WikEM - User contributions [en]

Penile fracture

2011-09-22T03:13:10Z

Russellm77: /* Work-Up */

==Background==
*Tunica albuginea of one or both corpus cavernosa ruptures due to trauma to erect penis
*Can be a/w urethral rupture and deep dorsal vein injury

==Clinical Features==
*Penis is swollen, discolored, tender, and flaccid

==Work-Up==
*Retrograde urethrogram may be necessary to assure urethral integrity
**Especially important if patient unable to urinate

==Treatment==
*Surgery
**Hematoma evacuation and suture apposition of the disrupted tunica albuginea

==Disposition==
Admit

==Source==
Tintinalli

[[Category:GU]]

Priapism

2011-09-22T03:11:24Z

Russellm77: /* Treatment */

==Background==
*Prolonged, unwanted erection not a/w sexual stimulation
*May lead to erectile dysfunction and penile necrosis if untreated
*2 types:
**1. High-flow (nonischemic)
***AV fistula from trauma (lacerated cavernous artery shunts blood into cavernous bodies)
***Not painful
***Ischemia/impotence does not occur
**2. Low-flow (ischemic)
***Veno-occlusion causing pooling of deoxygenated blood in cavernous tissue
****A/w SCD, trauma, leukemia, infection, spinal cord injury/cauda equina, meds
***Painful

==Work-Up==
#CBC
##Rule-out SCD, leukemia
#Ultrasound
##Can distinguish between high-flow and low-flow
#Exam
##Pt with erect corpus cavernosum, but flacid glans and spongiosum

==DDx==
#Peyronie's Disease
#Urethral foreign body
#Penile surgical implant
#Erection from sexual arousal

==Treatment==
#IV hydration (sickle cell)
#Morphine
#O2 (sickle cell)
#Transfusion (sickle cell)
#Aspiration/injection of corpus cavernosum
##Consent prior, thoroughly explain impotence is a possible adverse effect
##Penile nerve block
##Aspirate 5cc of blood from corpus cavernosum (2 or 10 o'clock position of shaft) w/ 19ga needle
###Inject 1mL diluted phenylephrine (100-500mcg/mL) q3-5m until resolution or one hour
###Use three way valve to perform above
#Urology consult, especially important with traumatic priapism

==Disposition==
#Admit if refractory to treatment
#May dispo home if treatment is successful with close f/u by urology

==Source==
Tintinalli, UpToDate

[[Category:GU]]

Priapism

2011-09-22T03:10:20Z

Russellm77: /* Treatment */

==Background==
*Prolonged, unwanted erection not a/w sexual stimulation
*May lead to erectile dysfunction and penile necrosis if untreated
*2 types:
**1. High-flow (nonischemic)
***AV fistula from trauma (lacerated cavernous artery shunts blood into cavernous bodies)
***Not painful
***Ischemia/impotence does not occur
**2. Low-flow (ischemic)
***Veno-occlusion causing pooling of deoxygenated blood in cavernous tissue
****A/w SCD, trauma, leukemia, infection, spinal cord injury/cauda equina, meds
***Painful

==Work-Up==
#CBC
##Rule-out SCD, leukemia
#Ultrasound
##Can distinguish between high-flow and low-flow
#Exam
##Pt with erect corpus cavernosum, but flacid glans and spongiosum

==DDx==
#Peyronie's Disease
#Urethral foreign body
#Penile surgical implant
#Erection from sexual arousal

==Treatment==
#IV hydration (sickle cell)
#Morphine
#O2 (sickle cell)
#Transfusion (sickle cell)
#Aspiration/injection of corpus cavernosum
##Consent prior, thoroughly explain impotence is a possible adverse effect
##Penile nerve block
##Aspirate 5cc of blood from corpus cavernosum (2 or 10 o'clock position of shaft) w/ 19ga needle
###Inject 1mL diluted phenylephrine (100-500mcg/mL) q3-5m until resolution or one hour
###Use three way valve to perform above
#Urology consult

==Disposition==
#Admit if refractory to treatment
#May dispo home if treatment is successful with close f/u by urology

==Source==
Tintinalli, UpToDate

[[Category:GU]]

Priapism

2011-09-22T03:08:44Z

Russellm77: /* Work-Up */

==Background==
*Prolonged, unwanted erection not a/w sexual stimulation
*May lead to erectile dysfunction and penile necrosis if untreated
*2 types:
**1. High-flow (nonischemic)
***AV fistula from trauma (lacerated cavernous artery shunts blood into cavernous bodies)
***Not painful
***Ischemia/impotence does not occur
**2. Low-flow (ischemic)
***Veno-occlusion causing pooling of deoxygenated blood in cavernous tissue
****A/w SCD, trauma, leukemia, infection, spinal cord injury/cauda equina, meds
***Painful

==Work-Up==
#CBC
##Rule-out SCD, leukemia
#Ultrasound
##Can distinguish between high-flow and low-flow
#Exam
##Pt with erect corpus cavernosum, but flacid glans and spongiosum

==DDx==
#Peyronie's Disease
#Urethral foreign body
#Penile surgical implant
#Erection from sexual arousal

==Treatment==
#IV hydration (sickle cell)
#Morphine
#O2 (sickle cell)
#Transfusion (sickle cell)
#Aspiration/injection of corpus cavernosum
##Penile nerve block
##Aspirate 5cc of blood from corpus cavernosum (2 or 10 o'clock position of shaft) w/ 19ga needle
###Inject 1mL diluted phenylephrine (100-500mcg/mL) q3-5m until resolution or one hour
#Urology consult

==Disposition==
#Admit if refractory to treatment
#May dispo home if treatment is successful with close f/u by urology

==Source==
Tintinalli, UpToDate

[[Category:GU]]

Hydrocele

2011-09-22T02:57:33Z

Russellm77: /* Background */

==Background==
*Accumulation of fluid around the testis
*Most common cause of painless scrotal swelling in children
**Secondary to persistent processus vaginalis
*Most resorb by 18-24 months of age
*Acute symptomatic hydroceles are not benign, require workup

==Diagnosis==
*+Transillumination

==DDx==
*Hydrocele
*Hematocele
*Spermatocele
*Malignancy

==Treatment==
*None indicated

==Disposition==
*Referral to urologist

==Source==
Tintinalli

[[Category:GU]]
[[Category:Peds]]

Orchitis

2011-09-22T02:54:08Z

Russellm77: /* Source */

==Background==
#rare acute infection of testis
#most common in prepubertal boys with viral infections (20% of patients with mumps)
##arises several days after onset of flu-like symptoms and parotitis in mumps patients
##Epididymis not involved; usually unilateral
#bacterial orchitis typically due to spread from epididymis: epididymo-orchitis
##bacterial pathogens: N. gonorrhea, c. trachomatis, E. Coli, Klebsiella, P. aeruginosa
##Differentiate from viral orchitis by involvement of epididymis, abscence of preceding parotid sx
#presents with fever and scrotal pain

==Diagnosis==
#affected testicle/scrotum: swollen, tender, erythematous
#testicular US shows testicular inflammation, rules out torsion, epididymitis
#UA: positive in epididymo-orchitis

==Work-Up==
#testicular US
#UA, Urine Culture, gonorrhea, chlamydia screen

==DDx==
#[[Testicular Torsion]]
#[[Epididymitis]]
#testicular tumor
#mumps (or other viral) orchitis
#lupus orchitis

==Treatment==
#viral orchitis (mumps): supportive care, ice, elevation, analgesia.
#bacterial orchitis (epididymo-orchitis):
##sexually transmitted (<35yo):
###ceftriaxone 250mg IM x1 or cipro 500mg PO x1 for gonorrhea
###doxycycline 100mg PO BID x 14 days for chlamydia
##anal intercourse, nonsexually active, instrumentation and/or >35yo:
###cipro 500mg PO BID x 14 days OR Ofloxacin 200mg PO BID x 14 days
###IV: piperacillin/taxobactam 3.375g IV q6 or ampicillin/sulbactam 3g IV q6
#treat sexual partner

==Disposition==
#admit for signs of systemic toxicity

==Source==
*Rosen's
*ER Atlas

[[Category:GU]]
[[Category:ID]]

Orchitis

2011-09-22T02:52:55Z

Russellm77: /* Background */

==Background==
#rare acute infection of testis
#most common in prepubertal boys with viral infections (20% of patients with mumps)
##arises several days after onset of flu-like symptoms and parotitis in mumps patients
##Epididymis not involved; usually unilateral
#bacterial orchitis typically due to spread from epididymis: epididymo-orchitis
##bacterial pathogens: N. gonorrhea, c. trachomatis, E. Coli, Klebsiella, P. aeruginosa
##Differentiate from viral orchitis by involvement of epididymis, abscence of preceding parotid sx
#presents with fever and scrotal pain

==Diagnosis==
#affected testicle/scrotum: swollen, tender, erythematous
#testicular US shows testicular inflammation, rules out torsion, epididymitis
#UA: positive in epididymo-orchitis

==Work-Up==
#testicular US
#UA, Urine Culture, gonorrhea, chlamydia screen

==DDx==
#[[Testicular Torsion]]
#[[Epididymitis]]
#testicular tumor
#mumps (or other viral) orchitis
#lupus orchitis

==Treatment==
#viral orchitis (mumps): supportive care, ice, elevation, analgesia.
#bacterial orchitis (epididymo-orchitis):
##sexually transmitted (<35yo):
###ceftriaxone 250mg IM x1 or cipro 500mg PO x1 for gonorrhea
###doxycycline 100mg PO BID x 14 days for chlamydia
##anal intercourse, nonsexually active, instrumentation and/or >35yo:
###cipro 500mg PO BID x 14 days OR Ofloxacin 200mg PO BID x 14 days
###IV: piperacillin/taxobactam 3.375g IV q6 or ampicillin/sulbactam 3g IV q6
#treat sexual partner

==Disposition==
#admit for signs of systemic toxicity

==Source==
Adapted from Rosen's

[[Category:GU]]
[[Category:ID]]

Epididymitis

2011-09-22T02:49:01Z

Russellm77: /* Work-Up */

==Background==
*Often confused with testicular torsion
**Cremasteric reflex intact
*Sexually active men <35yo:
**Consider chlamydia, gonorrhea
*Not sexually active, age >35yo, or anal intercourse:
**Also consider E. coli, pseudomonas, enterobacter, TB, syphilis

==Diagnosis==
*Pain of gradual onset, peaks at 24hr
**Dysuria, frequency, fever
*Pain relieved with elevation of testicle (positive Prehn sign)

==Work-Up==
#UA
##Pyuria seen in half of cases
#Ucx (children, elderly men)
#Urine GC/Chlam (urethral discharge or age <40)
#Ultrasound for equivocal cases
#Older men should be evaluated for urinary retention
#Note that testicular tumors are frequently misdiagnosed as epididymitis

==DDx==
#Testicular torsion
#Torsion of testicular appendage
#Testicular tumor
#Orchitis
#Scrotal abscess
#Indirect inguinal hernia

==Treatment==
#Scrotal elevation
#Analgesia
#Abx
##Sexually transmitted (<40yo):
###CTX 250mg IM x1 for GC AND:
###Doxycycline 100 mg BID x10d for chlamydia
##Anal intercourse, nonsexually active, and/or >40yo:
###PO: Cipro 500mg BID x 14d OR Ofloxacin 200mg BID x 14d
###IV: Piperacillin/taxobactam 3.375g IV q6 or ampicillin/sulbactam 3g IV q6
##Treat sexual partner

