA
acidosis
Hypomagnesemia Myeloma
High Low
Bromide
Hypermagnesemia
intoxication
Hypokalemia Hypocalcemia
Hypoalbuminemia
Endocrine/Metabolic/Electrolytes 459
A Aspirin Ingestion
T Toluene Toxic
M Methanol Ingestion
D DKA Ketoacidosis
S Salicylates Ingestion
Metabolic Acidosis
Exogenous Endogenous
Metabolic
increase in OR increase in OR Loss of HCO3 -
acidosis
acid acid
DKA Vomiting
Loss of HCO3-
Exogenous TPN Endogenous
Enterocutanous Renal tubular
fistulas acidosis
AKA
Decreased Stimulation
Metabolic Increase in
acidosis HCO3- Increased H+ of respiratory
ventilation
centers
Attempt to
lower H+ by
lowering PCO2
Lowest PCO2 in
spontaneous
respiration is 12
mm Hg
460 B. Desai
Lactic Acidosis
Seizures
Liver failure
Toxic alcohols
Sepsis
Myeloma
Hypoperfusion Lymphoma
Leukemia
Ethanol
Usually mild
Endocrine/Metabolic/Electrolytes 461
D Diarrhea
Other causes
Effects of Acidosis
Decreased systemic
Kidney Decreased perfusion
blood pressure
Increased pulmonary
Lungs vascular resistance
Treatment
Restore tissue
Correct underlying
Metabolic Acidosis? perfusion and
disorder
oxygenation
Correct
Poor respiratory
respiratory
compensation?
disorder first
No Bicarbonate
therapy for mild to
moderate acidosis
Metabolic Alkalosis
Introduction
Metabolic
alkalosis Gain of HCO3- OR Loss of acid
Chloride
Decrease Decrease in Increased Increased Na+ Increased
sensitive reabsorption +
of extracellular aldosterone HCO3-
metabolic
Chloride volume activity K+ & H+
alkalosis generation
secretion
Urine Cl- is
low
Chloride
Hypokalemic,
sensitive Responds to
Hypochloremic
metabolic normal Saline
Alkalosis
alkalosis
Chloride
Normovolemia Increased Urine Cl- is No
insensitive
or aldosterone normal or response
metabolic Hypervolemia activity elevated to NS
alkalosis
Also with
HTN
Endocrine/Metabolic/Electrolytes 463
Chloride
Chloride Sensitive
Insensitive
Diarrhea Adrenal
Diuretics Cushing syndrome
hyperplasia
Exogenous
mineralocorticoids
Chloride-wasting
processes Licorice
Enteropathies
Cystic fibrosis
Effects of Alkalosis
Decreased coronary
Cardiac blood flow
Refractory dysrhythmias
Decreased Neuromuscular
Neuro cerebral perfusion Seizures Tetany
instability
Treatment
Correct underlying
Metabolic Alkalosis? Supportive care Acetazolamide
disorder
Respiratory Acidosis
Introduction
Head trauma
Respiratory
Oversedation Chest trauma
Acidosis
Lung Disease
COPD
May be chronic
Treatment
Respiratory Improve
acidosis? ventilatory status Supportive care
Respiratory Alkalosis
Introduction
Infections
Sepsis
CVA
Respiratory
Anxiety Alkalosis
Hypoxia
Pain Pregnancy
Toxic overdose
Salicylates
Treatment
Introduction
Determined
Osmolal Gap by Sodium Chloride BUN Glucose
Presence of
unmeasured
Osmolal Gap Indicates
low molecular
weight solutes
Ethanol
Osmolal Gap
precipitants
Glycerol Methanol
Isopropyl alcohol
Ears, Nose, and Throat
Bobby Desai
Contents
Ear 468
Nose 478
Facial Fractures 482
Throat/Neck/Upper Airway Infections 484
Dental Emergencies 490
Neck Masses 494
Edema of Upper Airway 496
Soft Tissue Lesions 497
Intraoral and Tongue Lesions 499
Salivary Gland Disorders 501
Facial Infections 503
Other ENT Emergencies 504
Vertigo 508
Ear
Introduction: Otalgia
Infections
Otitis media
Otitis externa
Mastoiditis
Bullous myringitis
Primary Causes
of Otalgia
Dental infections
Neck Trigeminal
Some Referred neuralgia
Foreign body Causes of Otalgia
Thyroid disease
Ears, Nose, and Throat 469
Introduction: Tinnitus
Objective Heard by
tinnitus examiner
Antibiotics
Aminoglycosides
Aspirin
Refer to
Diagnosis
Otolarynogologist 1st sign of
toxicity
Conductive
Bone conduction Air conduction
hearing loss
Infections
Mumps
Intrinsic ear Herpes Family Rheumatologic
disorders
Syphilis
Otitis media Temporal arteritis
TM rupture Wegener’s
Cerumen impaction
Foreign bodies
Causes of
Sudden Hearing Medications &
Loss Drugs
Meniere’s disease
Acoustic
Hematologic
neuroma
Associated with Sickle cell disease
other CN deficits Leukemia
5, 7
Polycythemia
Hyperlipidemia
DM
Ears, Nose, and Throat 471
Alcohols
Ethanol
Propylene glycol
Antibiotics Salicylates
Aminoglycosides Aspirin
Vancomycin
Erythromycin
Medications &
Drugs Causing
Sudden Hearing
Loss
Chemotherapy NSAID’s
Ear Infections
Perichondritis
Pinna deformation
Complication
if not treated
472 B. Desai
Immune
Fungal agents Humid climates Aspergillus Candida
compromised
Contact
Noninfectious
dermatitis
Center right image (Reprinted from Önerci TM. External ear canal. In: Önerci TM, editors. Diagnosis in otorhinolaryngology: an illustrated
guide. Heidelberg: Springer Verlag; 2010. p. 18–23. With permission from Springer Verlag)
Malignant Otitis Life threatening Infection Soft tissue May extend Pseudomonas
Involves
externa of external auditory canal around the pinna into the skull > 90 % of time
Chondritis of Osteomyelitis of
Pathophysiology Simple OE Cellulitis of EAC
outer ear bone
Predisposing Immune
Diabetics Elderly
factors suppressed
Specifically
Diagnosis? CT of head
Temporal bone
Otalgia
May be severe
Evidence of
Headache
granulation tissue
in the EAC
Erythematous ear
Fever
Pustular drainage
Pain on
Sigmoid sinus
manipulation of
thrombosis
ear
Parotitis may be
CN deficits
present
7, 9, 10, 11
474 B. Desai
PEDIATRICS
Bullous Myringitis
For concomitant
OM
Top right image (Reprinted from Önerci TM. Acute otitis media. In: Önerci TM, editors. Diagnosis in otorhinolaryngology: an illustrated guide.
Heidelberg: Springer Verlag; 2010. p. 28–33. With permission from Springer Verlag)
Ears, Nose, and Throat 475
Acute Mastoiditis
Specifically
Diagnosis CT scan
Temporal bone
Top right image (Reprinted from Önerci TM. Complications of otitis media. In: Önerci TM, editors. Diagnosis in otorhinolaryngology: an illus-
trated guide. Heidelberg: Springer Verlag; 2010. p. 43–4. With permission from Springer Verlag)
Cholesteatoma
Treatment? Surgery
476 B. Desai
Ear Trauma
Auricular Hematoma
Auricular Result from Shearing forces perichondrium Tears blood
Due to Hematoma
Hematomas ear trauma from underlying cartilage vessels
Cauliflower Ear
Formation of new Deforms
Cauliflower ear Asymmetric
cartilage following trauma external ear
Ears, Nose, and Throat 477
+ Bloody Conductive
Ear pain + Vertigo + Tinnitus
otorrhea hearing loss
Barotrauma
Early Referral Penetrating Posterior
(<24 hours) trauma perforation
Otitis media Blunt trauma
Late Referral
Blunt trauma Noise trauma Causes of Tympanic
(>24 hours)
Membrane
Perforation
Penetrating
trauma
478 B. Desai
Nose
Epistaxis
Agents & methods Direct pressure & topical Chemical cautery Thrombogenic
Packing
to control bleeding vasoconstrictors with silver nitrate foams & gels
Controlled
Anterior Bleed Stable Discharge
bleeding
Causes of Epistaxis
Local causes
Deviated septum
Hereditary Digital trauma Rhinosinusitis
hemorrhagic
telangiectasia Inhaled medications
Neoplasia
Chronic renal
failure
Alcoholism
Causes of
Epistaxis
Malignancy Hypertension
Coagulopathy
Warfarin
NSAID use
Hemophilia
Von Willebrand’s
Toxic shock
Otitis media
Sinusitis
Complications of
Posterior Packing
Airway
Arrhythmias
compromise
Cardiac ischemia
480 B. Desai
Nasal Fractures
Clinical exam is
Imaging Insensitive Unnecessary
the best indicator
CSF
Fracture of
CSF rhinorrhea Dx by CT scan
cribiform plate Blood
Intranasal
Septal Abscess?
drainage
Allergic Rhinitis
PEDIATRICS
Sinusitis – Introduction
Purulent nasal
Facial pain + Fever Facial pressure Ear pain Hyposmia
discharge
Sinusitis
PEDIATRICS
Treat for
Chronic sinusitis > 90 days Give for 4 weeks Refer to ENT
anaerobes as well
482 B. Desai
Facial Fractures
Frontal Bone High energy Assess for crepitus to evaluate Dx = CT (As for all
Uncommon
Fractures injury for frontal sinus injury facial fractures)
Depressed Frontal
IV Antibiotics Admission
Bone Fracture
Zygoma Anterior-lateral
fractures force
Midface Fractures
Midface LeFort
I, II, III Dx = CT
fractures classification
Pyramidal Hard palate & nose are Hardt, N., & Kuttenberger, J.
LeFort II
fracture free floating on exam (2010).Craniofacial trauma: diagnosis
and management. Springer. Fig 3.4, p.
33
Mandible Fractures
Tongue Assess in low Bite on tongue blade Blade breaks & Unlikely
Bedside testing
blade test risk patients while MD twists blade patient tolerates? fracture
95%
sensitive
Blood in mouth Open fracture
CT
Imaging? Panorex
(complicated injury)
No specific Consideration of
Viral pharyngitis Unless
testing infectious mononucleosis
Erythema of
Sore throat Odynophagia Fever Chills Headache N/V
tonsils & palate
Tonsillar Tender anterior No
exudate cervical nodes Uvular edema No rhinorrhea No cough conjunctivitis
Penicillin is 1st
Treatment Dexamethasone Rheumatic Fever can be prevented
line drug
with Abx treatment
With EBV + To relieve pain
ampicillin, 95% Glomerulonephritis cannot be
will get a rash prevented
Ears, Nose, and Throat 485
Single dose of
Treatment? I&D Antibiotics For pain
high dose steroid
Epiglottitis
PEDIATRICS
Airway Consider need for early Prepare for Prepare for needle
Complications
obstruction airway intervention cricothyrotomy in adults cricothyrotomy in children
Ears, Nose, and Throat 487
Retropharyngeal Abscess
PEDIATRICS
Cervical
Sore throat Fever Torticollis Dysphagia Neck pain Neck edema
adenopathy
CT scan
Diagnosis? Soft tissue X-ray
(Gold standard)
Ludwig’s Angina
Painful swelling of
Fever Dysphagia Odynophagia Poor dentition Dysphonia
submandibular area
Edema of Edema at floor Potential for airway
Voice changes Trismus
upper neck of mouth compromise
Necrotizing Infections
Extension of
Complications Mediastinum
infection
Croup
PEDIATRICS
Subglottic
Diagnosis Clinical Plain films Steeple sign
narrowing
Nebulized epinephrine
Treatment Oral steroids
(Racemic or L-epi)
Bacterial Tracheitis
PEDIATRICS
Bacterial Can cause life-threatening Often a secondary 5–8 years of Clinically similar
Tracheitis airway obstruction infection after viral URI age to epiglottitis
Hemophilus
Bacterial agents Staph aureus Strep
influenza
Diagnosis? Bronchoscopy
Dental Emergencies
Odontogenic Infections
Deep neck Most deep neck infections arise from Fascial layers of head & neck have
infection tidbits dental source (esp. mandibular teeth) potential spaces for spread of infection
Localized dental Pulpitis or dental Intermittent pain worse with Rx = root canal
pain caries extremes of temperature or extraction
Periapical Most common cause Inflammation & infection Can erode into
abscess of severe dental pain of apical aspect of tooth cortical bone
Infections of anterior
Spread to neck
mandibular teeth
Penicillin is 1st
Treatment Clindamycin OR Metronidazole I&D
line drug
Muscular injury
Complications Trismus Due to TMJ injury Infection
during anesthesia
Referral to dentist
Disposition?
within 24 hours
Post-extraction Displacement of
Bleeding clot
Firm pressure to Topical thrombin/ Cautery with Injection of Lidocaine with epinephrine
Treatment? OR
extraction site Gel foam silver nitrate may tamponade the bleeding
Ears, Nose, and Throat 491
Periodontal Pathology
Most common
Gum disease
cause of tooth loss
Periodontal Entrapment of plaque & other Severe gum Warm saline Antibiotics &
abscess debris in the periodontal pocket pain rinses analgesia
Penicillin is 1st
Treatment Clindamycin OR Metronidazole I&D
line drug
Trench Caused by: Spirochetes Can be very May spread from gums to
ANUG
mouth & Fusobacteria destructive tissues of face to facial bones
Pseudomembrane
Lymphadenopathy
formation
Gingival Hyperplasia
Phenytoin
Medications
causing Calcium channel
Cyclosporine
gingival blockers
hyperplasia
Ellis Fractures
Dental Trauma
Higher incidence
Treatment Analgesia Soft diet Dental referral
of pulpal necrosis
Neck Masses
Neck
PEDIATRICS
75% of lateral neck masses present Most common cause of unilateral neck
In adults > 40
for > 6 weeks are malignant mass is squamous cell carcinoma
Reactive
Hemangioma lymphadenopathy
Rhabdomyosarcoma
Reactive
Metastatic cancer
lymphadenopathy
Lymphoma
Mononucleosis Tuberculosis Lymphoma
(Hodgkin’s)
PEDIATRICS
Branchial Cleft Congenital epithelial cyst on the lateral part of the neck due to
Cysts failure of obliteration of the second branchial cleft
PEDIATRIC
Usually
asymptomatic mass Soft & mobile Bluish hue
Larynx Trauma
Clothesline Motorcycle, ATV, Crushes thyroid May cause immediate Tracheostomy required
injury Football cartilage asphyxiation in these patients
Anterior neck
Hoarseness Dysphagia Stridor Dyspnea Cough Hemoptysis
pain
Subcutaneous Vascular injury = expanding
Aphonia Apnea hematomas, bruits, pulse deficits
emphysema
Diagnosis? CT scan
Angioedema
ACE inhibitor
Epinephrine H1 blocker H2 blocker Steroids
treatment
Uvular Edema
Quincke’s
Uvular Edema
edema
Candidiasis
HIV
Predisposing
factors for
Dentures Malnourished
Candidal state
infection
Extremes of age
HSV infections
To promote
Treatment Analgesia Acyclovir OR Valacyclovir
hydration
Painful vesicles on
GU pathologies
anus & genitalia
Congenital
Complications Part of TORCHES Encephalitis
transmission
498 B. Desai
Aphthous Stomatitis
Herpangina
PEDIATRIC
1–2 mm oral
High fever Sore throat Headache Malaise Dysphagia Vomiting
vesicles
Vesicle Posterior
Tonsils Soft palate Uvula
appearance pharynx
Leukoplakia
Candidiasis
Alcohol
Tertiary syphilis
Predisposing
factors for
Leukoplakia
Trauma Tobacco
UV radiation HPV
Strawberry Tongue
Antibiotics for
Treatment
Group A Strep
500 B. Desai
Oral Cancer
Fixed lesions to
Lymphadenopathy
surrounding tissue
Candidiasis
HIV Alcohol
Predisposing
factors for Oral
cancer Tobacco
HPV (esp. chewing)
Chronic iron
Excessive sunlight
deficiency
exposure
anemia
Ears, Nose, and Throat 501
PEDIATRIC
No pus from
Mumps
Stensen’s duct
Treatment Supportive
Orchitis in 20–
Complications Pancreatitis Myocarditis Polyarthritis Meningitis
30 % males
502 B. Desai
Suppurative Parotitis
Post- Chronic
Risk factors Medications Dehydration Sialolithiasis
operative illness
Imaging U/S OR CT
Sialolithiasis
Predisposition to
Diabetes Dehydration
sialolithiasis
Facial Infections
Facial Cellulitis
Removal of
Treatment Analgesics Antipyretics Antibiotics
inciting factors
Erysipelas
Streptococcus pyogenes
Erysipelas
is most common
Bullous 50 % caused by
More severe form
erysipelas MRSA
Treatment Antibiotics
504 B. Desai
Impetigo
Not prevented
Complication Glomerulonephritis
by antibiotics
Post-tonsillectomy Bleeding
Airway Hemorrhagic
Complications
obstruction shock
Ears, Nose, and Throat 505
Trigeminal Neuralgia
Referral to
Treatment Carbamazepine
neurologist
Causes of Trismus
Dystonia
Hypocalcemia
Tetanus
Abscess
Ludwig’s angina
Peritonsillar
abscess
506 B. Desai
Toxic
Chemosis Ptosis Eyelid edema Facial edema Proptosis Fever appearance
Decreased
visual acuity Headache
Diagnosis CT or MRI
Triad
Head or neck infection +
ophthalmoplegia + venous
Emergent ENT obstruction
Treatment IV antibiotics
consultation
Oculomotor Pituitary
Complications Blindness Hemiparesis
weakness insufficiency
Ears, Nose, and Throat 507
PEDIATRICS
Airway Foreign Most occurs 1–3 Must consider AFB in young Sudden coughing &
Body years of age child with respiratory Sx choking
May be Decreased
Stridor Hoarseness U/L wheezing
asymptomatic breath sounds
Vertigo
Introduction
Caused by
Central vertigo Cerebellum Brainstem
central disorders
May not necessarily
be distinct
Peripheral Disorders affecting Vestibular
vertigo 8th cranial nerve system
Central Peripheral
Tinnitus No Possible
TM No Possible
Tinnitus Nausea/Vomiting
Symptoms of
Peripheral
Vertigo
Photophobia
Diplopia
Visual Symptoms of
Dysarthria
abnormalities Central Vertigo
Headache
510 B. Desai
Peripheral Vertigo
Precipitated by
BPPV
head turning
Dix-Hallpike
Diagnosis
maneuver
No hearing problems
BPPV
or tinnitus
Particle repositioning
Treatment Medications
maneuvers
Bottom right image (Reprinted from Önerci TM. Vertigo. In: Önerci TM, editors. Diagnosis in otorhinolaryngology: an illustrated guide.
Heidelberg: Springer Verlag; 2010. p. 54–6. With permission from Springer Verlag)
Ears, Nose, and Throat 511
Meniere’s Disease
Salt restricted
Treatment Medications
diet
Vestibular Neuronitis
Vestibular
Last several days Does not recur
Neuronitis
Treatment Symptomatic
512 B. Desai
Perilymph Fistula
Opening in Allows pneumatic changes to be
Perilymph Fistula
round window transmitted to the vestibular system
Nystagmus with
Diagnosis Hennebert’s sign
pneumatic otoscopy
Labyrinthitis
Infection of Associated with Bacterial etiology as a
Labyrinthitis Viral in etiolgy
labyrinth measles & mumps sequelae of otitis media
May be caused by
Labyrinthitis
ototoxic medications
Treatment Symptomatic
Complications of
Meningitis
bacterial labyrinthitis
Ears, Nose, and Throat 513
Referral to
Treatment
neurosurgeon
Cerebellopontine Acoustic
Meningiomas Dermoids
Angle Tumors neuromas
Referral to
Treatment
neurosurgeon
Treatment of
Symptomatic
Post Concussive
514 B. Desai
Central Vertigo
Neurosurgical
Treatment
evaluation
Wallenberg Syndrome
Wallenberg Lateral medullary Vertigo is part of
Syndrome infarction of the brainstem the syndrome
Emergent neurosurgical
Treatment
consultation
Ears, Nose, and Throat 515
Vertebrobasilar Insufficiency
Vertebrobasilar TIA of the May cause Usually resolve
Insufficiency brainstem vertigo within 24 hours
Neurology
Treatment
consultation
Unilateral Horner’s
Symptoms Vertigo Headache
syndrome
Diagnosis CT/MRI
Multiple Sclerosis
Multiple Due to May lasts for Does not usually
sclerosis demyelination hours to weeks recur
Diagnosis MRI
Neurology Consider
Treatment
consultation steroids
516 B. Desai
Migraine-Related Vertigo
Migraine Related May be a symptom Develops over 5–20 min Does not usually
Vertigo of the aura and diminishes in 1 hour recur
Decreased Visual
Basilar migraine Vertigo
hearing disturbances
May have
Other symptoms Dysarthria Diplopia
decreased LOC
Contents
Bites and Envenomations 518
Dysbarism 526
Electrical Injuries 531
High-Altitude Illness 535
Submersion 538
Temperature-Related Illness 540
Radiation 548
Biological Weapons 548
Chemical Weapons 552
Tetanus 554
M.R. Marchick, MD
Department of Emergency Medicine,
University of Florida College of Medicine, Gainesville, FL, USA
B. Desai, MD, MEd (*)
Department of Emergency Medicine, University of Florida,
Gainesville, FL, USA
e-mail: [email protected]
Bees/Wasps
Majority within May occur up to 6 May recur 8–12 hours Most severe
Anaphylaxis? But…
15 minutes hours afterwards after initial reaction reactions occur early
Immediately Infection is
Stinger present? Wash area
remove stinger uncommon
Oral Elevation if
Local reactions NSAIDs Ice
antihistamine significant edema
Continued
IV crystalloids Pressors
hypotension?
