Pathological fractures (through multiple cystic bone lesions). \200 Rickets (enlarged, cu pped epiphyses, craniotabes, \200\230bow legs \200\231). \200 Copper de \201 ciency (eg Menkes \200\231 kinky hair syndrome). Neglect and emotional abuse There will be an element of emotional abuse as part of other fo rms of abuse, which may be manifest in the child in a variety of ways: behavioral problems, sleep disturbance, soiling, nocturnal enuresis. The neglected child may be dirty and unkem pt, fail to thrive, and/or fall below the 3rd centile for height and weight. Occasionally, nutritional de \201 ciencies may be extreme (eg rickets). Developmental milestones are oft en delayed (and may even regress). Note the apparent attitudes of the parents/carers towards their child (eg critical and host ile or remote and unconcerned) and the child \200\231s attitude to the parents/carers (if i n doubt as to whether this seems appropriate, ask an experienced nurse). 733 PRESENTATION OF CHILD ABUSE: 2 Sexual abuse This may affect boys or girls and takes many forms, ranging from exposure to i ndecent acts through to rape. The abuser is often a male relative or carer who is well know n to the child. The child may present in a variety of ways: \200 Injury to the genitalia or anus. \200 Perineal pain, discharge, or bleeding. \200 Behavioral disturbance, enure sis, encopresis. \200 Inappropriate sexual behavior. \200 The child may allege sexual a buse. \200 Sexually transmitted disease (including anogenital warts). \200 Pregnancy. A ccurately record statements made by the child \200\230word for word \200\231 using quotati on marks. Do not pursue a genital examination, but involve a senior doctor at an early stag e, who may wish to examine the genitalia using a colposcope, in collaboration with a police surgeon (clinical forensic physician). In the context of an allegation of recent sexual as sault, the collection of forensic samples for DNA analysis is likely to be required. Fabricated or induced illness (previously known as Munchausen syndrome by proxy) A parent/c arer may invent a history of illness in a child and fabricate physical signs to substantiat e it. The history often involves one or more of the following: apnoeic episodes, \201 ts, bowel disturbances, rashes, allergies, or fevers. Classically, the deceiver is the mother. The child may be made ill by administering drugs or poisons. If suspected, do not confront the deceiver, but take blood and urine samples for a toxicology screen and refer to the pe diatric team. Bear in mind that some parents may be naturally very anxious and may exaggerate symptoms, r ather than deliberately fabricate them. 734 CHAPTER 15 Pediatric emergencies Management of child abuse Role of the junior emergency department doctor The junior ED doct or needs to be vigilant in considering abuse when initially assessing and treating children . Any suspicion of child abuse should prompt involvement of an expert senior doctor (pediat rician or ED consultant). In every hospital system there will be a designated doctor for ch ild protection who should be available for advice. He or she will examine the child and arr ange hospital admission for further investigations (eg skeletal survey) as necessary. Socia l Services and the police may need to be involved. The child may require examination by a p olice surgeon (clinical forensic physician) and samples/photographs obtained. Follow local procedures. The chief consideration is the treatment and protection of the child, so do not delay treat ment of painful or apparently life-threatening problems, whilst awaiting an \200\230expert \200\231. Ensure that all documentation is legible and meticulous. Remember that if child abuse is considered likely, siblings may also be at risk. UK law: The Children Act 1989 This act replaced previous statutes. Central to the Act is th e concept that the welfare of the child is paramount. In the short term, the 1989 Children Act may be used to obtain orders to protect children. A variety of orders may be obtained: Police Protection Order A police of \201 cer has legal powers to take any child into \200 \230police protection \200\231 for up to 72hr if deemed necessary for his/her own protectio n. This order may be used to prevent a child being taken away from the ED by a parent or gu ardian against medical advice. Emergency Protection Order This has replaced the \200\230Place of Safety Order \200\231. A court order valid for up to 8 days may be obtained if the child is believed to be at signi \201 cant risk of harm. Such an order would normally be requested by a social worker. Child Assessment Order This court order may be obtained in order to allow an assessment to be performed of a child who appears to be at risk of injury. Care Order This transfers the care of a child from the parent(s) to the local authority Soc ial Services department. If a care order is in force, matters requiring parental consent sh ould be referred to the social worker (not the foster carer). Residence Order This court order de \201 nes where a child should live and who has parenta l responsibility. 