1 The term \200\230Reiter \200\231s syndrome \200\231 is to be avoided, in light of the in volvement of Hans Reiter (1881 \200\2231969) in the Nazi party, eugenics and research in concentration camps. OHFP.indb 456 OHFP.indb 456 30/05/2014 16:18 30/05/2014 16:18 457 JOINT PAIN Systemic lupus erythematosus (SLE) Chronic, relapsing-remitting, multi-organ infl ammatory disease; joint pain represents one of the commonest initial presentations of SLE. Common jo ints symmetrical or asymmetrical; PIP, MCP, wrists, knees. Risk factors 5 (90%); African or South East Asian ethnicity. Symptoms systemic malaise, fever, weight loss musculoskeletal joint or muscle pain skin photosensitive malar or discoid rash, oral ulcers renal oedema, h aematuria neurological seizures, psychosis lung pleuritic chest pain, dyspnoea cardiac exer tional chest pain or pain on sitting forwards (per- icarditis) GI abdo pain, diarrhea hemat ological pallor, frequent infections, recurrent miscarriage. Signs arthritis (swelling, ten der), malar/discoid rash, oral ulcers, altered mental state, pericardial or pleuritic rubs, peritonitis. Investigations blds dHb/WCC/plts, dC4 C3, iESR, ANA +ve (95%, but non specif i c), dsDNA +ve (70%, highly specifi c, refl ects disease activity), anti-Sm +ve (40%, most specifi c), U+E; urine blood, protein, casts; X-ray non-erosive arthritis, pleural eff usi ons; echo valve vegetations, pericardial eff usion. Treatment NSAIDs, hydroxychloroquine oral steroids (for fl ares) in mild disease; methotrexate, azathioprine, mycophenolate in more severe disease; limited evidence for biological therapies (eg belimumab, rituximab). C omplications IHD, stroke, antiphospholipid syndrome (10%). Drug induced certain drugs can c ause a lupus-like syndrome that resolves promptly upon drug withdrawal; these include isoni azid, methyldopa, hydralazine and diltiazem. American College of Rheumatology diagnostic classi \201 cation The presence of \211 4 of the following supports a diagnosis of SLE: \200 Arthralgia \200 Renal disease \200 AN A +ve \200 Serositis (pleuritic or Photosensitivity \200 Oral ulcers \200 Immunological tests (eg anti-dsDNA, anti-Sm) Neuropsychiatric symptoms (seizures, pericardial) Hematological abnormalities psychosis) \200 Malar rash \200 Discoid rash (dHb/WCC/plts) Can be remembered by the mnemonic \200\230A RASH POINts MD \200\231. Antiphospholipid syndrome (APS) Antibodies to membrane phospholipids (formerly confusingly referred to as \200\230lupus anticoagulant \200\231) are found in severe infl ammatory dis eases as well as in normal individuals. APS is the association of antiphospholipid antibodi es with arterial or venous thromboembolism, or recurrent or late-term miscarriage. Rheumati c fever This migratory polyarthritis occurring 2 \200\2236wk after a streptococcal infectio n was previously a common cause of childhood mortality and structural heart disease, but is now rare in the developed world. Diagnosis requires 2 major or 1 major and 2 minor \200 \230Jones \200\231 criteria: \200 Major Carditis (new murmur, valve lesions, CCF); migrat ory large joint polyarthritis; Aschoff bodies (fi rm, painless nodules on wrist, elbow or k nee); erythema marginatum (pink rings on trunk or limbs); Sydenham \200\231s chorea (face o r arms) Minor Prolonged PR interval (if carditis not counted); arthralgia (if polyarthritis not counted); iWCC/CRP/ESR; fever, previous rheumatic fever. Treatment penicillin, NSAIDs steroids (see Children \200\231s BNF). _OHFP.indb 457 _OHFP.indb 457 30/05/2014 16:18 30/05/2014 16:18 458 CHAPTER 15 Emergency department Neck lumps Worrying features >45yr, weight loss, night sweats, hard irregular lump. Think about serious malignancy (primary, metastases, lymphoma); common many of the lumps on b p420; see Table 15.9 for lumps found only in the neck. Table 15.9 Location and causes of neck lumps Location Causes Midline Anterior triangle Lymph node, thyroid mass, salivary gland mass, branchial Goiter, thyroid isthmus mass, dermoid cyst, thyroglossal cyst cyst, carotid artery aneurysm Posterior triangle Lymph node, cervical rib, pharyngeal pouch Ask about location, onset, duration, change with time, pain, other lumps, trauma, bites, in fections, skin changes, systemic symptoms (eg weight loss, vomiting, fever), sore throat, c ough, hoarse voice; PMH previous lumps, cancer, radiotherapy, thyroid problems; SH foreign travel, smoking, alcohol intake; FH thyroid disease, cancer. Look for assess as for other l umps (b p420) along with the following: movement on swallowing, movement on tongue protrusi on, dentition, mouth ulcers, lumps inside the mouth, lumps in the tongue, appearance of the tonsils (?asymmetry), ear examination, facial nerve palsies. Investigation blds consider FBC, U+E, LFT, TFT, CRP, ESR; imaging CXR, USS, CT/MRI; biopsy fi ne needle aspiration (FNA) especially for thyroid or salivary gland lumps, USS-guided bi