Wrists are the most commonly injured upper extremity joint, and 8.8% of injuries are missed, with 2% being clinically important. With 27 bones and 34 muscles, there is a significant possibility of missing a fracture. A high index of suspicion is required to prevent missing a significant injury.
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In patients with bradycardias or cardiac arrest, have a high index of suspicion for hyperkalemia, especially in patients with renal failure or hemodialysis. Death from hyperkalemia is typically secondary to diastolic arrest or fibrillation, and common symptoms include weakness, paresthesias, and nausea/vomiting.
Organophosphates, such as the VX agent used to kill Kim jong-nam this past month, are used as insecticides, nerve agents, and medications.
These fall into the category of acetyl cholinesterase inhibitors, which also includes many dementia medications. Symptoms of organophosphate poisoning (including overdose of dementia medications) includes muscle weakness, fatigue, muscle cramps, hypersalivation, and muscle fasciculations. The SLUDGEM mnemonic identifies many of the symptoms (salivation, lacrimation, urination, diarrhea, GI motility, emesis, miosis). Nicotinic Ach receptor over-stimulation initially causes fasciculations, however as muscles fatigue patients may become weak with poor respiratory function even after treatment, and may still require intubation. Treatment is based on empiric presentation, and should begin immediately with decontamination and atropine. Treatment should include atropine and pralidoxime. Organophosphates are extremely lipophilic, and could result in prolonged symptoms and, as such, prolonged need for treatment and potential for delayed symptoms after initial treatment. Of note, leather items such as belts must be discarded appropriately as leather can absorb nerve agents and result in additional poisoning. Since the 1950's, antipsychotics have become effective treatment for positive and negative symptoms of psychosis. With the introduction of second generation antipsychotics there was some decrease in the extrapyramidal effects associated with these medications, however side effects, including potentially deadly, are still commonly seen in the ER.
Antipsychotics bind and inhibit dopamine receptors, causing the varying effects of these medications. This is also the source of many of the adverse effects of the medications.
Burns of dilute hydrofluoric acid are difficult to distinguish from other chemical burns and can appear as minimally erythematous areas of skin without blistering. Over 12-24 hours, however, this can progress to severe burns and blistering, progressing to necrosis requiring debridement. Highly concentrated acids may present with severely reddened, swollen areas with blanched regions which rapidly progress to necrosis. Even burns without impressive physical appearance may cause severe pain due to nerve ending irritation. HF is unique in that it does not spontaneously dissociate from hydrogen ions, causing it to penetrate through the skin and cause deeper, even systemic damage and hypocalcemia and hypomagnesemia.
Patients with potential rabies exposures are a relatively frequent reason for evaluation in an emergency room. Animal bites account for approximately 1% of all ER visits. Within the District of Columbia, all cats and dogs are required to be vaccinated against rabies and distemper from the age of four months, and after the initial set of shots, must be re vaccinated at least every 3 years. Not all owners may comply or have documentation readily available after an animal bite, and many patients may present after contact with a wild animal. As many residents may have already found, many tourists present after contact with squirrels, which are not known to carry rabies. DC DOH Vaccination, Bites, & Rabies
Contact Phone: (202) 535-2323 Contact Fax: (202) 442-4817 Office Hours: Monday to Friday 8:15 am to 4:45 pm 899 North Capitol Street, NE Washington DC 20002 https://doh.dc.gov/service/vaccination-bites-and-rabies Identifying atypical headaches, treatment of primary headaches, and how to approach complicated and atypical headaches. Adapted from Sigrid Nasser's Grand Rounds lecture, January 25th, 2015
Blistering AgentsMustard Gas, Phosgene, and Lewisite are the three most prominent blister agents. These are warfare agents which are dispersed and cause severe blisters. Apart form Lewisite, there are no antidotes and treatment is supportive including decontamination. Sulfur Mustard (mustard gas) is a colorless, odorous liquid when pure, but is dispersed as a yellow/brown gas that smells like mustard when used as a warfare agent. Bullous lesions present 2-6 hours after exposure and can cause mucosal damage including the respiratory tract. Lewisite has a more rapid onset than mustard gas, and has an antidote called "British Antilewisite (BAL). Phsgene oxime has never been used in warfare, but can cause wheels with blanching welts, which turn to tissue necrosis within 24 hours. Tear AgentsMultiple chemicals are used to cause tearing and mucosal irritation. The most commonly used are pepper-spray (capsaicin), CS (2-chlorobenzalmalononitrile), CN (mace). Pepper spray ranges from 10%-90% capsaicin depending on the product. Pepper-spray is self-limiting and shouldn't require more treatment than washing out. CN, or 'mace' and CS are both used by military and police, and typically can cause severe irritation, corneal abrasions, and even skin blistering if the patient is not decontaminated. CS is known to provide worse effects. CS can induce severe coughing and vomiting. Effects usually last for 20 minutes to an hour, and effects can persist for hours. Clothing will need to be thrown away or washed multiple times.
Status epilepticus is a common neurological emergency when a patient has a prolonged seizure or a series of seizures with incomplete return to baseline. The approach to status epilepticus has focused on early seizure termination, and rapid escalation of care to include general anesthesia when needed.
Status Epilepticus: A prolonged seizure or multiple seizures with incomplete return to baseline. |
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