735 MANAGEMENT OF CHILD ABUSE Child Protection Plan (replaces the \200\230Child Protection Register \200\231) This regis ter is kept by the social services. It contains a list of names of those children considere d to be at current risk of harm. ED staff should be aware of how to access Child Protection Register information. Previous hospital case notes are also very useful in this respect. W hen searching for previous records, remember that many children may be known by several sur names. Child protection conferences A conference may be called by Social Services if it is suspect ed that a child has been abused. Child protection conferences should be held promptly and a im to de \201 ne a protection plan for the future protection of the child and family. Unli ke the criminal courts, where the onus is on the prosecution to prove abuse \200\230beyond reasonable doubt \200\231, child protection conferences will determine whether a child is deemed to be at risk of signi \201 cant harm and whether a protection plan is required. Ca se conferences consist of a number of individuals, including: chairman (usually a senior me mber of the Social Services department), hospital consultant, GP, social worker, police, he alth visitor, teacher, education welfare of \201 cer, child abuse advisor, local authority solicitor. Parents are always invited and older children may also attend. This page intentionally left blank 737 Index angioplasty for MI 76 anion gap 99 ankle newborn 642 \200\2235 pediatric 652 \200\2235 advanced trauma life A A2 pulley injury 440 abbreviations ix \200\223xv abdominal aortic aneurysm, support (ATLS) 321 fractures 486 injuries 484 aggression 608 , 610 AIDS and HIV 242 \200\2235 airway management 48 burns 390 , 392 , 394 \200\2235 cardiac arrest 50 children 646 , 654 foreign body 648 nasopharyngeal airway 325 n ewborn 642 spinal injury 380 surgical 326 \200\2237 ruptured 530 abdominal injury, children 714 abdominal mass, children 699 abdominal pain 504 in children 727 nerve blocks 306 \200\2237 Ottawa rules 484 \200\2235 sprains 487 ankylosing spondylitis 497 anorectal problems 518 anthrax 233 , 627 anti-D immunoglobulin 5 82 antibiotics analgesia 280 in cancer 506 in children 698 in pregnancy 590 abscess 526 bites 411 , 414 in compound fractures 422 and oral contraception 569 pneumonia 111 , 687 prophylaxis 411 anticoagulants 170 antidotes 186 \200\2237 antipsychotic drugs 61 9 aortic aneurysm, abdominal, abdominal trauma 348 , 350 abortion 584 abruptio placentae 588 , 594 abscess 526 airway obstruction 45 , 112 , 324 children 677 alcohol (ethanol) anorectal 519 Bartholin \200\231s 565 breast 599 peritonsillar 554 pilonidal 518 retrophary ngeal 555 absorption, metabolism, and elimination 622 abuse 622 intoxication 202 , 623 and police 30 withdrawal 624 alcohol-related brain ruptured 530 aortic dissection 92 aortic injury 344 apophysitis, traction 708 appendicitis 507 children 699 epiploic 517 pregnancy 591 Acanthamoeba keratitis 539 ACE inhibitor poisoning 199 acetabular fractures 468 acetaminoph en see paracetamol acetylcysteine 190 \200\2232 Achilles tendon injuries 482 acid-base nomo gram inside front cover injury 625 alteplase 77 Amanita phalloides 212 amaurosis fugax 540 ambulance crew 12 Ambulance Inciden t Of \201 cer 39 aminophylline 106 in children 679 arc (welder \200\231s) eye 538 arterial blood gasses 98 acidosis diagram inside front cover lactic 99 metabolic 99 arthritis 494 in children 705 septic 495 , 705 amiodarone 86 amniotic \202 uid acromio-clavicular joint injury 458 embolism 594 amphetamine 215 , 626 amputation 422 , 435 aspiration, pulmonary 112 , activated charcoal 185 activated partial 338 aspirin (salicylate) 274 thromboplastin time xviii , 167 poisoning 189 toes 490 anesthesia asthma acute confusional state 134 Addisonian crisis 155 adenosine, supraventricular acute 104 \200\2237 cardiac arrest 107 children 678 \200\22381 general 310 , 316 local 282 topical 288 see also local anesthesia tachycardia 88 adhesive capsulitis 461 adrenaline (epinephrine) asystole 51 atracurium 316 atrial \201 brillation 89 atrial \202 utter 89 atrioventricu lar block 80 atropine 82 , 654 as antidote 186 poisoning 194 anal \201 ssure 518 analgesia 274 \200\223281 anaphylaxis 44 bradycardia 82 \200\2233 cardiac arrest 53 children 650 \200\2232 local anes thesia 285 newborn 644 children 275 \200\2236 , 280 \200\2231 , 632 , 713 anaphylaxis 42 , 44 in children 650 \200\2231 angina 67 attenders Prinzmetal \200\231s (variant) 69 unstable 68 angio-oedema 42 advanced life support inappropriate 16 regular 17 adult 52 \200\2233 738 INDEX carbon monoxide Boerhaave \200\231s