Severe
ICU admission
anaphylaxis?
Typical Occasionally
resolution 8–12 hours
2–3 days
Severe Latrodectus
Pregnant Children Refractory HTN neurologic sx antivenin
Primarily south-
Brown Recluse central US
Several hours
Local Sx Bull’s eye lesion Local pain after bite
Usually due to
Systemic Sx F/C N/V Malaise Petechiae hypersensitivity reactions
Liver failure
Severe Sx Renal failure (Jaundice) DIC
Mammalian Bites
Bites: Introduction
Copious irrigation
Immune
compromised
Wounds requiring
surgical repair Cat bites
Treat
uninfected
wounds
Rabies
Raccoons
Most common
reservoir in US
Skunks
Rats
Domesticated Mice
rabbits
Hamsters Squirrels
No prophylaxis
Gerbils
Rabies Vaccination
Immunize
Suspect rabies?
immediately
Rabies
Days 0, 3, 7, 14
vaccination
Rabies
#1 cause
Incubation
20–90 days
period
Prodrome
phase 1–7 days Fever Malaise Dyspnea Flu-like Sx
Hydrophobia Aerophobia
Cat scratch Region of painful, Flu–like Rare severe multi- Generally self-
disease matted lymph nodes symptoms system involvement limited
Dog Bites
Most common
Pasteurella Streptococcus Staphylococcus Anaerobes
organisms
Capnocytophaga Encapsulated
canimorsus bacterium
Alcoholics
Immune Sepsis Renal failure
Capnocytophaga Post-splenectomy May lead to
canimorsus compromised pt DIC Death
Immunosuppressant
Marine Envenomation
Jellyfish Stings
Wash area with Fresh water may cause
Jellyfish Stings Increases pain
sea water discharge of nematocysts
Stingray Stings
Barbed wire Causes Followed by
Stingray stings
apparatus laceration envenomation
Local injury Local pain Nausea Flushing Sweats Diarrhea Muscle cramps
Deactivates the
ED treatment Hot water
toxin
Snake Bites
Snake Envenomation
Water
Pit Vipers Rattlesnakes Copperheads
moccasins
Worsening
Local Pain Edema Ecchymosis
symptoms
Any Treat with
Systemic AMS Hypotension Tachycardia Paresthesias
Sx antivenom
Initial dose 4–6 Give additional if local Additional 2 vials 6,12,18 hours
Antivenom
vials IV control not achieved after local control achieved
Dysbarism
Introduction
Descent
Can lead to
nystagmus/
vertigo Pressure on TM
from water in ear
Due to caloric canal increases
stimulation
Occlusion
Increased pain
Antibiotics if TM
Treatment No diving Decongestants
rupture
Environmental Emergencies 527
Descent
Pressure on TM
Symptoms begin from water in ear
canal increases
Descent
Preexisting
Bloody otorrhea blockage of
external auditory
canal
Barotitis Externa (e.g., cerumen)
Increased pain
Air in canal not
replaced by water
Increased
pressure with
descent
Sinus Barotrauma
Descent
Sinus Barotrauma
No air entry to
equalize pressure Due to polyps or
during descent congestion
Barotrauma of Ascent
Middle ear
barotrauma of
ascent
Sinus barotrauma
Barodontalgia
of ascent
Related Conditions
Decompression Pulmonary
Sickness (DCS) barotrauma
GI pain
Pneumomediastinum
Alveolar
hemorrhage
Environmental Emergencies 529
Pulmonary Barotrauma
Arterial Gas Damage to Air entry into Embolize to Symptoms develop within
Embolism pulmonary vein systemic circulation any site 10 minutes of surfacing
Coronary
Arterial Gas Sudden arteries
Embolism occurrence of Sx Cerebral
arteries
Retinal
arteries
Myocardial
infarction
If embolizedto
coronaries
Nitrogen Narcosis
Decreased Decreased
Euphoria Confusion Disorientation
judgment motor control
Decompression Sickness
Musculoskeletal Cutaneous
DCS Type 1
symptoms symptoms
Cardiovascular
DCS Type 2 CNS symptoms
symptoms
Immediate needle
Pneumothorax Thoracostomy
if tension PTX
Rapid recompression
DCS 100 % O2
with hyperbaric O2
Nitrogen washout
Environmental Emergencies 531
Recompression Therapy
Electrical Injuries
Introduction
Electrical Injuries High voltage > 1000 Volts Low voltage <1000 Volts
Electrical Injuries
Cardiac
dysrhythmias
Cataracts Rhabdomyolysis
Compartment
syndrome
Can occur with < 1
second exposure
if high-voltage
Observe 6 hours
< 600 Volts AC Any symptoms OR EKG abnormality
(or longer)
Lightning Injury
Current delivered
Ground current Ground is struck
across ground
Heat causes
Thermal burns Sweat OR Clothes burning
sweat to steam
Immediate
Apnea
cause of death?
Lightning Injuries
Asystole
Most common
cause of death
Neurologic injury Ruptured TM
LOC
Respiratory arrest
Amnesia
Peripheral nerve
damage Cataracts
Immediate or
Keraunoparalysis
delayed
Transient flaccid
paralysis Lightning
Injuries Burns
Linear
Ocular trauma
Punctate
Anisocoria / Contact
Pupillary dilatation
Flash
Due to autonomic
dysfunction, not Lichtenberg
brain injury figures
Fractures
Management in
Continue CPR!
the field?
Rare in lightning
Rhabdomyolysis?
injuries
Environmental Emergencies 535
High-Altitude Illness
Introduction
% of oxygen in atmosphere constant With altitude the total atmospheric Decline in partial
Physiology (~21 %) regardless of altitude
But
pressure decreases pressure of O2
Decreased
alveolar O2
Decreased
Renal arterial O2
compensation via
bicarbonate
diuresis Acute
Physiology
With time, will
have increased
Decreased pCO2 Carotid body
RBC production
stimulation
Respiratory
alkalosis
Increased minute
ventilation
Promotes
Treatment Acetalozamide Leads to Acclimatization
bicarbonate diuresis
536 M.R. Marchick and B. Desai
Frontal
headaches N/V Anorexia Sleeplessness
Worsened by
valsalva
Allows
acclimatization
Most commonly
on 2nd night at
altitude
Definitive
treatment Descent
Submersion
Drowning
Secondary
ARDS Delayed death
drowning
Laryngospasm
Dry drowning Hypoxia later 15 % of cases
1st
Drowning Management
Hypothermia (low
Poor prognosis? Asystole Need for ED CPR Severe acidosis
core temperature)
But better But some
prognosis if cold survivors of
water
prolonged
Rewarm! submersion
Otherwise? Admit
540 M.R. Marchick and B. Desai
Temperature-Related Illness
Radiation
Heat dissipation Conduction Convection Evaporation
(1o modality)
Vigorous activity
in hot
environment
Predisposing
Factors
Cardiovascular
disease Dehydration
Medications
Anticholinergics
Decreased ability
to sweat
Decreased
peripheral blood b -blockers Phenothiazines
flow Central action on
hypothalamus
Medications
Predisposing
to heat illness
Decreased heat Ca-channel
loss Diuretics
blockers
Decreased
plasma volume
Sympathomimetics
Vasoconstriction
Environmental Emergencies 541
Moderate form
Heat Exhaustion
of heat illness
Heat exhaustion
treatment Cooling IV hydration
Heat Stroke
Hyperthermia Neurologic
Heat Stroke > 40o C abnormality
Ataxia
Seizures Delirium Coma Hemiplegia Posturing Anhidrosis
Early Sx
Cerebellum
sensitive to
hyperthermia
Ineffective
cooling? Invasive cooling Bypass Lavage
Ice crystal
formation as
blood flow Decreased
further decreases cutaneous blood
and temp flow
decreases
Further cooling
Pathophysiology
Plasma leakage Cycles of cold-
induced
vasodilation
Face
Areas most
Feet Ears
affected
Hands Nose
Freezing injury
Frostbite 2nd degree 3rd degree 4th degree
(More severe)
Management
Hypothermia
Hypoglycemia
Decreased Elderly
metabolic rate
Decreased heat
generation
Predisposing
Sepsis Skin disorders
Factors
Altered Young
sensorium High surface area
Dementia / leads to poor heat
Delirium conservation
Hypothermia Manifestations
Fall in Cardiac
Cardiac Below 32 o C
output & Pulse
T wave Prolongation of
EKG Changes Osborne J waves
inversions PR, QRS & QT
Acute tubular
Kidney
necrosis
Hypothermia Treatment
Life-threatening
Rapid warming? Hypotension arrhythmias
Rewarming Physiology
External
rewarming
Core Peripheral
Temperature vasodilation
Afterdrop
Also caused by
conduction of
heat from core to
colder periphery
External Physiology
rewarming
techniques
often used in Cold blood
conjunction returns to core
with core
rewarming to
minimize this
phenomenon
Preferential Improved
Core rewarming rewarming of heart cardiac function
Rewarming Methods
Passive external
rewarming
Warm blanket
Active core
rewarming
Active external
Warm IV fluids rewarming
40 oC max Methods of Circulating
Gastric lavage
Rewarming warmed air
blanket
Bladder lavage Inhaled warmed
air
Peritoneal lavage
40 o C max
Thoracic lavage
Extracorporeal
methods
Bypass
Radiation
Free radical
Radiation effects Ionization DNA damage
formation
a b g
Radiation types
Least penetrating 8 mm penetration (burns) Deep penetration & radiation sickness
Massive
GI effects N/V N/V/D fluid/protein loss
Biological Weapons
Stability in
transport
Virulence Infectivity
Characteristics of
ideal biologic
weapons
Toxicity Length of
incubation in host
Ease of
Lethality
transmission
Environmental Emergencies 549
Tularemia
Cholera Plague
Hantavirus
Viral hemorrhagic
fevers Viral Smallpox
Venezuelan
equine
encephalitis
550 M.R. Marchick and B. Desai
Anthrax
Cutaneous
Anthrax 3 forms Gastrointestinal Inhalational
“ Woolsorter’s disease”
Plague
Bubonic
Transmitted by flea bite, 3 main
Plague Yersinia pestis Pneumonic
contact or inhalation forms
Septicemic
Gram stain of
Diagnosis Serology Blood culture
sputum
Complication of
Septicemic
pneumonic plague
Smallpox
Airborne
Smallpox Variola virus transmission Highly infectious Strict quarantine
Diagnosis PCR
Treatment Vaccine
552 M.R. Marchick and B. Desai
Toxins
Toxin absorbed Toxin binds to preganglionic Inhibits acetylcholine
Botulinum toxin through inhalation membrane of cholinergic synapses release
Pitfall in NO significant
NO miosis
diagnosis respiratory secretions
Diagnosis ELISA
Hemorrhagic
Airway necrosis Fever & chills Cough Sweats
pulmonary edema
Treatment Supportive
Chemical Weapons
Chemical Weapons
Nerve agents
Cyanide Vesicants
Chemical
weapons
Agents that affect
the lungs Tear gas
Environmental Emergencies 553
Nerve Agents
Secondary
Pitfall contamination
Protect self -
Treatment decontaminate Oxygen Atropine 2-PAM
Vesicants
Blister the
Vessicants
dermis
Tetanus
Tetanus
Crush injury
Devascularized
Burns
tissue
Wounds at
high risk
Wounds > 24
IV drug use
hours old
Postpartum
Soil in wounds
wounds
May occur with May not know of Neonatal 3–10 days after birth
Tetanus
minor wounds injury tetanus Poor prognosis
Contaminated wounds, Tetanus Tetanus immune <3 prior immunizations If 3 prior immunizations,
punctures, avulsions, burns toxoid globulin or unknown toxoid if last > 5 years
Neurologic Emergencies
Contents
Dermatomes and Reflexes 556
Altered Mental Status and Coma 556
Cerebrovascular Accidents 557
Seizures 565
CNS Infections 572
Encephalitis 578
Brain Abscess 580
Headache Syndromes 581
Bell’s Palsy 593
Neuromuscular Disorders 594
Movement Disorders 598
Neuropathies 600
Spinal Disorders 600
Miscellaneous Disorders 601
Psychiatric Emergencies 601
Abuse/Neglect/Violence 611
Addictive Behavior and Withdrawal 613
M.R. Marchick, MD
Department of Emergency Medicine, University of Florida College
of Medicine, Gainesville, FL, USA
B. Desai, MD, MEd (*)
Department of Emergency Medicine, University of Florida,
Gainesville, FL, USA
e-mail: [email protected]
AEIOU-TIPS
A Alcohol, Acidosis
E Epilepsy, Endocrine, Electrolytes, Encephalopathy
I Insulin
O Opiates, Overdose
U Uremia
T Trauma, Temperature
I Infection
P Poisoning, Psychiatric
S Stroke, Shock
Neurologic Emergencies 557
Coma Testing
Cerebrovascular Accidents
Stroke Mimics
Hyperosmolar
Hypoglycemia nonketoticstate
Conversion
disorder Hyponatremia
Hypertensive Complicated
encephalopathy migraine
Risk Factors
Subdural or
epidural bleed Multiple sclerosis
Seizures /
CNS infection
Todd’s paralysis
Tidbit
Contralateral motor & sensory deficits &
contralateral cranial nerve palsies
560 M.R. Marchick and B. Desai
Vertebrobasilar Infarction
Vertebrobasilar Infarction
Oculomotor
Vertigo Nystagmus Headache N/V Ataxia
palsies
Ipsilateral cranial Contralateral
Crossed deficits
nerve palsies motor deficits
Locked-in Wallenberg
Quadriplegia Coma Syncope Dysphagia Dysarthria
syndrome syndrome
Locked-in Patient is awake but cannot move or verbally communicate due Diaphragm breathing & vertical
syndrome to complete paralysis of voluntary muscles except for the eyes eye movements spared
Wallenberg Thrombosis of
syndrome vertebral artery
Oculomotor
Vertigo Nystagmus Ataxia N/V Ataxia
palsies
Decreased pain & Contralateral
Ipsilateral face
temperature sensation body
Ipsilateral Horner’s
Ptosis Miosis Anhidrosis
Syndrome
Lacunar Infarction
Cerebellar Infarction
Cerebellar Infarction
Hydrocephalus
Worse prognosis
Interventional
Longer window
capability?
Stroke
Admit
disposition?
IV tPA Exclusions
Significant stroke
or head trauma Prior ICH
within 3 months
Multilobar Intracranial
infarction with neoplasm, AVM,
hypodensity > aneurysm
33% of
hemisphere
Recent
intracranial or
CT head with ICH
spinal surgery
Heparin use
within 48 hours Symptoms of SAH
with ≠ PTT IV tPA Exclusions
Use of direct
Arterial puncture thrombin
within 7 days - inhibitor or factor
non-compressible Xa inhibitor with
site anticoagulant
effect on labwork
impairment
Relative Exclusions
MI in previous 3
Pregnancy
months
Major
GI or urinary tract
surgery/serious
bleeding within
trauma within 14 Age > 80
21 days
days
Relative Exclusions
Prior ischemic Any oral
for Treatment 3–4.5
stroke + DM anticoagulant use
Hours After Onset
Severe stroke
(NIHSS > 25)
Neurologic Emergencies 563
tPA Complications
Symptomatic
~ 5 % incidence
intracranial hemorrhage
D/C
If suspected Stat head CT
thrombolytics
Consider discontinuing
Major bleeding
thrombolytics
Hypertension
Sympathomimetic
AVM
use - Cocaine
Amyloid
Smoking Risk Factors
angiopathy
Masses Aneurysm
Anticoagulant use
Large
Indications for Evidence of
GCS < 8 intraventricular Hydrocephalus
invasive monitoring herniation hemorrhage
Seizures
Definitions
No apparent
Primary seizure
cause identified
Convulsive
Post-ictal state Headache Drowsiness
(Grand mal)
Manifestations
Lip-smacking
These may
Pitfall
generalize
Anoxia Infectious
Any meningitis
Encephalitis
Brain abscess
Causes of Secondary/Reactive
Neurocysticercosis
Structural Seizures
Latent syphilis
Neoplasm
HIV
CVA
AVM
Acute
hydrocephalus Trauma
Metabolic Toxic
Hypo/Hyperglycemia Cocaine
Hypo/Hypernatremia Amphetamines
Hypo/Hyperosmolar Lidocaine
states
Isoniazid
Hypo/Hypercalcemia
Bupropion
Thyrotoxicosis
Flumazenil
Uremia
Lithium
TCA’s
Theophylline
Neurologic Emergencies 567
Seizure Mimics
Syncope
Most common
mimic
Sandifer
Psychogenic
syndrome nonepilieptic
GERD seizures
Apparent life
threatening event TIA
Myoclonus /
movement Narcolepsy
disorders
Prodrome of
No aura or nausea,
prodrome lightheadedness,
darkened or
tunnel vision
May not be
present if
Generalized cardiogenic
Seizure
Syncope
Forceful
Post-ictal period tonic-clonic
movements NO post-ictal
May have “twitching”
period
568 M.R. Marchick and B. Desai
Laboratory BMP +
Glucose magnesium Drug screen h CG
studies
Hyponatremia
most common in
afebrile children
<2
New seizure
CT scan
pattern
Neurologic Emergencies 569
Maximum infusion
2nd line Phenytoin 20 mg/kg IV
rate 50 mg/min
Phenytoin Dissolved in May cause hypotension Need cardiac Potential for vascular
pitfalls propylene glycol & bradydysrhythmias monitoring injury & tissue necrosis
Emergent
Eclampsia Magnesium
delivery
Disposition
Status
Admit
epilepticus?
Return to
baseline mental
status
Instructions
neurologist
Febrile Seizures
Complex febrile Seizure associated with fever but not a < 6 m or > 5 yrs > 15 minutes
seizure serious infection and any of the following Focal Multiple
Complex febrile
Consider LP Septic workup
seizure
Prolonged
LP
seizure
Ill-appearing LP
Diazepam per
Treatment
rectum if prolonged
Anticonvulsants
Pitfall
not indicated
Intracranial
Apnea/ALTE CNS infection
hemorrhage
Hypomagnesemia Hypocalcemia
Phenobarbital Pyridoxine if
Seizures?
1st Line refractory
Background EEG
Poor prognosis
abnormalities?
572 M.R. Marchick and B. Desai
CNS Infections
Preterm
Term
Normal Bacterial Viral Fungal TB Abscess Child
Normals
0–25
WBCs <5 > 1000 < 1000 100-500 100-500 10-1000 7.3 ± 13.9
0–7
57
% PMNs 0-15 > 80 < 50 < 50 < 50 < 50 61–84
5
65–120
Protein
20-45 > 150 50-100 100-500 100-500 > 50 64.2 ± 24.2
(mg/dL)
5–40
24–63
Glucose
40-65 < 40 40-65 30-45 30-45 45-60 51.2 ± 12.9
(mg/dL)
40–80
Opening 8–11
pressure 6-20 > 25-30 Variable > 20 > 20 Variable < 20
(cm H2O) < 20
Viral profile may be seen with CSF sterilization can occur within 2
Pitfalls
partially treated bacterial meningitis hours of IV antibiotic administration
Neurologic Emergencies 573
Meningitis Introduction
Meningitis
Altered mental
Fever Headache Photophobia Vomiting Seizures Nuchal rigidity
status
Bulging
Infants Irritability Poor feeding
fontanelle
Exam Findings
Enteroviruses
Vast majority of
cases
Enterovirus
Coxsackievirus
Echovirus
Causes of Viral
Meningitis
Adenovirus Cytomegalovirus
Supportive
Treatment
(except HSV)
Neurologic Emergencies 575
Streptococcus
pneumoniae
#1 overall
Highest
> 50 years old morbidity & Neonates
mortality
Streptococcus E. coli
pneumoniae
Group b strep
Listeria
monocytogenes Listeria
monocytogenes
Causes of Bacterial
Meningitis
Children
Streptococcus
pneumoniae
Young adults Neisseria
meningitidis
Streptococcus
pneumoniae Group b Strep
Neisseria Haemophilus
meningitidis influenzae
Consider
Petechial rash?
meningococcus
576 M.R. Marchick and B. Desai
Risk Factors
Head trauma /
Endocarditis
CSF leak
S. pneumoniae
Pneumonia Immune
compromise
Risk Factors
Diabetes mellitus Splenectomy
Encapsulated
organisms
Alcoholism
Malignancy
Gram (-) bacilli
L. monocytogenes
Hx of Close living
neurosurgery or conditions
cochlear implant Dorms, barracks
S. aureus N. meningitidis
Meningitis Prophylaxis
Household
contacts
Intubation
without facemask
or mouth-to-
mouth
resuscitation
Prophylaxis for
Not indicated
S. pneumoniae ?
Neurologic Emergencies 577
Evaluation
Other
CBC Blood cultures
considerations
Imaging CT
Altered mental
status
Immune
Papilledema
compromise
Malignancy Seizure
Advanced age
Fungal Meningitis
Cryptococcus
Blastomyces Histoplasma
Causes of Fungal
Meningitis
Coccidiodes Candida
Disposition Admit
Encephalitis
Encephalitis: Introduction
Retrograde spread
Rabies virus Herpes Simplex Herpes Zoster
via axons to CNS
Encephalitis Causes
Arboviruses
Most common
La Crosse
St. Louis
West Nile
Eastern Equine
Western Equine
Causes of
Encephalitis
Herpes Simplex
Memory Psychological
HSV Encephalitis
disturbances disturbances
Diagnosis of HSV Neuroimaging is Inferior frontal lobe & medial MRI more
encephalitis helpful temporal lobe hypodense lesions sensitive than CT
Periodic sharp
EEG?