==Disposition==
#Admit for:
##Systemic signs of toxicity (fever, chills, N/V)
#D/c w/ urology f/u in 1wk if non toxic

==See Also==
[[Testicular Torsion]]

[[Torsion of Testicular Appendages]]
==Source==
Anatomical Approach to Scrotal Emergencies: A New Paradigm for the Diagnosis and Treatment of the Acute Scrotum. The Internet Journal of Urology 2010 : Volume 6 Number 2. Sardar Ali. KhanRosens

CDC Guidelines

[[Category:GU]]
[[Category:ID]]

Testicular torsion

2011-09-22T02:42:41Z

Russellm77: /* Source */

== Background ==
*Peak incidence in first year of life, 2nd peak incidence at puberty
*Consider torsion in setting of scrotal trauma if pain persists >1hr
*Half of all torsions occur during sleep
'''Salvage Rates for Detorsion Times'''

{| style="width: 500px" border="1" cellpadding="1" cellspacing="1"
|-
| '''Rate''' 
| '''Time''' 
|-
| 90-100%
| <6 hrs 
|-
| 20-50%
| 6-12 hrs 
|-
| 0-10%
| >24 hrs
|}

== Diagnosis ==
*History:
**Abrupt onset testicular pain a/w N/V
**May have had intermittent episodes in the past
*Exam:
**Swollen, high-riding testis w/ transverse lie
**Absent cremasteric reflex on affected side (99% Sn)
*Ultrasound
**Only indicated for equivocal cases
**Unilateral abscence of flow (specific)

== Work-Up ==
*UA
*US for equivocal cases
*Lab workup for surgery

== DDx ==
#Torsion of testicular appendage
#Epididymitis
#Testicular mass
#Incarcerated hernia

== Treatment ==
*Manual (ED) vs. surgical (urology)

=== Manual Detorsion ===
*Indicated if urologist is not immediately available
*Not definitive tx
**Pt still requires emergent urology consult even if successful
*"Open the book" = twist outward and laterally
**Hold testicle with left thumb and forefinger
***Rotate testicle outward 180° in medial to lateral direction
****Counterclockwise for right testicle and clockwise for left testicle
***Rotation may need to be repeated 2-3x for complete detorsion/pain relief

== Disposition ==
*To OR or urology

== See Also ==
[[Torsion of Testicular Appendages]]

== Source ==
Tintinalli, Rosen's, ER atlas

[[Category:GU]] [[Category:Peds]]

Testicular torsion

2011-09-22T02:42:21Z

Russellm77: /* Manual Detorsion */

Testicular torsion

2011-09-22T02:41:21Z

Russellm77: /* Background */

== Background ==
*Peak incidence in first year of life, 2nd peak incidence at puberty
*Consider torsion in setting of scrotal trauma if pain persists >1hr
*Half of all torsions occur during sleep
'''Salvage Rates for Detorsion Times'''

{| style="width: 500px" border="1" cellpadding="1" cellspacing="1"
|-
| '''Rate''' 
| '''Time''' 
|-
| 90-100%
| <6 hrs 
|-
| 20-50%
| 6-12 hrs 
|-
| 0-10%
| >24 hrs
|}

== Diagnosis ==
*History:
**Abrupt onset testicular pain a/w N/V
**May have had intermittent episodes in the past
*Exam:
**Swollen, high-riding testis w/ transverse lie
**Absent cremasteric reflex on affected side (99% Sn)
*Ultrasound
**Only indicated for equivocal cases
**Unilateral abscence of flow (specific)

== Work-Up ==
*UA
*US for equivocal cases
*Lab workup for surgery

== DDx ==
#Torsion of testicular appendage
#Epididymitis
#Testicular mass
#Incarcerated hernia

== Treatment ==
*Manual (ED) vs. surgical (urology)

=== Manual Detorsion ===
*Indicated if urologist is not immediately available
*Not definitive tx
**Pt still requires emergent urology consult even if successful
*"Open the book" = twist outward and laterally
**Hold testicle with left thumb and forefinger
***Rotate testicle outward 180° in medial to lateral direction
***Rotation may need to be repeated 2-3x for complete detorsion/pain relief

== Disposition ==
*To OR or urology

== See Also ==
[[Torsion of Testicular Appendages]]

== Source ==
Tintinalli, Rosen's

[[Category:GU]] [[Category:Peds]]

Subarachnoid hemorrhage

2011-09-20T15:18:58Z

Russellm77: /* Diagnosis */

== Background ==

=== Pearls ===

#Obtain GCS before intubation
#If intubate prevent hypertension (rebleeding)
##Pretreatment
###Lidocaine 1-1.5mg/kg (100mg) (blunts incr in BP)
###Fentanyl 200mcg (sympatholytic)
##Sedation
###If pt has high BP - use propofol
###If pt has good BP - use etomidate
#Treat pain
##Prevents incr catacholamines/ incr BP

=== Epidemiology ===

Of All pts in ED with c/o HA:

*1% will have SAH
*10% will have SAH if c/o worst HA of life
*25% will have SAH if c/o worst HA of life + any neuro deficit

=== Risk Factors ===

(in order of relative risk)

#Genetics (polycystic kidney disease, Ehler-Danlos, family hx)
#Hypertension
#Atherosclerosis
#Cigarette smoking
#Alcohol
#Age > 50
#Cocaine use
#Estrogen deficiency

=== Etiology of Spontaneous SAH ===
#Ruptured aneurysm 85%
#Nonaneurysmal 15%
##Perimesencephalic hemorrhage 10%
##Other - tumor, coagulopathy, dissection, vasculitis, sickle cell, venous sinus thrombosis

== Clinical Manifestations ==

#Sudden, severe headache (97% of cases)
##Sudden onset is more important finding than worst HA
#May be associated with syncope, seizure, nausea/vomiting, and meningismus
##Meningismus may not develop until several hours after bleed (caused by blood breakdown > aseptic meningitis)
#Retinal hemorrhages
##May be the only clue in comatose patients
#Approximately 30-50% will have sentinel bleed/HA 6-20 days before SAH

== Diagnosis ==
'''If concerned for SAH, must do BOTH CT and LP'''

#Non-Contrast Head CT
##90%-98% sensitive if performed w/in 24 hours of bleed
##91% sensitive in patients w/ normal neuro exam
###Decreases to ~50% sensitive by day 5
##Not as sensitive/specific for minor bleeds
##SAH 2/2 aneurysm (90%) - look in cisterns (especially suprasellar cistern)
##SAH 2/2 trauma - Look at convexities of frontal & temporal cortices
#Lumbar Puncture
##Findings:
###Elevated RBC count that doesn't decrease from tube one to four
####(Decreasing RBCs in later tubes can occur in SAH; only reliable if RBC count in final tube is nl)
###Opening pressure > 20 in 60% of patients with SAH
####Can help differentiate from a traumatic tap (opening pressure expected to be normal)
####Elevated opening pressure also seen in cerebral venous thrombosis, IIH
###Xanthrochromia
####May help differentiate between SAH and a traumatic tap
####Takes at least 2 hours after the bleed to develop (beware of false negatives)
####Sensitivity (93%) / specificity (95%) highest after 12 hours
##If unable to obtain CSF consider CTA

== Treatment ==

#Nimodipine
##Associated with improved neuro outcomes and decreased cerebral infarction
##Give 60mg q4hr PO or NGT only! (never IV)
#BP control
##No consensus on HTN (incr BP may maintain CPP but may also increase rate of bleeding)
###If pt is alert this means CPP is adequate so consider lowering sbp to 120-140
####If pt has history of HTN consider lowering sbp to ~160
###If pt is ALOC consider leaving BP alone as the ALOC may be 2/2 reduced CPP
##If BP control is necessary use NICARDIPINE, LABETALOL, or ESMOLOL
###Avoid vasodilators such as nitroprusside or NTG (increase cerebral blood volume > increased ICP)
##Avoid hypotension
###Maintain MAP > 80
####Give IVF
####Give pressors if IVF ineffective
#Discontinue/reverse all anticoagulation
##Coumadin - give (prothrombin complex conc or FFP) and vit K)
##Aspirin - give DDAVP
##Plavix - give platelets
#Seizure prophylaxis
##Controversial; 3 day course may be preferable
##Phenytoin load
#Glucocorticoid therapy
##Controversial; evidence suggests is neither beneficial nor harmful
#Glycemic control
##Controversial; consider sliding scale if long pt stay in ED while awaiting ICU bed
#Keep head of bed elevated

== Complications ==

#Rebleeding
##Risk is highest within first 24 hours (2.5-4%), particularly within first 6 hours
##Usually diagnosed by CT after acute deterioration in neuro status
##Only aneurysm treatment is effective in preventing rebleeding
#Vasospasm
##Leading cause of death and disability after rupture
##Typically begins no earlier than day three after hemorrhage
##Characterized by decline in neuro status
##Aggressive treatment can only be initiated after the aneurysm has been treated (sx or intraluminal tx)
###Triple-H therapy (hemodilution + induced hypertension (pressors) + hypervolemia)
#Cardiac abnormalities (?2/2 release of catecholamines due to hypoperfusion of hypothalamus)
##Ischemia
###Elevated troponin (20-40% of cases)
###ST segment depression
##Rhythm disturbances
###Torsades, a fib, a flutter
##QT prolongation
##Deep, symmetric TWI
##Prominent U waves
#Hydrocephalus
##Consider ventricular drain placement for deteriorating LOC + no improvement within 24 hours
#Hyponatremia
##Usually due to SIADH
###Treat via isotonic, or if necessary, hypertonic saline (do not treat via water restriction!)

== Prognosis ==

=== Hunt and Hess ===
*Grade 0: Unruptured aneurysm
*Grade 1: Asymptomatic or mild HA and slight nuchal rigidity
**Grade 1a: No acute meningeal/brain reaction, with fixed neurological def
*Grade 2: Moderate to severe headache, stiff neck, no neurologic deficit except cranial nerve palsy
*Grade 3: Mild mental status change (drowsy or confused), mild focal neurologic deficit
*Grade 4: Stupor or moderate to severe hemiparesis
*Grade 5: Coma or decerebrate rigidity

^Grade 1 or 2 have curable dz, if dx missed pts return w/ higher grade (ie 3 or 4), 2/3 will be dead or vegetative at 6 mos if grade 3 or 4!