syndrome 333 Bohler \200\231s angle 488 bombs (blast injuries) 389 bone anatomy 421 Bordetella pertussis , whooping Australian Mental Health Triage Scale 612 poisoning 208 , 394 \200\2235 carboxyhaemoglobin 70 , Autopulse 51 avian \202 u 33 , 252 aviator \200\231s astragalus 498 208 , 394 \200\2235 cardiac arrest 46 \200\22355 algorithms 47 , 52 asthma 107 children 646 \200\2237 , 652 \200\2235 drugs 50 , 644 , 654 hyperkalaemic 163 newborn 644 pregnancy 596 reversible cause s 51 cough 684 botulism 143 , 237 boutonni re deformity 433 , B back pain 492 bacterial tracheitis, children 677 440 , 498 bowel problems 511 \200\2237 boxer \200\231s fracture 498 brachial plexus blocks 298 bradyc ardia 80 algorithm 83 children 656 bad news, breaking 24 balanitis 702 Bankart lesion 498 barbiturate poisoning 197 barotrauma 260 \200\2233 , 551 Bartholin \200\231s abscess 565 Barton \200\231s fracture 446 basic li fe support 48 newborn 642 \200\2234 pediatric 646 \200\2237 cardiac arrhythmias 80 \200\22389 in children 656 in poisoning 183 cardiac markers 71 cardiac pacing 53 , 82 cardiac tamponad e 342 cardiogenic pulmonary brain injury, alcohol-related 625 breast abscess 527 , 599 swelling, babies 660 oedema 100 breastfeeding and drugs 576 breathlessness cardiogenic shock 60 , 77 cardiopulmonary resuscitation BASICS 34 batteries, button 213 Bazett \200\231s formula (QTc) 65 Beck \200\231s triad 342 bee stings 416 Bell \200\231s palsy 556 Bennett \200\231s fracture 439 benzodiazepine poiso ning 196 bereavement 24 berry poisoning 212 beta-blocker poisoning 198 biceps injury 452 , 459 Bier \200\231s block 290 biliary tract problems 510 bilious vomiting 661 birth, emergen cy delivery 578 (dyspnoea) 96 British Association for Immediate Care (BASICS) 34 bronchiolitis 682 bronchus , ruptured 336 Brown-S quard adult 46 \200\22353 children 646 \200\2237 , 652 \200\2235 mechanical 51 newborn 644 cardioversion, synchronized 86 carpal tunnel syndrome 445 casts 424 catheterization, male 521 cauda equina syndrome 493 CB RN incidents (chemical/ biological/radiological/ nuclear) 39 , 210 syndrome 383 Brugada syndrome 65 bruises 403 child abuse 728 \200\22331 bumper fractures 498 bupivacaine 283 burns 390 \200\2233 , 396 \200\2237 cellulitis 234 , 413 , 453 , 528 airway, from cocaine 555 and child abuse 397 children 715 inhalation injury 394 BURP maneuv er 314 bursitis 427 ear canal 550 orbital 542 bites 414 \200\2237 dogs 415 human 416 infection 413 \200\2235 insects 416 reverse \201 g ht bites 415 \200\22316 , 435 snake bites 417 and stings 416 tetanus 410 ticks 231 , 416 bl adder injury 352 blast injuries 389 bleeding disorders 166 blepharitis 543 blindness, sudde n 540 blood pressure, normal, cement burns 397 central cord syndrome 383 central retinal artery occlusion 540 central ret inal vein occlusion 540 infrapatellar 479 button batteries 213 central venous access 56 cephalhaematoma 660 cerebral hemorrhage 144 cerebral infarction 14 4 cerebral venous C Caesarian section 597 CAGE questionnaire 622 calcaneal fracture 488 calci \201 c tendoni tis 461 calcium antagonist poisoning 198 calculous disease 557 calf thrombosis 133 cervical cancer 566 , 574 cervical cord syndrome, central 383 cervical disc herniation 463 cervical erosion 574 cervical spine control 320 , children 633 blood transfusion 172 injuries 482 squeeze test 482 \200\2233 cancer and abdominal reactions 175 712 blow-out fracture 374 BMA Counseling Service chalazion 543 chance fracture 498 charcoal, activated 185 pain 506 capacity, de \201 ning 629 carbamate insecticides 206 for Doctors 15 body packers 217 739 INDEX collateral ligament injuries CHEMDATA 36 chemical burns 397 D dacrocystitis 543 dantrolene 183 , 214 , 265 dashboard dislocation 499 De Quervain \200 \231s knee 475 , 478 thumb 438 , 440 of eyes 538 chemical incidents 36 , Colles fracture 444 , 499 colovaginal \201 stulae 566 coma 136 , 138 37 , 210 decontamination 211 roadside 36 tenosynovitis 447 alcohol overdose 623 Glasgow Coma Scale 360 \200\2231 children 717 death 24 \200\22327 decompression illness 260 decontamination chemical 211 radiation incide nts 211 , 268 chest compression 49 children 646 newborn 644 hypoglycaemia 151 chest drain insertion 115 , compartment 336 \200\2237 deep venous syndrome 398 chest injury 328 \200\223344 thrombosis 118 in IV drug users 627 in pregnancy 593 compound fractures 422 compulsory analgesia 279 children 714 penetrating 340 , 342 hospitalization 628 de \201 brillation 50 children 652 \200\2233 concussion 368 confusional state 134 conjunctival FB 538 conjunctivitis 543 neonatal 660 chest pain 66 assessment units 71 atypical 67 differential diagnosis 66 pericarditis 78 sickle cell disea se 176 de \201 brillator, implantable 82 dehydration 152 , 227 , 681 deliberate self-harm 612 del irium 134 , 603 delirium tremens 624 delivery, emergency 578 delusion 603 dementia 135 deng