waves
Disposition for all
Admit
CSF? May have RBC’s
Acyclovir
Treatment
10 mg/kg IV every 8 hours
CMV
Ganciclovir
Encephalitis
Herpes Zoster
Acyclovir
Encephalitis
580 M.R. Marchick and B. Desai
Brain Abscess
Hematogenous Typically
Polymicrobial
spread multiple
Gram negative
Post-surgical S. aureus OR rods
Management
Oto/sino/
Hematogenous OR Cefotaxime Metronidazole
odontogenic
Disposition Admission
Neurologic Emergencies 581
Headache Syndromes
Odor Agent
Headache Classification
Migraine
Acute mountain
CNS infection
sickness
Central venous
Temporal arteritis
thrombosis
Hypertensive
Cervicogenic
urgency
Post lumbar
Post concussion
puncture
582 M.R. Marchick and B. Desai
Migraine Introduction
F>M Menses
Migraine
Typical onset in teens to 20’s
Even pregnancy
Potential Triggers
Alcohol use
Visual
Most common
Scintillating
scotoma
Brainstem Sx Visual field Hemiparesis
Typically < 60 minute duration
deficits
Vertigo, ataxia
Migraine aura Resolves spontaneously
Auras
15 % of overall cases
Aphasia Ophthalmoplegia
Paresthesia
Neurologic Emergencies 583
Migraine Treatment
Dopamine
Prochlorperazine OR Metoclopramide OR Droperidol
antagonists
Dopamine and
DHE 5HT1B/1D agonist
Selective 5HT1D
Triptans Less N/V Prophylactic Treatments
agonists
(Usually not started in ED)
Lifestyle modification
Triptan β–blockers
Patients with HTN Patients with CAD Ca-channel blockers
contraindications
TCA’s
Tension Headache
No aggravation
with activity
If severe, consider
Treatment NSAIDs
migraine treatment
584 M.R. Marchick and B. Desai
Cluster Headache
Horner’s
Facial flushing
syndrome
High flow
Treatment 75 % effective DHE OR Triptans
oxygen
Steroids with
Prophylaxis Verapamil
taper
Trigeminal Neuralgia
Carbamazepine
Treatment
1st line
Surgical
Refractory case?
treatment
Neurologic Emergencies 585
Consider
Treatment Hydration Analgesia
caffeine
Definitive
Blood patch
treatment
Carbon
Other causes Alcohol Hypoxia
monoxide
Bilateral Diffuse
Underlying
Treatment
condition
586 M.R. Marchick and B. Desai
HA may be HA may be new onset or an increase HA worse with HA worse with Sleep Focal neurologic
diffuse or focal in frequency or duration of chronic HA valsalva laying down disturbance deficit
N/V Seizures
Lung
Most common
Colon metastases to
Breast
brain
Genitourinary Melanoma
Pseudotumor Young obese Typically with irregular Due to impaired ↑ CSF pressure without
Cerebri females menses & amenorrhea CSF absorption mass or obstruction
NO focal
Tinnitus
deficits
CT shows slit-like or
Imaging No mass effect
normal ventricles
Shunt if
Treatment Repeated LP’s Acetazolamide
refractory Vision perimetry
testing guides
adequacy of
Other treatment Nerve sheath treatment
Weight loss Steroids
considerations fenestration
Neurologic Emergencies 587
Hydrocephalus
PEDIATRICS
Non-
Hydrocephalus Obstructive Communicating Non-obstructive
communicating
Blockage Impaired CSF
Increased CSF
between absorption by
volume with
ventricles & arachnoid
increased CSF
arachnoid granulations
pressure
granulations
Normal pressure
Congenital Acquired hydrocephalus
Arnold-Chiari Masses
malformation Non- Hydrocephalus
Infection Hemorrhage Communicating
Dandy-Walker Communicating ex-vacuo
malformation Hemorrhage
Intrauterine Post-trauma Meningitis
infection
Horizontal
Gait instability
diplopia
Diagnosis CT OR MRI
PEDIATRICS
Enlarged
Diagnosis
ventricles on CT
Often misdiagnosed as
“Wacky” Dementia
Alzheimer’s or Parkinson’s
Mechanism to
VP Shunt valves One way valve
flush CSF
Body cavities
Peritoneal Right atrium Pleura
used for shunts
PEDIATRICS
CSF protein
Overdrainage
ICP
PEDIATRICS
50 % within 2 Up to 10 % > 1
Shunt infection
weeks post-op year post-op
Typical S. epidermidis
S. aureus H. influenzae
pathogens (#1)
May have
Pitfall
peritonitis
Suspected
Shunt tap
infection?
Standard LP may
Pitfall
miss shunt infection
Treatment of Vancomycin +
infection Ceftazidime
Hypercoagulability
Exogenous Pregnancy &
estrogens post-partum
Risk Factors
Connective tissue Primary CNS
disorders infection
Spread of
infection from
contiguous area
Treatment Heparin
Subarachnoid 75 % due to ruptured Occasionally due 20 % of patients have onset during activities
hemorrhage aneurysm to AVM which ≠ ICP (intercourse, defecation, exercise)
Moyamoya
Hypertension
syndrome
Idiopathic Dissection Family history Smoking
Other Causes Risk Factors
Sympathomimetic Mycotic Polycystic kidney
Heavy EtOH use
drugs aneurysm disease
Tumor Connective tissue
disorders
Marfan’s syndrome
Ehlers-Danlos Type
IV
Headache
Sentinel bleed
“worst of life”
SAH Diagnosis
No
Negative CT < 5 RBC’s No SAH
xanthochromia
Avoid
Pitfalls
hypotension
Trauma
Chiropractic
manipulation
Headache / Facial pain Neck pain Horner’s Cranial nerve Neurologic deficits typically
Visual changes
(Typically unilateral) (Typically unilateral) syndrome palsies follow pain by hours to months
MR generally preferred
Diagnosis MRI/MRA OR CT Angiography
for vertebral arteries
Prevent subsequent
Treatment Anticoagulation
embolic stroke
Bell’s Palsy
CVA
Upper face spared CVA affecting CN VI nucleus
Genu VII nerve and CN VII
Bacterial middle,
palsy Patient’s cannot abduct
external ear or
ipsilateral eye
mastoid
infections Differential
Lyme disease
Neuromuscular Disorders
Multiple Sclerosis
Other treatment
ACTH Interferon
options
IV steroids Ø rate of
Optic neuritis
development of MS
Neurologic Emergencies 595
Guillain-Barre Syndrome
Most common
1/2 with autonomic 1/3 require
dysfunction mechanical ventilation
More likely to need Forced vital capacity Negative inspiratory force (NIF)
mechanical ventilation < 20 mL/kg OR < 30 cm H2O
Plasma
Management Supportive care IVIG OR
exchange
Thyroid Use of
Associations Hypokalemia Steroids Renal disease
disease alcohol
Tick Paralysis
Similar to Guillain-
Tick Paralysis Rapidly ascending paralysis Reversible
Barre
Myasthenia Gravis
Medication
change or missed Infection
dose
Metronidazole Aspiration
Macrolides Pregnancy
Risk Factors
Clindamycin Beta-blockers
Calcium channel
Phenytoin
blockers
Neuromuscular
Lidocaine
blockers
Neurologic Emergencies 597
Very unpredictable
Pitfall
response to succinylcholine
Chronic Pyridostigmine
≠ ACh Immunosuppressants Thymectomy
management or neostigmine
Repeated
≠ ACh release ≠ Strength
stimulation
Treat underlying
Treatment Plasmapheresis OR IVIG
condition
Movement Disorders
Treatment
Diphenhydramine Benztropine Benzodiazepines
options
Huntington’s
disease
Creutzfeldt-Jakob Chronic
disease antipsychotic use
Pregnancy Cocaine
Rare
Rheumatic fever
Sydenham’s
chorea
Neurologic Emergencies 599
Akathisia Subjective and objective Typically seen early in High incidence with
motor restlessness treatment with antipsychotics prochloperazine
Tardive Prolonged use of Late onset, chronic, rapid Especially of face, with
dyskinesia anitpsychotics involuntary movements trunk/limb choreoathetosis
Often
Pitfall
irreversible
Parkinson’s Disease
Parkinson’s
Drug induced Idiopathic
types
Treatment Carbidopa
Benztropine Amantadine
Idiopathic Levodopa
Neuropathies
Peripheral Polyneuropathies
Ethanol
Heavy metals:
Aminoglycosides Causes
Arsenic, Lead
Phenothiazines HIV
Vitamin
deficiencies
B1 (Beriberi)
Niacin (Pellagra)
Pyridoxine
B12 (Pernicious
anemia)
Gabapentin,
Treatment Glucose control
Pregabalin, or TCAs
Spinal Disorders
Miscellaneous Disorders
Wernicke’s Encephalopathy
Psychiatric Emergencies
Acute/subacute
¯ cognitive Drug
function intoxication/
Consciousness withdrawal
Abnormal VS
impaired
Delirium Hepatic
Infection Common Causes
encephalopathy
Fluctuating Duration
severity Days-weeks
Visual CNS lesions Hypoxia
hallucinations
common
Gradually ¯ Alzheimer’s
cognitive function disease
No acute focal
findings
CT = atrophy
Duration Consciousness
Often permanent Dementia Anoxic brain Parkinson’s
intact Common Causes
injury disease
Can have
superimposed Multi-infarct
dementia
acute worsening
CT = lacunar
of cognition
infarcts
602 M.R. Marchick and B. Desai
EtOH Benzodiazepines
Anticholinergics Cocaine
Digitalis Amphetamines
Medications &
Phenytoin Drugs THC
Tricyclic
antidepressants Opioids
INH PCP
Hypoglycemia
Hepatic
Hypercalcemia
encephalopathy
Pellagra (niacin
Hyponatremia
deficiency)
Uremia Lupus
Wernicke- Pernicious
Korsakoff anemia (B12
Syndrome deficiency)
Neurologic Emergencies 603
Age < 40
Orientation Auditory
hallucinations
Amnesia
Anterograde Retrograde
Amnesia Loss of prior memories
Inability to create new memories
Invented
memories
604 M.R. Marchick and B. Desai
Major Depression
Underlying
Risk Factors Female Family history
medical condition
15 % lifetime
Pitfall
suicide risk
Suicide
Frequency of Lethality of
Suicide Women > Men Men > Women
attempts attempts
Advanced age
Pre-existing Non-married,
mental illness especially
widowed
Risk Factors for
Completed Suicide
Comorbid
physical illness Lives alone
Most common
Drug overdose
attempt method
Most common
Gun shot wound
completed method
Grief Reaction
Sadness
Symptoms
> 2 months
Abnormal Grief
Reaction
Psychomotor
Guilt
retardation
Thoughts of
death
But, desire to be
with deceased =
normal
Bipolar Disorder
Typical onset
Bipolar Disorder Male = Female
20–30’s
Manic Symptoms
Pressured or Racing
¯ Sleep Activity self esteem Euphoria Risky behavior
rapid speech thoughts
Schizophrenia
Anxiety
Acute coronary
syndrome
Alcohol, Dysrhythmias
benzodiazepine
withdrawal
Pulmonary embolism
Hypothyroidism
Pheochromocytoma COPD
Hyperthyroidism Asthma
Anxiety Disorders
Irrational fear of
Phobia Avoidance
specific situation
Obsessive-Compulsive Disorder
Recurrent, intrusive,
Obsessions
unwanted thoughts
Anorexia
Onset typically
Anorexia Female >> Male
in teens
Significant Suicide is a
Pitfall
mortality common cause
Bulimia Nervosa
Metabolic Mallory-Weiss
Vomiting ¯K ¯ Cl alkalosis tears
Tooth decay
Metabolic
Laxative Abuse ¯ Na ¯K alkalosis
Generally better
Prognosis
than anorexia
Somatoform Disorders
Example of a
Munchausen's
factitious disorder
Personality Disorders
Paranoid
Cluster A
Schizoid Schizotypal
“Odd, eccentric”
Antisocial
Cluster B
Narcissistic “Dramatic, Borderline
emotional, erratic”
Histrionic
Avoidant
Cluster C Obsessive-
Dependent compulsive
“Anxious, fearful”
Borderline
Chronically labile Unstable relationships Impulsiveness
personality
Abuse/Neglect/Violence
Elder Abuse
M>F
F>M Typically primary
Substance abuse caregiver
Hx of domestic Cognitive Characteristics of
violence impairment History of Abusers
Risk factors for Mental illness
Elders violence
Lack of social Physical Financial
support dependency
dependence on
elder
Patterns of Injury
Electrolyte Forearm
Decubiti Dehydration Rhabdomyolysis Rape marks
abnormalities injuries
Sexual Assault
> 72 hours post Unlikely to find Consider deferring Shared decision making with
assault? evidence forensic exam victim & victim advocate
ED Staff/Patient Safety
Neurovascular
Potential injuries Rhabdomyolysis Asphyxia
injury
Substance Abuse/Dependence
Failure to fulfill
work, school, or
home obligations
Use continues
DSM IV definition Recurrent use in
despite
1 of these in past hazardous
interpersonal
year situations
problems
Use continues
Recurrent legal
problems despite known
physical /
psychological
problem caused
Large amount of by substance Important
time activities given up
obtaining/using/ or reduced
recovering DSM IV definition
Persistent desire
3 of these in past
to ¯ use
year
Withdrawal Tolerance
Substance taken
in larger
amounts/longer
period than
intended
614 M.R. Marchick and B. Desai
Alcohol Withdrawal
Visual Elevated
Paranoia Diaphoresis Irritability Tachycardia Hypertension
hallucinations temperature
Benzodiazepine Withdrawal
Opiate Withdrawal
Body aches
Heroin/oxycodone/other
Onset/Duration Methadone
short acting agents
Onset 36–72 hours after Onset 72–96 hours
last use Duration up to 14
Duration 7–10 days days
Partial opioid
Buprenorphine
agonist & antagonist
Cocaine/Sympathomimetic Withdrawal
Increased
Fatigue Malaise Depressed mood
appetite
Cocaine/Sympathomimetic
Duration 8–48 hours
Withdrawal
Treatment Supportive
THC Withdrawal
Decreased
Irritability Mood swings Sleep disturbance
appetite
Relatively
THC Withdrawal
uncommon
Treatment Supportive
Obstetrics and Gynecology
Contents
Infections 618
Gynecologic Oncology 627
Obstetrics 629
Infections
Introduction
Infections of the Ascending from Includes a Most common
PID upper the vagina & spectrum of gynecologic cause
reproductive tract cervix diseases of ED visits
Chlamydia Polymicrobial
PID Due to OR Gonorrhea OR
(Most common) (30–40 %)
Including
anaerobes
Fitz-Hugh-Curtis
RUQ pain Jaundice
syndrome
Laparoscopy Laboratory
Diagnostic tests Ultrasound OR CT OR
(Gold standard) evaluation
Thickened fluid
Ultrasound
filled fallopian Free pelvic fluid Dx of TOA
utility
tubes
Cefotetan
Inpatient Ampicillin/
or Doxycycline Clindamycin Gentamicin Doxycycline
treatment Sulbactam
Cefoxitin
Cefotetan
Outpatient Levofloxacin
or Doxycycline Metronidazole OR Metronidazole
treatment or Ofloxacin
Cefoxitin
Pregnancy
Tubo-ovarian
abscess Intractable N/V
Compliance
issues
Complications of PID
Ectopic pregnancy
Menstrual
Infertility
irregularities
Majority resolve
with Abx alone Fitz-Hugh-Curtis
Syndrome
Adhesions Dyspareunia
Fitz-Hugh-Curtis Syndrome
Spillage of purulent
Fitz-Hugh-Curtis Lymphatic
Perihepatitis Due to material from tubes Direct spread OR
Syndrome spread
into abdomen
Referred
Symptoms RUQ pain shoulder pain
Violin string
Laparoscopy adhesions around
liver
Vulvovaginitis
Introduction
PEDIATRICS
Vaginal + Abdominal
Burning Itching + Pelvic pain
discharge pain
Normal vaginal
pH 4 – 4.5
Sx of vaginitis &
pH 4 – 4.5? Normal OR Candidiasis
Sx of vaginitis &
pH >4.5? BV OR Trichomonas
Obstetrics and Gynecology 621
Flagellated
Trichomoniasis Due to Common STD
protozoan
Increases risk of
Trichomoniasis HIV/HSV/HPV
Motile
Diagnosis trichomonads on Culture Antigen testing
wet mount
PO
Treatment Treat partners
Metronidazole
Trichomoniasis
Flagellated
Trichomoniasis Due to Common STD
protozoan
Increases risk of
Trichomoniasis HIV/HSV/HPV
Motile
Diagnosis trichomonads on Culture Antigen testing
wet mount
PO
Treatment Treat partners
Metronidazole
622 B. Desai and A. Desai
Candida Vaginitis
Vaginal Vulvar
Leukorrhea Vulvar Itching Dyspareunia Dysuria Vulvar erythema
discharge excoriations
“Cottage cheese” Most common &
most specific Sx Vulvar edema
More effective
than nystatin
Obstruction on the
Located in labia Provide moisture
Bartholin glands duct may lead to
minora for the vestibule
cyst or abscess
Rare presence of
Abscess Very painful Indurated area Polymicrobial
systemic signs
Ovarian Cysts
Two types of
First 2 weeks of Corpus luteal Last 2 weeks of
functional Ovarian Follicular cyst
menstrual cycle cyst menstrual cycle
cysts
Growths filled
Dermoid cyst with various types
of tissue
Pressure on
Pain from Rupture in
adjacent Torsion
ovarian cysts peritoneum
structures
Sudden onset of
Torsion OR Rupture
unilateral pain
Shock due to
hemorrhage
Transient
Usually
Mittelschmerz (<1 day) mid cycle
unilateral
pain
Shock or
possible torsion? Laparoscopy
624 B. Desai and A. Desai
Chemical
Pregnancy Large cysts or
Risk factors induction of
(Corpus luteum) tumors
ovulation
Treatment Laparoscopy
Endometriosis
Common cause of Endometrial Chronic Mostly in
Endometriosis infertility & pelvic Due to tissue outside of inflammatory
pain uterus reaction reproductive age
Endometrial
Adenomyosis tissue in uterine
wall
Imaging test of
Pelvic U/S
choice
Diagnosis Laparoscopy
Leiomyomas
Most common
Benign tumors of
Leiomyomas Uterine fibroids pelvic tumor in
uterine muscle African Americans
Pregnancy results
May outgrow May torse if on a
Complications in growth and loss Pain
blood supply pedicle
of blood supply
Lower Mass on
Pelvic pain Hypermenorrhea
abdominal pain examination
Imaging test of
Pelvic U/S
choice
Bleeding
Heavy Excessive irregular
Menorrhagia Metrorrhagia outside Menometrorrhagia
bleeding normal cycle bleeding
Oral
Treatment NSAIDs
contraceptives
Oral
Treatment contraceptives NSAIDs
Ovulatory Bleeding
Tumors
Endometrial
hyperplasia
Ovulatory Bleeding
Polyps Endometriosis
Endometrial Adenomyosis
Malignancy Infections
Anovulatory Bleeding
Polycystic ovary
Extremes of Endocrine
reproductive age disorders
Anovulatory Oral
Bleeding contraceptives
Eating disorders
Liver diseases
Lower urinary
tract lesions Cirrhosis
Renal diseases
Obstetrics and Gynecology 627
Gynecologic Oncology
Ovarian Cancer
Has highest
2nd most common May be advanced Peak incidence
Ovarian cancer But… mortality rate of
gyn malignancy on diagnosis 55–65
GYN malignancy
Obesity Hx of breast or
Risk factors Infertility Low parity Family history
(high fat diet) colon cancer
Urinary frequency
Abdominal pain Bloating Weight loss Pleural effusion Ascites Early satiety
or urgency
Unilateral fixed
mass
Rare torsion
Uterine Cancer
Abnormal Uterine
vaginal bleeding Weight loss
enlargement
Cervical Cancer
Obstetrics
Ectopic Pregnancy
No definitive IUP
Consider
IUP on U/S? Ectopic unlikely heterotopic in Indeterminate Close f/u
fertility patients
Serial US & HCG
Embryonic cardiac
High probability Free fluid Adnexal activity outside
NO IUP Diagnostic
U/S in pelvis mass uterus
Abortions
Treatment D&C
Treatment D&C
Passage of all
Complete Vaginal bleeding <20 weeks Closed os
fetal tissue
Infection during
Septic
abortion
RhoGAM
Gestational
Spectrum of Partial
trophoblastic OR Choriocarcinoma
disease processes hydatidiform mole
Gestational Arises in
trophoblastic trophoblastic cells
disease of the placenta
Hydatidiform Complete is
mole Noninvasive Partial OR Complete
more common
Deformed
Complete No fetus Incomplete nonviable fetus
present
st
1 Trimester 2nd Trimester
Suction
Treatment
curettage
Hypertension in Pregnancy
Complications of Abruptio
Preterm birth Preeclampsia Low birth weight
chronic HTN placentae
Resolves within
HTN during Complications to
Transient HTN Proteinuria 2–4 weeks of
pregnancy pregnancy delivery
632 B. Desai and A. Desai
Preeclampsia
Visual
Headache Abdominal pain Edema
symptoms
Eclampsia
Treatment of Magnesium
Seizures sulfate
Treatment of
Hydralazine OR Labetalol
HTN
HELLP Syndrome
Same as
Treatment Delivery of fetus Control of BP Magnesium
Preeclampsia
Placental Emergencies
Abruptio Placentae
Separation of 2nd most
Abruptio placenta from Can occur
common cause
Placentae uterine wall spontaneously of fetal death
HTN
(most Advanced Cocaine Hx of abd Prior
Risk factors Trauma Smoking
common) age abuse surgery incidence
Placenta Previa
Placenta near or
Placenta Previa
over the cervical os
Highly sensitive
Ultrasound?
