New this month in Scientific American Emergency Medicine:

  • General Approach to the Poisoned Patient
  • Pediatric Seizures in the Emergency Department
  • Congenital Heart Disease
  • Penetrating Neck Trauma

 


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A patient with methemoglobinemia.

General Approach to the Poisoned Patient

Emily Gordon, MD
Instructor of Emergency Medicine, University of Massachusetts Medical School, Worcester MA
Steven B. Bird, MD
Professor of Emergency Medicine, University of Massachusetts Medical School, Worcester MA

 

Poisoning and ingestions constitute an increasing amount of morbidity and mortality nationwide. According to the American Association of Poison Control Centers (AAPCC), 2.2 million exposures were reported in 2013, and ingestions are currently the leading cause of injury-related death in the United States. Exposures include intentional overdose or suicide attempts, accidental overdose in drug abusers or children, and work-related injuries or acts of terrorism. According to the AAPCC, 50% of exposures are in children less than 5 years old and 80% of exposures are unintentional. When it comes to the unstable undifferentiated and possibly poisoned patient, one must take a stepwise approach similar to that for any critically ill patient, This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of poisoning. Figures show The Full Outline of Unresponsiveness (FOUR) scale, a patient with methemoglobinemia, a hand with scaling due to mercury poisoning, an electrocardiogram with examples of QT prolongation and QRS widening, and an electrocardiogram of bidirectional ventricular tachycardia, pathognomonic of digitalis glycoside poisoning. Tables list a stepwise approach to a potentially poisoned patient, a general approach to the poisoned patient,  heart rate, toxidromes, anticholinergic toxidrome, cholinergic toxidrome, Glasgow Coma Scale, toxins and associated odors, electrocardiogram findings, causes of anion-gap metabolic acidosis, and antidotes.

 


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Tongue bite from seizure.

Pediatric Seizures in the Emergency Department

Lindsey Retterath, MD
Banner University Medical Center – Tucson, Resident Physician, Department of Emergency Medicine and Department of Pediatrics
Dale Woolridge, MD
Banner University Medical Center – Tucson, Program Director, Emergency Medicine and Pediatrics Combined Residency Program

 

Seizures represent a common neurologic complaint among pediatric patients in the emergency department (ED). They can be classified as generalized or focal. In terms of etiology, seizures are most basically broken down into “acute symptomatic” seizures, which are due to another primary medical cause, and unprovoked seizures which occur as a primary pathology. Febrile seizures are the most common types of seizures in children, which themselves can be simple or complex. The most concerning seizures are those which associate with meningismus, encephalitis, metabolic derangements, intracranial mass, and, of course those which progress to status epilepticus. Significantly, it is appropriate and even critical to assume status epilepticus and intervene accordingly whenever a child arrives to the ED seizing for an unspecified period of time. This review covers the initial evaluation, resuscitation, management, work-up, and disposition of pediatric patients who present to the emergency room with seizures. Figures in this chapter illustrate stepwise and algorithmic approaches to initial management, expanded differential, systematic diagnostic approach, and disposition for pediatric patients presenting with seizures and status epilepticus. Tables list important physical exam components for evaluating children with seizures, classifications of seizures, common seizure look-alikes in children, features of febrile seizures, etiologies of pediatric seizures.

 


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Differential four-extremity blood pressure based on the location of coarctation of the aorta.

Congenital Heart Disease

Zachary Pittsenbarger, MD
Instructor in Pediatrics, Division of Emergency Medicine
Northwestern University Feinberg School of Medicine
Evanston, IL
Emily Roben, MD
Clinical Fellow in Pediatrics, Division of Emergency Medicine
Northwestern University Feinberg School of Medicine
Evanston, IL

 

Congenital heart disease (CHD) is common, affecting approximately 8 in 1000 live-born children, and encompasses a broad range of diagnoses and presentations.  CHDs can include inborn derangements in almost any aspect of the hearts structure of function, but the most common type of congenital heart disease are structural lesions of the heart that affect the normal pattern of blood flow.  These structural lesions can present with varied symptoms and physical exam signs that are rooted in their underlying blood flow patterns often lead to one of four groups of diseases based on blood flow patterns.  Overcirculation, systemic outflow obstruction, systolic failure, and cyanosis are the four groups used as descriptive classifications of structural CHD.  CHD findings can be present prenatally, in the newborn nursery, and well child office visits, but very often present to the EDs without any cardiac history when the lesion progresses to a point of crisis when the cardiac output is no longer meeting the body’s perfusion demands.  Early presentations of CHD frequently are related to closure of the ductus arteriosus and may benefit from early treatment with prostaglandin E.  Lab tests, radiology studies, and exam findings may be suggestive of certain types of lesions, but the gold standard to determine the type of CHD is an echocardiogram.  Once the diagnosis of CHD is suspected, consultation with a pediatric cardiologist is highly recommended to arrange the timely evaluation of the child and prompt initiation of therapies if needed to mitigate the disease progression.

 


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Internal structures of the neck.

Penetrating Neck Trauma

Adam R. Kellogg, MD, FACEP
Associate Residency Director
Department of Emergency Medicine
Baystate Medical Center
Assistant Professor of Emergency Medicine
University of Massachusetts Medical School – Baystate Health
Springfield, MA
B. Witkind Davis, DO, MPH, MS
Resident Physician
Department of Emergency Medicine
Baystate Medical Center
Springfield, MA

 

Penetrating neck injuries are approximately 1% of all traumatic injuries in the US, yet the case fatality rate approaches 10%. All emergency physicians need to be able to expediently differentiate those requiring emergent interventions from those with less serious injuries. Initial management of penetrating neck injuries focuses on identification of patients requiring early airway management or emergent surgical evaluation. Due to bleeding, anatomic distortion, hemodynamic instability, or potential airway violation patients with penetrating neck trauma should be presumed to have difficult to manage airways. The emergency physician must be prepared to perform cricothyrotomy, and even tracheostomy, should orotracheal intubation attempts fail. Diagnosis of injury in the stable patient with evidence of violation of the platysma has moved away from the traditional zone based approach and now focuses on structured physical exam and the use of MDCTA. Further diagnostic testing may be required dependent on the results of the MDCTA and should be at the direction of a surgeon.

 


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WRITTEN BY

decker

The Decker Team