ue fever 248 dental anesthesia 302 dental anatomy 558 dental emergencies 558 consent 28 contact lens problems 539 contraceptive problems 568 convulsions 148 \200\2239 c hildren 688 poisoning 183 chickenpox 240 child abuse 728 \200\22335 fractures 732 child protection plan 735 COPD 108 coping as a junior doctor 14 Children Act (1989) 734 chlorine poisoning 209 choking 45 , 648 cholangitis, ascending 510 cholecystitis 510 cholesteatoma 551 Christmas disease 169 chronic obstructive see also teeth dento-alveolar corneal trauma 538 coronary syndromes, fractures 372 acute 68 Coroner 26 , 31 corpus luteum cyst 572 , 587 cortical blindness 717 cot death 658 counseling service 15 court, going to 31 cranial arteritis 132 , 541 cricoid pressure 312 \200\2235 cricothyroidotomy 326 \200\2237 Crohn \200\231s disease 517 croup 676 cruciate li gaments 474 , 478 crush syndrome 398 crushed \201 ngers 435 crying babies 661 CS gas 209 CT scan depression 616 dermatitis herpetiformis 672 pulmonary disease 108 dermatomes 386 \200\2237 detention, compulsory 628 diabetes mellitus 152 hypoglycaemia 150 pregnancy 593 chronic renal failure 160 ciguatera \201 sh poisoning 229 clavicle fracture 458 children 722 clay-shoveller \200\231s fracture 499 diabetic ketoacidosis 152 children 691 clomethiazole diagnostic peritoneal poisoning 196 Clothier report 620 clozapine 619 CN gas 209 co-codamol 274 co-dydramol 274 c oagulation cascade 169 coagulation disorders 166 cocaine 215 , 626 lavage 347 dialysis problems 160 \200\2231 diamorphine 276 nasal 281 diaphragm, ruptured 333 diarrhea 226 diazepam coma 138 headache 127 \200\2238 head injury 362 stroke 145 trauma 322 , 348 ureteric colic 525 CURB-65 score 111 Cushing response 354 cut down, venous 639 cyanide poisoning 207 , 395 cystic \201 brosis 685 cystitis 158 overdose 196 status epilepticus 149 pharyngeal burns 555 children 690 coccyx fractures 469 cochlear implants 549 codeine 276 cognitive assessment 607 cold injury 257 colitis diclofenac 275 digital nerve block 294 \200\2235 digital nerve injury 432 , 434 digoxin poi soning 199 diphtheria 676 discharge from ED 2 , 8 ischaemic 515 ulcerative 517 against advice 29 elderly patient 20 collapse 140 740 INDEX external jugular vein 57 eye 533 tachyarrythmias 87 \200\2239 tricyclic antidepressant poisoning 194 \200\2235 disclosure in public interest 30 burns 538 examination 534 foreign bodies 537 injury 536 problems and HIV 244 dislike of a patient 18 dislocations 423 eclampsia 592 ecstasy 214 , 626 ankle 486 children 718 elbow 449 , 451 \201 nger 436 hip 468 knee 477 patella 476 liquid 215 ectopic pregnancy 586 eczema 662 edrophonium test 142 elbow eye signs head injury 360 in poisoning 182 eyebrow wounds 464 eyelid wounds 464 eyelids, superglued 5 38 fat-pad sign 450 injuries 450 children 726 shoulder 454 \200\2237 thumb 438 toes 490 wrist 442 , 448 children 724 problems, soft tissue 452 \200\2233 F fabricated illness 620 , 733 facial burns 394 \200\2236 facial fractures 370 \200\2237 fa cial injury 370 , 464 facial nerve palsy 556 facial wounds 464 factitious disorder 621 pulled 724 elderly patient, disseminated intravascular coagulation 169 , 592 diverticular disease 516 diving emergencie s 260 \200\2233 documentation see notes dog bites 415 dressings 412 burns 396 discharge 20 electrical injuries 266 emesis, induced 185 EMLA cream 288 emotional abuse 732 endocarditis 740 endometriosis 572 en \202 urane 317 enteric fever 248 Entonox 278 \200\2239 environmental in health care Dressler \200\231s syndrome 79 driving 30 , 535 drowning 258 children 715 workers 620 fainting 140 FAST scan (focused assessment with sonography for trauma) 346 drug abuse emergencies 253 complications 627 illicit drugs 214 withdrawal 627 epicondylitis 452 epididymitis 522 epididymo-orchitis 701 epiglottitis 677 epilepsy 148 , 6 88 see also seizures fatal accident inquiry 31 febrile child 663 febrile convulsions 688 feeding dif \201 culti es, babies 661 drugs anesthetic 316 doses in children 633 , 644 interactions with OCP 569 epinephrine see adrenaline epiphyseal injury children 718 Salter-Harris femoral neck, fracture 470 femoral nerve block 304 \200\2235 femoral shaft newborn doses 644 , 655 psychiatric, complications fracture 472 of 619 classi \201 cation 719 epiphysis, slipped upper children 726 see also poisoning dry socket pain 561 Dupuytren \200\231s fracture 499 dyspnoea 96 dystoni c reaction 619 femoral vein femoral 706 children 639 venous access 56 \200\2237 fentanyl 276 , 281 fetal injury 594 \201 bula, fr actures 480 \201 eld block 289 \201 ght bites, reverse 415 \200\2236 \201 nger pad am putations 435 \201 ngers epiploic appendagitis 517 episcleritis 543 episiotomy 580 epistaxis 552 ergotamine 130 erys ipelas 528 erythema E ear chronicum migrans 673 marginatum 672 multiforme 672 nodosum 672 toxicum, infants 662 examination 548 , 674 nerve blocks 300 \200\2231 