for Dx
Tidbits
Inpatient
Pyelonephritis?
therapy
Membrane
PROM rupture <37
weeks gestation
Limited digital
Examine vaginal Blue is positive =
PROM Diagnosis exams (use sterile Nitrazine test
speculum) fluid pH >6.5
Prolapsed
High mortality
umbilical cord
Elevate Emergent
Treatment Impede delivery
presenting part C-section
Postpartum Hemorrhage
Most common
Postpartum cause of maternal Primary Secondary
Hemorrhage mortality worldwide In 1st 24 hours >24 hours, < 6 weeks
Abruptio Amnio -
Occurs with C-section Labor Abortion Trauma
placentae centesis
Immediate
Place in left lateral
Treatment Supportive delivery of the
decubitus position infant
636 B. Desai and A. Desai
Peripartum Cardiomyopathy
Symptoms &
CHF
Signs
Association with
Treatment CHF treatment Heparinization Due to
thrombotic events
Endometritis
Usually
Endometritis
polymicrobial
Foul-smelling Uterine
Abdominal pain Fever Tachycardia
lochia tenderness
Broad spectrum
Treatment
antibiotics
Mastitis
Breast ducts
Mastitis Infection Staph
blocked
Continue breast
Treatment Antibiotics
feeding
Ophthalmology
Bobby Desai
Contents
Neuro-ophthalmology 638
Pupil Abnormalities 640
Visual Field Deficits 641
External Eye 642
Conjunctiva 648
Cornea 653
Corneal Abrasion, Laceration, and Ulcers 657
Uveitis and Iritis 660
Vitreous and Intraocular Cavities 661
Retina 663
Optic Nerve 666
Temporal Arteritis 668
Glaucoma 669
Trauma 670
Blow-Out Fractures 673
Retrobulbar Hematoma 673
Chemical Burns 674
Lacerations to Refer 674
SR
O
S
Lateral Medial
rectus rectus
VI
MR LR
Inferior Superior
rectus oblique
IV
IR
LR6(SO4)3
Cranial Nerves
Eyelid opened by
Eyelid closed by 7
Eyelid Control CN 3 &
(hook closing lid) Sympathetic chain
Bell’s palsy affects Horner’s syndrome
eye closure + 3rd nerve palsies
cause ptosis
Pupillary fibers
Compression of Ipsilateral fixed
CN 3 dilated pupil Run on outer part of nerve
Medial
Diabetic CN 3
Pupil is spared Ptosis Abnormal gaze Upwards
palsy
Downwards
Loss of Horner’s
Ptosis Miosis Anhidrosis
Sympathetic chain Syndrome
Evaluation of CT angiogram of
Horner’s CT of brain and
CXR head & neck
syndrome cervical spine vessels
Carotid or vertebral
Pancoast tumor
dissection
CVA Aneuryrsm
Neuroblastoma Tumors
(esp. at lung apex)
Children Causes of Horner’s
Syndrome
Lymphoma Trauma
Carotid Artery
Herpes Zoster
Dissection
640 B. Desai
Pupil Abnormalities
Introduction
Surgery
Inspect pupil Teardrop shaped Acute Trauma
Irregular pupil
shape pupil with iris rupture
Remote trauma
Globe
Retina
Optic nerve
Temporal arteritis
Lateral geniculate
body
3
Occipital cortex
Bottom right image (Reprinted from Galloway NR, Amoaku WMK, diseases and their management. London: Springer Verlag; 2006.
Galloway PH, Browning AC. Neuro-ophthalmology. In: Galloway NR, p. 179–88. With permission from Springer Verlag)
Amoaku WMK, Galloway PH, Browning AC, editors. Common eye
642 B. Desai
External Eye
Lids
Infection of eyelash
External Pustule at eyelid
follicle & sebaceous or Usually bacterial
hordeolum (Stye) sweat gland margin
Topical ointment
Warm
Hordeolum Rx to prevent
compresses infection
Erythromycin
Refer to
Need I&D?
ophthalmology
Center right image (Reprinted from Khairallah M, Kahloun R. Infections of the eyelids. In: Tabbara KF, Abu El-Asrar AM, Khairallah M, editors.
Ocular infections. Heidelberg: Springer Verlag; 2014. p. 51–61. With permission from Springer Verlag)
Chalazion
Associated with
Chalazion squamous cell
carcinoma
Erythromycin
Center right image (Reprinted from Khairallah M, Kahloun R. Infections of the eyelids. In: Tabbara KF, Abu El-Asrar AM, Khairallah M, editors.
Ocular infections. Heidelberg: Springer Verlag; 2014. p. 51–61. With permission from Springer Verlag)
Ophthalmology 643
Blepharitis
Bottom right image (Reprinted from Khairallah M, Kahloun R. Infections of the eyelids. In: Tabbara KF, Abu El-Asrar AM, Khairallah M, editors.
Ocular infections. Heidelberg: Springer Verlag; 2014. p. 51–61. With permission from Springer Verlag)
644 B. Desai
Dacryocystitis
Infection of Strep
Dacryocystitis Usually Staph OR
lacrimal sac pneumoniae
Top right image (Reprinted from Khairallah M, Attia S. Infections of the orbit. In: Tabbara KF, Abu El-Asrar AM, Khairallah M, editors. Ocular
infections. Heidelberg: Springer Verlag; 2014. p. 37–43. With permission from Springer Verlag)
Dacryoadenitis
Inflammation of
Dacryoadenitis Bacterial or Viral
lacrimal gland
Preseptal Postseptal
Subperiosteal Orbital Cavernous sinus
Orbital infections cellulitis cellulitis
(Periorbital) (Orbital) abscess abscess thrombosis
Mechanism of Hematogenous
Local infection Skin disruption
spread? spread
Less common
Specific
None
laboratories?
Definitive
CT scan
diagnosis?
646 B. Desai
Preseptal Cellulitis
PEDIATRICS
Hordeolum
Preseptal Associated with Especially
upper respiratory Eyelid problems Chalazion
cellulitis infections sinusitis
Insect bites or other
skin trauma
Preseptal Childhood
<10 years old
cellulitis disease
Amoxicillin/Clavulanate
Mild Preseptal 24 hour
cellulitis Outpatient Rx Hot packs
1st generation follow-up
cephalosporin
Moderate – Vancomycin
Ophthalmology
Severe Preseptal Inpatient Rx Admission
cellulitis consult
Ceftriaxone
Preseptal
< 5 years Septic workup
cellulitis
Ophthalmology 647
Postseptal Cellulitis
Intraocular FB
Postseptal Associated with Especially ethmoid
Hematogenous
sinus & denta l sinusitis Other factors spread
cellulitis infections (most common cause)
Insect bites or other
skin trauma
Postseptal Usually
Staph aureus S. pneumoniae Anaerobes
cellulitis polymicrobial
Abnormal
Postseptal Painful ROM of + Decreased
Eye is involved pupillary
cellulitis eye visual acuity reactivity
Elevated IOP
Diagnosis CT
Amoxicillin/Sulbactam
Postseptal Ophthalmology
Inpatient Rx Metronidazole
cellulitis 3rd generation consult
cephalosporin
Debridement
Meningitis
Most common
Subperiosteal
abscess Septicemia
Brain abscess
Orbital Cellulitis
Vision loss Complications
Conjunctiva
Conjunctivitis
Introduction
Inflammatory
Common cause
Conjunctivitis condition of the
conjunctiva of the red eye
Parasitic Chemical
Bacterial Conjunctivitis
Preauricular Consider
adenopathy Gonococcus
Typical Streptococcus
Staphylococcus
pathogens species
Gonococcus &
Other pathogens Pseudomonas
Chlamydia
Ophthalmia Contact lens
neonatorum wearers
Topical Warm
Treatment Severe = Culture Patching
antibiotics compresses
Ophthalmia Neonatorum
PEDIATRICS
Evaluation for
GC Treatment disseminated IV Abx
disease
GC Corneal Corneal
Complications ulceration perforation
Chlamydia
PO Erythromycin
Treatment
Keratitis Hx of
Bilateral lid Conjunctival
Viral (Herpes) 6–14 days of life (Corneal maternal
edema injection dendrites) herpes
Center right image (Reprinted from Galloway NR, Amoaku WMK, editors. Common eye diseases and their management. London:
Galloway PH, Browning AC. Common diseases of the conjunctiva and Springer Verlag; 2006. p. 45–60. With permission from Springer
cornea. In: Galloway NR, Amoaku WMK, Galloway PH, Browning AC, Verlag)
Ophthalmology 651
Viral Conjunctivitis
Typical Epidemic
Adenovirus
pathogens keratoconjunctivitis
Frequent hand
Treatment Warm compresses Patching
washing
Muscle
EKC Preceded by Cough Fevers Malaise N/V
aches
Cycloplegic Ophthalmology
EKC Treatment Artificial tears Cool compresses
agents consult
Severe
photophobia
652 B. Desai
Mild-Moderate Topical
Artificial tears
AC Treatment antihistamines
Subconjunctival Hemorrhage
Increased pressure
Causes Trauma OR OR Hypertension OR Spontaneous
from Valsalva
Cavernous sinus
Trauma thrombosis
Subconjunctival Mistaken for Raised circular
Due to
Hemorrhage Pitfall bloody chemosis lesions Perforation of sclera Coagulopathy
Ophthalmology 653
Cornea
Keratitis
Introduction
Viral Drugs
Inflammation of
Keratitis Multiple causes Bacterial Exposure
the cornea
Fungal Sjorgren’s
Redness
Keratitis “Perilimbic flush” circumferential of
sclera at corneal edge
Bacterial Keratitis
Bacterial
May cause iritis
Keratitis
Center right image (Reprinted from Mete G, Turgut Y, Osman A, Gülşen Ü, Hakan A. Anterior segment intraocular metallic foreign body
causing chronic hypopyon uveitis. J Ophthalmic Inflamm Infect. 2011;1(2):85–7. With permission from Springer Verlag)
Ophthalmology 655
HSV Keratitis
“Amoeba -like”
HSV Affecting
Oral Acyclovir
Lids?
HSV Keratitis
Corneal scarring
Complication
Center right image (Reprinted from Sundmacher R. Herpes simplex guide to clinical management. Heidelberg: Springer Verlag; 2008.
virus (HSV) diseases of the anterior segment and the adnexa. In: p. 5–112. With permission from Springer Verlag)
Sundmacher R, editor. Color atlas of herpetic eye disease: a practical
656 B. Desai
Herpes Zoster Shingles in 1st Has ocular Involves upper Does not cross
Ophthalmicus division of CN V involvement eyelid the midline
Rare V2/V3
Facial Pain Paresthesias Fever Headache Malaise Red eye Blurred vision
+ Cranial nerve
+ Optic neuritis Photophobia Eye pain + IOP
palsies
Herpes Zoster
Ophthalmicus Eye Retinitis Choroiditis Uveitis Keratitis Iritis
involvement
HZV Affecting
Oral antivirals
Skin?
Ophthalmology
HZV Iritis?
consultation
Center image (Reprinted from Sundmacher R. Varicella zoster virus guide to clinical management. Heidelberg: Springer Verlag; 2008.
(VZV) diseases of the anterior segment and the adnexes. In: p. 113–57. With permission from Springer Verlag)
Sundmacher R, editor. Color atlas of herpetic eye disease: a practical
Ophthalmology 657
Ultraviolet Keratitis
No visual Conjunctival
FB sensation Eye pain Tearing Photophobia changes injection Corneal edema
On slit lamp
Blepharospasm
Corneal Abrasion
Patching eye
Corneal abrasion Metal FB causing Not examining Dispensing topical
abrasions due to
pitfalls abrasion under the lids anesthestics organic matter
Consider Retained FB Retards healing Increases
intraocular FB infection risk
“Ice rink sign”
658 B. Desai
Corneal Lacerations
Corneal Emergent
Avoidance of
Laceration Ophthalmology Eye Shield
Treatment consult eye movements
Extrusion of
vitreous with eye
muscle contraction
Corneal Traumatic
Laceration Endophthalmitis Vision loss
Complications Cataracts
Ophthalmology 659
Corneal Ulcers
Pseudomonas
Decrease pain
Bottom right image (Reprinted from Heiligenhaus A, Heinz C, Schmitz Reinhard T, Larkin F, editors. Cornea and external eye disease.
K, Tappeiner C, Bauer D, Meller D. Amniotic membrane transplanta- Heidelberg: Springer Verlag; 2008. p. 15–36. With permission from
tion for the treatment of corneal ulceration in infectious keratitis. In: Springer Verlag)
No visual
FB sensation Blurred vision Tearing Edema of lids Chemosis Photophobia
changes
Introduction
Inflammation in Iris
Multiple
Iritis anterior segment Choroid
of uveal tract etiologies
Ciliary body
Conjunctival Decreased
Eye Pain Photophobia Perilimbal flush Cells & Flare + Systemic Sx
injection vision
U/L, but may be B/L Red eye Ciliary spasm Injection is On slit lamp Arthritis
in systemic irritates trigeminal greatest around
processes nerve the limbus Urethritis
May be consensual Poorly reactive
miotic pupil
Decrease pain
Malignancies
Leukemia
Viral Lymphoma
Trauma
Zoster Melanoma
Corneal foreign body
Adenovirus
UV Keratitis
HSV
Bacterial
Endophthalmitis
Penetrating globe
Inflammation of Postsurgical injuries
Endophthalmitis aqueous or Leads to Loss of vision Due to
vitreous humor Most common Hematogenous
spread
Usually infectious
Rare
Septic emboli
Right eye 2x more
affected due to
blood supply
Headache Eye pain Eye discharge Photophobia Visual loss Lid swelling Lid erythema
Endophthalmitis 3 rd generation
Vancomycin Gentamicin OR Amphotericin B
treatment cephalosporin
If fungal etiology
suspected
Vitreous Hemorrhage
Vitreous
Diabetic Vitreous
Hemorrhage Ocular trauma
causes retinopathy detachment
Shaken baby Elderly
syndrome
Vitreous
Failure to check Not referring to
Hemorrhage
INR Ophthalmology
pitfalls
In those patients
on Warfarin
Ophthalmology 663
Retina
Monocular Afferent Fixed dilated Cherry red spot “Box car” appearance
Pale retina
blindness pupillary defect pupil in macula to retinal artery
Due to decreased
flow
Anterior
Gentle globe Increase Topical
CRAO Treatment Acetazolamide chamber
massage PCO2 β-blocker paracentesis
Dislodge Dilates Decrease
By ophtho
emboli retinal aqueous
artery humor
Breathe production
into paper
bag
Center right image (Reprinted from Galloway NR, Amoaku WMK, Common eye diseases and their management. London: Springer
Galloway PH, Browning AC. Systemic disease and the eye. In: Verlag; 2006. p. 165–78. With permission from Springer Verlag)
Galloway NR, Amoaku WMK, Galloway PH, Browning AC, editors.
664 B. Desai
Emboli
Carotid
Sickle cell disease Cardiac Thrombosis
Vasospasm
Trauma
Migraine
Hypercoagulable
Temporal arteritis
states
DM Hypertension
Cerebrovascular Cardiovascular
disease disease
CRVO Risk Factors
Glaucoma Vasculitis
No specific Refer to
CRVO Treatment
treatment Ophthalmology
Center right image (Reprinted from Galloway NR, Amoaku WMK, Common eye diseases and their management. London: Springer
Galloway PH, Browning AC. Systemic disease and the eye. In: Verlag; 2006. p. 165–78. With permission from Springer Verlag)
Galloway NR, Amoaku WMK, Galloway PH, Browning AC, editors.
666 B. Desai
Retinal Detachment
Separation of the
Retinal Ophthalmologic
retina from its
Detachment supporting layers emergency
Retinal Detachment
Trauma Retinopathy
Risk Factors
Prior Hx of
detachment
Optic Nerve
Optic Neuritis
Multiple sclerosis
Inflammation of Causing acute Over hours to
Optic Neuritis until proven
optic nerve reduction in vision days otherwise
Increased
Bilateral optic disc
Papilledema Due to intracranial
swelling pressure
Malignant
Hypertension
Pseudotumor
Causes of cerebri
CNS Tumors
Papilledema Idiopathic intracranial
hypertension
Hydrocephalus
Pseudotumor
Papilledema Increased ICP Normal CT/MRI Normal CSF
cerebri
Can occur at any But…elevated
age opening pressure
Pseudotumor
Papilledema
cerebri
Top right image (Reprinted from Galloway NR, Amoaku WMK, Galloway their management. London: Springer Verlag; 2006. p. 179–88. With
PH, Browning AC. Neuro-ophthalmology. In: Galloway NR, Amoaku permission from Springer Verlag)
WMK, Galloway PH, Browning AC, editors. Common eye diseases and
668 B. Desai
Temporal Arteritis
Involves medium
Temporal Systemic Painless ischemic Can progress
sized arteries in the
Arteritis vasculitis optic neuropathy bilaterally
carotid circulation
Bilateral blindness
in 50 % of
untreated patients
Temporal Decreased
Temporal Arteritis New onset
Age > 50 artery pulsations in ESR > 50
Dx headache artery
tenderness
3 of 5
Worse at night
Glaucoma
Ocular emergency
Parasympatholytic
Inhaled β-agonists
agents
Topical
Systemic
Familial
Some risk factors
DM
for Acute Angle
Anything else Closure Glaucoma
Sympathomimetic
causing pupillary agents
dilation
Topical
Systemic
HTN Cocaine
“Steamy” or Non-reactive
Abrupt in onset Red eye Eye pain pupil Blurred vision
hazy cornea
Abdominal
Headache pain N/V
Rare
670 B. Desai
Emergent
Glaucoma Decrease aqueous Increase drainage Reduce volume of
Ophthalmology
Treatment humor production of aqueous humor aqueous humor consult
Lower IOP
Reduce volume of
Mannitol
aqueous humor
Osmotic
decompression of
eye
Trauma
Initial Anterior
Visual acuity Globe integrity
Assessment Chamber
Projectiles to Penetration of
globe until proven
eye otherwise
Penetration of
Eyelid Lacerations near
OR globe until proven
lacerations the orbit otherwise
Hammering or Penetration of
globe until proven
grinding metal otherwise
Decreased sensation
Injury to inferior
below the eye or
orbital nerve
ipsilateral nose?
IV Update
Ophthalmology
Treatment Tetanus if Analgesia CT/MRI
Antibiotics needed consult
No MRI for
metal FB
Ophthalmology 671
Flat Anterior
Chamber
Due to lowered
IOP
Hyphema Eye pain
Most globe
ruptures will have
this Pupillary
irregularity
Subconjunctival
Signs & Symptoms hemorrhage
Traumatic Iritis
of Blunt Ocular
Trauma & Globe Large
Cells & flare on slit
lamp Rupture
Lid laceration
Restricted gaze
Up
Afferent pupillary
Lateral defect
Periorbital
Uveal prolapse (+) Seidel Test + Decreased IOP
ecchymosis
Involvement of
CN 3, 4, or 6
672 B. Desai
Hyphema
Microhyphema
Circulating red blood cells
Grade I
< 1/3 anterior chamber vol.
Blood or clots in
Hyphema Traumatic OR Spontaneous
anterior chamber
Grade II
1/3 - 1/2 anterior chamber vol.
Blow-Out Fractures
Sites for blow Inferior wall into Medial wall into Most common Caused by direct
out fractures the maxillary sinus the ethmoid sinus orbital wall fx trauma to orbit
Blowout fx until
Epistaxis Eye Trauma Nasal trauma
proven otherwise
Update
PO Ophthalmology &
Treatment Tetanus if Analgesia CT
Antibiotics Face consult
needed
Retrobulbar Hematoma
Decreased blood
Large hematoma Increase in IOP Acute glaucoma flow to optic nerve Retinal ischemia
& retina
Decreased Afferent
Eye pain Proptosis
vision pupillary defect
Penetration of
Increased IOP Lateral Medications to
globe NOT Measure IOP
suspected (>40) canthotomy reduce IOP
Blood in Tenon’s
Diagnosis CT
capsule
674 B. Desai
Chemical Burns
Immediate 1–2 L
Chemical Burns irrigation before
examination
Damaged area
Coagulation Usually no deep
Acid burns Chlorine, Sulfur coagulates and
necrosis penetration prevents deeper burns
Continuous Emergent
Topical
Treatment irrigation until pH Ophthalmology
anesthetic is normal consult
7.4
Lacerations to Refer
Lid Margin
Lacerations to Refer
Wounds involving
Require specialist Involving lacrimal
orbital septum
repair for proper lid duct or sac
function & lacrimal
system function
Any wounds
Inner surface of
causing ptosis eyelid
Tarsal plate
Toxicologic Emergencies
Contents
General Approach to the Poisoned Patient 676
Data Interpretation 685
Toxidromes 687
Specific Toxins and Poisons 692
Primary Survey
Rapid
Survey algorithm Primary
resuscitation
What, when,
route, dose,
co-ingestions,
why
Airway Assessment
Breathing Assessment
Signs of Manage as
Assess breathing Respiratory rate Retractions
aspiration needed
Airway protection
& intubation
Circulation Assessment
Disability Assessment
Disability
Assess GCS Pupils
assessment
678 M. Ryan and B. Desai
Exposure
Complete
Skin/soft tissue
exposure of Wounds Track marks Pressure ulcers
infections
patient
Other Decontaminate
considerations as needed
Not searching
Pitfall
patient
Can be given
Naloxone 2 mg bolus No effect? 10 mg repeat
IV/IM/SL/SC/ETT
Laboratory Studies
Important
Renal function Potassium Bicarbonate
aspects of BMP?