^Add one grade for serious systemic dz (HTN, DM, severe atherosclerosis, COPD)

=== World Federation of Neurosurgical Societies (WFNS) ===

{| cellspacing="1" cellpadding="1" border="1" width="200"
|-
| '''Grade''' 
| '''GCS''' 
| '''Major Focal Deficit''' 
|-
| 0 (unruptured) 
| NA 
| NA 
|-
| 1 
| 15 
| Absent 
|-
| 2 
| 13-14 
| Absent 
|-
| 3 
| 13-14 
| Present 
|-
| 4 
| 7-12 
| Present/absent 
|-
| 5 
| 3-6 
| Present/absent 
|}

 

== See Also ==

[[Intracranial Hemorrhage]]

== Source ==

UpToDate

EB Emergency Medicine, July 2009

EMCrit Podcast 8

[[Category:Neuro]]

Subarachnoid hemorrhage

2011-09-20T14:37:49Z

Russellm77: /* Risk Factors */

== Background ==

=== Pearls ===

#Obtain GCS before intubation
#If intubate prevent hypertension (rebleeding)
##Pretreatment
###Lidocaine 1-1.5mg/kg (100mg) (blunts incr in BP)
###Fentanyl 200mcg (sympatholytic)
##Sedation
###If pt has high BP - use propofol
###If pt has good BP - use etomidate
#Treat pain
##Prevents incr catacholamines/ incr BP

=== Epidemiology ===

Of All pts in ED with c/o HA:

*1% will have SAH
*10% will have SAH if c/o worst HA of life
*25% will have SAH if c/o worst HA of life + any neuro deficit

=== Risk Factors ===

(in order of relative risk)

#Genetics (polycystic kidney disease, Ehler-Danlos, family hx)
#Hypertension
#Atherosclerosis
#Cigarette smoking
#Alcohol
#Age > 50
#Cocaine use
#Estrogen deficiency

=== Etiology of Spontaneous SAH ===
#Ruptured aneurysm 85%
#Nonaneurysmal 15%
##Perimesencephalic hemorrhage 10%
##Other - tumor, coagulopathy, dissection, vasculitis, sickle cell, venous sinus thrombosis

== Clinical Manifestations ==

#Sudden, severe headache (97% of cases)
##Sudden onset is more important finding than worst HA
#May be associated with syncope, seizure, nausea/vomiting, and meningismus
##Meningismus may not develop until several hours after bleed (caused by blood breakdown > aseptic meningitis)
#Retinal hemorrhages
##May be the only clue in comatose patients
#Approximately 30-50% will have sentinel bleed/HA 6-20 days before SAH

== Diagnosis ==
'''If concerned for SAH, must do BOTH CT and LP'''

#Non-Contrast Head CT
##90%-98% specific if performed w/in 24 hours of bleed
##91% sensitive in patients w/ normal neuro exam
###Decreases to ~50% sensitive by day 5
##Not as sensitive/specific for minor bleeds
##SAH 2/2 aneurysm (90%) - look in cisterns (especially suprasellar cistern)
##SAH 2/2 trauma - Look at convexities of frontal & temporal cortices
#Lumbar Puncture
##Findings:
###Elevated RBC count that doesn't decrease from tube one to four
####(Decreasing RBCs in later tubes can occur in SAH; only reliable if RBC count in final tube is nl)
###Opening pressure > 20 in 60% of patients with SAH
####Can help differentiate from a traumatic tap (opening pressure expected to be normal)
####Elevated opening pressure also seen in cerebral venous thrombosis, IIH
###Xanthrochromia
####May help differentiate between SAH and a traumatic tap
####Takes at least 2 hours after the bleed to develop (beware of false negatives)
####Sensitivity (93%) / specificity (95%) highest after 12 hours
##If unable to obtain CSF consider CTA

== Treatment ==

#Nimodipine
##Associated with improved neuro outcomes and decreased cerebral infarction
##Give 60mg q4hr PO or NGT only! (never IV)
#BP control
##No consensus on HTN (incr BP may maintain CPP but may also increase rate of bleeding)
###If pt is alert this means CPP is adequate so consider lowering sbp to 120-140
####If pt has history of HTN consider lowering sbp to ~160
###If pt is ALOC consider leaving BP alone as the ALOC may be 2/2 reduced CPP
##If BP control is necessary use NICARDIPINE, LABETALOL, or ESMOLOL
###Avoid vasodilators such as nitroprusside or NTG (increase cerebral blood volume > increased ICP)
##Avoid hypotension
###Maintain MAP > 80
####Give IVF
####Give pressors if IVF ineffective
#Discontinue/reverse all anticoagulation
##Coumadin - give (prothrombin complex conc or FFP) and vit K)
##Aspirin - give DDAVP
##Plavix - give platelets
#Seizure prophylaxis
##Controversial; 3 day course may be preferable
##Phenytoin load
#Glucocorticoid therapy
##Controversial; evidence suggests is neither beneficial nor harmful
#Glycemic control
##Controversial; consider sliding scale if long pt stay in ED while awaiting ICU bed
#Keep head of bed elevated

== Complications ==

#Rebleeding
##Risk is highest within first 24 hours (2.5-4%), particularly within first 6 hours
##Usually diagnosed by CT after acute deterioration in neuro status
##Only aneurysm treatment is effective in preventing rebleeding
#Vasospasm
##Leading cause of death and disability after rupture
##Typically begins no earlier than day three after hemorrhage
##Characterized by decline in neuro status
##Aggressive treatment can only be initiated after the aneurysm has been treated (sx or intraluminal tx)
###Triple-H therapy (hemodilution + induced hypertension (pressors) + hypervolemia)
#Cardiac abnormalities (?2/2 release of catecholamines due to hypoperfusion of hypothalamus)
##Ischemia
###Elevated troponin (20-40% of cases)
###ST segment depression
##Rhythm disturbances
###Torsades, a fib, a flutter
##QT prolongation
##Deep, symmetric TWI
##Prominent U waves
#Hydrocephalus
##Consider ventricular drain placement for deteriorating LOC + no improvement within 24 hours
#Hyponatremia
##Usually due to SIADH
###Treat via isotonic, or if necessary, hypertonic saline (do not treat via water restriction!)

== Prognosis ==

=== Hunt and Hess ===
*Grade 0: Unruptured aneurysm
*Grade 1: Asymptomatic or mild HA and slight nuchal rigidity
**Grade 1a: No acute meningeal/brain reaction, with fixed neurological def
*Grade 2: Moderate to severe headache, stiff neck, no neurologic deficit except cranial nerve palsy
*Grade 3: Mild mental status change (drowsy or confused), mild focal neurologic deficit
*Grade 4: Stupor or moderate to severe hemiparesis
*Grade 5: Coma or decerebrate rigidity

^Grade 1 or 2 have curable dz, if dx missed pts return w/ higher grade (ie 3 or 4), 2/3 will be dead or vegetative at 6 mos if grade 3 or 4!

^Add one grade for serious systemic dz (HTN, DM, severe atherosclerosis, COPD)

=== World Federation of Neurosurgical Societies (WFNS) ===

{| cellspacing="1" cellpadding="1" border="1" width="200"
|-
| '''Grade''' 
| '''GCS''' 
| '''Major Focal Deficit''' 
|-
| 0 (unruptured) 
| NA 
| NA 
|-
| 1 
| 15 
| Absent 
|-
| 2 
| 13-14 
| Absent 
|-
| 3 
| 13-14 
| Present 
|-
| 4 
| 7-12 
| Present/absent 
|-
| 5 
| 3-6 
| Present/absent 
|}

 

== See Also ==

[[Intracranial Hemorrhage]]

== Source ==

UpToDate

EB Emergency Medicine, July 2009

EMCrit Podcast 8

[[Category:Neuro]]

Bronchiolitis (peds)

2011-09-20T14:14:42Z

Russellm77: /* Source */

==Background==
*<2yr old (peak 2-6mo age)
*Preemies, neonates, congenital heart dz are at risk for serious disease
*Peaks in winter
*Duration = 7-14d (worst during days 3-5)
*Inflammation, edema, and epithelial necrosis of bronchioles

==Diagnosis==
*Symptoms
**Rhinorrhea, cough, irritability, apnea (neonates)
*Signs
**Tachypnea, cyanosis, wheezing, retractions
**Fever is usually low-grade or absent
***If high-grade fever consider OM, UTI
*Assess for dehydration (tachypnea may interfere with feeding)

==Work-Up==
*Rapid RSV
**Obtain if <1mo old
**If positive then admit pt

*CXR
**Not routinely necessary
***May lead to unnecessary use of abx (atelectais mimics infiltrate)
**Consider if
***Diagnosis unclear
***Critically ill

*Infants <60 days with RSV bronchiolitis and fever
**Concern is for SBI with RSV
**UTI 5.4% in RSV+, 10.1% RSV-
**Bacteremia 1.1% RSV+, 2.3% RSV-
**Meningitis 0% RSV+, 0.9% RSV-
**CONCLUSION-Low risk of bacteremia and meningitis in RSV+, still appreciable UTI risk

==DDx==
#Asthma
#PNA
#FB
#Pertusis
#CHF
#Cystic fibrosis
#Vascular ring
#CA

==Treatment==
#O2 (maintain SaO2 >90%)
#Racemic epi neb
##Only repeat if initial beneficial response
#+/- albuterol
#Suction nares / nasal saline drops
#Steroids are controversial (?efficacy)

==Disposition==
Consider admission for:
#Age <3months
#Preterm (<34wks)
#Underlying heart/lung disease
#Initial SaO2 <92%
#Unable to tolerate PO

==See Also==

==Source==
*Rosen's, Tintinalli
*Pediatrics.2004 Jun;113(6):1728-34
*Kelly Young Fever Handout

[[Category:Peds]]
[[Category:ID]]

Bronchiolitis (peds)

2011-09-20T14:14:04Z

Russellm77: /* Work-Up */

==Background==
*<2yr old (peak 2-6mo age)
*Preemies, neonates, congenital heart dz are at risk for serious disease
*Peaks in winter
*Duration = 7-14d (worst during days 3-5)
*Inflammation, edema, and epithelial necrosis of bronchioles

==Diagnosis==
*Symptoms
**Rhinorrhea, cough, irritability, apnea (neonates)
*Signs
**Tachypnea, cyanosis, wheezing, retractions
**Fever is usually low-grade or absent
***If high-grade fever consider OM, UTI
*Assess for dehydration (tachypnea may interfere with feeding)

==Work-Up==
*Rapid RSV
**Obtain if <1mo old
**If positive then admit pt

*CXR
**Not routinely necessary
***May lead to unnecessary use of abx (atelectais mimics infiltrate)
**Consider if
***Diagnosis unclear
***Critically ill

*Infants <60 days with RSV bronchiolitis and fever
**Concern is for SBI with RSV
**UTI 5.4% in RSV+, 10.1% RSV-
**Bacteremia 1.1% RSV+, 2.3% RSV-
**Meningitis 0% RSV+, 0.9% RSV-
**CONCLUSION-Low risk of bacteremia and meningitis in RSV+, still appreciable UTI risk

==DDx==
#Asthma
#PNA
#FB
#Pertusis
#CHF
#Cystic fibrosis
#Vascular ring
#CA

==Treatment==
#O2 (maintain SaO2 >90%)
#Racemic epi neb
##Only repeat if initial beneficial response
#+/- albuterol
#Suction nares / nasal saline drops
#Steroids are controversial (?efficacy)

==Disposition==
Consider admission for:
#Age <3months
#Preterm (<34wks)
#Underlying heart/lung disease
#Initial SaO2 <92%
#Unable to tolerate PO

==See Also==

==Source==
Rosen's, Tintinalli

[[Category:Peds]]
[[Category:ID]]

Bronchiolitis (peds)

2011-09-19T19:45:00Z

Russellm77: /* Background */

==Background==
*<2yr old (peak 2-6mo age)
*Preemies, neonates, congenital heart dz are at risk for serious disease
*Peaks in winter
*Duration = 7-14d (worst during days 3-5)
*Inflammation, edema, and epithelial necrosis of bronchioles