problems 546 \200\223551 wounds 464 crushed \201 ngers 435 digital nerve block 294 \200\2235 dislocations 436 fractures 456 \200\2237 , 725 \201 shhooks, removal of 406 \201 sh bones in pharynx 547 \201 sh poi soning 229 \201 sh spine stings 416 \201 ts see convulsions; seizures \202 ail segmen t 332 \202 eas 230 \202 exor tendon injury 432 \200\2234 earache 550 Ebola fever 250 ECG 64 ESR xviii Essex Lopresti fracture 499 ethanol see alcohol ethyl chloride 288 ethylene glyco l bradyarrhythmias 81 diagram inside back cover hyperkalaemia 162 hypothermia 255 myocardial infarction poisoning 203 etomidate 316 extensor tendon 72 \200\2235 injury 432 , 434 pericarditis 78 741 INDEX handover of patients 9 hangman \200\231s fracture 499 Hawkin \200\231s impingement glue snif \201 ng 626 golfer \200\231s elbow 452 gonorrhea 238 gout, acute 496 gout bursit is 453 GPs, liaising with 5 , 10 Graves \200\231 disease 156 gravidity 576 grease gun injur ies 435 groin lumps 700 GTN intravenous infusion 68 Guillain-Barr \202 umazenil 196 , 309 follow-up arrangements 5 food poisoning 226 \200\2239 foot test 460 Hazchem board 36 , 37 head injury 354 \200\223368 dislocations 488 fractures 488 soft tissue problems 491 analgesia 279 and child abuse 731 children 714 , 716 examination 360 Glasgow Coma Scale 360 \200\2231 forearm injuries 448 , 725 forehead, nerve blocks 300 foreign bodies ear 546 eye 537 \200\2238 foot 491 ingested 213 , 547 inhaled 112 , 547 , 648 , 677 nose 21 3 , 546 rectal 519 under \201 ngernail 435 vaginal 567 wounds 405 history 358 imaging 362 \200\2233 management 364 minor 366 monitoring 356 \200\2237 risks o f haematoma 363 triage 356 syndrome 142 gunshot injuries 30 , 388 gynecological problems 564 \200\223 575 H haemarthrosis, knee 478 haematemesis 122 haematoma block 289 extradural 365 intracranial 365 risks, after head injury 363 soft tissue 426 subdural 365 subungual 435 headache 126 \200\223133 analgesic 133 cluster 132 sudden severe 128 tension 132 foreskin problems 523 , 702 fractures and child abuse 732 eponymous 498 \200\223502 see also speci \201 c fractures fragmentatio n injuries 389 frontal sinus, fractures 374 frostbite 257 fundoscopy 535 funny turns 689 fu runculosis of ear 550 hearing 548 heart block 80 \200\22381 heart rates inside back cover normal, children 633 heat illness 264 heat stroke 265 helicopters 36 Henoch-Sch nlein purpura 664 haematuria, children 695 haemodialysis problems 161 G Galeazzi fracture 448 , 499 gallstones 510 haemolytic uraemic syndrome 694 hemophilia 166 , 168 Haemophilus in \202 uenzae 636 haemop tysis 94 hemorrhage hepatitis 220 , 239 , 415 hernia 161 , 512 , 698 , 700 \200\2231 heroin 188 , 217 , 233 , in pregnancy 591 276 , 627 gamekeeper \200\231s thumb 438 , herpes simplex 240 , 565 herpes zoster 240 Hib vaccine 636 high pressure injection 440 , 499 gammahydroxybutyrate (GHB, GBH) 215 Garden classi \201 cation 471 gas gangrene 237 gastric lavage 184 gastroenteritis 226 , 228 gastrointestinal bleeding antepartum 588 and anticoagulants 170 cerebral 144 lower GI 124 post-partum 598 subarachnoi d 128 tooth extraction 561 upper GI 122 vitreous 541 hemorrhoids 518 haemostasis 167 haemot horax 335 hallucinations 603 haloperidol 611 halothane 317 hamate fracture 443 hand injuries 435 Hill-Sachs lesion 500 hip dislocations 468 fractures 468 , 470 in children 726 lower 124 upper 122 hip pain in children 706 General Medical Council 30 generalized weakness 142 genital injury 570 , 733 genital ulcers /sores 238 german measles 223 gestational trophoblastic HIV 242 \200\2235 horse rider \200\231s knee 500 hospitalization, compulsory 628 Hume fractures 449 , 500 humerus disease 588 fractures 459 children 722 Hunt and Hess scale, subarachnoid hemorrhage 129 Hutchinson frac ture 500 hydatid of Morgagni, torsion GHB 215 giant cell arteritis 132 , 541 glandular fever (infectious mononucleosis) 241 Glasg ow Coma Scale 360 \200\2231 anatomy 430 arthritis 496 crushed \201 ngers 435 infections 413 , 441 injuries 430 , 432 wounds 413 , 434 children 717 glaucoma 542 glue (for wounds) 406 of 701 hand hygiene 32 742 INDEX immobilization, spinal 380 \200\2231 immunization 636 immunoglobulin, intra-hospital transfers 22 intracranial haematoma 365 intracranial pressure 354 \200\2235 Intralipid in hydrocarbons 112 , 205 hydrocoele 700 hydro \202 uoric acid burns 397 anti-D 582 , 595 impetigo 235 , 662 impingement syndromes in shoulder 460 impingement test 460 inappropriate attenders 16 incubation periods of poisoning 187 , 284 hyperbaric LA toxicity 284 chambers 261 oxygen 208 , 395 intraocular pressure 535 intraosseous infusion 640 \200\2231 intrauterine contraceptive hyperglycaemic crises 152 hyperkalaemia 162 device 569 intravenous \202 uids children 640 trauma 340 intubation 312 \200\2235 dif \201 cult 314 failed intubation drill 315 renal failure 160 , 694 hypernatraemia 154 hyperosmolar infectious