Assess for
CK?
rhabdomyolysis
Toxicology Screens
Urine toxicology Not always Most drugs are Initial screen Positive findings
tidbits indicated not screened may be negative may be unrelated
Rarely impacts Many drugs
management not have half lives:
Cocaine, Benzos
Urine is better Can detect metabolites 2–3 days Check blood levels on all drugs in
Urine vs Blood
than serum after ingestion or injection which levels can guide therapy
Amphetamines
Pseudoephedrine
Tricyclic
PCP
antidepressants
Ketamine False positive Cyclobenaprine
drug screens
Dextromethorphan Phenothiazines
Diphenhydramine
Urinalysis Tidbits
Ketones in
Dehydration OR Ketosis OR Toxic alcohols Ethanol
urine?
Metabolic
pH
acidosis
Assess for
Blood Hyperthermia OR Cocaine
rhabdomyolysis
Consider
Crystals
Ethylene glycol
Urine drug
As needed
screen?
Toxicologic Emergencies 681
Physical exam Track Pressure Skin/Soft tissue Skin Check groin &
features marks ulcers infections popping axilla for sweat
“Toxicology
handshake”
Modified release
Whole bowel
medication or
irrigation
ingestion?
Charcoal Tidbits
Lithium Bases
Not effective for ionic or
Pitfall
charged substances
Acids Heavy Metals
Sustained release
Lithium
drugs
Alcohols Hydrocarbons
Altered mental
Contraindications Caustics Ileus OR Obstruction
status
Urine
INH Phenobarbital Salicylates Urine pH 7–8
alkalinization
Dialysis Tidbits
Some dialyzable
medications
Anticonvulsants Alcohols
Phenobarbital Ethanol
Toxicologic Emergencies 683
Anticholinergics
Throxine Sympathomimetics
Hyperthermia
Methylxanthines Serotoninergics
Salicylates
Opiates
Phenothiazines Alcohols
Salicylates
Oral
Hypoglycemia Acetaminophen
hypoglycemics
Alcohol Insulin
684 M. Ryan and B. Desai
Select Antidotes
Acetaminophen N-Acetylcysteine
Anticholinesterase Atropine/Pralidoxime
Anticholinergics Physostigmine
Benzodiazepines Flumanezil
b-blockers Glucagon
Coumadin Phytonadione
Iron Deferoxamine
Narcotics Naloxone
Odor Agent
Data Interpretation
Arterial-Alveolar Gradient
Normal A-a
(Age/4) + 4
gradient?
Anion Gap
Measured Measured
Anion gap
cations anions
Normal anion
10–15
gap?
Largely due to
Anion gap
albumin
Hypo-
Lower anion gap Malnourished Chronically ill
albuminemic pts
Toxins Tidbits
Toluene
Uremia
Diabetic Ketoacidosis
Osmolar Gap
Measured Calculated
Osmolar Gap
osmolality osmolality
Differential
Increased
diagnosis of OR Alcohols OR Hyperglycemia OR Ketosis OR Acidosis
protein
osmolar gap
Most common
Ethanol
cause of gap?
Toxicologic Emergencies 687
Toxidromes
Anticholinergic Toxidrome
Anticholinergic Causes
Antihistamines
Botanicals
Mandrake
Other agents
Scopolamine
Anti-diarrheals
Atropine
Ipatropium
Bladder spasm
medications
688 M. Ryan and B. Desai
Agitation or
OR Seizures Benzodiazepines
Delirium
Physostigmine Tricyclic
Heart block
contraindications? overdose
Cholinergic Toxidrome
Miosis
Salivation Lacrimation Urination Defecation GI Upset Emesis
(& Muscle spasm)
Muscle Respiratory
Fasciculations
weakness failure
Respiratory
Pitfalls Seizures Coma
failure
Toxicologic Emergencies 689
Cholinergic Causes
Organophosphates
Muscarinic
Cholinergic Carbamates
agents
Causes
Physiostigmine &
Some nerve gases
Pyridostigmine
Opioid Toxidrome
Respiratory
Obtundation Miosis Coma Hypotension
depression
Not always
seen!
Common Opioids
Morphine
Propoxyphene Oxycodone
Common Hydrocodone
Hydromorphone
Opioids
Codeine Methadone
Meperidine Fentanyl
Sedative Toxidrome
Ethanol
Gamma
Benzodiazepines
hydroxybutyrate
Spice Barbituates
Sepsis Trauma
Toxicologic Emergencies 691
Sympathomimetic Toxidrome
Sympathomimetic Agents
Amphetamines
Common
Sympathomimecs
Cocaine Smulants
692 M. Ryan and B. Desai
Withdrawal Symptoms
Opioid Mimics
Usually not fatal
withdrawal cholinergic crisis
Alcohol Mimics
Can be fatal
withdrawal sympathomimetic crisis
Mimics
Hypoglycemia
sympathomimetic crisis
Alcohols: Introduction
Metabolism of By alcohol
alcohols? dehydrogenase
Alcohols: Methanol
Respiratory
N/V Seizures Pancreatitis Blindness
failure
Repletion of Repletion of
Initial Treatment ABC’s IV Fluids
Thiamine electrolytes & glucose
Agitation &/or
Benzodiazepines
seizures?
Alcohols: Ethanol
Alcohol toxicity
Respiratory Alcoholic
Hypothermia Hypotension Hypoglycemia
depression ketoacidosis
Repletion of Repletion of
Initial Treatment ABC’s IV Fluids
Thiamine electrolytes & glucose
Agitation &/or
Benzodiazepines
seizures?
Ethanol Tidbits
Thiamine Multivitamins
Treatment Fluids Magnesium Benzodiazepines
(Vitamin B1) & Folate
Wernicke’s Oculomotor
Confusion Ataxia Nystagmus CN VI Palsy
encephalopathy crisis
Korsakoff’s Retrograde
Confabulation
Psychosis amnesia
Disulfiram
Alcohol Metronidazole
reaction
Disulfiram
Flushing Diaphoresis N/V Headache
reaction
Severe Disulfiram
Arrhythmias Seizures Hypotension
reaction
Toxicologic Emergencies 695
Repletion of Repletion of
Initial Treatment ABC’s IV Fluids
Thiamine electrolytes & glucose
Agitation &/or
Benzodiazepines
seizures?
Overdose causes
Isopropyl alcohol Solvent found in Rubbing alcohol
osmolar gap
Repletion of Repletion of
Initial Treatment ABC’s IV Fluids
Thiamine electrolytes & glucose
Amphetamine Examples
Ephedrine
MDMA ADHD
medications
“Ecstacy” Lisdexamfetamine
“Molly” Methylphenidate
Dextroamphetamine
Amphetamines
Prescription Sympathomimetic
Amphetamines Drugs of abuse
medication syndrome
Agitation &/or
Benzodiazepines
seizures?
Acidification of urine is
Pitfall
NOT recommended
Unopposed a Diffuse
Ischemia Hypertension
stimulation vasoconstriction
Toxicologic Emergencies 697
Analgesics: Acetaminophen
Major
pathways
> 4 g/day
May be
Early stage N/V asymptomatic
Rumack-Matthew Nomogram
Based on Rumack -
Antidose dosing
Matthew Nomogram
5000 5000
1000 1000
500 500
Po
ss Probable hepatic toxicity
ibl
eh
200 ep 200
ati
ct
No hepatic toxicity ox
100 ici
ty 100
50 50
25%
20 20
10 10
4 8 12 16 20 24
Hours after ingestion
Rumack matthew nomogram
A level of > 150 mg/dL at the four Treat multiple ingestions as a single
Tidbits
level requires treatment with NAC ingestion initiated at the first ingestion
Provides cofactors to allow production Lack of NAC results with the liver’s
NAC importance
of inert metabolites of acetaminophen production of toxic metabolites
Load Followed by
NAC Dosing
140mg/kg po 70 mg/kg every 4 hours for 17 doses
Other indications
Co-ingestions Acute psychosis Suicidal intent
for admission
Salicylate Examples
Aspirin
Analgesics: Salicylates
Sweating
< 150 mg/kg N/V GI upset
(esp. in kids)
Tachypnea
150–300 mg/kg N/V AMS Tinnitus
(esp. in kids)
Celecoxib
Combination
Diclofenac
formulations
Naproxen Etodolac
Nonsteroidal Anti-
Nabumetone Inflammatory Ibuprofen
Agents
Meoxicam Indomethicin
Ketorolac Ketoprofen
Analgesics: NSAIDs
Other Intentional
Co-ingestions Suicidal intent
considerations overdose
702 M. Ryan and B. Desai
Anticonvulsants: Valproate
Valproate Supportive
overdose treatment
Anticonvulsants: Carbamazepine
Carbamazepine Supportive
overdose treatment
Other
Slurred speech Sleepiness
neurologic Sx
Severe
Seizures Coma Arrhythmias
symptoms
Other
GI upset
symptoms
Acute vs Chronic
Considerations Oral vs IV
ingestion
Vertical, horizontal
Common Sx Nystagmus Ataxia Dysarthria Hyporeflexia Hypotonia
or both
Respiratory
Severe AMS Seizures Coma
failure
Conduction
Cardiovascular Hypotension Bradycardia AV Blocks Tachydysrhythmias
delays
Initial Others as
Phenytoin level Electrolytes ECG
Laboratories needed
Seizures? Benzodiazepines
Antihistamines
Definitive
Supportive
Treatment
Agitation or Avoid
Benzodiazepines
psychosis? phenothiazines
Severe Consider
symptoms? physostigmine
704 M. Ryan and B. Desai
Antimicrobials
Isoniazid
Toxicity
Toxicity
Conduction
Hypotension Bradycardia Dysrhythmias AV Block Hypoglycemia
delays
Specific Glucagon 0.1 mg/kg bolus up to 10 mg/hr High dose insulin up to 2 mg/kg/hr
Treatment thereafter as a continuous infusion OR OR & dextrose
Refractory Epinephrine
hypotension? infusion
High grade
Pacemaker
blocks?
Toxicity
Conduction
Hypotension Bradycardia Dysrhythmias
delays
Specific Calcium Glucagon 0.1 mg/kg bolus up to 10 mg/hr High dose insulin up to 2 mg/kg/hr
OR
Treatment gluconate thereafter as a continuous infusion & dextrose
Refractory Epinephrine
hypotension? infusion
Bradycardia? Atropine
706 M. Ryan and B. Desai
Refractory
Pressors
hypotension?
Bradycardia? Atropine
Clonidine
Hypertension Anxiety Tachycardia Sweating
withdrawal
Children or Accidental or
Acute toxicity
young adults intentional overdoses
Due to decreased
Chronic toxicity Older patients
renal excretion
Altered mental
Acute toxicity Dysrhythmias N/V Visual changes Hyperkalemia
status
Ventricular PVC’s
Dysrhythmias SVT AV Block Bradycardia Tachycardia
tachycardia (most common)
Specific
Digibind Hyperkalemia
Treatment
Unstable vital
Renal Failure
Start with 5–10 Discuss with signs
Amount?
vials initially poison control
Digibind indications
Neurologic Hyperbaric
sequelae? chamber
Laboratory
Chemistries CBC ABG
investigations
Assess for
Imaging CXR
perforation
Severe burning
pain at site
Calcium binds
Pathophysiology Pain improves
with fluoride
IV Fluids
Initial Treatment ABC’s O2 Cardiac monitor
(prevent shock)
May dilute solid agent with milk Dilution is contraindicated in May lead to
Dilution?
or water if able to tolerate po any other caustic ingestion vomiting
Laboratory
Chemistries CBC ABG
investigations
Assess for
Imaging CXR
perforation
Chlorine
Irritation of Irritation of
Eye irritation Dermal injury
throat upper airway
Cocaine
Initial
ABC’s O2 Cardiac monitor
Management
Nitroglycerin Avoid
Treatment Benzodiazepines
(for chest pain) Haloperidol
Evaporative
Hyperthermia? Cooling blankets
cooling
Cocaine Tidbits
Fires
Synthetic rubber
Burning plastic
Jewelers
Common
Apricot pits sources
Wood treatment
Cyanide
Decreased mental Decreased Labile heart rate Metabolic Bitter almond Cherry red color
status + coma respiratory rate & blood pressure acidosis odor especially of blood
Secondary to ↓ O2
Normal PaO2 &
metabolism No cyanosis Abdominal pain No cyanosis Acidosis
O2 saturation
Initial IV Fluids
ABC’s O2 Cardiac monitor
Management (prevent shock)
Lactic acidosis
from anaerobic
metabolism
Toxicologic Emergencies 713
Cyanide Treatment
Sodium
Cyanide Thiocyanate Renal excretion
thiosulfate
Hallucinogens
LSD
Anticholinergics Amphetamines
Jimson weed
Common
sources
Mushrooms
Cannabinoids
Amanita causes
most deaths
Mescaline PCP
714 M. Ryan and B. Desai
Hallucinogens
Serotonin
Pathophysiology
antagonism
Initial
ABC’s IV Fluids O2 Cardiac monitor
Management
Hyperthermia? Cooling
IV fluids to maintain
Rhabdomyolysis?
adequate urinary output
Phencyclidine (PCP)
Rotatory
↑HR and BP Agitation Seizures Psychosis Hyperthermia
nystagmus
Initial
ABC’s IV Fluids O2 Cardiac monitor
Management
Hyperthermia? Cooling
IV fluids to maintain
Rhabdomyolysis?
adequate urinary output
Arsenic
Mercury Lead
Arsenic
Initial
ABC’s IV Fluids O2 Cardiac monitor
Management
BAL Succimer
Antidote? OR
3–5 mg/kg IM every 4 hours For patients able to tolerate PO
716 M. Ryan and B. Desai
Iron
Toxicity Stages
Up to 6 hours
Stage 1 N/V Diarrhea Hematemesis Hematochezia
after ingestion
Metabolic
Stage 3 > 12 hours Shock Coma Coagulopathy
acidosis
Coagulopathy
Stage 4 12–48 hours Liver failure
worsens
Initial O2
ABC’s IV Fluids Cardiac monitor
Management
Whole bowel
Large ingestion?
irrigation
Deferoxamine
Antidote?
15mg/kg/hr continuous IV infusion
Lead
Most poisoning is chronic due to Disrupts neural tissue both Due to interference with
Lead
exposure of lead laden paints centrally and peripherally enzyme activity
Initial O2
ABC’s IV Fluids Cardiac monitor
Management
Lead level
Indications Symptomatic
> 70 µg/dL
718 M. Ryan and B. Desai
Mercury
Altered mental
CNS Symptoms Depression Memory loss Ataxia
status
24 hour urine
Diagnosis
collection
BAL Succimer
Antidote? OR
3–5 mg/kg IM every 4 hours 10 mg/kg PO every 8 hours
Child swallowed
This mercury is Not absorbed
thermometer
inert by GI tract
mercury?
Metal Fume Cause from breathing in fumes Can result from the preparation of coinage
Fever secondary to welding metals: copper, silver and gold
Flu-like
URI symptoms F/C Nausea Malaise Myalgias Headaches
Symptoms
Treatment Supportive
Toxicologic Emergencies 719
Hydrocarbons
Solvents and
Oils
refrigerants
Hydrocarbons
Benzene and
Paint thinners
Toluene
Hydrocarbons: Introduction
Halogenated
Liver toxic
agents
Peripheral
Due to
nervous system
demyelination
effects?
Mostly Decontaminate
Treatment
supportive as required
Initial O2
ABC’s IV Fluids Cardiac monitor
Management
General rule for Aspiration Unless the hydrocarbon has an inherent systemic
“CHAMP”
lavage outweighs benefits toxicity or has additives that cause systemic toxicity
Symptomatic
Admission
patient?
Hypoglycemic Agents
Short acting Replete glucose with Give a meal (e.g., turkey and cheese sandwich D/C if asymptomatic
agent? IV & oral modalities which contains protein, carbohydrates and fat after observation
Sulfonylurea Toxicity
Initial O2
ABC’s IV Fluids Cardiac monitor
Management
Gastric
May consider Glucagon D10 drip
decontamination
Lithium
Used to treat Small therapeutic Most pts under long term therapy
Lithium
manic depression window will develop toxicity at some time
Early CNS
Fatigue Confusion Tremor
Symptoms
Late CNS
Clonus Rigidity Seizures Coma
Symptoms
Cardiac QT
Arrhythmias
Symptoms Prolongation
Maculopapular
Skin Symptoms
rash
722 M. Ryan and B. Desai
Initial O2
ABC’s IV Fluids Cardiac monitor
Management
Aggressive hydration
IV fluids?
with normal saline
Severely toxic
Hemodialysis
patient?
Use
Seizures? OR Phenobarbital
benzodiazepines
Toxicologic Emergencies 723
Used in
MAOI’s Parkinson’s
depression
HTN
Headache Tachycardia Hyperthermia Seizures
(May be severe)
IV Fluids O2
Treatment ABC’s Cardiac monitor
(may have severe dehydration)
Seizures? Benzodiazepines
Mushrooms: Amanita
Symptoms
Benign course
within 2 hours?
Symptoms
Higher chance of
delayed > 6 Toxic ingestion
liver & kidney failure
hours?
GI
Treatment IV fluids
decontamination
Mushrooms: Others
Hydrazine used as a
Gyromitrins
fuel & propellant
GI Benzodiazepines &
Treatment Supportive care
decontamination Pyridoxine for seizures
Muscarinic
Muscarines DUMBELS Psychoactive
effects
Treatment Supportive
Narcotics
Respiratory
Overdose Obtundation Miosis
depression
Respiratory Respiratory Decreased Aspiration Pulmonary
Septic emboli
complications depression cough reflex pneumonia edema
Similar to
Withdrawal Yawning Piloerection
cholingeric crisis
Half lives of Methadone, Modified-release morphine & Oxycodone have long half-lives
Pitfall
narcotics is variable and may require repeated dosing of Naloxone and continuous infusion
Skin & Soft Look for sites of injection, track Abscess at injection site
tissue infections marks & retained foreign bodies or distal to site (CNS)
Toxicologic Emergencies 725
Respiratory
CNS effects Coma
depression
Muscarinic see Cholinergic
“SLUDGEM” “Killer B’s”
effects toxidrome
Nicotinic Muscle Respiratory
Cramps Weakness
effects fasiculations failure
Presentation of If presence of
“DUMBELS” Intubation!
patient? “Killer B’s”
Initial
Decontamination!!
Management
Other Intubation as O2
ABC’s Cardiac monitor
Management required
Phenothiazines
Compazine
Phenergan Prochlorperazine
Phenothiazines
Chlorpromazine Promethazine
Fluphenazine Mesoridazine
Initial O2
ABC’s IV Fluids Cardiac monitor
Management
Extrapyramidal
Diphenhydramine OR Benztropine
symptoms?
Seizures? Benzodiazepines
Sodium
Dysrhythmias? Lidocaine
bicarbonate
Other Consider GI
considerations decontamination
Altered mental
CNS effects Rigidity Opisthotonus Opisthotonus
status
Constitutional Severe
symptoms hyperthermia
Cardiovascular
Tachycardia Hypertension
effects
Consider Consider
Treatment Control fever Benzodiazepines
Dantrolene Bromocriptine
Cooling blankets
Cool IV fluids
Medications
may not be
effective
Serotonin
Serotonin syndrome occurs Rigidity is Except in lower extremities where
syndrome
soon after starting medications greater in NMS in serotonin syndrome it is greater
comparison
728 M. Ryan and B. Desai
Serotonin Syndrome
Hypertonicity
and Hunter Criteria Inducible Clonus
Fever (>38 °C)
with Agitation or
and Ocular
Diagnosis can be Diaphoresis
Clonus or
made if 1 criteria
Inducible Clonus
is present
Ocular Clonus
Tremor and
with Agitation or
Hyperreflexia
Diaphoresis
No serotonin
None of these?
syndrome
Toxicologic Emergencies 729
Meperidine Dextromethorphan
LSD Fentanyl
Agents Causing
Cocaine & Serotonin Levodopa
Amphetamines Syndrome
Tramadol Linezolid
Triptans Lithium
Sedative-Hypnotics: Barbiturates
Short-acting Metabolized by
Pentobarbital
Barbituates liver
Respiratory Cutaneous
Coma Shock Hypothermia Hypotension Bad prognosis
depression bullae
Initial ABC’s O2
IV Fluids Cardiac monitor
Management (Especially “A”)
Definitive Urinary
treatment alkalinization
Long acting
Hemodialysis
agent?
