Emergency Notes

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Anatomic considerations

Target: abscess is usually superior to the tonsil, at the intersection of the base of the uvula and the anterior tonsillar pillar (see circled area in diagram below), and deep to the mucosa and palatoglossus muscle.

The carotid is usually 2cm posterolateral to the target.

May consider bending the needle at 1.5cm or cutting off the a needle cap to expose only 1.5cm of needle

Needle aspiration of a PTA can be done with a 1.5 inch needle on a syringe. However, the barrel of the syringe often can obscure the practitioner's line of sight, as shown in this photo. To optimize the view, use a 3.5 inch spinal needle so that the syringe remains outside of the patient's mouth.


 

 

Peritonsillar Abscess Management - Iowa Head and Neck Protocols - ITS Wiki Service

http://academiclifeinem.blogspot.com/2009/09/trick-of-trade-peritonsillar-abscess.html?m=1


 
 
-LE (produced by neutrophils in the urine) can read falsely negative with oxidizing antibiotics such as cephalexin, nitrofurantoin, tetracycline and gentamicin as well as vitamin C

-Nitrites (converted from nitrate by bacteria in the urine) can read falsely positive if the dipstick was exposed to air (ie 1 week of exposure to air results in 33% false positive)
Nitrites and bacteria to be highly specific but not sensitive while LE and WBC >5 were found to be quite sensitive but not specific.


http://boringem.com/2012/12/12/urinalysis-voodoo/

 
Acutely thrombosed external hemorrhoids may be safely excised in the emergency department in patients who present within 48-72 hours of symptom onset.

In patients presenting after 72 hours from the start of symptoms, conservative medical therapy is preferable.

Bathing in tubs with warm water universally eases painful perianal conditions. Relaxation of the sphincter mechanism and spasm is probably the etiology. Ice can relieve the pain of acute thrombosis.

Excision of thromboses

Enucleation of the thrombosis alone can result in recurrence of the hemorrhoid at the same spot; excision of the underlying vein completely prevents this event. Electrocoagulation or topical astringent (Monsel solution) provides hemostasis. Suturing the wound closed is not necessary and may cause more pain. Remember, acute thromboses spontaneously resolve in 10-14 days; therefore, a patient who presents late and has diminishing pain is best left alone. Recurrence occurs up to 50% of the time when thromboses are left alone.

Contraindications

Absolute contraindications to thrombosed external hemorrhoid excision in the emergency department (ED) include the following:

  • Any concern that the lesion may be something other than a thrombosed external hemorrhoid, such as a painless rectal mass (thrombosed external hemorrhoids are always painful)
  • A grade IV internal hemorrhoid associated with a thrombosed external hemorrhoid
  • Known severe coagulopathy
  • Hemodynamic instability
Relative contraindications to ED excision of a thrombosed external hemorrhoid include the following:

Acute hemorrhoidal crisis


Acute hemorrhoidal crisis is a rare event that usually requires emergency treatment. The mechanism of action is a large internal hemorrhoid prolapse. The sphincter mechanism squeezes, incarcerating the internal hemorrhoids and strangulating them. The resulting spasm causes edema and occasionally thrombosis of the external hemorrhoids. The resulting pain and swelling are dramatic and very painful. Emergent operative resection is safe and, with conservation of the anoderm, provides good relief. Rapid pain relief with office excision of thromboses and ligation of internal hemorrhoids has been reported.

Technique


Tape bottom T

Apply an ice pack for 15 minutes

2-6 mL of local anesthetic (eg, lidocaine with epinephrine) at the base of the thrombosed hemorrhoid, then inject approximately 1-2 mL of the local anesthetic within the hemorrhoid


Use 0.25-in. packing material to pack any space left by the removal of the clot, taking care not to pack tightly

Dress the wound with 4 × 4 gauze pads folded over once and taped into place in a transverse fashion

Postcare

After excision of a thrombosed external hemorrhoid, the patient may be discharged home for several hours of bedrest followed by warm baths 2-3 times daily, stool softeners, and topical or systemic analgesia. The patient should return in 48-72 hours for a wound check.


Patient should start sitz baths as soon as possible. Sitz baths should be taken 3-4 times a day for 20 minutes at a time in warm but not hot water. Packing gauze can be removed in 48 hours if it has not yet fallen

 

Conservative tx

✓ If topical mucosal anesthetic does not give enough relief to permit examination, follow with subcutaneous injection of 5 to 10 mL of 1% lidocaine with epinephrine or bupivacaine 0.5% with epinephrine for extended pain relief.

