Emergency & Trauma Care Flashcards
Cat Bite
Highest risk of infection - 80% of bites become infected - 53-80% with Pasteurella multocida - Watch for bone and joint infection RX: Amoxicillin-clavulanate
Human Bite
• Copious irrigation, avoid closure • RX: Amoxicillin-clavulanate x 5 days
Dog Bite
• 80 to 90% of all reported bites (#1) • Only 5% of bites develop infection - Higher rate in hands, deep puncture, older pts. • Primary closure - OK • +/- Amoxicillin-clavulanate
Cat Scratch Disease
• Bartonella (Rochalimaea) henselae - small Gr (-) rod • Diagnosis: Cat scratch and serologic testing (IFA) • Self-limiting disease, 1 to 2 months Do NOT I & D!!! 5-day course of azithromycin.
A 24-year-old male presents with a 3-day history of a rash that is continuing to increase in size. The rash is not painful or tender. It is flat, oval, 14 cm x 7 cm in size, has central clearing and has no fluctuance. No associated fever/chills or systemic symptoms. No new medications. No recall of any insect bite. He recently vacationed on Martha’s Vineyard, MA.
Prescribe doxycycline 100 mg BID x 14 days
Lyme Disease
Due to spirochete: Borrelia burgdorferi
Transmitted by: Deer tick
–Ixodes scapularis and Ixodes pacificus
Lyme Disease: Early Stages
Early Lyme Disease – Erythema migrans: present 50-70% of cases
– Neurologic disease: • Cranial neuropathy (7th nerve), radiculopathy, lymphocytic meningitis
– Cardiac disease: think A-V block
Lyme Disease: Late Stages
Late Lyme disease
– Lyme arthritis: •Large joints, typically knees
– Neurologic disease: •Encephalopathy •Peripheral neuropathy
Lyme Disease: Testing
Stage 1: Erythema migrans Do not test, just treat
- Doxycycline 100 mg BID, 10-21 days
- Amoxicillin 500 mg TID, 10-21 days
Treatment of Lyme Disease Early Neurologic Disease
Early Neurologic Disease
– 7th cranial nerve palsy oral regimen (14-21 days)
– Meningitis/radiculopathy parenteral (10-28 days) • Lyme Carditis oral or parenteral (14-21 days)
Jarisch-Herxheimer reaction
– Fever, chills, myalgias, headache
Remember syphilis…
– Treat symptomatically, do not d/c or switch antibiotic
Two Tier testing system for lyme disease
3 Deer Tick-Borne Illnesses
Other Deer Tick-Borne Illnesses (besides lyme)
- HGA: Human granulocytic anaplasmosis –Previously known as “ehrlichiosis”
- Due to Anaplasma phagocytophilum –Within 3 weeks of tick bite…
- Fever, chills, and headache, with • Thrombocytopenia, leukopenia, elevated LFT’s
Babesiosis –Malaria-like illness with intracellular protazoa –Hemolytic anemia, thrombocytopenia, elevated LFT’s
Other Tick-Borne Illnesses (not deer)
Rocky Mountain Spotted Fever – Organism: Rickettsia rickettsii, transmitted by • The American dog tick and the Rocky Mountain wood tick.
– Symptoms: 5-10 days after tick bite: • Flu-like illness • Rash • Later…multisystem involvement
Allergic Reaction: Treatment
• Vasoconstrictors: Epinephrine *Mild-moderate: 0.3-0.5 cc 1:1000 solution, SQ or IM
**Severe: 1-5 cc of 1:10,000 solution, IV
***If pt. On B-Blocker - Give glucagon 1-5 mg IV
If Epi-Pen is used, refer to ED for follow up Reason: chance of biphasic reaction “second wave ”
- H1 antagonist: diphenhydramine 50mg IV
- H2 antagonist: yes, H2-blocker du jour (ranitidine 50mg IV)
- Steroids: - Do nothing for acute episode - May prevent recurrence
Scombroid Poisoning: “Pseudo ” Fish Allergy
- Mimics allergic reaction – facial flushing, diaphoresis, hives, edema, diarrhea, peppery taste
- Occurs minutes to 1-2 hours after eating contaminated fish
- Classically tuna and mackerel (Scombroidae family), can occur in others
- Histidine in muscle converted by bacteria to histamine.