==Diagnosis==
*Symptoms
**Rhinorrhea, cough, irritability, apnea (neonates)
*Signs
**Tachypnea, cyanosis, wheezing, retractions
**Fever is usually low-grade or absent
***If high-grade fever consider OM, UTI
*Assess for dehydration (tachypnea may interfere with feeding)

==Work-Up==
*Rapid RSV
**Obtain if <1mo old
**If positive then admit pt

*CXR
**Not routinely necessary
***May lead to unnecessary use of abx (atelectais mimics infiltrate)
**Consider if
***Diagnosis unclear
***Critically ill

==DDx==
#Asthma
#PNA
#FB
#Pertusis
#CHF
#Cystic fibrosis
#Vascular ring
#CA

==Treatment==
#O2 (maintain SaO2 >90%)
#Racemic epi neb
##Only repeat if initial beneficial response
#+/- albuterol
#Suction nares / nasal saline drops
#Steroids are controversial (?efficacy)

==Disposition==
Consider admission for:
#Age <3months
#Preterm (<34wks)
#Underlying heart/lung disease
#Initial SaO2 <92%
#Unable to tolerate PO

==See Also==

==Source==
Rosen's, Tintinalli

[[Category:Peds]]
[[Category:ID]]

Blunt neck trauma

2011-09-19T19:20:39Z

Russellm77: /* Unilateral */

==Background==
*Suspect vascular damage to cord if discrepancy between neuro deficit and level of spinal column injury
*Down syndome predisposes to atlanto-occipital dislocation
*RA predisposes to C2 transverse ligament rupture
*Cord injury is more likely if ant (vertebral bodies) AND post (spinal canal) columns are disrupted
*If find injury consider CT C-spine, x-ray rest of spine
*Penetrating injury rarely results in unstable fx

==Atlanto-occipital Disassociation==
*Unstable
*Often associated w/ brain injury
*Evaluate with the Powers ratio
**Ratio of BC:OA > 1 suggests anterior subluxation
**BC = distance between basion and midpoint of C2 post laminar line
**OA = Distance between opisthion and ant arch of C2

==C1 Fractures==
===Burst (Jefferson)===
*Unstable
*Axial loading transmitted through occipital condyles to the lateral masses
**Results in fx of the ant AND post arches
**Degree of instability determined by whether or not the transverse ligament is disrupted
*Suspect disruption if:
**Lateral x-ray: Increase in the predental space between C1 and the dens
***Predental space greater than 3 mm in adults or 5 mm in children is abnormal
**Odontoid xray: Masses of C1 lie lateral to outer margins of articular pillars of C2
**If either of the above findings on xray then obtain CT c-spine
===Anterior Arch===
*Stable
===Posterior Arch===
*Stable (b/c anterior arch and transverse ligament are unaffected)
*Must ensure that you are not confusing this with a burst fx
**Odontoid view must be normal
*Due to forced neck extension
*Vertical fx line through posterior arch seen on lateral xray

==C2 Fractures==
===Odontoid (dens) Fracture===
*Only stable if fx confined to avulsion of the tip (superior to transverse ligament)
*Frequently involves other cervical spine injuries
*25% a/w neurologic injury
*Types
**Type I
***Fx above transverse ligament
***Stable
**Type II
***Fx at base of odontoid process where it attaches to C2
***Unstable
**Type III
***Extension of the fx through upper portion of body of C2
***Unstable

===Traumatic Spondylolisthesis ("Hangman's Fx")===
*Unstable
*Fracture of both C2 pedicles leads to C2 displacing anteriorly on C3
*Seen in MVA and diving accidents (not in suicidal hangings)
**Forced extension of an already extended neck
*Spinal cord damage is often minimal (diameter of neural canal is greatest at C2)

==C3-C7 Fractures==
===Anterior Wedge Fracture===
*Only unstable if lose over half of vertebral height OR multiple adjacent wedge fractures

===Flexion Teardrop Fracture===
*Unstable
*Severe flexion > vertebral body colliding with the one below
**Displacement of teardrop shaped fragment of antero-inferior portion of sup vertebra
**Leads to disruption of posterior longitudinal ligament
*Associated with acute anterior cervical cord syndrome

===Extension Teardrop Fracture===
*Unstable
*Abrupt neck extension > anterior longitudinal ligament avulses anteroinferior corner
**Avulsed fragment is greater in height than width (contrast with flexion teardrop)
*Often occurs at C5-C7 associated with diving accidents
**Associated with central cord syndrome

===Spinous Process Fracture (Clay Shoveler's)===
*Stable
*Isolated fracture of one of the spinous processes of the lower cervical vertebrae

===Burst Fracture===
*Unstable if:
**Associated neurologic deficits
**Loss of >50% of vertebral body height
**>20 degrees of spinal angulation
**Compromise of >50% of spinal canal
**Axial compression > nucleus pulposus forced into vertebral body
*Imaging
**Lateral x-ray - Comminuted body and loss of vertebral height
**AP x-ray - Vertical fracture of the body

==Facet Dislocations==
===Bilateral===
*Unstable
*Complete spinal cord injury most often results
*Disruption of annulus fibrosus and ant longitudinal ligament > ant displacement of spine
*Imaging
**Lateral xray: vertebral body will be displaced >50% of its width

===Unilateral===
*Stable
*Imaging
**Lateral x-ray: vertebral body will be displaced <50% of its width
**Anterior x-ray: affected spinous process points toward side that is dislocated
*Spinal cord injury rarely occurs

== Vascular Injuries ==
*Carotid and vertebral artery injuries can occur with blunt c-spine trauma
**Half of patients present with initially normal neuro exam
**OR for carotid/vertebral artery injury of 8.6 with c-spine fracture
**OR for vertebral artery injury of 30.6 with transverse process fracture
*Indications for screening (CTA or MRA) for vascular injury
**Unexplained neuro deficit with hyperflexion or extension injury
**Blunt trauma to neck or seatbelt injury
**C-spine or skull base fractures involving vascular foramina
**Le Fort II or III facial fractures

==See Also==
*[[Spinal Cord Trauma]]
*[[Spinal Cord Compression (Non-Traumatic)]]
*[[Neurogenic Shock]]
*[[C-spine (NEXUS)]]
*[[C-Spine X-Ray]]

==Source==
*UpToDate
*Tintinalli's

[[Category:Trauma]]
[[Category:Ortho]]

Cervical spine x-ray interpretation

2011-09-19T18:08:40Z

Russellm77: /* Odontoid */

==Background==
#Make sure that the C7-T1 junction is adequately visualized
##Obtain swimmer's view or oblique view if not
#Peds
##Most peds fx occur higher than C3
##Pseudosubluxation of C2-C3 is common in children <8yr
###To distinguish from true dislocation or fracture:
####Draw line from cortex of post arch of C1 to cortex of posterior arch of C3
####This line should pass through or be <1mm ant to posterior arch of C2

==Measurements (Normal)==
#Predental space (anterior aspect of odontoid to post aspect of ant ring of C1)
##Adult <3mm
##Peds <5mm
##Widening of space suggests Jefferson burst fx of C1
#Anterior soft tissue
##Distance between ant border of C2 and post pharynx should be <6mm in adults and peds
##Distance between ant border of C6 and post trachea should be <22 mm in adults
###Should be <14mm in children <15yr or less than width of vertebral body at each level
#Bones
##Vertebral body
###Anterior height should be no more than 3mm shorter than posterior height

==Lateral==
#Alignment
##Disruption in the anterior, posterior, or spinolaminal lines
#Bones
##Obvious fx
##Disruption of ring of C1
##Double facet sign indicates fractured articular facet
##Loss of vertebral height
#Cartilage
##Intervertebral disc space height and length should be uniform
###Narrowing: disc herniation or adjacent vertebral fx
###Widening: posterior ligamentous injury
#Soft tissue
##Widening of the prevertebral soft tissue suggests fx

==AP View==
#Alignment of spinous processes
#Distance between spinous processes
#Uniformity and height of vertebrae

==Odontoid==
#Spacing of dens and lateral masses
#Lateral aligment of C1 and C2
#Uniformity of bones

== X-ray vs CT ==
#Plain radiographs are appropriate in low-risk patients
#High risk patients requiring CT
##Closed head injury
##Neurologic deficits
##High energy trauma
##Unreliable examination
##Pain out of proportion to exam
##Inadequate plain films

==See Also==
[[C-Spine (NEXUS)]]

==Source==
Cervical Spine Injury, EB Medicine, April 2009

[[Category:Neuro]]
[[Category:Ortho]]
[[Category:Rads]]
[[Category:Trauma]]

Cervical spine x-ray interpretation

2011-09-19T17:49:55Z

Russellm77: /* Measurements (Normal) */

==Background==
#Make sure that the C7-T1 junction is adequately visualized
##Obtain swimmer's view or oblique view if not
#Peds
##Most peds fx occur higher than C3
##Pseudosubluxation of C2-C3 is common in children <8yr
###To distinguish from true dislocation or fracture:
####Draw line from cortex of post arch of C1 to cortex of posterior arch of C3
####This line should pass through or be <1mm ant to posterior arch of C2

==Measurements (Normal)==
#Predental space (anterior aspect of odontoid to post aspect of ant ring of C1)
##Adult <3mm
##Peds <5mm
##Widening of space suggests Jefferson burst fx of C1
#Anterior soft tissue
##Distance between ant border of C2 and post pharynx should be <6mm in adults and peds
##Distance between ant border of C6 and post trachea should be <22 mm in adults
###Should be <14mm in children <15yr or less than width of vertebral body at each level
#Bones
##Vertebral body
###Anterior height should be no more than 3mm shorter than posterior height

==Lateral==
#Alignment
##Disruption in the anterior, posterior, or spinolaminal lines
#Bones
##Obvious fx
##Disruption of ring of C1
##Double facet sign indicates fractured articular facet
##Loss of vertebral height
#Cartilage
##Intervertebral disc space height and length should be uniform
###Narrowing: disc herniation or adjacent vertebral fx
###Widening: posterior ligamentous injury
#Soft tissue
##Widening of the prevertebral soft tissue suggests fx

==AP View==
#Alignment of spinous processes
#Distance between spinous processes
#Uniformity and height of vertebrae

==Odontoid==
#Spacing of dens and lateral masses
#Lateral aligment of C1 and C2
#Uniformity of bones

==See Also==
[[C-Spine (NEXUS)]]

==Source==
Cervical Spine Injury, EB Medicine, April 2009

[[Category:Neuro]]
[[Category:Ortho]]
[[Category:Rads]]
[[Category:Trauma]]

NEXUS cervical spine rule

2011-09-19T17:43:46Z

Russellm77: /* Background */

==Background==
*Inclusion criteria is blunt trauma to the cervical spine
*99.6% sensitive for a clinically important injury (only 12.9% Sp)
*Only 8.6% of patients were elderly in the initial study, use caution in applying to elderly
**Nexus does not risk stratify based on age like CCR
**Small studies show elderly pts with c-spine fractures do not often have midline tenderness

==Rule==
Radiography is Unnecessary if pts satisfy ALL 5 of the following low risk criteria:
#No midline cervical tenderness
#No focal neuro deficits
#Normal alertness
#No intoxication
#No painful distracting injury

==See Also==
*[[C-Spine X-Ray]]
*[[Spinal Cord Trauma]]