diseases 220 induced illness 620 , 733 infantile spasm 688 infection hyperglycaemic state 152 hypertension 90 malignant 133 in pregnancy 91 , 592 in renal failure 160 , 694 bites 413 \200\22315 cellulitis 528 control and prevention 32 dental 561 pelvic 566 , 573 w ounds 235 , 413 see also abscess intussusception 699 ipratropium bromide, in asthma 679 , 680 hyperthermia 183 , 264 hypertrophic iritis, acute 542 iron poisoning 201 irradiated patient 268 \200\2239 irritable bowel cardiomyopathy 141 ECG 141 hyperventilation 97 hypoglycaemia 150 \200\2231 alcohol-induced 623 coma 136 , 138 newborn 644 sulphonylurea infections staphylococcal 235 streptococcal 234 , 528 infectious diseases 33 , 219 syndrome 517 irritable hip, children 706 ischaemic colitis 515 ischaemic limb 531 iso \202 urane 317 IS S (injury severity score) 323 childhood 222 duration of infectivity 220 imported 246 incubation periods 220 noti \201 ab le 221 tropical diseases 246 poisoning 197 hypokalaemia 164 hyponatraemia 154 hypotension IUCD 569 IVU in renal trauma 351 poisoning 183 see shock 60 \200\2231 hypothermia 254 \200\2236 infectious mononucleosis 241 J jaundice infestations 230 in \202 uenza bleeding disorders 166 blood transfusion 174 and drowning 258 ECG 255 in poisoning 183 rewa rming methods 256 pandemic 33 , 252 hepatitis 239 neonatal 660 obstructive 510 infraorbital nerve block 302 infrapatellar bursitis 479 inguinal swellings children 700 inh alation injury 394 jaw thrust maneuver 325 Jefferson fracture 500 jelly \201 sh stings 416 Johansson-Larsen \200\231s disease 708 joint aspiration 494 Jones fracture 489 , 500 jugular vein 56 \200 \2238 children 639 hypovolaemic shock 60 aortic aneurysm 530 burns 390 GI bleed 122 , 124 pregnancy 582 \200 \2239 transfusion 172 trauma 320 children 715 inhalational anesthetics 317 injury prevention 711 injury severity score (ISS) 323 inquest 31 INR xviii , 167 , 170 insect bites 416 insecticide poisoning 206 insulin overdos e 151 insulin therapy in poisoning 187 intercostal (chest) drain insertion 115 , 336 \200 \2237 intercostal nerve block 303 internal jugular vein 57 \200\2238 interview, psychiatric 604 intestinal obstruction 512 , junior doctor, coping as 14 I ice 428 ice skater \200\231s fracture 500 idiopathic thrombocytopenic K Kawasaki disease 672 Kemler plate 36 Kernig \200\231s sign 127 ketamine 278 , 316 childre n 715 purpura 664 iliac fossa mass 507 imaging children 720 head injury 362 \200\2233 spine and spinal ketoacidosis alcoholic 624 children 691 diabetic 152 ketorolac 275 cord 384 , 482 see also CT; X-ray immersion foot 257 591 in pregnancy 591 743 INDEX locked knee 479 long bone anatomy 421 lorazepam 611 low back pain 492 lower GI tract bleedi ng 124 LSD 215 Lucas CPR device 51 lumbar puncture, children 670 menstrual cycle and knee pain 572 children 726 injuries 474 \200\2238 problems 479 Mental Capacity Act 29 , 615 , 629 mental health, triage 612 mental health Kocher \200\231s method, shoulder dislocation 454 Kohler \200\231s disease 708 Korsakoff \200\231s psychosis 625 legislation 615 , 628 \200\2239 mental nerve block 302 mental state lunate dislocation 442 Lund and Browder charts examination 606 mephedrone 215 , 626 mesenteric ischaemia 514 metabolic acidosis 99 metabol ic diseases 661 metacarpal fractures 436 \200\2237 L labor 578 lactic acidosis 99 Langer \200\231s lines 464 \200\2235 laryngospasm 315 laryng otracheobron chitis 676 Lassa fever 250 Le Fort fractures 372 \200\2233 , 500 learning dif \201 culties 21 legal aspects 28 \200\22331 Legg-Calv -Perthes \200\231 disease 706 \200 \2237 leptospirosis 239 leukemia, acute 664 levonorgestrel 568 lice 230 lidocaine 283 lidoc aine gel 288 life support, advanced 52 \200\2233 (for burns) 391 luxatio erecta 457 , 500 Lyme disease 231 children 725 M magnesium metacarpophalangeal joint 438 metatarsal fractures 489 methanol poisoning 202 methedrone 215 methicillin resistant Staph. arrhythmias 53 , 85 , 87 children 654 , 656 asthma 106 children 679 , 680 aureus 235 methionine 191 \200\2232 midazolam de \201 ciency 164 eclampsia 149 , 592 normal range xvii sedation 308 status epilepticus 149 , 655 , 688 , 690 Maisonneuve injury 480 , 501 major incidents 38 chemical 36, 37 , 210 radiation 268 migraine 130 Milch method, shoulder dislocation 455 malar fractures 374 malaria 247 Malgaigne \200\231s fracture 501 malingering 620 mallet \201 nger 433 , 436 , newborn 642 \200\2235 pediatric 652 \200\2235 trauma (ATLS) 321 life support, basic 46 \200 \2239 milestones, pediatric 637 milia 662 Mini-Mental State newborn 643 pediatric 646 \200\2237 Examination 607 440 , 501 miscarriage (abortion) 584 mittelschmerz 572 Mobile Medical Team 39 monilial infection 662 monoamine oxidase inhibitors 619 mandibular injuries 376 \200\2237 mania 617 mannitol 129 , 365 , 542 MAOIs 619 Marburg feve r 250 march fracture 501 mastitis 599 mastoiditis 550 