- Rx: H1 and H2 blockers • Self-limiting: 4-6 hours
Ciguatera Poisoning
- Ingestion of reef fish that have accumulated sufficient amounts of the dinoflagellate – Most common: barracuda, amberjack, grouper, snapper, sturgeon, king mackerel
- GI or neurologic symptoms (or a mixed) – Onset 1-6 hrs after eating, lasts weeks-months –Cold sensation reversal: perceives cold temperatures as hot sensations (and vice versa) – Occurs in 80% of patients and pathognomonic
Heat exhaustion versus Heat Stroke
- Heat exhaustion: nonspecific symptoms –Dizziness, weakness, N/V, HA, diaphoresis –Temp: normal - 104F (40C), normal neuro exam
- Heat stroke: (+) CNS dysfunction
Treatment for heat stroke: “evaporate cooling ” or “immersion cooling ” Note: antipyretics don’t work
Acetaminophen Toxicity
Max daily dosing: 4 g per day, toxic dose = 150 mg/kg
- Acetaminophen levels: drawn at 4 hours after ingestion, treatment based on Rumack-Matthew nomogram
- Treatment: N-acetylcysteine (NAC)
A 21-year-old college student presents to the ED with friends who report the student swallowed “a whole bottle” of acetaminophen 1 hour before arrival. They also note the patient has been drinking alcohol. The patient is awake but appears intoxicated.
What of the following would be the best course of action?
Administer activated charcoal
- If given < 30 min, decreases absorption by 70%
- If given 30-60 min, decreases absorption by 30% - Dose: 1-2 g/kg (max 100 g)
Toxicology Emergencies
- Acetaminophen
- Aspirin
- B-blocker
- Ca-channel blocker
- Digitalis
- Heparin
- Isoniazid (INH)
- Opiates
- Organophosphates
- TCA •
Anticholinergic Presentation
– Hot as Hades……..Hyperthermia
– Blind as a Bat……..Mydriasis
– Dry as a Bone…….Thirst, decreased salivation
– Red as a Beet……..Flushing, vasodilation
– Mad as a Hatter…..Delirium, agitation, confusion
Serotonin Syndrome Presentation
Differences Between Serotonin and Anticholinergic Syndromes
Treatment for the serotonin syndrome is:
Cyproheptadine (Periactin) - Has antiserotonergic properties - Only available orally
Head-tilt-chin lift versus jaw thrust
Opening the Airway:
Head-tilt-chin lift: Preferred if no trauma
Jaw thrust maneuver: Preferred in (+) trauma
Pediatric Trauma/Fluid Resuscitation
- Initial: 20 mL/kg isotonic fluid (NS or LR)
- After 3 boluses, if shock persists, Start PRBC 10 cc/kg
“3 in 1 Rule ”
Head Trauma
A. Intracerebral hemorrhage
– Often not seen on initial CT (delayed presentation)
B. Epidural hematoma
– 80% due to rupture middle meningeal artery – Rare in the elderly, associated with skull fx – Lucid interval (“talk and deteriorate”)
C. Subdural hematoma
– Tear of bridging veins between dura and arachnoid – Common in elderly, alcoholics
Subdural versus epidural hematoma on imaging
Head Trauma and steriods
Steroids provide no benefit, possible harm
2001 AAP Guidelines for Minor Head Injury in Children < 2 Years of Age
Low Risk
Low risk (needs all)
- Low energy mechanism (eg, fall from < 3 feet)
- No signs or symptoms (eg, no vomiting, no STS)
- Older age more reassuring (eg, age > 12 months Observation
OK with reliable parents
2001 AAP Guidelines for Minor Head Injury in Children < 2 Years of Age
High Risk
High risk (any one):
- Depressed mental status
- Focal neuro deficits
- Signs of skull fracture
- Seizure
- Irritability
- Bulging fontanel
- Vomiting > 5x
- LOC > 1 min
Go to CT
2001 AAP Guidelines for Minor Head Injury in Children < 2 Years of Age
Intermediate risk
Everything else: Intermediate risk Observe 4-6 hrs in hospital setting or go to Radiology testing
NEXUS (C-Spine) Guidelines
- No posterior midline cervical tenderness
- No alcohol intoxication
- A normal level of alertness
- No focal neurologic deficits
- No distracting injuries
If meets all, no C-spine x-ray required!!!
Post- splenectomy vaccines:
• Pneumococcal • HIB • Meningococcal
Wound Care Tetanus Prophylaxis
A. Tetanus Prophylaxis
– Clean wound > 10 years since last dose
– Dirty wound > 5 years since last dose
– Safe in pregnancy
Nerve Function: Hand Median Nerve
- Sensory: Palmer surface, thumb to radial 1/2 of ring finger
- Motor: Flexion of wrist and fingers
- Best test: Make “OK ” sign
Nerve Function: Hand Ulnar Nerve
- Sensory: little finger and ulnar 1/2 of ring finger
- Motor: innervates interosseous muscles (intrinsics)
Test: Abduction of fingers
Toddler’s Fracture – Is Not “Abuse”
- Most common fx in age 9 mos - a 3 yrs that present with a limp (29 of 100)
- Spiral fracture of distal tibia