==Source==
Cervical Spine Injury. EB Medicine April, 2009

[[Category:Trauma]]
[[Category:Ortho]]
[[Category:Rads]]

Genitourinary trauma

2011-09-15T21:58:25Z

Russellm77: /* Imaging */

==Upper Tract Injuries (kidney + ureter)==
*Majority of blunt trauma injuries present w/ hematuria
*Renal pedicle injuries and penetrating injuries to ureter may not cause hematuria
*Renal injuries are a/w flank hematoma, lower rib fx, penetrating wounds to flanks

===Diagnosis===
*Who to image?
**Penetrating Trauma
***Any degree of hematuria
**Blunt Trauma
***Gross hematuria
***Hypotension and any degree of hematuria
***Child with >50rbc/HPF
***High index of suspicion for renal trauma
****Deceleration injuries even with no hematuria
****Multiple trauma pt

===Renal Injuries===
====AAST Grading System for renal injuries====
*Non-operative management
**Grade I: Cortex contusion
**Grade II: Cortex laceration
*Possible operative management
**Grade III: Corticomedullary junction laceration
***Grade IV: Collecting system laceration
*Operative management
**Grade V: Shattered kidney, thrombosis of renal artery, avulsion of hilum

====Treatment====
*Absolute indications for renal exploration and intervention:
**Life-threatening hemorrhage
**Expanding, pulsatile, or non-contained retroperitoneal hematoma
**Renal avulsion injury

====Disposition====
*Admit
**All penetrating renal injuries
**All gross hematuria
**All grade II and higher injuries
*Discharge
**Microscopic hematuria and no indication for imaging
**Isolated renal trauma and contusion-type grade I injury
***Instruct no heavy lifting; f/u in 1-2wk to document resolution of the hematuria
**Grade I subcapsular hematoma can d/c'd w/ 24hr f/u

===Ureter Injuries===
*90% of injuries occur from penetrating injury
*Isolated ureter injury is rare
*Absence of hematuria does NOT rule out ureteral injury

====Management====
*If CT is nondiagnostic but high index of suspicion perform IV urography or retrograde pyelography
*Treatment
**Surgery
*Disposition
**Admit

==Lower Tract Injuries (bladder + urethra + genitalia)==
*Often accompany pelvic fracture

===Bladder Injury===
====Presentation====
*Suprapubic pain, blood at meatus, inability to void
*Gross hematuria is present in 95% of significant bladder injuries
**Pelvic fracture + gross hematuria = bladder rupture
**<1% of all blunt bladder injuries p/w UA w/ <25 RBCs/HPF
*Bladder Rupture
**Extraperitoneal
***Assoc w/ pelvic fx and laceration by bony fragments
***Leakage of urine into perivesicular space
***"Tear drop" shape on imaging

**Intraperitoneal
***Assoc w/ compresive force in presence of full bladder
====Management====
*Imaging
**Retrograde cystogram (CT or plain film) indicated for:
**Gross hematuria
***Inability to void
***Pelvic fx in assoc w/ microscopic hematuria
***Clinical suspicion of bladder injury
**CT A/P w/ IV contrast NOT sensitive enough for bladder rupture
*Treatment
**Extraperitoneal rupture - nonoperative management with bladder cathether drainage
**Intraperitoneal rupture - primary surgical repair

===Urethral Injury===
====Types====
*Anterior
**Located anterior to the membranous urethra
**Straddle injuries, self-instrumentation
*Posterior
**Located in the membranous and prostatic urethra
**Due to blunt trauma from massive deceleration
**Often accompanies pelvic fx
====Presentation====
*Hematuria, dysuria, inability to void, blood at meatus
*Vaginal bleeding
*Perineal hematoma
*High-riding or detached prostate
**Associated w/ complete posterior urethral disruption
====Management====
=====Imaging=====
*Retrograde urethrogram
**Must perform before catheterization to prevent further urethral injury
**60 mL of water soluble contrast in toomey syringe
**Inject into urethra, shoot KUB during last 10 mL
**No bladder filling with extravasation - complete tear
**Bladder filling with extravasation - partial tear

=====Treatment=====
**Posterior urethral injury
***Suprapubic cathether placement
***Surgery is usually performed weeks later
**Anterior urethral injury
***Penetrating injuries require surgical exploration and repair

===Genitalia Injury===
====Testicular Injury====
*Presentation
**Blunt trauma due to impingement against symphysis pubis
***Will have contusion or rupture based on whether tunica albuginea is disrupted
***Large, blue, tender scrotal mass (hematocele),
*Imaging
**Scrotal ultrasound required for all blunt testicular injuries
***Reliable in diagnosing ruptured testes
*Treatment
**Most testicular injuries are managed conservatively
***Analgesia, ice, elevation, scrotal support, urology f/u
**Tesicular rupture requires early surgical intervention

====Penile Injury====
*General
**Any pt w/ trauma to genitalia w/ a prothesis in place should be seen by a urologist
**All penetrating trauma to the penis requires surgical consultation
**Avulsed penile skin should not be reapplied (invariably becomes necrotic and infected)
*Penile fracture
**Results from rupture of corpus cavernosum
***Cracking sound followed by pain, detumescence, swelling, discoloration, deformity
**Obtain retrograde urethrogram to r/o urethral injury
**Requires operative removal of blood cut and repair of tunica albuginea
*Penile contusion
**Treat conversevely ice, rest, elevation, foley placement if pt unable to void
*Zipper Injury
**Mineral oil and lidocaine infiltration can be used to free the penile skin
**Wire-cutting or bone-cutting pliers can be used to cut the median bar of the zipper
*Traumatic epididymitis
**Noninfectious inflammatory condition that occurs w/in few days after trauma to testis
***Treatment is similar to that for nontraumatic epididymitis

====Vaginal Injury====
*Perform speculum examination when vaginal hemorrhage or hematoma is present to exclude vaginal laceration

==Source==
Tintinalli

[[Category:Trauma]]
[[Category:GU]]

Perilunate and lunate dislocations

2011-09-14T19:09:29Z

Russellm77: /* Sources */

== Background ==

• Perilunate Dislocation 

  · Dorsal displacement of capitate in relation to lunate 

  · Note that the radius, capitate, lunate, and third metacarpal form a straight line on lateral x-ray 

• Lunate Dislocation 

  · Volar dislocation of the lunate in relation to the radius, spilled teacup 

== Clinical Features ==

• FOOSH injury with excessive hyperextension, ulnar deviation, and intercarpal supination

• On exam, decreased range of motion with focal swelling 

  · Dorsal swelling with mass in perilunate dislocation   · Volar swelling with palpable mass in lunate dislocation 

• Median nerve compression possible, perform thorough neurovascular exam

• Scaphoid fractures and scaphoid rotary subluxation are common

• Degenerative arthritis is very common, 60% incidence

== Workup ==

• X-ray, wrist series, minimum of three views 

• Perilunate dislocation

  · Lateral view, dorsal dislocation of capitate when an imaginary line is drawn through radius, luante, and capitate

  · PA view, capitate and lunate overlap

• Lunate dislocation

  · Lateral view, lunate displaced and tilted volarly

  · PA view, lunate is triangular in shape

== Differential Diagnosis ==

• Fractures of the distal radius

• Fractures of the carpal bones, the scaphoid being the most common

• Scapholunate dissociation

• Ligamentous injury

• Septic arthritis

== Treatment ==

• Immediate orthopedic consult for closed vs open reduction

  · The longer the dislocation is left unreduced, the lower the likelihood of reduction

• In ED, volar splint in neutral

== Sources ==

• Emergency Orthopedics, The Extremeties
• Radiopaedia.org

[[Image:PL 1.jpg|thumb|left|200x264px|PL 1.jpg|Perilunate lateral]] 

[[Image:PL 2.jpg|thumb|center|279x293px|PL 2.jpg|Perilunate AP]]

[[Image:Lun 1.jpg|thumb|left|201x299px|Lun 1.jpg|Lunate]]

[[Category:Ortho]]

Perilunate and lunate dislocations

2011-09-14T19:07:53Z

Russellm77: /* Treatment */

== Background ==

• Perilunate Dislocation 

  · Dorsal displacement of capitate in relation to lunate 

  · Note that the radius, capitate, lunate, and third metacarpal form a straight line on lateral x-ray 

• Lunate Dislocation 

  · Volar dislocation of the lunate in relation to the radius, spilled teacup 

== Clinical Features ==

• FOOSH injury with excessive hyperextension, ulnar deviation, and intercarpal supination

• On exam, decreased range of motion with focal swelling 

  · Dorsal swelling with mass in perilunate dislocation   · Volar swelling with palpable mass in lunate dislocation 

• Median nerve compression possible, perform thorough neurovascular exam

• Scaphoid fractures and scaphoid rotary subluxation are common

• Degenerative arthritis is very common, 60% incidence

== Workup ==

• X-ray, wrist series, minimum of three views 

• Perilunate dislocation

  · Lateral view, dorsal dislocation of capitate when an imaginary line is drawn through radius, luante, and capitate

  · PA view, capitate and lunate overlap

• Lunate dislocation

  · Lateral view, lunate displaced and tilted volarly

  · PA view, lunate is triangular in shape

== Differential Diagnosis ==

• Fractures of the distal radius

• Fractures of the carpal bones, the scaphoid being the most common

• Scapholunate dissociation

• Ligamentous injury

• Septic arthritis

== Treatment ==

• Immediate orthopedic consult for closed vs open reduction

  · The longer the dislocation is left unreduced, the lower the likelihood of reduction

• In ED, volar splint in neutral

== Sources ==

• Emergency Orthopedics, The Extremeties
• Radiopaedia.org

[[Image:PL 1.jpg|thumb|left|200x264px|PL 1.jpg]] 

[[Image:PL 2.jpg|thumb|center|279x293px|PL 2.jpg]]

[[Image:Lun 1.jpg|thumb|left|201x299px|Lun 1.jpg]]

[[Category:Ortho]]

Needle cricothyrotomy

2011-09-14T19:06:19Z

Russellm77: /* Source */

== Indications ==
#Failed airway in adults or children
#Temporizing measure until definitive airway management
##Especially useful in children <8 yrs old, whom cricothyrotomy contraindicated
#Used for transtracheal jet ventilation

== Contraindications ==
#Tracheal transection
#Complete upper airway obstruction

== Equipment ==
#Provodone iodine
#Sterile drapes, gloves, gown, gauze
#12-14 G angiocath
#3mL syringe x 2
#Adapter to 7-0 ETT
#BVM appropriate for size of pt
##Can also use jet vet ventilation setup in adults
###High flow O2 source, 50 PSI
###O2 tubing
###Valve-3 way stop cock or cut holes in O2 tubing
###Depending on O2 source, calculate time valve must be open for tidal vol
###BVM setup does not allow adequate exhalation in adults

== Procedure ==
#Prep and drape
#Locate cricothyroid membrane
#Pierce membrane with angiocath directed 30-45 deg caudal
##Attach 3mL syringe with saline, aspirate as you enter
##Advance until air is aspirated in syringe
#Advance catheter over needle, hub to skin
##Remove needle
#Attach 3 mL syringe to catheter
#Attach 7-0 ETT adapter to syringe
#Attach BVM to ETT adapter
#Secure system
#Ventilate with BVM or high flow O2 setup
#OBTAIN DEFINITIVE AIRWAY