maxillofacial injuries 370 measles 22 2 meconium aspiration 645 median nerve block 296 \200\2237 median nerve lightning 266 lignocaine see lidocaine limb injuries acute ischaemia 531 pediatric 720 salvage 422 limping child 704 lip wounds 464 lipid emulsi on in Monteggia fracture 449 , 501 mood, affect 616 \200\234morning after pill \200\235 568 morp hine 276 children 280 overdose 188 smooth muscle spasm 277 trauma 279 poisoning 187 , 284 LA toxicity 284 Lisfranc fracture 500 lithium 617 injury 432 , 442 complications of 619 Morton \200\231s metatarsalgia 491 mouth to mouth medical defense lithium organization 29 poisoning 197 , 619 ventilation 48 , 646 Medical Incident Of \201 cer 39 medically unexplained symptoms 621 liver transplantation, paracetamol poisoning 191 MRSA 235 MSU 158 multiple sclerosis 142 mumps 222 medicolegal aspects 28 , 30 melaena 124 meningitis 224 \200\2235 , 666 \200\2239 local anesthesia 272 , 282 children 287 consent 286 contraindications 282 indications 282 in \201 ltration 289 toxici ty 284 see also nerve blocks orchitis 222 , 701 fungal 225 tuberculous 225 viral 225 meningococcal Munchausen \200\231s syndrome 620 by proxy 733 muscle injuries 426 muscle relaxants 316 mushroom poisoning 212 infection 224 , 664 , 666 \200\2239 locked \201 nger 441 menorrhagia 574 744 INDEX osteochondritis 708 \200\2239 osteochondritis newborn resuscitation 642 NHS Direct 11 NHS 24 , 11 nimodipine 129 nitrous oxide 278 , 317 non-accidental myasthenia gravis 142 myocardial infarction 68 \200\22377 dissecans 452 , 479 , 491 , 709 osteomyelitis 705 ECG changes 72 \200\2235 localization 74 NSTEMI 68 STEMI 70 , 76 \200\2237 myoclonic \201 t 688 myositis ossi \201 cans 427 \201 nger infection 441 sickle cell disease 176 tuberculosis 232 otitis externa 550 otiti s media 550 Ottawa ankle rules 484 \200\2235 Ottawa knee rules 475 ovarian problems 572 oxy gen therapy 95 injury 728 \200\22333 non-cardiogenic pulmonary oedema 102 non-shockable rhythms 51 non-steroidal anti- in \202 ammatory drugs 275 normal values N N-acetylcysteine 190 nailbed lacerations 435 naloxone 188 nappy rash 662 narrow complex blood tests xvii \200\223xviii physiological, children 633 pregnancy 577 hyperbaric oxygen 208 , 261 , 395 tachycardia 88 nasal bleeding 552 nasal diamorphine 281 nasal foreign bodies 546 nasal frac ture 553 nasoethmoidal fracture 372 nasopharyngeal airway 325 near drowning 258 neck note keeping 4 \200\2235 , 28 noti \201 able infectious diseases 221 P P wave 64 pacemakers 82 pacing (in ALS) 53 pediatric emergencies 630 pediatric fractures 718 pediatric milestones 637 pediatric resuscitation NSAIDs 275 nursemaid \200\231s elbow 501 nutcracker fracture 501 nystagmus 548 cervical spine O obsession 603 obstetrics and injury 380 \200\2235 chart 655 pain relief 272 palivizumab, pain 463 penetrating injury 378 soft tissue injury 462 wounds 378 gynecology 563 obstructive jaundice 510 OCP 4 , 569 O \200\231Donahue \200\231s triad 501 o esophageal intubation 314 oesophageal obstruction (food bolus) 547 oesophageal rupture 333 olecranon bursitis 453 olecranon fracture 450 ophthalmology 533 opioids 276 RSV disease 683 pancreatitis 508 in pregnancy 591 necrotizing fasciitis 234 needle cricothyroidotomy paracetamol 274 326 \200\2237 poisoning 190 \200\2233 paraf \201 n poisoning 205 paralysis, periodic 143 paranasal sinus itis 555 paraphimosis 523 , 702 paraquat poisoning 204 paratyphoid 248 parity 576 paronychi a 441 parotid gland injury 464 parotitis 557 Parvolex (acetylcysteine) needlestick injury 418 Neer \200\231s impingement test 460 neglect 732 nephroblastoma 699 nephrotic syndrome 694 nerve blocks 292 ankle 306 \200\2237 digital 294 \200\2235 ear 300 \200\2231 femoral 304 \200\2235 forehead 300 \200 \2231 infraorbital 302 intercostal 303 median 296 \200\2237 mental 302 radial 297 \200\2239 supraorbital 300 \200\2231 sural 306 \200\2237 tibial 306 \200\2237 ulnar 296 \200\2237 poisoning 188 sedation 308 optic neuritis 142 , 541 oral contraceptive pill 4 drug interactions 569 190 patella fracture 476 , 726 patellar tendon rupture 478 pathological fractures 420 patients oral rehydration therapy 228 oral wounds 464 orbital blow-out fractures 374 orchitis 522 , 701 mumps 222 discharge from ED 2 , 8 discharge of elderly patient 20 organ donation 27 organophosphate poisoning 206 dislike of speci \201 c 18 inappropriate nerve injuries, hand 432 , 434 neuroblastoma 699 neuroleptic malignant syndrome 265 attenders 16 regular attenders 17 \200\230special \200\231 patient groups 19 transfer of p atient 22 with a label 17 with learning oropharyngeal airway 325 children 654 Osgood-Schlatter \200\231s disease 708 osmolal gap 99 ossi \201 cation centers 721 osteoar thritis 495 neurological examination coma 138 head injury 360 spinal injury 382 dif \201 culties 21 PEA 51 745 INDEX tension 328 \200\2239 traumatic 334 psychiatric drugs, peak