730 M. Ryan and B. Desai
Sedative-Hypnotics: Benzodiazepines
Initial ABC’s O2
IV Fluids Cardiac monitor
Management (Especially “A”)
Definitive
Supportive
treatment
Initial ABC’s O2
IV Fluids Cardiac monitor
Management (Especially “A”)
Strychnine Toxicity
Paralysis of medulla
Pitfall
with death
Amitriptyline
Trimipramine Amoxapine
Nortriptyline Doxepin
Imipramine
732 M. Ryan and B. Desai
Initial O2
ABC’s IV Fluids Cardiac monitor
Management
Agitation or
OR Seizures Benzodiazepines
Delirium
Overdrive pacing
Dysrhythmias? Lidocaine Magnesium Cardioversion
for Torsades
Xanthines
Multifocal atrial
Cardiovascular Tachycardia
tachycardia
Initial O2
ABC’s IV Fluids Cardiac monitor
Management
Seizures? Phenobarbital
Toxicologic Emergencies 733
Malignant Hyperthermia
Muscle Hyperthemia
Muscle rigidity Tachypnea Tachycardia Rhabdomyolysis Mottled skin
stiffness (> 40.5 °C)
Some laboratory
Acidosis Hyperkalemia Myoglobinuria
findings
Initial O2
ABC’s IV Fluids Cardiac monitor
Management
Bobby Desai
Contents
Tidbits 736
The Hand 738
Fractures and Dislocations of the Wrist 750
The Forearm 756
The Elbow 760
The Humerus and Shoulder 766
Nontraumatic Hip Disorders 777
The Femur 781
The Knee 782
The Leg 791
The Ankle 795
The Foot 797
Osteomyelitis 800
Thoracic and Lumbar Pain 801
Rheumatologic Emergencies 808
Tidbits
Epiphysis
Metaphysis
Diaphysis
Salter-Harris Fractures
PEDIATRICS
Most common in males
10–16
Epiphysis
A Above the growth plate
Complete
Growth issues
physeal fx
related to: L Lower than the growth plate
Amount of
fragmentation
T Through the growth plate
A L
Size of fracture
75 % 10 % fragment
R Ram the growth plate
Extent of
epiphyseal
Most Chip fx of Physeal fx extends Fractures due to epiphyseal growth
injury
common metaphysis thru epiphysis plate being weaker than supporting
Worst ligaments
prognosis
Crush or May result in growth
compression complications
with severe
T R abduction or
10 % <1 % adduction
Knee/Ankle
Most common Physeal fx+ most
epiphyseal fx+ Increase in complications from I–V
in distal common
humerus metaphyseal fx Compression fx IV & V – future growth impairment
of growth plate
Blood supply to growth plate
Long bones in children I&V comes from epiphysis
All involve growth plate or X-ray may be negative Greater the injury to epiphysis, higher
surface of joint likelihood of growth disturbances
738 B. Desai
The Hand
Sensory Motor
Radial Radial
U
U M
M
Median Median
M M
M
Ulnar Ulnar
Multiple digits
Metacarpal (Palm)
area
Orthopedic Emergencies 739
Hand Infections
Eikenella Amoxicillin-
Human bites Fusobacterium Staph
corredens Clavulate for these
Atypical
DM + HIV Mycobacterium Candida albicans
organisms
Felon
Pulp space
Felon Due to Staph aureus
infection
Occurs in distal
Felon fingertip
Volar
longitudinal
incision
Starts 3 to
5 mm from
the distal
interphalangeal
joint
a b
d e
Top right image (Reprinted from Dailana ZH, Rigopoulos N. Infections of the hand. In: Bentley G, editor. European surgical orthopaedics and
traumatology. Heidelberg: Springer Verlag; 2014. p. 2009–31. With permission from Springer Verlag)
Orthopedic Emergencies 741
Paronychia
Acute nailbed
Paronychia Due to Staph aureus
infection
Osteomyelitis
Complication
(if not improving)
Eponychium
Pus beneath Germinal
eponychial fold matrix
Nail
Hyponychium
Sterile matrix
Top right image (Reprinted from Dailana ZH, Rigopoulos N. Infections of the hand. In: Bentley G, editor. European surgical orthopaedics and
traumatology. Heidelberg: Springer Verlag; 2014. 2009–31. With permission from Springer Verlag)
742 B. Desai
Flexor Tenosynovitis
Tenderness over
Symmetric Pain with passive Flexed posture
Kanavel’s signs flexor tendon
finger swelling extension of digit
sheath
Tenderness along
tendon sheath
Finger held
in flexion
Fusiform
swelling
Bottom right image (Reprinted from Dailana ZH, Rigopoulos N. Infections of the hand. In: Bentley G, editor. European surgical orthopaedics
and traumatology. Heidelberg: Springer Verlag; 2014. p. 2009–31. With permission from Springer Verlag)
Sporotrichosis
Supersaturated
Treatment Itraconazole OR
potassium iodide
Orthopedic Emergencies 743
Boutonniere Deformity
Central slip extensor
Boutonneire Forced flexion at
hood disruption near Due to
Deformity PIP joint
PIP joint
Boutonneire deformity
Boutonneire May have concomitant Flexed PIP
Deformity avulsion fracture
Extended DIP
PIP flexion
+
Splint PIP in
Treatment DIP extension
extension
744 B. Desai
Mallet Finger
Splint DIP in
Treatment
extension
X-ray
Bottom left image (Reprinted from Almusa E, Peterson II WM, Bianchi S, Jacob D, Hoffman D. Radiological investigations. In: Chick G, editor.
Acute and chronic finger injuries in ball sports. Paris: Springer Verlag; 2013. p. 89–124. With permission from Springer Verlag)
Orthopedic Emergencies 745
X-ray
Thumb spica
Treatment Partial tear Complete tear Surgery
splint
Chronic instability
Pitfall
of thumb
Bull rider’s Thumb
>40o radial angulation Surgical RCL injury
Complication
indicates complete rupture consultation
Center left image (Reprinted from Almusa E, Peterson II WM, Bianchi S, Jacob D, Hoffman D. Radiological investigations. In: Chick G, editor.
Acute and chronic finger injuries in ball sports. Paris: Springer Verlag; 2013. p. 89–124. With permission from Springer Verlag)
Herpetic Whitlow
Associated with
Adults HSV 2 Children gingivostomatitis
HSV-1
Mistaken for
Pitfall DO NOT I&D!
felon
De Quervain’s Tenosynovitis
Referral to hand
Treatment Volar splint NSAIDs
surgeon
Orthopedic Emergencies 747
Treatment Splinting
Splint from
Unstable Fx? Hand follow-up
elbow to DIP
Spiral or intra-
Internal fixation
articular fx?
Metacarpal neck Metacarpal neck is Boxer’s Fracture of the neck All will have
fx most common hand fx Fracture` of the 5th metacarpal volar angulation
Any rotation
PItfall requires urgent
hand followup
Metacarpal Base Associated with Caused by axial Base of 4th & 5th may result in paralysis
fx carpal bone fractures force or direct blow or motor branch of ulnar nerve
748 B. Desai
Thumb spica
Treatment Will require ORIF
splint
Comminuted fracture Fx is
Rolando Fracture Worse prognosis
at base of metacarpal intraarticular
Hand
Treatment Thumb spica
consultation
Finger Dislocation
Distal
Have firm
interphalangeal Uncommon attachments
joint
Proximal
Axial load &
interphalangeal Common hyperextension
joint
Hyperextension
Thumb MCP mechanism
Orthopedic Emergencies 749
Ischemia of Chemical
Mechanism Tissue edema Due to
tissues inflammation
Initial benign
Pitfall
appearance
Amputation rate
Complication
30 %
750 B. Desai
Colles’ Fracture
X-ray
Median nerve
Complications Malunion Joint instability Arthritis
injury
Center right image (Reprinted from Raby N. Imaging of wrist trauma. In: Davies AM, Grainger AJ, James SJ, editors. Imaging of the hand and
wrist. Heidelberg: Springer Verlag; 2013. p. 141–69. With permission from Springer Verlag)
Orthopedic Emergencies 751
Smith’s Fracture
X-ray
Center image (Reprinted from Raby N. Imaging of wrist trauma. In: Davies AM, Grainger AJ, James SJ, editors. Imaging of the hand and wrist.
Heidelberg: Springer Verlag; 2013. p. 141–69. With permission from Springer Verlag)
752 B. Desai
Scaphoid Fracture
X-ray
Center image (Reprinted from Raby N. Imaging of wrist trauma. In: Davies AM, Grainger AJ, James SJ, editors. Imaging of the hand and wrist.
Heidelberg: Springer Verlag; 2013. p. 141–69. With permission from Springer Verlag)
Orthopedic Emergencies 753
Triquetral Fracture
X-ray
Orthopedic
Treatment Splint referral
Center bottom image (Reprinted from Raby N. Imaging of wrist trauma. In: Davies AM, Grainger AJ, James SJ, editors. Imaging of the hand and
wrist. Heidelberg: Springer Verlag; 2013. p. 141–69. With permission from Springer Verlag)
Risk of avascular
Pitfall
necrosis
Orthopedic
Treatment Splint
referral
Scapholunate Dissociation
Widening of scapholunate
Diagnosis Plain film
joint space > 3mm
X-ray
Arthritis if
Complications
untreated
Center image (Reprinted from Raby N. Imaging of wrist trauma davies. In: Davies AM, Grainger AJ, James SJ, editors. Imaging of the hand and
wrist. Heidelberg: Springer Verlag; 2013. p. 141–69. With permission from Springer Verlag)
Orthopedic Emergencies 755
Perilunate
Perilunate& Lunate aligned but capitate
Forced Fall on displaced
Lunate Due to
hyperextension outstretched hand
Dislocations Lunate
Capitate aligned but lunate
displaced
Lateral view has
Diagnosis Plain film
best view
a b a b
X-ray
Lunate Perilunate
“Piece of pie”
Avascular
Median nerve
Complications necrosis if Scaphoid fx Arthritis Malunion
injury
lunate fx
Center left image (Reprinted from Raby N. Imaging of wrist trauma davies. In: Davies AM, Grainger AJ, James SJ, editors. Imaging of the hand
and wrist. Heidelberg: Springer Verlag; 2013. p. 141–69. With permission from Springer Verlag)
Center right image (Reprinted from Raby N. Imaging of wrist trauma davies. In: Davies AM, Grainger AJ, James SJ, editors. Imaging of the hand
and wrist. Heidelberg: Springer Verlag; 2013. p. 141–69. With permission from Springer Verlag)
756 B. Desai
The Forearm
X-ray
Immobilized in Orthopedic
Nondisplaced fx
splint referral
Displaced fx ORIF
Center right image (Reprinted from De Boeck H, Haentjens P, Handelberg F, Casteleyn PP, Opdecam P. Treatment of isolated distal ulnar shaft
fractures with below-elbow plaster cast. Arch Orthop Trauma Surg. 1996;115(6):316–20. With permission from Springer Verlag)
Orthopedic Emergencies 757
Galeazzi Fracture
Usually
Galeazzi Fracture
displaced
MUGR X-ray
Monteggia – Ulna
Galeazzi - Radius
Ulnar nerve
Complications Malunion injury
Lower right image (Reprinted from Haugstvedt JR. Galeazzi’s fracture and Essex-Lopresti injuries: dislocation fractures of the forearm. In: Hove LM, Lindau
T, Hølmer P, editors. Distal radius fractures: current concepts. Heidelberg: Springer Verlag; 2014. p. 391–401. With permission from Springer Verlag)
758 B. Desai
Monteggia Fracture
X-ray
Treatment ORIF
Bottom center image (Reprinted from Casado-Sanz E, Barco R, of the limbs. Zug: Springer International Publishing; 2014. p. 1–8.
Antuña SA. Complex fractures of the proximal humerus. In: With permission from Springer International Publishing)
Rodríguez-Merchán EC, Rubio-Suárez JC, editors. Complex fractures
Orthopedic Emergencies 759
X-ray
Inability to
Neurovascular Compartment Non-or
Complications supinate & Osteomyelitis
injury syndrome malunion
pronate
Volkmann’s
Pronation of Flexion of wrist Paralysis of
Ischemic
Contracture
forearm & digits intrinsic muscles
Swelling &
Pain Paresthesias
edema of digits
Forearm Inappropriately
Causes Elbow fracture
fractures tight casts
The Elbow
Pain
Snapinoranterior
pop is Pain in anterior Swelling, tenderness, & Flexion of elbow causes pain
heard
shoulder
& felt shoulder crepitus over bicipial groove and produces avmidarm “ball”
Pain in posterior Complete ruptures cause Partial tears may have some Swelling & tenderness posteriorly
elbow inability to extend the elbow function proximal to olecranon
Bursitis
Not recognizing
Pitfall
septic bursitis
Treatment
RICE NSAID’s
non-septic
PO vs IV Depends on
Treatment septic
antibiotics clinical condition
Epicondylitis
Lateral Overuse of
“Tennis elbow” Due to
Epicondylitis forearm extensors
Anti-
Treatment RICE Immobilization
inflammatories
Medial Overuse of
“Golfer’s elbow” Due to
Epicondylitis forearm flexors
Ulnar
Complication
neuropathy
762 B. Desai
Nursemaid’s Elbow
PEDIATRICS
Nursemaid’s Subluxation of the radial head Arm being May have tear of Typically ages
Due to
Elbow beneath the anular ligament pulled anular ligament 1–4
X-rays
Diagnosis Clinical Hx
unnecessary!
Flexion
Supination
Supination-flexion Hyperpronation
Orthopedic Emergencies 763
Elbow Dislocation
Ulnar nerve
Most common nerve
Elbow Pt presents with Must assess Brachial injury
dislocation elbow in 45o flexion neurovascular status artery
Radial nerve
Most common
arterial injury Median nerve
Consider Arterial
No radial pulse Open dislocation Arteriogram
injury?
Causes bleeding
Pitfalls Hyperextension
from arterial injury
Median nerve
Complications Malunion Joint instability Arthritis
injury
Left center image (Reprinted from Spina V, Baldini L. Imaging of the elbow. In: Celli A, Celli L, Morrey BF, editors. Treatment of elbow lesions:
new aspects in diagnosis & surgical techniques. Milan: Springer Verlag; 2008. p. 21–38. With permission from Springer Verlag)
764 B. Desai
Anterior Picks up occult In normal imaging, the anterior aspect of the humerus
humeral line test supracondylar fx bisects middle 1/3 of capitellumon the lateral view
Radial Head Most common Fall on Radial head is driven May have
Due to
Fracture fx of the elbow outstretched hand into the capitellum additional injury
Most common Capitellum fx
occult fx in adults
Coronoid fx
Symptoms & Signs Olecranon fx
Elbow dislocation
Lateral elbow Lateral elbow Tenderness of Pain with passive MCL injury
pain swelling radial head rotation of forearm
Avulsion fx of
medial
epicondyle
Diagnosis Plain film Look for fat pads
X-ray
Treatment
Immobilization RICE
Non-displaced
Restricted elbow
Complications Chronic pain
ROM
Right center image (Reprinted from Daneshvar P, Pollock JW, Athwal Right image (Reprinted from Daneshvar P, Pollock JW, Athwal
GS. Fractures and dislocations of the proximal ulna and radial head. GS. Fractures and dislocations of the proximal ulna and radial head.
In: Antuña S, Barco R, editors. Essentials in elbow surgery. London: In: Antuña S, Barco R, editors. Essentials in elbow surgery. London:
Springer Verlag; 2014. p. 61–89. With permission from Springer Springer Verlag; 2014. p. 61–89. With permission from Springer
Verlag) Verlag)
Orthopedic Emergencies 765
Supracondylar Fracture
X-ray
Left center image (Reprinted from Abdelgawad A, Enes Kanlic. Orthopedic trauma. In: Abdelgawad A, Naga O, editors. Pediatric orthopedics:
a handbook for primary care physicians. New York: Springer; 2014. p. 409–83. With permission from Springer Science + Business Media)
766 B. Desai
X-ray
Right center image (Reprinted from Erhardt JB, Roderer G, Grob K, Forster TN, Stoffel K, Kuster MS. Early results in the treatment of proximal
humeral fractures with a polyaxial locking plate. Arch Orthop Trauma Surg. 2009;129(10):1367–74. With permission from Springer Science +
Business Media)
Orthopedic Emergencies 767
Displacement of fx Actions of
Diagnosis Plain film Due to
fragments is common various muscles
a b
X-ray
Immobilization Orthopedic
Treatment with sling & RICE Analgesics
swathe referral
Left center image (Reprinted from Ristevski B, Hall J. Humeral shaft fractures. In: Sethi MK, editor. Orthopedic traumatology: an evidence-
based approach. New York: Springer Science. 2014. p. 129–40. With permission from Springer Science + Business Media)
Nontraumatic
Intrinsic causes Extrinsic causes
Shoulder Pain
Rotator cuff
Immobilization strengthening
Treatment RICE Analgesics
for comfort exercises
Adhesive After long period Painful & limited Both active &
capsulitis of immobilization ROM passive
768 B. Desai
Sternoclavicular Injuries
Shoulder Pain worsened with Shoulder Shoulder rolled Anterior have prominent Posterior may impinge on contents
pain arm movement shortened forward clavicle anterior to sternum of superior mediastinum
Emergent
Treatment Orthopedic
If uncomplicated reduction not Sling Analgesia
Anterior necessary referral
Diagnosis Clinical
Type 2 AC rupture, coracoclavicular (CC) ligament sprain Clavicle 25–50 % above acromion
Types 5 & 6 have AC dislocation, gross deformity and have potential for multiple associated injuries
Immobilization
Treatment Types Orthopedic
with sling & RICE Analgesics
1&2 swathe referral
Most common in
children
Imaging b c
Rupture of Medial
Distal Needs Intrathoracic
Complications coracoclavicular clavicle
clavicle surgery injury
ligament injury
Has significant Subclavian
medial elevation artery & vein
Left center image (Reprinted from Geddes CR, McKee MD. Clavicle fractures. In: Sethi MK, editor. Orthopedic traumatology: an evidence-based approach. New York: Springer Science. 2014.
B. Desai
a b
X-ray
Immobilization
Treatment Orthopedic
with sling & RICE Analgesics
uncomplicated swathe referral
Bottom center image (Reprinted from Cole PA, Hill BW. Scapula fractures. In: Sethi MK, editor. Orthopedic traumatology: an evidence-based approach. New York: Springer Science. 2014.
p. 71–86. With permission from Springer Science + Business Media)
771
772 B. Desai
Glenoid
Scapula
Inferior dislocation
Normal Anterior Posterior
anatomy dislocation dislocation
Bottom left image (Reprinted from Missiroli C, Singh A. Emergencies of the biliary tract. In: Singh A, editor. Emergency radiology: Imaging of
acute pathologies. New York: Springer Science; 2013. p. 11–25. With permission from Springer Science + Business Media)
Orthopedic Emergencies 773
Distinguishes b/w
Y view?
anterior & posterior
Recurrent Vascular
Complications Bony injury Nerve injury Other
dislocation injury
Most common Rare Bankart lesion Axillary nerve Rotator cuff tear
Adhesive
Axillary artery Hill-Sach’slesion capsulitis
Avascular necrosis Greater
tuberosity fx
Continued pain
Pitfall Rotator cuff tear 2–4 weeks after Needs MRI
injury
774 B. Desai
Commonly
Pitfall
missed
Treatment
Closed reduction
uncomplicated
Orthopedic
Treatment Closed reduction RICE Analgesics
referral
Most common
Supraspinatus
muscle injury?
Brachial plexus
Thoracic Outlet Compression As they pass through Associated with
Due to Subclavian artery
Syndrome of: the thoracic outlet a cervical rib
Subclavian vein
Pain in upper
Weakness Numbness Paresthesias Neck pain Cool extremity
extremity
Legg-Calve-Perthes Disease
PEDIATRICS
Imaging
Orthopedic
Treatment Pain control
referral
Left center image (Reprinted from Abdelgawad A, Naga O. The hip. In: Abdelgawad A, Naga O, editors. Pediatric orthopedics: a handbook for
primary care physicians. New York: Springer; 2014. p. 85–116. With permission from Springer Science + Business Media)
778 B. Desai
PEDIATRICS
“Melting ice
Diagnosis Plain film Frog leg view
cream cone”
Imaging
No weight
Treatment ORIF
bearing
Right center image (Reprinted from Abdelgawad A, Naga O. The hip. In: Abdelgawad A, Naga O, editors. Pediatric orthopedics: a handbook
for primary care physicians. New York: Springer; 2014. p. 85–116. With permission from Springer Science + Business Media)
Orthopedic Emergencies 779
Septic Arthritis
PEDIATRICS
H. N. Gram
Organisms Salmonella S. aureus Strep spp
influenza gonorrhoeae negatives
Most
Sickle cell common
Adolescents
Refusal to Decreased
Pseudoparalysis Fever Localizing signs Erythema Hip tenderness
ambulate ROM of hip
Joint drainage by
Treatment IV antibiotics
orthopedics
Staphylococcus Group B
Newborn causes Neisseria Enterobacter
aureus Streptococcus
Staphylococcus aureus
Direct extension
most common
Sickle cell
Salmonella
disease
Early Late
Joint prosthesis
Staphylococcus Gram (-)’s
Involves axial
IV Drug Users Pseudomonas
skeleton
780 B. Desai
Toxic Synovitis
PEDIATRICS
Toxic Synovitis
Post trauma Viral illness Allergic reaction
Associations
Frequently
Plain films
nondiagnostic
The Femur
Fracture types
Imaging
Traction splint & Not for open fracture Potential for These need
Treatment But… OR
Ortho consult with contaminated ends sciatic injury ORIF!
The Knee
Imaging for
Typically show MRI may be
ligamentous OR Will be normal
injury? joint effusion needed
Avulsion fracture
at lateral tibial ACL rupture
condyle?