== Complications ==
#Hemorrhage
#Infection
#Tracheal stenosis
#Not obtaining definitive airway management

== Source ==
Roberts and Hedges

== See also ==
[[Intubation]]

Intubation

2011-09-14T19:05:00Z

Russellm77: /* See Also */

==Indications==
#Failure to ventilate
#Failure to oxygenate
#Inability to protect airway (gag unhelpful)
#Anticipated clinical course (anticipated deterioration, transport, or impending airway compromise)
#Increased ICP (for hyperventilation)
#Combative, needing imaging

==Difficult BVM (MOANS)==
#Mask seal
#Obesity
#Aged
#No teeth
#Stiffness (resistance to ventilation)

"Remove dentures to intubate; keep them in to bag/mask ventilate"

==Difficult Intubation (LEMON)==
#Look externally (gestalt)
#Evaluate 3-3-2 rule
#Mallampati
#Obstruction
#Neck mobility

==Difficult Extraglottic Device (RODS)==
#Restricted motnh opening
#Obstruction
#Distorted airway
#Stiff lungs or neck (c-spine)

==Difficult Critcothyrotomy (SHORT)==
#Surgery
#Hematoma
#Obesity
#Radiation (Burn or other distortion)
#Tumor

==Severe Metabolic Acidosis==
*Further drop in pH during intubation can be catastrophic
#NIV (SIMV Vt 550, FiO2 100%, Flow Rate 30 LPM, PSV 5-10, PEEP 5, RR 0)
#Attach end-tidal CO2 and observe value
#Push [[Rapid Sequence Intubation (RSI)|RSI]] meds
#Turn the respiratory rate to 12
#Perform jaw thrust
#Wait 45sec
#Intubate
#Re-attach the ventilator
#Immediately increase rate to 30
#Change Vt to 8cc/kg
#Change flow rate to 60 LPM (normal setting)
#Make sure end-tidal CO2 is at least as low as before

==GI Bleeder==
#Empty the stomach
##Place an NG and suction out blood
###Varices are not a contraindication
##Metoclopramide 10mg IV
###Increases LES tone
#Intubate with HOB at 45°
##Consider Glidescope
#Preoxygenate!
##Want to avoid bagging if possible
#Intubation meds
##Use sedative that is BP stable (etomidate, ketamine)
##Use paralytics (actually increases LES tone)
#If need to bag:
##Bag gently and slowly (10BPM)
##Consider placing LMA
#If pt vomits place in Trendelenberg
#If pt aspirates anticipate a sepsis-like syndrome
##May need pressors, additional fluid (not abx!)

==Nasal Intubation==
#sniffing position (like oral ET)
#pretreat with lido, hurricaine, or 4cc nebulized lidocaine for 5 minutes
#Tube size = 1.0 mm smaller
#listen with stethoscope at end of tube (breath sounds become louder as tube approaches cords)
#when tube hits cords patient will cough, back up 1 or 2 cm. wait for beginning of inspiration, as patient begins inspiration advance 3-4 cm (tube should be 22-26cm in women, 23-28cm in men)

tips: occlude other nostril to hear better, cricoid pressure when advancing, use a small suciton catheter as a seldinger guide, precurve tube before insertion.

==See Also==
*[[Difficult Airway Algorithm]]
*[[Rapid Sequence Intubation (RSI)]]
*[[LMA]]
*[[Needle cricothyrotomy]]

==Source ==
Rosen

EMCrit Podcasts 3, 4, 5

[[Category:Airway/Resus]]
[[Category:Procedures]]

Needle cricothyrotomy

2011-09-14T19:01:36Z

Russellm77: /* Source */

Needle cricothyrotomy

2011-09-14T19:01:07Z

Russellm77: /* Equipment */

Needle cricothyrotomy

2011-09-14T19:00:24Z

Russellm77: /* Equipment */

== Indications ==
#Failed airway in adults or children
#Temporizing measure until definitive airway management
##Especially useful in children <8 yrs old, whom cricothyrotomy contraindicated
#Used for transtracheal jet ventilation

== Contraindications ==
#Tracheal transection
#Complete upper airway obstruction

== Equipment ==
#Provodone iodine
#Sterile drapes, gloves, gown, gauze
#12-14 G angiocath
#3mL syringe x 2
#Adapter to 7-0 ETT
#BVM appropriate for size of pt
##Can also use jet vet ventilation setup in adults
###High flow O2 source, 50 PSI
###O2 tubing
###Valve-3 way stop cock or cut holes in O2 tubing
###Depending on O2 source, calculate time valve must remain open for TV
###BVM setup does not allow adequate exhalation in adults

== Procedure ==
#Prep and drape
#Locate cricothyroid membrane
#Pierce membrane with angiocath directed 30-45 deg caudal
##Attach 3mL syringe with saline, aspirate as you enter
##Advance until air is aspirated in syringe
#Advance catheter over needle, hub to skin
##Remove needle
#Attach 3 mL syringe to catheter
#Attach 7-0 ETT adapter to syringe
#Attach BVM to ETT adapter
#Secure system
#Ventilate with BVM or high flow O2 setup
#OBTAIN DEFINITIVE AIRWAY

== Complications ==
#Hemorrhage
#Infection
#Tracheal stenosis
#Not obtaining definitive airway management

== Source ==
Roberts and Hedges

##Very rigid system, may dislodge with small movements
#Ventilate

Needle cricothyrotomy

2011-09-14T18:59:15Z

Russellm77: /* Indications */

== Indications ==
#Failed airway in adults or children
#Temporizing measure until definitive airway management
##Especially useful in children <8 yrs old, whom cricothyrotomy contraindicated
#Used for transtracheal jet ventilation

== Contraindications ==
#Tracheal transection
#Complete upper airway obstruction

== Equipment ==
#Provodone iodine
#Sterile drapes, gloves, gown, gauze
#12-14 G angiocath
#3mL syringe x 2
#Adapter to 7-0 ETT
#BVM appropriate for size of pt
##Can also use jet vet ventilation setup in adults
###High flow O2 source, 50 PSI
###Valve-3 way stop cock or cut holes in O2 tubing
###Depending on O2 source, calculate time valve must remain open for TV
###BVM setup does not allow adequate exhalation in adults

== Procedure ==
#Prep and drape
#Locate cricothyroid membrane
#Pierce membrane with angiocath directed 30-45 deg caudal
##Attach 3mL syringe with saline, aspirate as you enter
##Advance until air is aspirated in syringe
#Advance catheter over needle, hub to skin
##Remove needle
#Attach 3 mL syringe to catheter
#Attach 7-0 ETT adapter to syringe
#Attach BVM to ETT adapter
#Secure system
#Ventilate with BVM or high flow O2 setup
#OBTAIN DEFINITIVE AIRWAY

== Complications ==
#Hemorrhage
#Infection
#Tracheal stenosis
#Not obtaining definitive airway management

== Source ==
Roberts and Hedges

##Very rigid system, may dislodge with small movements
#Ventilate

Needle cricothyrotomy

2011-09-14T18:58:52Z

Russellm77: Created page with " == Indications == #Failed airway in adults or children #Temporizing measure until definitive airway management ##Especially useful in children <8 hrs old, whom cricothyrotomy co..."

== Indications ==
#Failed airway in adults or children
#Temporizing measure until definitive airway management
##Especially useful in children <8 hrs old, whom cricothyrotomy contraindicated
#Used for transtracheal jet ventilation

== Contraindications ==
#Tracheal transection
#Complete upper airway obstruction

== Equipment ==
#Provodone iodine
#Sterile drapes, gloves, gown, gauze
#12-14 G angiocath
#3mL syringe x 2
#Adapter to 7-0 ETT
#BVM appropriate for size of pt
##Can also use jet vet ventilation setup in adults
###High flow O2 source, 50 PSI
###Valve-3 way stop cock or cut holes in O2 tubing
###Depending on O2 source, calculate time valve must remain open for TV
###BVM setup does not allow adequate exhalation in adults

== Procedure ==
#Prep and drape
#Locate cricothyroid membrane
#Pierce membrane with angiocath directed 30-45 deg caudal
##Attach 3mL syringe with saline, aspirate as you enter
##Advance until air is aspirated in syringe
#Advance catheter over needle, hub to skin
##Remove needle
#Attach 3 mL syringe to catheter
#Attach 7-0 ETT adapter to syringe
#Attach BVM to ETT adapter
#Secure system
#Ventilate with BVM or high flow O2 setup
#OBTAIN DEFINITIVE AIRWAY

== Complications ==
#Hemorrhage
#Infection
#Tracheal stenosis
#Not obtaining definitive airway management

== Source ==
Roberts and Hedges

##Very rigid system, may dislodge with small movements
#Ventilate

Bacterial tracheitis

2011-09-14T17:58:59Z

Russellm77:

== Background ==

#Bacterial infection of tracheal epithelium
##Often secondary infection after viral illness
##S. Aureus most common, also strep spp, H. Influenza and anaerobes
#Peak age is 3-5 years old
##Occurs throughout childhood and adulthood

== Diagnosis ==

#Severely ill child, starts out as viral prodrome
##Followed by stridor, resp distress, and copious purulent secretions
#Difficult to differentiate from croup and epiglottis
##Severe decompensation, high fever, purulent secretions help differentiate
##May also have concomitant pneumonia

 

== Workup ==

#Clinical diagnosis
#XR neck may show subglottic narrowing with ragged tracheal epithelium
#CXR may show concominant pneumonia
#Emergent bronchoscopy is diagnostic and therapeutic

 

== Treatment ==

#Intubation, emergent, usually necessary
#Bronchoscopy to confirm dx, rule out supraglottic pathology
#Antibiotics
##third gen cephalosporin and vanco/clinda

== Disposition ==

#ICU admit
#Often require prolong intubation, 4-5 days

== Source ==

Rosen

[[Category:Peds]]
[[Category:ID]]

Bacterial tracheitis

2011-09-14T17:57:11Z

Russellm77: Created page with "== Background == #Bacterial infection of tracheal epithelium ##Often secondary infection after viral illness ##S. Aureus most common, also strep spp, H. Influenza and anaerob..."

Croup

2011-09-14T17:20:42Z

Russellm77: /* Source */

==Background==
*Croup = laryngotracheobronchitis
*Affects 6 mo-3 yr (peak in 2nd year)
*Fall & winter
*Etiology
**Parainfluenza (50%), RSV, rhinovirus
***Consider diphtheria if not immunized
*Spasmodic croup
**Sudden onset of barking cough/stridor
**No viral prodrome, unlike standard croup
**Difficult to differentiate from croup
*Must rule-out foreign body

==Diagnosis==
#1-2 day of URI followed by barking cough, stridor
#Low-grade fever
#NO drooling or dysphagia
#Duration = 3-7d, most severe on days 3-4

===Croup Score===
*Inspiratory stridor
**None (0 points)
**When agitated (1 points)
**On/off at rest (2 points)
**Continuous at rest (3 points)
*Retractions
**None (0 points)
**Mild (1 points)
**Moderate (2 points)
**Severe (3 points)
*Air entry
**Normal (0 points)
**Decreased (1 points)
**Moderately decreased (2 points)
**Severely decreased (3 points)
*Cyanosis
**None (0 points)
**When crying (2 points)
**At rest (3 points)
*Alertness
**Alert (0 points)
**Restless, anxious (2 points)
**Depressed (3 points)

'''Assessment'''
*<2 Very mild
*2-9 Mild to moderately severe
*>9 Severe croup

==Work-Up==
#Consider CXR if concerned about alternative dx
##Steeple sign on AP (not Sp, not Sn)
#Consider nasal washings for RSV, parainfluenza, influenza.

