Rosen & Barkin's 5-Minute Emergency Medicine Consult (146 page)

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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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ALERT
For patients presenting between 3 and 4.5 hr of onset, there are additional exclusion criteria:
  • Age >80 yr
  • Oral anticoagulant use (regardless of INR)
  • NIH-SS >25 or >1/3 MCA territory involved
  • History of previous stroke
    and
    diabetes
MEDICATION
First Line
  • Alteplase (tPA): 0.9 mg/kg IV; max. 90 mg, with 10% of dose given as bolus and remainder infused over 60 min
  • Aspirin: 81–325 mg PO/PR
  • Labetalol: 10–20 mg IV bolus, repeat q10min max. 300 mg; follow with continuous infusion 0.5–2 mg/min
Second Line
  • Clopidogrel: 75 mg PO daily
  • Diazepam: 5 mg IV q5–10min max. 20 mg
  • Enalapril: 0.675–1.25 mg IV
  • Hydralazine: 10–20 mg IV q30min
  • Mannitol (15–25% solution): 0.5–2 g/kg IV over 5–10 min, then 0.5–1 g/kg q4–q6h
  • Nicardipine: 5 mg/h IV, increase by 2.5 mg/h q5–15min max. 15 mg/h
  • Nitroprusside: 0.25–10 μg/kg/min IV
  • Trimetaphan: 1–4 mg/min IV
Pediatric Considerations
  • Heparin or low-molecular-weight heparin is often used in children with ischemic stroke
  • May call 1-800-NOCLOTS for pediatric stroke consultation and guidance
FOLLOW-UP
DISPOSITION
Admission Criteria
  • Patients with acute cerebral vascular accident should be admitted to hospital
  • Indications for ICU:
    • Severely decreased level of consciousness
    • Hemodynamic instability
    • Life-threatening cardiac dysrhythmias
    • Significantly increased intracranial pressure
    • Administration of alteplase
Discharge Criteria
  • Patients who present with completed strokes that are days to weeks old may be discharged if they are able to function independently or have adequate social support
  • Patients with multiple prior strokes who experience relatively minor new episodes may also be treated on outpatient basis if similar criteria are met and stroke is completed
FOLLOW-UP RECOMMENDATIONS
  • Neurology
  • Primary care
  • Speech therapy/occupational therapy
PEARLS AND PITFALLS
  • Always note pre-hospital observations
  • Onset of symptoms is crucial to determining treatment with tPA
    • Include additional exclusion criteria between 3 and 4.5 hr
  • Avoid aggressive BP correction due to risk of hypoperfusion and extension of stroke
  • Door to needle goal is <60 min
ADDITIONAL READING
  • Clinical Policy: Use of intravenous tPA for the management of acute ischemic stroke in the emergency department.
    Ann Emerg Med.
    2013;61:225–243.
  • Freundlich CL, Cervantes-Arslanian AM, Dorfman DH. Pediatric stroke.
    Emerg Med Clin N Am
    . 2012;30:805–828.
  • Fulgham JR, Ingall TJ, Stead LG, et al. Management of acute ischemic stroke.
    Mayo Clin Proc
    . 2004;11:1459–1469.
  • Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professional from American Heart Association/American Stroke Association Stroke Council.
    Stroke
    . 2013;44:870–947.
  • Lees KR, Bluhmki E, von Kummer R, et al. Time to treatment with intravenous alteplase and outcomes of stroke: An updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials.
    Lancet
    . 2010;375:1695–1703.
  • Leira EC, Ludwig BR, Gurol ME, et al. The types of neurological deficits might not justify withholding treatment in patients with low National Institutes of Health Stroke Scale scores.
    Stroke
    . 2012;43:782--786.
  • Perry JM, McCabe KK. Recognition and initial management of acute ischemic stroke.
    Emerg Med Clin North Am
    . 2012;30:637–657.