Age > 55
Tenderness at
head of fibula
Ottawa Knee
Inability to Rules
transfer weight
Radiograph if 1
for 4 steps criterion is met
immediately after
Rules are valid in
injury & in the ED Isolated
children as well
tenderness of
patella
Inability to flex
knee to 90º
Orthopedic Emergencies 783
Patellar Fractures
Local patella
Knee swelling Knee effusion Ecchymosis
tenderness
X-ray
Left center image (Reprinted from Kaewlai R, Singh A. Lower extremity trauma. In: Singh A, editor. Emergency radiology: imaging of acute
pathologies. New York: Springer Science; 2013. p. 277–98. With permission from Springer Science + Business Media)
Center image (Reprinted from Kaewlai R, Singh A. Lower extremity trauma. In: Singh A, editor. Emergency radiology: imaging of acute pathol-
ogies. New York: Springer Science; 2013. p. 277–98. With permission from Springer Science + Business Media)
784 B. Desai
Patellar Dislocation
May recur
Laterally
Knee pain
displaced patella
Confirm with
Diagnosis Clinical
imaging
Tibial plateau Axial load with rotational e.g., MVC In older Lateral is more
Due to force driving femoral
fractures condyle into tibia Fall from height population common
Lateral plateau ACL & MCL Medial plateau PCL & LCL
Associations
fx injuries fx injuries
CT may be
Diagnosis Plain film
needed
X-ray
Treatment ORIF
Left center image (Reprinted from Kaewlai R, Singh A. Lower extremity trauma. In: Singh A, editor. Emergency radiology: imaging of acute
pathologies. New York: Springer Science; 2013. p. 277–98. With permission from Springer Science + Business Media)
786 B. Desai
Knee Dislocation
Loss of distal
Knee pain Unstable knee Knee deformity Late
pulses
X-ray
Immediate
Treatment
reduction
No pulse after Emergent vascular Return of pulse Emergent ankle- Vascular surgery
reduction? surgery consultation after reduction? brachial index consult
Left center image (Reprinted from Kaewlai R, Singh A. Lower extremity trauma. In: Singh A, editor. Emergency radiology: imaging of acute
pathologies. New York: Springer Science; 2013. p. 277–98. With permission from Springer Science + Business Media)
Orthopedic Emergencies 787
Surgical repair of
Treatment
involved tendon
788
Osteochondritis Dissecans
a b
X-ray
Treatment Activity
Analgesics
Open Epiphysis modification & PT
Treatment Detached
Arthroscopy
Closed Epiphysis fragments
Left center image (Reprinted from Abdelgawad A, Naga O. The knee/leg. In: Abdelgawad A, Naga O, editors. Pediatric orthopedics: a handbook for primary care physicians. New York:
Springer; 2014. p. 117–56. With permission from Springer Science + Business Media)
B. Desai
Osgood-Schlatter Disease
Osgood- Patella tendon Males Repeated normal Microavulsions
Schlatter Disease apophysitis 10–15 Due to stress or overuse of ossification centers
Orthopedic Emergencies
May be bilateral
Chronic anterior knee Swelling over the Tender patellar Activity aggravates Erythema over
pain, intermittent tibial tubercle tendon the pain site
X-ray
Avoidance of
Treatment Self limited NSAIDs Rest knee extension
Left center image (Reprinted from Abdelgawad A, Naga O. The knee/leg. In: Abdelgawad A, Naga O, editors. Pediatric orthopedics: a handbook for primary care physicians. New York:
Springer; 2014. p. 117–56. With permission from Springer Science + Business Media)
789
790 B. Desai
Baker’s Cyst
Tender at
Painful knee Painful calf Swollen knee Swollen calf
popliteal fossa
Diagnosis Ultrasound
Baker’s
cyst
Normal knee
joint fluid
Baker’s
cyst
Complication Compartment
syndrome
Toddler’s Twisting of foot Dx via imaging Splint entire leg NOT child abuse
Fracture with a planted leg
Left center image (Reprinted from Lichte P, Pape H-C. Tibial shaft fractures. In: Oestern HJ, Trentz O, Uranues S, editors. Bone and joint injuries: trauma surgery III. Heidelberg: Springer Verlag;
2014. p. 341–46. With permission from Springer Verlag)
791
792 B. Desai
Compartment Syndrome
Pain Pulselessness
Pallor Paresthesias Poikilothermia Paralysis
earliest Sx (Late)
Compartment pressures
Surgery?
40–50 mm Hg
Irreversible damage
Pitfall
in 4–6 hours!
No success? Fasciotomy
Fractures
Distal radius
Tibial shaft
Most common
Bleeding
Crush injury
disorders
Causes of
Compartment
Syndrome
Prolonged
compression
Bleeding -
hematoma Tight casts
High pressure
Infection
injection injury
Pilon (Tibial Plafond) Fracture
High energy
tissue damage comminution of bone
X-ray
Surgical
Treatment
treatment
Bottom center image (Reprinted from Kaewlai R, Singh A. Lower extremity trauma. In: Singh A, editor. Emergency radiology: imaging of acute pathologies. New York: Springer Science; 2013.
793
Fibula Fracture
May be missed
Pitfall
on plain film
Right center image (Reprinted from Kaewlai R, Singh A. Lower extremity trauma. In: Singh A, editor. Emergency radiology: imaging of acute
pathologies. New York: Springer Science; 2013. p. 277–98. With permission from Springer Science + Business Media)
Gastrocnemius Rupture
The Ankle
Ankle Sprains
Evaluate for
Isolated Associated Tear of
Medial Injury? Eversion OR Maissoneuve
injury is rare with fibular fx syndesmosis
fx!
Anterior Posterior
Ankle ligaments Calcaneofibular
talofibular Talofibular
Inability to
Ankle pain Ankle swelling Painful ROM Ecchymosis
ambulate
Ottawa ankle
Diagnosis Clinical
rules for imaging
Depends on
Treatment Stable RICE Analgesics
stability of ankle
Orthopedic
Unstable Splint
referral
Point tenderness
over the navicular
bone
Tenderness along
Inability to bear Ottawa Ankle posterior edge of
weight Rules the distal 6 cm of
immediately after Radiograph if 1 either the lateral
injury & in the ED criterion is met or medial
malleolus
Point tenderness
over the proximal
base of the 5th
metatarsal
796
Ankle Dislocations
Anterior Lateral
Ankle Can occur in
May be open!
dislocations 4 planes
Posterior (m.c.) Upwards
X-ray
Orthopedic IV antibiotics
Treatment Reduction Immobilization Analgesics
consult if open
Left center image (Reprinted from Ríos-Luna A, Villanueva-Martínez, M, Fahandezh-Saddi H, Pereiro J, Martín-García A. Isolated dislocation of the ankle: two cases and review of the literature.
Eur J Orthop Surg Traumatol. 2007;17(4):403–7. With permission from Springer Verlag)
B. Desai
Orthopedic Emergencies 797
The Foot
Calcaneal Fractures
Tender
Foot pain Foot swelling Ecchymosis Low back pain
hindfoot
Imaging &
Boehler’s angle
20˚-40˚
Bohler’s angle
Orthopedic
Treatment Immobilization Posterior splint Analgesics
referral
Right center image (Reprinted from García-Rey E. Complex fractures of the calcaneus. In: Rodríguez-Merchán EC, Rubio-Suarez JC, editors.
Complex fractures of the limbs. Zug: Springer International Publishing; 2014. p. 95–9. With permission from Springer International Publishing)
798
Lisfranc Injuries
2nd metatarsal
Occurs at the tarsal- Range from sprains to MVC
Lisfranc Injuries needed for
metatarsal joint fracture-dislocations Football injury
midfoot stability
Common
mechanisms
Symptoms & Signs
X-ray
Treatment of
Displaced fx Unstable fx ORIF
Compartment
Complications syndrome
Left center image (Reprinted from Kaewlai R, Singh A. Lower extremity trauma. In: Singh A, editor. Emergency radiology: imaging of acute pathologies. New York: Springer Science; 2013.
p. 277–98. With permission from Springer Science + Business Media)
B. Desai
Orthopedic Emergencies 799
Metatarsal Fractures
Has high
Transverse fx at Common in athletes Treatment is
Jones Fracture incidence of
proximal diaphysis that run & jump ORIF
nonunion
Jones fracture
Imaging Pseudo-jones/
tennis fracture
Stress fracture
Jones fracture
Avulsion fracture
Osteomyelitis
Most common
Staph aureus
agent?
Preferred
imaging? MRI
Treatment
IV Abx Admission
Acutely ill
Bottom right image (Reprinted from Abdelgawad A, Naga O. Musculoskeletal infections. In: Abdelgawad A, Naga O, editors. Pediatric
orthopedics: a handbook for primary care physicians. New York: Springer; 2014. p. 561–84. With permission from Springer Science + Business
Media)
Orthopedic Emergencies 801
Neonates Children
Grp B Strep Staph + MRSA
Staph + MRSA
Postoperative Elderly
Staph aureus Staph + MRSA
Coagulase (-) Gram (-)’s
staph
Risk Factors &
Likely Agents for Human bite
Osteomyelitis
Sickle cell disease Staph is most Streptococci
Salmonella has a common overall Anaerobes
higher incidence Eikenella
Foot puncture
Animal bite
wound
Pasteurella Pseudomonas
Diabetes + vascular
IV Drug user
insufficiency
Staph + MRSA Staph aureus
Pseudomonas Strep agalactiae
Strep pyogenes
Anaerobes
Fractures &
Considerations Tumor or Consider Consider Congenital & other
other
< 18 & > 50 infection > 50 < 18 bony abnormalities
processes
Fevers, chills,
Constitutional Rheumatologic
sweats, weight Infection OR Malignancy OR
complaints? process
loss
Achy pain that worsens with Radicular back pain in the distribution
Benign back pain movement & is palliated by rest Sciatica of a lumbar or sacral nerve root
Straight leg raise 70–80 % sensitive for Crossed straight Radicular pain down Specific for
test L4-L5 or L5-S1 leg raise test affected leg when other herniated disk
herniated disk leg raised
802 B. Desai
Red Flags
HIV positive
Other immune
Fever
disorders
Prolonged
Night time pain
duration of pain
Unnecessary
Laboratories
unless red flags
Diagnosis Clinical
Disk Herniation
No diagnostic No diagnostic
Diagnosis Clinical
tests required tests required
Spinal Stenosis
Low back pain worsened with Pain relieved with rest Low back & lower extremity
standing & extension of spine & forward flexion pain with walking
Neurogenic
claudication
Diagnosis CT OR MRI
Analgesia,
Treatment Leg exercises Physical therapy Epidural steroids
NSAIDs
Ankylosing Spondylitis
Ankylosing
Spondylitis Pts < 40 Males 3:1
Referral to
Treatment NSAIDs rheumatology
804 B. Desai
Most common
finding
Diagnosis MRI
Emergent neurosurgical
Treatment Dexamethasone
consultation
For tumor
Spinal canal
hemorrhage
Tumors of the
spine
Orthopedic Emergencies 805
Transverse Myelitis
Triggers Differential
MS & Lupus Post vaccination
Cord
Cancer Malignancy
compression
Neck or back Bilateral motor, sensory & Urinary & fecal Urinary & Fecal Sciatica in one
Leg weakness Fever
pain autonomic dysfunction retention incontinence or both legs
Steroids Plasma
Treatment
(Unclear benefit) exchange
Spinal Infections
Imaging may be
Diagnosis Elevated ESR
normal
Diskitis
Immune
Risk Factors Spinal surgery OR OR IV drug use
compromise
S. aureus
Most common
Fungal Pseudomonas
Pathogens
TB Klebsiella
Proteus
± Radicular
Fever Localized pain
symptoms
S. aureus
Most common
Fungal Pseudomonas
Pathogens
Streptococcus
TB
spp
E. coli
IV drug use
Chronic renal
Cancer
failure
Indwelling
catheter or Risk Factors for
device Diabetes mellitus
Epidural Abscess
Pacemaker
Rheumatologic Emergencies
Non-
Normal Inflammatory Septic
Inflammatory
Translucent to
Clarity Transparent Transparent Opaque
opaque
Yellow to
Color Clear Yellow tinged Yellow tinged
green
WBC
< 200 200–2000 2,000–50,000 >50,000
(per mm3)
None or
Crystals None None None
multiple
Gout, pseudogout,
Conditions Osteoarthritis Staph, GC
Lupus
Orthopedic Emergencies 809
Needle shaped
Gout Non-specific imaging
crystals
Rhomboid
Pseudogout Chondrocalcinosis
shaped crystals
Steroids for
Treatment NSAID’s
severe cases
Rheumatoid Arthritis
Treatment with
Predispose to serious
disease modifying
bacterial infections
agents
Rheumatoid
Tidbit Felty syndrome Neutropenia Enlarged spleen
arthritis
810 B. Desai
Antiphospholipid Syndrome
Cerebral infarction
Ischemia of
placenta with Selected syndromes
Retinal ischemia
fetal loss
due to thrombosis
Multiple
miscarriages
Pulmonary
Low platelets embolism
Life long
Treatment
anticoagulation
Orthopedic Emergencies 811
Typical
symptoms Fever Rash Joint pain
Persistent Possible
Renal Lupus nephritis chronic failure
proteinuria
Pleural Pulmonary
Pulmonary Pneumonitis Pleurisy effusions infarcts PE
Intestinal
GI Ulcerations vasculitis
Chronic
Neurologic Stroke Seizures Neuropathy
migraines
Treatment Steroids
Trauma
Henry Young II and Bobby Desai
Contents
Introduction 814
Spinal Injuries 826
Spinal Cord Injuries 830
Penetrating Neck Injury 835
Chest Trauma 838
Abdominal Trauma 847
Pelvis and Hip Trauma 852
Extremity Injuries 856
Trauma in Special Populations 858
H. Young II, MD
Department of Emergency Medicine, UF Health at the University
of Florida, Gainesville, FL, USA
B. Desai, MD, MEd (*)
Department of Emergency Medicine, University of Florida,
Gainesville, FL, USA
e-mail: [email protected]
Introduction
Most common Systemic approach Provide
Establishment of
Trauma cause of death created to decrease multidisciplinary
morbidity & mortality trauma centers care
<45
Primary Survey
Airway
obstruction
Cardiac Massive
tamponade hemorrhage
Life threatening
injuries
Open
Flail chest pneumothorax
Tension
pneumothorax
Trauma 815
Airway Assessment
Consider Consider
Airway NOT Remove Perform jaw Suction
placement of endotracheal
patent? obstruction thrust airway
OPA intubation
Avoid head tilt- Avoid NPA in
disrupts C-spine setting of facial OPA
stabilization! trauma Oropharyngeal airway
Avoid NPA for NPA
concern of basilar Nasopharyngeal airway
skull fracture
Unable to
Surgical airway
intubate?
Contraindications
Basilar skull Maxillofacial
to nasotracheal Apnea
intubations fracture trauma
Breathing Assessment
Pneumothorax Inappropriate
Symmetrical If decreased
Auscultate ETT placement
breath sounds? consider
Hemothorax Displacement
Obstruction
Pneumothorax
Tube in Esophagus
Circulation Assessment
Classification of Hemorrhage
HR normal or
Warm, pink,
< 15 % slightly Normal or
Class I normal Normal output
< 750 ml increased; BP slightly anxious
capillary refill
normal
Significant
tachycardia, Cool, mottling,
Lethargic,
30–40 % thready pulse, pallor, Oliguria,
Class III diminished
1500-2000ml hypotension, prolonged elevated BUN
metabolic pain response
capillary refill
acidosis
Severe
tachycardia & Cold
>40 % Lethargic,
Class IV hypotension, extremities, Anuria
>2000ml coma
thready central pallor, cyanosis
pulse
818 H. Young II and B. Desai
Disability Assessment
GCS
Center bottom image (Reprinted from Allen B, Ganti L, Desai B. Trauma and ATLS. In: Allen B, Ganti L, Desai B, editors. Quick hits in emergency
medicine. New York: Springer Science; 2013. p. 37–45. With permission from Springer Science + Business Media)
Exposure
Maintenance
Complete Midline back Prevent
Exposure Log roll of spinal
exposure of pt precautions palpation hypothermia!
For step offs Warm blankets
Secondary Survey
Head to toe Identify as
Secondary Consultations
examination of many injuries AMPLE Hx FAST exam
Survey patient as possible as needed
Allergies PMH
AMPLE Hx Events of injury
Medications Time of Last meal
Secondary Extremities as
CXR Pelvis
Survey Imaging needed
Palpable pulse
Pupil Organized Purposeful Respiratory
Signs of life or blood OR OR OR OR
pressure reactivity cardiac rhythm movement effort
Liberal Abdominal Cardiac Requiring cross clamping Blunt chest trauma with
OR
indications trauma activity of aorta to get to OR loss of vital signs in ED
Return of
spontaneous Operating room
circulation?
Late &
Sudden Respiratory
Cushing Reflex Due to Hypotension Bradycardia unreliable sign
increase in ICP irregularity of increased ICP
Head trauma Accounts for 50 % Higher risk of Males MVA/MCC Elderly falls
tidbits of trauma deaths head injury Ages 15–30 Assaults Alcoholics
Sudden acceleration
Mechanisms Direct trauma OR Indirectly
or deceleration
Increased morbidity
ICP > 20 mm Hg?
& mortality
Headache Nausea
Scalp laceration May bleed enough to
in children? cause shock state! Hypertension Vomiting
Signs of increased
ICP
Serious head Evaluate for cervical
Bradycardia Seizure
injury? spine fracture!
Agonal
respirations Lethargy
Trauma 821
Brain Herniation
Due to increased
Brain herniation
ICP
Cerebellotonsillar
Central
transtenorial Upward herniation
herniation transtentorial Cerebellar tonsils
herniation herniate thru the
Earliest sign is
CN 6 palsy foramen magnum
Agitation increases
ICP
Avoid Decreases
Elevated ICP?
hypotension cerebral perfusion
Prevention of Beware in
Other treatment Mannitol
seizures hypotension!
30 min. onset,
lasts 6 hours
1 g/kg
Consider invasive
GCS < 8 Intubation
monitoring
822 H. Young II and B. Desai
Traumatic Seizures
Immediate &
Seizure? Non focal exam No treatment
brief?
Accounts for 10 %
GCS 4 % of severe TBI
Severe TBI of patients with Mortality = 40 %
<9 have cervical injury
head trauma
Trauma 823
Cerebral Contusions
Intracerebral Can occur days after Patient on Increased risk of Admission for
hemorrhage in at sites of resolving
contusions? contusions anticoagulants? delayed bleeding monitoring
Concussion
Postconcussive Syndrome
Visual Judgment
Anxiety Vertigo
disturbances problems
824 H. Young II and B. Desai
Skull Fracture
Intracranial Hemorrhage
Meningeal
Headache Photophobia
signs
Biconcave bleed
CT scan
(lens shaped)
Dilated
Immediate LOC Lucid interval Skull fracture
ipsilateral pupil
PEDIATRICS
Differences in
More waxing & More non-surgical
pediatric head Weaker skull
trauma waning of GCS lesions
Spinal Injuries
Unstable
> 25 % of 3rd to 7th > 50 % in T or L
compression
injuries cervical vertebrae vertebrae (acute)
Trauma 827
No posterior
midline tenderness
No focal neurologic
No intoxication
deficits NEXUS criteria 99 % sensitive
Failure to meet any
Normal level of 1 = need for No distracting
consciousness imaging injury
Altered mental
Distracting injury OR Intoxication OR NO clearance!
status
PEDIATRICS
Plain film
CT
inadequate?
Pseudosubluxation
Normal alignment of
Pseudosubluxation
the spinolaminar line
Atlantoaxial
Atlantoaxial or Atlanto-occipital Atlantoaxial or Atlanto-occipital C1/2 disruption
(or Any Fx/dislocation) = Flexion or extension Rheumatoid arthritis or ankylosing
spondylitis
Odontoid Fractures
Atlanto-dens interval
Odontoid Increase in Most common cervical
3 types 5 mm in pediatrics
Fractures prevertebral space fracture in children 3 mm in adults
Avulsion at tip of
Type 1 Stable
dens
At the junction of
Type 2 Most common Unstable
odontoid & body of C2
Fracture at base
Type 3 Unstable
of dens
Thoracolumbar Fractures
Not injured as
Increased Higher incidence Narrower spinal
Thoracic spine frequently as C Due to But… Due to
or L spine rigidity of cord injury canal
Wedge Compression
Fracture Flexion
Anterior
Anterior
Brown-sequard syndrome
Posterior
Corticospinal
tract
Spinothalamic
tract Anterior
Trauma 831
Anterior Cord
SCIWORA syndrome
Incomplete Spinal
Cord Injury
Transverse cord
syndrome
Anterior cord Flexion or Vascular injury of the Injury due to retropulsion Disc herniation is
OR
syndrome extension anterior spinal artery of bony fragments common
Needs surgical
Treatment
intervention
Brown-Sequard Syndrome
SCIWORA
PEDIATRICS
Normal
Diagnosis Complete exam MRI
radiographs
Spinal Shock
Partial or complete Transient reflex depression of all Reflex function below the level of the
Spinal shock Causes
injury of spinal cord cord function below the injury injury spontaneously returns in 1–2 days
Loss of neurological function can cause an incomplete Not able to determine true
Pitfalls
spinal cord injury to mimic a complete one effect until resolution
Neurogenic Shock
Subcutaneous
Stridor Dysphonia Hemoptysis Hematemesis Dyspnea
emphysema
Hard Signs Associated with Neck Trauma Associated with Significant injury
Death from
Airway Extreme
penetrating neck Due to Intubate early CNS injury
injury compromise bleeding
Apply pressure to
active bleeds
Respiratory
distress
Expanding neck Airway
hematoma obstruction
Indications for Do tracheostomy
Pitfall Fractured larynx
intubation Massive instead
Altered mental subcutaneous May result in
status emphysema complete
transection or
Tracheal shift creation of false
lumen
836 H. Young II and B. Desai
Zones of the Neck
Zone 1
Angiography/
Thoracic surgical
Treatment Stable? Esophagram or endoscopy/ Unstable?
Bronchoscopy approach
Angle of
Zone 2 Cricoid
mandible
Zone 2
Angle of
Zone 3 Base of skull
mandible
Zone 3
Violation of the Emergent surgical Do not explore Any vascular injuries need NO blind
But…
platysma? consultation at bedside! proximal & distal control clamping!