==Treatment==
#Cool mist
#Steroids
##Give to all pts with croup
###Dexamethasone 0.15-0.6mg/kg PO/IM (max 10mg)
#Epineprhine (nebulized)
##Give for moderatate-severe cases
#Do NOT give albuterol (may worsen edema (vasodilation))
#Intubation rarely needed
##Use one half size smaller tube if intubating

==Disposition==
#Consider discharge if:
##3hr since last epinephrine
##Able to tolerate PO
##Nontoxic apperance

==Source==
#Tintinalli
#Rosen
[[Category:Peds]]
[[Category:ID]]

Croup

2011-09-14T17:19:53Z

Russellm77: /* Treatment */

Croup

2011-09-14T17:16:54Z

Russellm77: /* Background */

==Background==
*Croup = laryngotracheobronchitis
*Affects 6 mo-3 yr (peak in 2nd year)
*Fall & winter
*Etiology
**Parainfluenza (50%), RSV, rhinovirus
***Consider diphtheria if not immunized
*Spasmodic croup
**Sudden onset of barking cough/stridor
**No viral prodrome, unlike standard croup
**Difficult to differentiate from croup
*Must rule-out foreign body

==Diagnosis==
#1-2 day of URI followed by barking cough, stridor
#Low-grade fever
#NO drooling or dysphagia
#Duration = 3-7d, most severe on days 3-4

===Croup Score===
*Inspiratory stridor
**None (0 points)
**When agitated (1 points)
**On/off at rest (2 points)
**Continuous at rest (3 points)
*Retractions
**None (0 points)
**Mild (1 points)
**Moderate (2 points)
**Severe (3 points)
*Air entry
**Normal (0 points)
**Decreased (1 points)
**Moderately decreased (2 points)
**Severely decreased (3 points)
*Cyanosis
**None (0 points)
**When crying (2 points)
**At rest (3 points)
*Alertness
**Alert (0 points)
**Restless, anxious (2 points)
**Depressed (3 points)

'''Assessment'''
*<2 Very mild
*2-9 Mild to moderately severe
*>9 Severe croup

==Work-Up==
#Consider CXR if concerned about alternative dx
##Steeple sign on AP (not Sp, not Sn)
#Consider nasal washings for RSV, parainfluenza, influenza.

==Treatment==
#Cool mist
#Steroids
##Give to all pts with croup
###Dexamethasone 0.15-0.6mg/kg PO/IM (max 10mg)
#Epineprhine (nebulized)
##Give for moderatate-severe cases
#Do NOT give albuterol (may worsen edema (vasodilation))

==Disposition==
#Consider discharge if:
##3hr since last epinephrine
##Able to tolerate PO
##Nontoxic apperance

==Source==
Tintinalli

[[Category:Peds]]
[[Category:ID]]

Croup

2011-09-14T17:16:18Z

Russellm77: /* Background */

==Background==
*Croup = laryngotracheobronchitis
*Affects 6 mo-3 yr (peak in 2nd year)
*Fall & winter
*Etiology
**Parainfluenza (50%), RSV, rhinovirus
***Consider diphtheria if not immunized
*Spasmodic croup
**Sudden onset of barking cough/stridor
**No viral prodrome
**Difficult to differentiate from croup
*Must rule-out foreign body

==Diagnosis==
#1-2 day of URI followed by barking cough, stridor
#Low-grade fever
#NO drooling or dysphagia
#Duration = 3-7d, most severe on days 3-4

===Croup Score===
*Inspiratory stridor
**None (0 points)
**When agitated (1 points)
**On/off at rest (2 points)
**Continuous at rest (3 points)
*Retractions
**None (0 points)
**Mild (1 points)
**Moderate (2 points)
**Severe (3 points)
*Air entry
**Normal (0 points)
**Decreased (1 points)
**Moderately decreased (2 points)
**Severely decreased (3 points)
*Cyanosis
**None (0 points)
**When crying (2 points)
**At rest (3 points)
*Alertness
**Alert (0 points)
**Restless, anxious (2 points)
**Depressed (3 points)

'''Assessment'''
*<2 Very mild
*2-9 Mild to moderately severe
*>9 Severe croup

==Work-Up==
#Consider CXR if concerned about alternative dx
##Steeple sign on AP (not Sp, not Sn)
#Consider nasal washings for RSV, parainfluenza, influenza.

==Treatment==
#Cool mist
#Steroids
##Give to all pts with croup
###Dexamethasone 0.15-0.6mg/kg PO/IM (max 10mg)
#Epineprhine (nebulized)
##Give for moderatate-severe cases
#Do NOT give albuterol (may worsen edema (vasodilation))

==Disposition==
#Consider discharge if:
##3hr since last epinephrine
##Able to tolerate PO
##Nontoxic apperance

==Source==
Tintinalli

[[Category:Peds]]
[[Category:ID]]

Pulmonary edema

2011-09-13T23:46:37Z

Russellm77: /* Treatment */

==Background==
*Mechanism
**Failing heart > pulm edema > stress response > incr afterload
***Incr afterload > incr pulm edema
*Pts often intravascularly depleted; avoid diuretics!

==Diagnosis==
*Crackles
*Respiratory distres

==Treatment==
#CPAP/BiPAP with PEEP 6-8; titrate up to PEEP of 10-12
#Nitroglycerin
##Dosing Options
###Loading dose: 400mcg/min x 2min
####With 100mg/250mL NTG in D5W, draw up 2mL (400mcg/mL), push over 2 min, equiv to above
#####Helpful is RN unwilling to run at 400 mcg/min or delay in setting up drip
####Then drop to 100mcg/min and titrate up as needed
###Repeated sublingual 0.4 mg q1min until IV NTG (0.5-0.7 mcg/kg/min) is started
####Titrate IV NTG rapidly upward (200mcg/min or higher) until BP is controlled
##If NTG fails to reduce BP consider nitroprusside
#ACEI
##After pt improves titrate off NTG as enaliprilat or captopril are started

==See Also==
*[[Congestive Heart Failure (CHF)]]

==Source==
Tintinalli

EMCrit Podcast 1

[[Category:Cards]]

Pulmonary edema

2011-09-13T23:42:13Z

Russellm77: /* Treatment */

==Background==
*Mechanism
**Failing heart > pulm edema > stress response > incr afterload
***Incr afterload > incr pulm edema
*Pts often intravascularly depleted; avoid diuretics!

==Diagnosis==
*Crackles
*Respiratory distres

==Treatment==
#CPAP/BiPAP with PEEP 6-8; titrate up to PEEP of 10-12
#Nitroglycerin
##Dosing Options
###Loading dose: 400mcg/min x 2min
####With 100mg/250mL NTG in D5W, draw up 2mL (400mcg/mL), push over 2 min, equiv to above
####Then drop to 100mcg/min and titrate up as needed
###Repeated sublingual 0.4 mg q1min until IV NTG (0.5-0.7 mcg/kg/min) is started
####Titrate IV NTG rapidly upward (200mcg/min or higher) until BP is controlled
##If NTG fails to reduce BP consider nitroprusside
#ACEI
##After pt improves titrate off NTG as enaliprilat or captopril are started

==See Also==
*[[Congestive Heart Failure (CHF)]]

==Source==
Tintinalli

EMCrit Podcast 1

[[Category:Cards]]

Mandible dislocation

2011-09-13T23:37:32Z

Russellm77: /* Disposition */

== Background ==
*Anterior dislocation of mandibular condyle(s) in relation to fossa
*Risk factors include prior dislocation,weak capsule, and torn ligaments
*Yawning, "popping" ears, or laughing may predispose

== Diagnosis ==
*Clinical diagnosis, but XR/CT if fracture suspected in setting of trauma
*Pt unable to open mouth with locked jaw
**Unilateral or bilateral
**Jaw deviates to contralateral side if unilateral
*Palpation of TMJ reveals anterior condyle(s)
**Palpate with fingers in the auditory canal

== Treatment ==
*Analgesia
*Benzodiazepines for muscle relaxation
*Wrap physician's thumbs circumferentially with 4x4's and tape
**Thumbs will be placed intra-orally and may be bitten upon relocation
*Can stand anterior or posterior to patient (see image below)
**First, downward pressure is applied to release condyles
**Second, move chin posteriorly to seat condyles in fossa
**Posterior position is easier in this author's opinion
***Allows for increased leverage, less patient anxiety
*Soft diet for one week
*Avoid wide opening of mouth, Barton's bandage may be helpful
*Refer recurrent dislocations

== Disposition ==
*Outpatient management as above
*ENT or OMFS referral with recurrent dislocations

== Sources ==
*Clinical Procedures in Emergency Medicine
*emedicine

[[Category:ENT]]

[[File:Mandible dislocation.jpg|thumb|Posterior position]]

Mandible dislocation

2011-09-13T23:34:31Z

Russellm77: /* Disposition */

== Background ==
*Anterior dislocation of mandibular condyle(s) in relation to fossa
*Risk factors include prior dislocation,weak capsule, and torn ligaments
*Yawning, "popping" ears, or laughing may predispose

== Diagnosis ==
*Clinical diagnosis, but XR/CT if fracture suspected in setting of trauma
*Pt unable to open mouth with locked jaw
**Unilateral or bilateral
**Jaw deviates to contralateral side if unilateral
*Palpation of TMJ reveals anterior condyle(s)
**Palpate with fingers in the auditory canal

== Treatment ==
*Analgesia
*Benzodiazepines for muscle relaxation
*Wrap physician's thumbs circumferentially with 4x4's and tape
**Thumbs will be placed intra-orally and may be bitten upon relocation
*Can stand anterior or posterior to patient (see image below)
**First, downward pressure is applied to release condyles
**Second, move chin posteriorly to seat condyles in fossa
**Posterior position is easier in this author's opinion
***Allows for increased leverage, less patient anxiety
*Soft diet for one week
*Avoid wide opening of mouth, Barton's bandage may be helpful
*Refer recurrent dislocations

== Disposition ==
*Outpatient management as above
*ENT or OMFS referral with recurrent dislocations

[[Category:ENT]]

[[File:Mandible dislocation.jpg|thumb|Posterior position]]

Mandible dislocation

2011-09-13T23:33:50Z

Russellm77: /* Treatment */

== Background ==
*Anterior dislocation of mandibular condyle(s) in relation to fossa
*Risk factors include prior dislocation,weak capsule, and torn ligaments
*Yawning, "popping" ears, or laughing may predispose

== Diagnosis ==
*Clinical diagnosis, but XR/CT if fracture suspected in setting of trauma
*Pt unable to open mouth with locked jaw
**Unilateral or bilateral
**Jaw deviates to contralateral side if unilateral
*Palpation of TMJ reveals anterior condyle(s)
**Palpate with fingers in the auditory canal