expiratory \202 ow complications of 619 psychiatric interview 604 psychiatry 601 psychogenic coma 138 psychosi s 603 pulmonary aspiration 112 , rates 105 children 678 Pelligrini-Stieda \200\231s disease 501 poisoning 179 chemical incidents 38 , 211 deliberate 180 , 753 diagnosis 182 \201 sh 229 food 226 \200 \2238 general principles 180 in children 181 , 696 \200\2237 reducing pelvic fractures 466 \200\2237 pelvic infection 598 pelvic in \202 ammatory disease 573 338 pulmonary contusion 332 , pelvic injury, children 714 penile problems 523 , 702 peptic ulcer disease 511 338 pulmonary embolus 120 absorption 184 \200\2235 supportive care 183 in pregnancy 593 pulmonary oedema cardiogenic 100 \200\2231 non-cardiogenic 102 pregnancy 591 poisons information 180 \200\2231 police requests for blood pericardial effusion 78 \200\2239 pericardiocentesis 79 , 343 pericarditis 78 perineal tear , imminent 580 periodic paralysis 143 peritoneal dialysis 161 peritoneal lavage 347 periton itis 161 , 504 , 507 , pulp infections 441 pulse oximetry 95 , 96 CO poisoning 208 alcohol 30 police statements 31 poliomyelitis 249 polyhydramnios 590 polymyositis 142 porphyria 165 po st-coital pulseless electrical activity (PEA) 51 , 107 puncture wounds 419 purpuric rash 664 pyelonephritis 158 , 159 516 contraception 568 peritonsillar abscess 554 peroneal nerve block 306 \200\2237 peroneal nerve injury 487 pero neal tendon children 692 \200\2233 pregnancy 591 pyloric stenosis 698 pyogenic tenosynovitis 441 pyrexi a of unknown origin 246 post-concussion symptoms 368 post-partum problems 598 post-resuscitation care 54 Pott \200\231s fracture 502 PR interval 64 pre-eclampsia 590 , 592 pregnancy 563 , 576 \200\223 599 abdominal pain 590 bleeding i n 582 \200\2233 , 588 cardiac arrest 596 ectopic 586 electric shock 266 hypertension 91 , 5 92 psychiatric problems 599 thrombosis 593 trauma 594 subluxation 487 perseveration 603 personal protective equipment 32 , 34 Perthes disease 706 \200\2237 pertussis, whooping cough 684 pethidine 276 petit mal 688 gasoline poisoning 205 phalangeal fractures 436 pharyngeal burns (cocaine) 5 55 phenol burns 397 phenothiazine Q Q waves 65 , 72 QRS amplitude 65 QRS width 64 QT interval 65 quadriceps rupture 478 quins y 554 R rabies 249 , 415 radial fractures 444 \200\2236 , pregnancy tests 582 prepatellar bursitis 479 pretibial lacerations 481 priapism 523 priloca ine 283 Prinzmetal \200\231s angina 69 Procurator Fiscal 10 , 26 , 31 propofol 308 , 316 pr ostatitis 523 prostheses, hip 468 prosthetic joint infection 495 prosthetic valve failure 1 01 protective equipment 32 , 34 prothrombin time poisoning 196 phimosis 702 physiological values in children 633 physiotherapy 428 Pilon fractures 501 pil onidal abscess 518 Pipkin fracture 501 placenta praevia 588 placental abruption 588 , 594 p lant poisoning 212 plantar fasciitis 491 plaster of Paris 424 \200\2235 platelet disorders 168 pleural effusion 103 Pneumocystis 448 \200\2239 , 724 \200\2235 radial head fracture 450 , 724 radial head subluxation (pulled elbow) 724 radial nerve block 297 \200\2239 radial nerve in jury 432 , 453 radial styloid fracture 446 radial tenosynovitis 447 radiation incidents 268 decontamination 211 , 269 radiological requests 6 radius, fractures 444 \200\2236 , (INR) xviii , 167 , 170 proxymetacaine 283 pruritus ani 518 pruritus vulvae 565 pseudo-gout 496 psychiatric assessm ent 604 448 \200\2239 infection 110 , 244 children 724 \200\2235 pneumonia 110 children 686 differential diagnosis 111 Ramsay Hunt syndrome 556 rape 570 rapid sequence induction after deliberate self harm 612 \200\2234 pneumothorax spontaneous 114 \200\2236 (intubation, RSI) 312 \200\2235 history 605 746 INDEX self-labeled patients 17 sepsis 59 rifampicin 190 , 225 , 569 ring avulsions 435 Rinne \200\231s test 548 Road Traf \201 c Ac t 30 roadside procedures 36 Rockall score 123 Rolando fracture 502 Romano \200\223Ward rashes 664 , 666 , 672 records see note keeping recuronium 316 red cell transfusion 173 red dot system 6 red eye 542 referral 8 , 28 in babies 660 septic arthritis 495 septic shock 59 \200\22361 septicaemia, meningococcal 666 \200\2239 sero-negative spondylo- arthropathies 497 serotonin syndrome 216 severe acute inappropriate 16 patient with a label 17 syndrome 65 regular attenders 17 Reiter \200\231s disease 238 , 497 rejection, transplant 161 relatives Rosier score, stroke 145 rotator cuff tears 459 rotator cuff tendonitis 461 Rovsing \200 \231s sign 507 RSV 682 \200\2233 rubella 223 runner \200\231s fracture 502 respiratory syndrome (SARS) 33 , 251 Sever \200\231s disease 708 sevo \202 urane 317 sexua l abuse 733 sexual assault 570 sexually transmitted diseases 238 Sgarbossa criteria, bereaved 24 \200\2235 in cardiac arrest 46 in major incidents 39 renal failure 160 , 694 renal trauma 351 rescue breaths 48 children 646 resin casts 424 res piratory depression