  • www.ninds.nih.gov/doctors
See Also (Topic, Algorithm, Electronic Media Element)
  • Transient Ischemic Attack
  • Intracranial Hemorrhage
CODES
ICD9
  • 434.01 Cerebral thrombosis with cerebral infarction
  • 434.11 Cerebral embolism with cerebral infarction
  • 434.91 Cerebral artery occlusion, unspecified with cerebral infarction
ICD10
  • I63.59 Cereb infrc due to unsp occls or stenosis of cerebral artery
  • I63.8 Other cerebral infarction
  • I63.9 Cerebral infarction, unspecified
CERVICAL ADENITIS
Julie Zeller
BASICS
DESCRIPTION
  • Acute bacterial infection of a cervical lymph node
    • Often arising after a prior bacterial infection of the head or neck area
  • Primarily a pediatric disease:
    • Becoming more common in adults owing to immunocompromised disease states (HIV, cancer, transplant patients)
  • Any cervical node can become infected:
    • >80% of childhood cervical lymphadenitis involves the submandibular or deep cervical nodes
    • Jugulodigastric node located just below the angle of the mandible is common site
    • Cervical nodes act as the final common pathway for lymphatic drainage of all areas of the head and neck
    • Initial lymphadenopathy results after bacterial invasion of regional areas of the head and neck
    • Local lymph nodes swell secondary to hyperplasia of sinusoidal cells and infiltration of lymphocytes
    • If the infection is not contained, the bacteria enter the lymph system and proliferate (lymphadenitis)
    • Pus forms when neutrophils are incited, and an abscess develops when host defenses are unable to clear infection
    • Clinically manifests as warm, tender, swollen, erythematous node
ETIOLOGY
  • ∼70% of cases are a result of group A β-hemolytic Streptococcal infection
    • 20% Staphylococcal infection
    • 10% related to viral infection or other bacteria
  • Infections secondary to community-acquired MRSA (CA-MRSA) have increased in frequency
  • Children have one of the highest rate of CA-MRSA colonization and invasive disease
  • Mycobacteria TB:
    • Scrofula or tuberculous lymphadenitis
    • Rarely seen
    • Usually a chronic lymphadenitis in the posterior cervical nodes
    • Purified protein derivative (PPD) is usually strongly reactive
    • Treatment is nonsurgical
  • Atypical mycobacteria (nontuberculous)
    Mycobacterium avium
    complex:
    • More commonly seen
    • Usually a chronic lymphadenitis in the submandibular or anterior cervical nodes
    • PPD test results are unreliable
    • Treatment is primarily surgical
  • Bartonella henselae
    (catscratch disease):
    • Subacute lymphadenitis
    • Fever and mild systemic symptoms occur in only ∼3% of patients
    • Has indolent course but usually spontaneously resolves after 4–6 wk
  • Anaerobes:
    • Consider when associated with infections of the teeth or gingiva
  • Rare organisms:
    • Gram-negative bacilli
    • Yersinia pestis
    • Group B streptococcus
    • Francisella tularensis
    • Alpha-streptococcus
    • Anthrax
Pediatric Considerations
  • One of the most common causes of a neck mass in a child
  • Overall, group A Streptococcus and
    Staphylococcus aureus
    most common causes
  • In neonates, group B Streptococcus and
    S. aureus
    most common
  • Group B
    Streptococcal cellulitis
    –adenitis syndrome:
    • Infants are usually 3–7 wk of age, male, febrile, with submandibular or facial cellulitis, and an ipsilateral otitis media
    • 94% incidence of concurrent bacteremia
  • S. aureus
    associated with more indolent course and higher frequency of suppuration
  • Viral infections generally result in bilateral lymphadenopathy
Geriatric Considerations
  • Consider malignancy over infection in this population, especially in the absence of fever, leukocytosis, etc.
  • Fixed, nontender, hard node most likely not cervical adenitis
DIAGNOSIS

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