== Treatment ==
*Analgesia
*Benzodiazepines for muscle relaxation
*Wrap physician's thumbs circumferentially with 4x4's and tape
**Thumbs will be placed intra-orally and may be bitten upon relocation
*Can stand anterior or posterior to patient (see image below)
**First, downward pressure is applied to release condyles
**Second, move chin posteriorly to seat condyles in fossa
**Posterior position is easier in this author's opinion
***Allows for increased leverage, less patient anxiety
*Soft diet for one week
*Avoid wide opening of mouth, Barton's bandage may be helpful
*Refer recurrent dislocations

== Disposition ==
*Outpatient management as above
*ENT or OMFS referral with recurrent dislocations

[[Category:ENT]]

[[File:Mandible dislocation.jpg|thumb]]

Mandible dislocation

2011-09-13T23:32:49Z

Russellm77: /* Disposition */

== Background ==
*Anterior dislocation of mandibular condyle(s) in relation to fossa
*Risk factors include prior dislocation,weak capsule, and torn ligaments
*Yawning, "popping" ears, or laughing may predispose

== Diagnosis ==
*Clinical diagnosis, but XR/CT if fracture suspected in setting of trauma
*Pt unable to open mouth with locked jaw
**Unilateral or bilateral
**Jaw deviates to contralateral side if unilateral
*Palpation of TMJ reveals anterior condyle(s)
**Palpate with fingers in the auditory canal

== Treatment ==
*Analgesia
*Benzodiazepines for muscle relaxation
*Wrap physician's thumbs circumferentially with 4x4's and tape
**Thumbs will be placed intra-orally and may be bitten upon relocation
*Can stand anterior or posterior to patient
**First, downward pressure is applied to release condyles
**Second, move chin posteriorly to seat condyles in fossa
**Posterior position is easier in this author's opinion
***Allows for increased leverage, less patient anxiety
*Soft diet for one week
*Avoid wide opening of mouth, Barton's bandage may be helpful
*Refer recurrent dislocations

== Disposition ==
*Outpatient management as above
*ENT or OMFS referral with recurrent dislocations

[[Category:ENT]]

[[File:Mandible dislocation.jpg|thumb]]

File:Mandible dislocation.jpg

2011-09-13T23:31:48Z

Russellm77: obtained from emedicine.org under CC license

obtained from emedicine.org under CC license

Mandible dislocation

2011-09-13T23:23:45Z

Russellm77: Created page with "== Background == *Anterior dislocation of mandibular condyle(s) in relation to fossa *Risk factors include prior dislocation,weak capsule, and torn ligaments *Yawning, "popping" ..."

== Background ==
*Anterior dislocation of mandibular condyle(s) in relation to fossa
*Risk factors include prior dislocation,weak capsule, and torn ligaments
*Yawning, "popping" ears, or laughing may predispose

== Diagnosis ==
*Clinical diagnosis, but XR/CT if fracture suspected in setting of trauma
*Pt unable to open mouth with locked jaw
**Unilateral or bilateral
**Jaw deviates to contralateral side if unilateral
*Palpation of TMJ reveals anterior condyle(s)
**Palpate with fingers in the auditory canal

== Treatment ==
*Analgesia
*Benzodiazepines for muscle relaxation
*Wrap physician's thumbs circumferentially with 4x4's and tape
**Thumbs will be placed intra-orally and may be bitten upon relocation
*Can stand anterior or posterior to patient
**First, downward pressure is applied to release condyles
**Second, move chin posteriorly to seat condyles in fossa
**Posterior position is easier in this author's opinion
***Allows for increased leverage, less patient anxiety
*Soft diet for one week
*Avoid wide opening of mouth, Barton's bandage may be helpful
*Refer recurrent dislocations

== Disposition ==
*Outpatient management as above
*ENT or OMFS referral with recurrent dislocations

[[Category:ENT]]

Tongue diagnoses

2011-09-11T22:56:20Z

Russellm77: /* Tongue Swelling */

== Tongue Laceration ==
*Secondary to tongue biting
*Serious injuries can cause hemorrhage and potential airway compromise
*Do not need primary repair unless >1 cm in length,widely gaping,involving tip, or large hemorrhage
**Use absorbable sutures
**Anesthesia of the anterior 2/3 of the tongue is obtained through an inf. alveolar block
**Peridex mouth wash to prevent infection
**If the tip is not repaired, a forked tongue may result

== Strawberry Tongue ==
*Hypertrophied lingual papillae,initially with white exudate
*Ass'd with scarlet fever and Kawasaki's disease

== Black Hairy Tongue ==
*Benign reactive process
*Hyperplasia and increased pigmentation of filiform papille
*Smoking, GERD, Abx, poor hygiene predispose
*Treat with improved oral hygiene, gentle brushing, and a reducing pigment intake

== Oral Thrush ==
*Candidal infection
*White curd-like plaques, easily removable, with erythematous base
*Usually painless
*Steroids, Abx, radiation, immunodeficiency predispose
*Rx with nystatin, topical analgesia

== Tongue Swelling ==
*Differential includes trauma, angioedema, other conditions listed
*Angioedema is true emergency, suggested by face,lip, and tongue swelling
**Hereditary,allergic (ACE), or idiopathic

[[Category:ENT]]

Tongue diagnoses

2011-09-11T22:55:54Z

Russellm77: Created page with "== Tongue Laceration == *Secondary to tongue biting *Serious injuries can cause hemorrhage and potential airway compromise *Do not need primary repair unless >1 cm in length,wide..."

Dental problems

2011-09-11T16:12:04Z

Russellm77: /* See Also */

==Dentoalveolar Injuries==

===Fracture===
# Enamel
## Routine f/u
## Nothing to do
# Enamel + dentin (yellowish)
## Adult
### Next day f/u
### Consider placing calcium hydroxide paste over fracture site as needed for comfort
## Child
### Place calcium hydroxide paste
#### More important in children than adults because children have less dentin to protect the pulp
## Immediate referral
# Enamel + dentin + pulp (reddish)
## Immediate referral (dental emergency)
## If no dentist is available, place moist cotton over exposed pulp and cover with foil or seal with canal sealant
## Consider antibiotics (penicillin or clindamycin)
===Subluxation===
# Minimally mobile
## Soft diet for 14 days
# Markedly mobile
## Immediate referral for stabilization
## Temporizing measure: Periodontal pack in which tooth is bonded to its two neighboring teeth on both sides
===Avulsion===
# Dental emergency
# Where is the tooth?
## May be intruded, aspirated, swallowed, or embedded in the oral mucosa
### Consider facial films, CXR
# Adult
## Replace avulsed tooth as soon as possible! (as long as no alveolar ridge fx, no severe socket injury)
### Rinse tooth in saline, socket is suctioned (if necessary), reimplant tooth, bond tooth to neighboring teeth
### Manipulate tooth only by the crown
## Storage solution (in order of efficacy): Hank's balanced salt solution > Milk > saliva > saline
## Tetanus vaccine if indicated
## Consider antibiotics (penicillin or clindamycin)
# Child
## Do not reimplant primary teeth
### Refer to pedodontist for space maintainer

===Bleeding Socket===
# Apply pressure by having pt bite on gauze or tea bag

== Odontogenic infections ==

=== Dental Carie/Pulpitis ===

#dental referral only

=== Periapical vs. Periodontal Abcess ===

#drain
#PCN V
#dental referral

Exquisite pain to percussion suggests an underlying periapical abscess, though may point on gingiva (gumboil)

More commonly, fluctuant abscesses are a result of periodontal abscesses and are best treated with an incision and drainage

=== Trench Mouth (Acute Necrotizing Ulcerative Gingivitis) ===
#Severe gingival disease with inflamed,friable,ulcerated gingiva with gray pseudomembranes
#Present with fever,foul breath,strong metallic taste
#Anaerobic flora are most commons source
#Treat with peridex and PO Abx covering oral flora, dental referral
#Admission with parenteral Abx in patients with severe/systemic symptoms

 

==See Also==
[[Acute Alveolar Osteitis (Dry Socket)]]

[[Dental Numbers]]

[[Category:ENT]]

== Source ==
ER Atlas

Dental problems

2011-09-11T16:11:13Z

Russellm77: /* Odontogenic infections */

Dental problems

2011-09-11T16:05:17Z

Russellm77: /* Periapical vs. Periodontal Abcess */

==Dentoalveolar Injuries==

===Fracture===
# Enamel
## Routine f/u
## Nothing to do
# Enamel + dentin (yellowish)
## Adult
### Next day f/u
### Consider placing calcium hydroxide paste over fracture site as needed for comfort
## Child
### Place calcium hydroxide paste
#### More important in children than adults because children have less dentin to protect the pulp
## Immediate referral
# Enamel + dentin + pulp (reddish)
## Immediate referral (dental emergency)
## If no dentist is available, place moist cotton over exposed pulp and cover with foil or seal with canal sealant
## Consider antibiotics (penicillin or clindamycin)
===Subluxation===
# Minimally mobile
## Soft diet for 14 days
# Markedly mobile
## Immediate referral for stabilization
## Temporizing measure: Periodontal pack in which tooth is bonded to its two neighboring teeth on both sides
===Avulsion===
# Dental emergency
# Where is the tooth?
## May be intruded, aspirated, swallowed, or embedded in the oral mucosa
### Consider facial films, CXR
# Adult
## Replace avulsed tooth as soon as possible! (as long as no alveolar ridge fx, no severe socket injury)
### Rinse tooth in saline, socket is suctioned (if necessary), reimplant tooth, bond tooth to neighboring teeth
### Manipulate tooth only by the crown
## Storage solution (in order of efficacy): Hank's balanced salt solution > Milk > saliva > saline
## Tetanus vaccine if indicated
## Consider antibiotics (penicillin or clindamycin)
# Child
## Do not reimplant primary teeth
### Refer to pedodontist for space maintainer

===Bleeding Socket===
# Apply pressure by having pt bite on gauze or tea bag

==Odontogenic infections==
===Dental Carie/Pulpitis===
#dental referral only

===Periapical vs. Periodontal Abcess===
#drain
#PCN V
#dental referral

Exquisite pain to percussion suggests an underlying periapical abscess, though may point on gingiva (gumboil)

More commonly, fluctuant abscesses are a result of periodontal abscesses and are best treated with an incision and drainage

==See Also==
[[Acute Alveolar Osteitis (Dry Socket)]]

[[Dental Numbers]]

[[Category:ENT]]

Buccal space infections

2011-09-11T15:57:06Z

Russellm77: /* Diagnosis */

== Background ==
*Cellulitis or abscess in buccal space
**Space between buccinator and superficial fascia/skin
*Odontogenic source
**Maxillary second and third molars most common

== Diagnosis ==
*Ovoid cheek swelling with odontogenic disease
*CT not always necessary, but can define abscess
*Differential
**Parapharyngeal space infxn
***Swelling of neck and jaw angle,dysphagia,drooling,trismus,nuchal rig
**Parotitis, bacterial or mumps
**Neoplasm
**Trauma
**Facial cellulitis
**Canine space infection from infected maxillary canine
***Suggested by loss of nasolabial fold

== Treatment ==
*Parenteral Abx coveral oral flora
**Clindamycin,PCN V,third gen cephalosporin
*OMFS consult for abscess drainage,if present,and tooth extraction

== Disposition ==
*OMFS/ENT consult
*Admit diabetics,immunocompompromised, discuss others with consultant

== Source ==
*ER Atlas
*Rosen

[[Category:ENT]]