Rosen & Barkin's 5-Minute Emergency Medicine Consult (494 page)

• Atropine: 1–2 mg (peds: 0.05–0.2 mg/kg) IV q5min (see the previous section for details)
  
• Dextrose: D
  ₅₀
  W, 1 amp (25 g) of 50% dextrose (peds: 2–4 mL/kg D
  ₂₅
  W) IV push
  
• Naloxone (Narcan): 2 mg (peds: 0.1 mg/kg) IV/IM
  
• Pralidoxime: 1–2 g (peds: 25–50 mg/kg) dissolved in 0.9% NS over 30 min IV; repeat in 1 hr if necessary, then q6h as needed:
  
  • Some propose continuous infusion (500 mg/h) for serum concentration of 4 mg/L.
    

FOLLOW-UP

• ICU admission for any exposure confirmed with atropine response.
  
• Any symptomatic patient should be admitted for monitoring.
  
• Avoid opioids, phenothiazines, and antihistamines; these may potentiate toxicity of organophosphates.
  

• Asymptomatic for 6–12 hr after exposure
  
• Ensure close reliable follow-up and specific instructions when to return for evaluation.
  

Contact toxicologist or poison center for patients with significant exposures requiring repeat atropine administration.

Psychiatry referral for intentional ingestions.

• Treatment failure often secondary to inadequate atropine dosing
  
• Recognize nicotinic manifestations (tachycardia, seizures).
  

• Buckley NA, Eddleston M, Li Y, et al. Oximes for acute organophosphate pesticide poisoning.
  Cochrane Database Syst Rev.
  2011;(2):CD005085.
  
• Cannard K. The acute treatment of nerve agent exposure.
  J Neurol Sci.
  2006;249:86–94.
  
• Eddleston M, Clark RF. Insecticides: Organic phosphorous compounds and carbamates. In: Goldfrank LR, ed.
  Goldfrank’s Toxicologic Emergencies
  . New York, NY: McGraw-Hill; 2010.
  
• Masson P. Evolution of and perspectives on therapeutic approaches to nerve agent poisoning.
  Toxicol Lett.
  2011;206:5–13.
  
• Yanagisawa N, Morita H, Nakajima T. Sarin experiences in Japan: Acute toxicity and long-term effects.
  J Neurol Sci.
  2006;249:76–85.
  

CODES

• 987.9 Toxic effect of unspecified gas, fume, or vapor
  
• 989.3 Toxic effect of organophosphate and carbamate
  

BASICS

• Most frequent cause of knee pain in children aged 10–15 yr
  
• Pain and edema of the tibial tuberosity:
  
  • Tenderness at insertion site for patellar tendon just below the knee joint
    
• Extra-articular disease:
  
  • Pain is worse with activity and improves with rest
    
  • Caused by repetitive stress and is common in children participating in sports
    
• Benign, self-limited knee condition
  

• Etiology is controversial
  
• Leading theory: Microfractures caused by traction on the apophysis
  
• Pain occurs during activities that stress the patellar tendon insertion onto tibial tubercle.
  

DIAGNOSIS

• Pain and swelling over tibial tuberosity
  
• Pain exacerbated by running, jumping
  
• Pain relieved by rest
  

• Risk factors:
  
  • Age: 10–15 yr of age, associated with growth spurt in puberty
    
  • More common in boys
    
  • Sports: Activities with running, jumping, swift changes in direction (i.e., soccer, basketball, figure skating)
    
• Knee pain is worse with activity and improves with rest.
  
• Usually unilateral, with 20% occurring bilateral
  

• Prominence and soft tissue swelling over the tibial tuberosity
  
• Pain reproduced by extending the knee against resistance
  
• Tenderness over tibial tuberosity at patellar tendon insertion site
  
• Tight quadriceps and hamstrings compared to unaffected side
  
• Erythema of tibial tuberosity may be present.
  
• Knee joint exam is normal.
  

Diagnosis is clinical:

• Pain, swelling, and tenderness localized to the tibial tubercle
  

Knee x-ray:

• Irregular ossification and fragmentation at the tibial tuberosity may be seen.
  
• Ultrasound has the advantage of imaging surrounding soft tissues
  

• Patellar stress fracture
  
• Patellar or quadriceps tendonitis
  
• Prepatellar or infrapatellar bursitis
  
• Osteochondritis dissecans
  
• Osteomyelitis
  
• Patellofemoral pain syndrome
  
• Septic joint
  
• Inferior patellar pole traction apophysitis (Sinding-Larsen–Johansson disease)
  
• Fat pad impingement (Hoffa disease)
  
• Referred pain, especially from the hip
  

TREATMENT

• Stabilize lower extremity in position of comfort.
  
• Apply ice to affected knee.
  

• Rest from painful activities:
  
  • Limited activity for 6–8 wk
    
  • Avoid cutting and jumping sports, such as basketball, soccer, volleyball, etc.
    
• Ice affected area.
  
• Analgesic medications
  
• Stretch the quadriceps and hamstrings.
  
• Apply protective padding to knee during activities.
  
• Infrapatellar tendon strap may be worn for 6–8 wk.
  
• Avoid corticosteroid injections.
  
• Reassurance; it is a benign, self-limited condition.
  

Analgesic medications:

• Ibuprofen: 10 mg/kg PO q6h
  
• Acetaminophen: 15 mg/kg PO q4h
  

FOLLOW-UP

No admission is necessary.

Discharge home.

If patient fails nonoperative therapy, then refer to pediatric orthopedic surgery:

• Rarely, surgical excision is required but is delayed until after skeletal maturity.
  

Rest from painful activities and follow-up with pediatrician in 2–3 wk for repeat exam.

• Diagnosis is clinical:
  
  • Pain, swelling, and tenderness at the tibial tuberosity:
    
    • Tenderness and pain worse during and after exercise
      
  • Risk factors:
    
    • 10–15 yr of age
      
    • Sports activities with running, jumping
      
• Treatment is conservative:
  
  • Treat with rest, ice, and NSAIDs
    
  • Avoid sports activities until pain resolves.