NO violation of Minor neck No signs of structural damage Careful D/C after 4-6 hours
the platysma? trauma to nerves or major vessels closure in ED of observation
Pharynx Trauma
Larynx trauma
see ENT
Pneumomediastinal Retropharyngeal
Hematemesis Odynophagia SQ emphysema
air air
Broad spectrum
Treatment NPO
antibiotics
838 H. Young II and B. Desai
Injuries may be
Pitfall? Require imaging!
subtle
Carotid or
Dissection Pseudoaneurysm
vertebral injury
Hyperextension
CT scan of neck
Diagnostic tools
with contrast
CT angiogram
Chest Trauma
25 % of trauma
Chest trauma
deaths
Hypotension due Pelvic fracture Abdominal Thoracic Consider other reasons other
to blunt trauma #1 reason injury injury than thoracic structures
Hypotension due
Lung
to penetrating Heart Great vessels
trauma
#1 reason
Trauma 839
Pneumomediastinum (PM)
Pneumothorax (PTX)
Accumulation of air
Pneumothorax
within pleural space
Expiratory
Ipsilateral low
Ipsilateral decreased Subcutaneous Decubitus CXR has higher
CXR findings lateral diaphragm
lung markings emphysema (Deep sulcus) sensitivity than upright CXR
Pneumothorax Treatment
No improvement
Surgical
with 2nd chest
tube? intervention
Tension Pneumothorax
Waiting for a
Pitfall? May be fatal
CXR
Trauma 841
Hemothorax
25 % are
Accumulation of blood A hemthorax can hold 40% Intercostal
Hemothorax associated
within pleural space of circulating blood volume with PTX artery injury
Other
Persistent air
thoracotomy Unstable patient
indications leak
Rib Fractures
Multiple rib
Increased risk Liver, kidney, spleen Higher incidence Aspiration
fracture
considerations for other injuries potential injury of fat emboli pneumonitis
Lower ribs
Flail Chest
Free floating segment of ribs not connected to thorax Sx more severe as pulmonary
Flail chest
with fx of 3 or more adjacent ribs in 2 or more places compliance worsens
Fx of 8 or more
Age > 65
ribs
Sternal Fracture
Associated with
Sternal Fx
head on MVC
Adequate
Treatment
analgesia
Pulmonary Contusion
CT is more
Diagnosis CXR OR CT
accurate
Tracheobronchial Injuries
Continuous
Bronchopleural
bubbling in
chest tube? fistula
Hamman’s Subcutaneous
Chest pain Dyspnea Hypoxemia Hemoptysis
crunch emphysema
CT is more
Diagnosis CXR CT
accurate
Cardiac Trauma
Cardiac Tamponade
Cardiac Most commonly due Fluid within pericardial cavity resulting in elevation of intra-
Tamponade to penetrating trauma pericardial pressure that decreases ventricular filling pressures
Sinus Narrow pulse Elevated central Pulsus Low voltage Electrical Enlarged cardiac
tachycardia pressure venous pressure paradoxus QRS alternans silhouette
Lower systolic
Alternating
pressure with
inspiration QRS direction
Diagnosis Echocardiogram
Cardiac Contusion
Post-trauma Ventricular
Complications VSD Valve defects Tamponade
pericarditis aneurysm
2nd most common Sudden death due Caused by impact to chest wall 10-30
Commotio cordis cause of death in to blunt trauma to milliseconds before T wave that induces
young athletes chest ventricular fibrillation
Deceleration
Traumatic Aortic 90 % with blunt trauma 50 % of the rest die High speed side
Mechanism impact
Injury (TAI) & TAI die at scene within 24 hours
Penetrating trauma
Transesophageal
Diagnosis CXR CT – angio scan
echo
Displacement of
left mainstem
bronchus 40º Loss of paraspinal
below horizontal stripe
Loss of pleural
apical cap
Diaphragmatic Injury
Diaphragmatic Usually penetrating Chest or upper Usually left Right side is missed
Injury trauma abdomen posterolateral more often due to liver
Abdominal viscera
CXR findings Hemothorax
within thorax
Treatment Surgery
Trauma 847
Abdominal Trauma
>35 % of blunt trauma pts with Pts with solid organ injury Especially in younger pts &
Pitfalls initial benign exam are later found may present with minimal Sx those with head injury or
to have a significant injury & nonspecific findings distracting injuries
Abdominal Signs
Kehr’s
Left shoulder
referred pain
Due to splenic
injury or
diaphragmatic
irritation
Rovsing’s
RLQ pain due to
LLQ palpation
Appendicitis
Positive PPV > 90 % for significant Negative Cannot rule 1/3 of pts with blunt trauma
FAST intra-abdominal injury FAST out injury & (–) FAST require laparatomy
Consider
Blunt trauma Positive FAST Hypotension
laparatomy
Solid organ injury Spleen most Also consider with Solid organ injury Liver most
with blunt trauma commonly injured left lower rib injuries penetrating trauma common
Diagnosis CT
Pancreas/Stomach/Duodenum/Intestine Trauma
Retroperitoneal
Pain May be delayed Due to
location
Diagnosis CT
Depends on
Treatment
extent of injury
Typically transverse
Large intestine Due to Location
colon injured
Diagnosis of
hollow viscus May be difficult
injuries
850 H. Young II and B. Desai
Penetrating Flank Consider rectal Look for gross Bowel injury until
Blood on exam?
& Buttock Injuries exam blood & rectal tone proven otherwise
GSW to flank
entering Laparatomy
peritoneum?
Kidney Injuries
Flank bruising
Present in 10 % of pts
Kidney injuries Higher risk with Lower rib fx
with abdominal trauma
Hematuria
Penetrating
Mechanism Compression Deceleration
trauma
Retrograde
Diagnosis
cystogram
Extraperitoneal
Most common?
bladder rupture
Penetrating
Ureteral injury Due to
trauma
Diagnosis Contrasted CT
Abnormal
Consider position of
Boggy Blood at Perineal Scrotal
Urethral trauma prostate prostate meatus ecchymosis hematoma
May need
Treatment Primary repair
suprapubic catheter
Complications
Fistula Strictures CBC
Anterior Injury
Complications
Incontinence Impotence
Posterior injury
852 H. Young II and B. Desai
Scrotal
Hematuria Scrotal pain Scrotal edema
ecchymosis
Introduction
Pedestrian vs
Mechanisms MVC Fall from height
MVC
Iliac vessels
Pelvic fx Significant Neurologic Close proximity to
Due to Lumbar plexus
associations hemorrhage injury major vessels & nerves
Sacral plexus
Young-Burgees
Classification
Based on Can predict likelihood
System mechanism of severe hemorrhage
Avulsion &
Three Types Major ring fx Acetabular fx
Single bone fx
Lateral
Due to Horizontal force T-bone MVC OR Pedestrian vs car
compression fx
Center bottom image (Reprinted from Kaewlai R, Singh A. Lower extremity trauma. In: Singh A, editor. Emergency radiology: imaging of acute
pathologies. New York: Springer Science; 2013. p. 277–98. With permission from Springer Science + Business Media)
Center image (Reprinted from Zamora-Carrera E, Rubio-Suarez Springer International Publishing; 2014. p. 51–60. With permission
JC. Complex fractures of the acetabulum. In: Rodríguez-Merchán EC, from Springer International Publishing)
Rubio-Suarez JC, editors. Complex fractures of the limbs. Zug:
854 H. Young II and B. Desai
Assesses antero-
Inlet view
posterior displacement
Assesses superior-
Outlet view
inferior displacement
Extent of fx is underestimated
Pitfall
with plain films
Posterior arch
Superior to plain
CT of pelvis Assesses Hemorrhage
films
Acetabulum
Minimize Surgical
Unstable pelvis? Displaced fx?
manipulation! evaluation
Emergent
Unstable patient Positive FAST
laparatomy
Transfusion of 4U
of PRBC in 24 hrs
After treatment
Indications for
of other
Embolization?
bleeding sources
Transfusion of 6U Persistent
of PRBC in 48 hrs hypotension
Trauma 855
Anterior hip
Anterior force Medial force Abducted leg
dislocation
Patient’s Internally
Shortened ADducted
extremity? rotated
Plain
Diagnosis CT
radiographs
Adequate
Treatment Closed reduction
analgesia
Complications
Avascular necrosis From prolonged
Posterior hip
dislocation of femoral head dislocation
Bottom right image (Reprinted from Kaewlai R, Singh A. Lower extremity trauma. In: Singh A, editor. Emergency radiology: imaging of acute
pathologies. New York: Springer Science; 2013. p. 277–98. With permission from Springer Science + Business Media)
856 H. Young II and B. Desai
Extremity Injuries
Introduction
Assess for
Pulse presence Color of
neurovascular Warmth Capillary refill Sensation
injury & strength extremity
Coolness
Distal ischemia Pain Pallor Paresthesias
poikilothermia
Amputations
Amputated body Cleaned with Wrapped in saline Placed in closed Placed on ice which
parts sterile saline soaked gauze plastic bag extends viability
Amputated Re-implant
penis? within 6 hours
Fingertip
4 categories Zone 1 Zone 2 Zone 3 Zone 4
amputations
Distal Exposed
Amputation Amputation
amputation bone of
of entire near DIP
distal
Nail bed & nail bed joint
phalanx
bone intact
Local wound
Require reimplantation
care
by hand surgeon
Pediatric Trauma
PEDIATRICS
SCIWORA
Pediatric Acute pancreatitis most often Most common Handlebar Symptoms may be
pancreas caused by abdominal trauma mechanism? injury mild or delayed
Chest wall in More pliable Less likely to More likely to have pulmonary
Pediatrics than adults have rib fx & cardiac contusion!
PEDIATRICS
Facial trauma & Infants < 6 Obligate nose Facial trauma + Potential
airway pitfall? months breathers nasopharynx bleeding respiratory distress
Larynx & vocal Airway more Use Miller Better Displaces large
Lifts tongue
cord pitfall? anterior blade visualization tongue easier
Depth of
insertion of ETT 3 x tube size
PEDIATRICS
Ejection from
vehicle
Multiple severe
trauma
Severe head
> 3 long bone fractures
trauma
Penetrating head,
Severe facial
Anatomic injury chest, or
trauma
abdominal trauma
Spinal fractures
Nonaccidental Trauma
PEDIATRICS
Mechanism of
injury not
consistent with
sustained injuries
Pattern injuries
Skeletal fx in
different stages Non-Accidental
of healing Trauma Retinal
hemorrhage
Poor prognosis
Unexplained
bruising
Trauma 861
Child Abuse
PEDIATRICS
Face Buttocks
Metaphyseal
Posterior ribs
862 H. Young II and B. Desai
Geriatric Trauma
Trauma in Pregnancy
Introduction
Most common blunt trauma = MVC
Leading cause of non-obstetric
Trauma
morbidity & mortality in pregnancy Most common penetrating trauma = GSW
Physiologic Difficult to
Pitfall
changes interpret VS
Physiologic Blood volume RBC mass increases Pt may lose 35 % of blood volume
Pitfall
anemia increases to a lesser degree before manifesting signs of shock
Supine
When a pregnant Compresses Decrease in Tilt pt to left 30
hypotension
female is supine inferior vena cava venous return degrees
syndrome
Complications of Abruptio
Preterm labor See OB/GYN
trauma placenta
Maternal-Fetal Well-Being
Depends on maternal
Fetal well being
stability & survival
Burns
Burn Classification
1st degree
Epidermis only
No blisters
Painful
Ex: Sunburn
3rd degree
Full thickness
Charred, pale, &
leathery
Eschar formed
NO PAIN
Burn Tidbits
The pts palm
Rule of palms
= 1 % BSA
Adults Pediatrics
Burn estimation
Rule of 9’s Lund-Browder
Potential for
Early intubation
airway burn?
Other
Update tetanus
considerations
Burn Estimation
Head = 9 %
(front and back)
Back =
18 %
Chest = 18%
Head = 18 %
(front and
back)
Back =
18 %
Chest =
Perineum = 18%
1% Right arm = Left arm =
9% 9%
Perineum =
1%
Right leg =
Left leg =
18 %
18 %
Adult Child
Parkland formula = LR 4ml/kg/% burn TBSA in
first 24 hrs + maintain fluids w/half in first 8 hrs + second half in last 16 hrs.
Center image (Reprinted from Allen B, Ganti L, Desai B. Trauma and ATLS. In: Allen B, Ganti L, Desai B, editors. Quick hits in emergency medi-
cine. New York: Springer Science; 2013. p. 37–45. With permission from Springer Science + Business Media)
866 H. Young II and B. Desai
Burns
2nd degree burns
complicated by fx
involving > 20 %
or other trauma
BSA: Ages < 10 or
> 50
Electrical &
chemical burns
Indications for
3rd degree burns
transfer to burn
> 10 % BSA in any
All inhalational center
age
injuries
Burn Complications
Other gram
Infection Pseudomonas
negatives
Carbon
Toxins Cyanide
monoxide
Barotrauma
Blast injury
from explosions
Escharotomy
Center right image (Reprinted from Sjöberg F. Pre-hospital, fluid and volume 1. Vienna: Springer-Verlag/Wien; 2012. p. 105–16. With
early management, burn wound evaluation. In: Jeschke MG, Kamolz permission from Springer-Verlag/Wien)
L-P, Sjöberg F, Wolf SE, editors. Handbook of burns: acute burn care
Blast Injuries
Barotrauma
Type I Pulse pressure
effects
Penetrating
Type II Flying debris
trauma
Rupture of
GI injury
hollow viscus
A diagnosis, 248
AAA. See Abdominal aortic aneurysm (AAA) symptoms and signs, 247
Abdominal and pelvic pain, nonpregnant patient treatment, 248
endometriosis, 624 Acute bronchitis, 149
leiomyomas, 625 Acute chest syndrome, 326
ovarian/adnexal torsion, 624 Acute constipation, etiologies of, 187
ovarian cysts, 623 Acute COPD exacerbation causes, 145
Abdominal aortic aneurysm (AAA) Acute coronary syndrome (ACS)
description, 64 angina pectoris, 3
diagnosis, 66 atypical chest pain, 5
general, 64 causes, 4
signs, 65 cocaine and chest pain, 5
symptoms, 65 description, 2
treatment, 66 initial therapy, 17
Abdominal trauma pathophysiology, 4
abdominal signs, 848 physical exam, 3
bladder and ureter injury, 851 Prinzmetal’s/variant angina, 6, 7
imaging, 848 stable and unstable angina, 6
kidney injuries, 850 Acute diverticulitis. See Diverticulitis
pancreas/stomach/duodenum/intestine trauma, 849 Acute hemolytic transfusion reaction
penetrating, 847 description, 317
penetrating flank and buttock injuries, 850 laboratory investigations, 318
spleen and liver trauma, 849 Acute ischemic stroke treatment, 561
testicular injury, 852 Acute limb ischemia
urethral injury, 851 clinical diagnosis, 88
Abnormal vaginal bleeding, 625 clinical features, 87
Abortions, 630 description, 87
Abruptio placentae, 633 diagnosis, 88
Abuse/neglect/violence treatment, 88
ED staff/patient safety, 612 Acute mastoiditis, 475
elder abuse, 611 Acute mountain sickness, 536
intimate partner violence, 611 Acute myocardial infarction (AMI)
sexual assault, 612 complications, 22
AC. See Allergic conjunctivitis (AC) conduction disturbances, 23
Acalculous cholecystitis, 227 description, 7
Accelerated idioventricular rhythm (AIVR) EKG, 8
description, 21 reperfusion, 18, 19
EKG changes, 21 rhythm abnormalities, 23
treatment, 21 Acute necrotizing ulcerative gingivitis (ANUG), 491
Acetaminophen, 697 Acute periodic paralysis, 595
overdose treatment, 699 Acute renal failure
Rumack-Matthew nomogram, 698 in children, 263
Achilles tendon rupture, 794 description, 262
Acquired hemolytic anemia, 330 glomerular disease causes, 267
ACS. See Acute coronary syndrome (ACS) interstitial disease causes, 266
Acute angle-closure glaucoma intrinsic renal failure, 265
symptoms and signs, 669 laboratory investigations, 272
treatment, 670 macroscopic urine, 272
Acute appendicitis microthrombosis, 270
appendicitis confounders, 247 postrenal failure, 270–271
description, 246 prerenal failure, 264
R S
Rabies, 521–522 Salicylate, 699–700
Radiation, 548 Salivary gland disorders
Radiocontrast-induced nephropathy, 269 sialolithiasis, 502
Ramsay Hunt syndrome, 506 suppurative parotitis, 502
Ranson’s criteria, 232 viral parotitis, 501
Rapid sequence intubation, 179 Salmonella, 191
RBBB. See Right bundle branch block (RBBB) Salter-Harris fractures, 737
Reactivation tuberculosis, 169 Sarcoid, 177
Recompression therapy, 531 SBP. See Spontaneous bacterial peritonitis (SBP)
Rectal prolapse, 259 Scarlet Fever, 384
Red flags, 802 Schizophrenia, 606
Renal transplant, 295 SCIWORA, 833
Renal tubular acidosis, 279 Scombroid, 195
Respiratory acidosis Scrotal disorders, 295
causes of, 464 Seborrheic dermatitis, 360
description, 463 Second-degree type 1 Heart Block (2° type 1 HB)
treatment, 464 description, 122
Respiratory alkalosis EKG changes, 122
causes of, 465 treatment, 123
description, 464 Second-degree type 2 Heart Block (2° type 2 HB), 125
treatment, 465 description, 123
Respiratory distress and tracheostomy, 180 EKG changes, 124
Restrictive cardiomyopathy treatment, 124
clinical features, 55 Second impact syndrome, 824
description, 55 Sedative-hypnotics
treatment, 56 barbituates, 729
Retina benzodiazepines, 730
central retinal artery occlusion, 663 gamma-hydroxybutyrate, 730
central retinal vein occlusion, 665 Seizures
etiologies of central retinal artery syndrome, 664 adult status epilepticus management, 569
retinal detachment, 666 causes of, 566
Retinal detachment, 666 definitions, 565
Retrobulbar hematoma, 673 disposition, 570
Retropharyngeal abscess, 487 febrile, 570–571
Rewarming methods, 547 focal classification, 566
Rewarming physiology, 547 generalized classification, 565
Rhabdomyolysis mimics, 567
causes, 274 neonatal, 571
clinical features, 275 recurrent seizure evaluation, 568
complications, 276 routine first seizure evaluation, 568
description, 274 vs. syncope, 567
diagnosis, 275 Serotonin syndrome
treatment, 276 agents, 729
Rheumatic heart disease Hunter criteria, 728
884 Index
Transport dysphagia U
description, 202 Ulcerative colitis
motor causes, 204 description, 256
obstructive causes, 203 diagnosis, 257
Transudates, 174 irritable bowel syndrome, 257
Transverse cord syndrome, 832 toxic megacolon, 256
Transverse myelitis, 805 treatment, 257
Trauma Ulcer-forming processes, 301
abdominal, 847–852 Ultraviolet keratitis, 657
airway assessment, 815 Umbilical cord prolapse, 635
basilar skull fracture, 824 Unstable angina, 6
blast injuries, 867 Unstable cervical fractures, 828
blunt eye, 670 Upper GI bleeding (UGIB)
blunt ocular trauma and globe rupture, 671 description, 215
brain herniation, 821 diagnosis and treatment, 216
breathing assessment, 815 disposition, 216
burns, 864–867 symptoms and signs, 215
cerebral contusions, 823 Uremia
chest (see Chest trauma) cardiovascular complications of, 280
circulation assessment, 816 gastrointestinal complications of, 282
classification of hemorrhage, 817 hematologic complications of, 281
concussion, 823 neurologic complications of, 281
disability assessment, 818 Urethral injury, 851
elevated ICP, 821 Urethritis, 300
exposure, 818 Urinalysis, 273
extremity injuries, 856–857 Urinary retention, 301
geriatric, 862 Urinary tract infections (UTI)
head trauma, 820 clinical features, 290
hyphema, 672 complicated vs. uncomplicated, 289
intracranial hemorrhage, 825 description, 288
mild TBI, 822 diagnosis, 291
moderate and severe TBI, 822 Uterine cancer, 627
pediatric, 858–861 UTI. See Urinary tract infections (UTI)
pediatric head trauma, 825 Uveitis and iritis, 660
pelvis and hip, 852–855 Uvular edema, 496
penetrating neck injury, 835–838
postconcussive syndrome, 823
pregnancy, 863 V
primary survey, 814 Valproate, 702
secondary survey, 819 Valvular emergencies
second impact syndrome, 824 aortic regurgitation, 39–41
skull fracture, 824 aortic stenosis, 37–38
spinal cord injuries, 830–834 mitral regurgitation, 33–35
spinal injuries, 826–829 mitral stenosis, 32–33
traumatic arrest and ED thoracotomy, 819 mitral valve prolapse, 35–36
traumatic seizures, 822 new murmur, 31
Traumatic aortic injury, 845 Variant angina. See Prinzmetal’s angina
Traumatic penis and foreskin disorders, 296 Varicella, 380
Traumatic seizures, 822 Vascular/related disease, 269
Trichomoniasis, 303, 621 Vaso-occlusive crisis, sickle cell anemia, 326
Tricyclic antidepressants (TCA), 731–732 Vasovagal syncope, 78
EKG changes, 101 Venous sinus thrombosis, 591
Trigeminal neuralgia, 505, 584 Venous stasis ulcers, 385
Triggering agents, 139 Ventilator management and risks, 147
Trismus, 505 Ventral hernias, 243
Troponin elevation, reasons for, 17 Ventricular aneurysm, predicting factors on EKG, 22
TTP. See Thrombotic thrombocytopenic purpura (TTP) Ventricular fibrillation (VF)
Tuberculosis (TB), 168 description, 117
diagnosis, 171 EKG changes, 118
initial evaluation, 170 Ventricular shunt headache, 589
pathophysiology, 169 Ventricular tachycardia (VT)
PPD and CXR, 170 description, 115
presentation, 170 EKG changes, 115
reactivation, 169 EKG features, 116
treatments and side effects, 171 treatment, 117
Tubular disease, causes, 268 Vertebral artery dissection, 515
Tympanic membrane perforation, 477 Vertebrobasilar infarction, 560
Index 887