✓ If topical anesthetics on the rectal mucosa help control the pain, provide for more of the same, perhaps also with some added corticosteroid for anti-infl ammatory eff ect (Anusol-HC cream).

✓ Pain may also be relieved by reducing sphincter spasm. Prescribe topical nifedipine 0.3% or diltiazem gel 2% with lidocaine gel 1.5% to be applied every 12 hours. Topical glyceryl trinitrate 0.2% or nitroglycerin ointment can be substituted for the diltiazem and nifedipine, but many patients are unable to tolerate the headaches that frequently occur.

 

http://emedicine.medscape.com/article/81039-overview#aw2aab6b4
Source: HQMedEd

Nexus works if > 9 years

Most common complaint is a sensory deficit

8 screening factors: (Leonard 2010, annals of emergency medicine) 98% Sn, 26% Sp if have 1

  • Altered mental status
  • Focal neuro findings/symptoms
  • Complaints of neck pain
  • Torticollis
  • Substantial injury to torso
  • Diving injury
  • High risk mva:head on, rollover, ejection, death, >55mph
  • Predisposing conditions (downs, Marfans, oi,ehlers danlos)
2011 trauma Canadian consensus- no need imaging if:

  • Low risk mechanism
  • No distracting injuries
  • Able to verbalize/cooperate with exam
  • No altered mental status
  • No neck pain, tenderness, limitation to movement
  • No neuro deficit (including paresthesia)
 

Pediatric Cervical Spine Injuries from HQMedEd on Vimeo.

 
Chronic ingestion

  • In 2004, Daly et al demonstrated that patients with delayed presentations (more than 24 hours after ingestion) or chronic ingestions who had an acetaminophen level of less than 10 mcg/mL and an AST below 50 IU/mL had a 0% risk of developing hepatotoxicity
  • detectable serum acetaminophen levels (>10 mcg/mL) or elevated liver enzymes should be presumed to have acetaminophen toxicity.
  • all patients with delayed presentations should be empirically treated with NAC prior to any laboratory evaluation.
  • If the acute ingestion occurred within the past 24 hours, the acetaminophen level should be plotted on the nomogram. If the patient's level is above the toxic level, NAC should be continued
Which patients should be transferred to a liver transplant center following acetaminophen overdose? (king criteria)
  • serum pH below 7.3 after adequate fluid resuscitation
  • INR above 6.5,
  • grade III or IV encephalopathy.
  • If any of the above criteria are met, serious consideration should be given to transferring the patient to a regional liver transplant center for definitive management
acute poisoning key numbers

  • Toxic dose: 150mg/kg
  • 4 hr toxic level: 150mcg/ml
  • Loading dose: 150mg/kg
Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Syncope. 2007

1. What history and physical examination data help to risk-stratify patients with syncope?


  • heart failure - higher risk of an adverse outcome.
  • Riskmfactors: older age, structural heart disease, or a history cad
  • Low risk: younger patients with syncope that is nonexertional, without history or signs of cardiovascular disease, a family history of sudden death, and without comorbidities
2. Who should be admitted after an episode of syncope of unclear cause?

  • evidence of heart failure or structural heart disease.
  • other factors that lead to stratification as high-risk for adverse outcome: Older age and associated comorbidities, Abnormal ECG, hct< 30 (if obtained), History or presence of heart failure, coronary artery disease, or structural heart disease
EKGs



-(short pr interval)- wpw: most common ventricular pre excitation syndrome. 1) short pr 2) prolonged qrs complex, 3) slurred upstroke of qrs complex- delta wave; can produce large r wave in v 1

-brugada syndrome: abnormalities in v1-v3: RBBB or incomplete RBBB and ST elevation; ST elevation convex upward (saddle) or "coved" (concave) morphology; need electrophysiology studies to diagnose; can develop polymorphic or monomorphic VT

-prolonged qt

-bradycardia: hr < 50 sick sinus syndrome

-prolonged pr interval: 2nd or 3rd degree av block

-Arryythmogenic Right Ventricular Dysplasia (ARVD): T Wave inversion in leads V1-V3, QRS Complex duration > 110 ms in leads V1-V3

-Abnormal QRS: Left Bundle Branch Block or Bifascicular Heart Block, QRS Duration > 120 ms, Q Waves

References:



http://www.fpnotebook.com/cv/ekg/EkgChngsInSyncpDTArhythm.htm