opsy, excision biopsy. Management a neck lump should always be taken seriously and referred to ENT unless it is cl early a reactive lymph node. Preauricular Postauricular Parotid Occipital Submandibular (submaxillary) Anterior triangle Retropharyngeal (tonsillar) Submental Anterior cervical Posterior cervical Posterior triangle Supraclavicular nodes (a) Fig. 15.3 (a) Lymph nodes of the head and neck. (b) Anatomical tr iangles of the neck. Sternocleidomastoid (b) OHFP.indb 458 OHFP.indb 458 30/05/2014 16:18 30/05/2014 16:18 459 NECK LUMPS Thyroid lump/goiter Symptoms and signs midline or anterior triangle mass, moves with swallowing but not with pr otruding tongue, may be hypo/eu/hyperthyroid. Management send TFT, arrange USS and refer to ENT for fi ne needle aspiration; increasing r isk of malignancy with increasing age. Salivary gland lump Causes stone, gland infl ammation (eg mumps), malignancy. Symptoms and signs lump in sublingual, submandibular, or parotid gland. Management refer discrete lumps to ENT for fi ne needle aspiration; increasing risk of mali gnancy with increasing age; suspect mumps if diff use uni- or bilateral parotid enlargement with fever (supportive management). Thyroglossal cyst Embryological remnant from the descent of the thyroid gland. Symptoms and signs young patient (<40yr) with single lump by the hyoid which moves with swa llowing and protruding tongue, may be infl amed. Management confi rm presence of functioning thyroid gland, since may be the only thyroid ti ssue; refer to ENT for removal (Sistrunk procedure). Dermoid cyst A benign, cystic teratoma which may contain fat or hair. Symptoms and signs single subcutaneous lump, found in the midline of the neck or next to th e eye in young patients (<20yr). Management refer to ENT for complete removal, can recur. Branchial cyst Incomplete closure of an embryological branchial arch, resulting in a cyst. Symptoms and signs slowly enlarging smooth mass, typically presenting in 2nd or 3rd decade; most arise from 2nd branchial arch, appearing at the anterior border of sternocleidomastoi d; may be tender, or enlarge after URTI. Management refer to ENT for surgical excision, may recur. Pharyngeal pouch (Zenker diverticulum) Symptoms and signs elderly patient with upper oesoph ageal dysphagia; regurgitation of undigested food; halitosis; mass rarely palpable. Management confi rmed by contrast swallow, treated by surgical myotomy. Cervical rib Congenital abnormality, with an extra rib arising from C7. Symptoms and signs hard mass in posterior triangle; usually unilateral; may have Raynaud \200\231s, distal muscle weakness or pain. Adson \200\231s sign is loss of radial pulse on elevation of arm on aff ected side. Management may require physiotherapy or excision if causing problems. _OHFP.indb 459 _OHFP.indb 459 30/05/2014 16:18 30/05/2014 16:18 460 CHAPTER 15 Emergency department ENT Worrying features unilateral hearing loss, mastoid pain, unilateral tonsillar enlargeme nt, hoarse voice >3wk, stridor, dysphagia, systemic symptoms, night sweats. Earache and deafness (OHGP3 b p942) Think about serious acute mastoiditis; common acute URT I, foreign body otitis media, otitis externa, tonsillar pathology; serious chronic cho- les teatoma, acoustic neuroma; common chronic glue ear, chronic suppu- rative otitis media (CSO M), earwax, presbyacusis (age-related deafness). Ask about onset, duration, discharge, itching, hearing loss, speech problems, runny nose, s ore throat, trauma, malaise. Look for pyrexia, appearance of eardrum (?perforated), eff usi on, color of canal, discharge, tonsils, lymphadenopathy, dental abscess, mastoid/ sinus pai n. Management most earache simply requires analgesia, consider: \200 Otitis media red, bulgi ng drum eff usion; pus/bloody discharge if drum perforated; analgesia, antibiotics if <2 yr old, moderate to severe pain, or T>39 C (eg amoxicillin at dose appropriate for age; ch eck children \200\231s BNF) Otitis externa itching, tender, discharge pus; clean canal and keep dry (may need aural toilet by ENT), give gentamicin + steroid ear drops Ear wax olive oil (drops into ear/6h for 5d) prior to syringing with warm water (ensure drum not perforated) Glue ear persistent middle ear eff usion with deafness usually lasts 3 \200\2236mth; a 2 \200\2236wk course of amoxicillin may help. ENT referral for grommets is only required if p ersistent and falling behind at school CSOM central perforation of drum, treat as for otitis externa \200 Cholesteatoma squamous epithelium proliferating within middle ear; unilateral deafness with chronic, painless discharge; requires ENT referral \200 Acoustic neuroma unilateral deafness tinnitus or vertigo; requires ENT referral Presbyacusis bilateral hearing loss with age, consider hearing aid. Epistaxis (nosebleeds) Ask about onset, duration, previous episodes, trauma, iBP, NSAID/ anticoagulation therapy, bleeding tendency, cirrhosis, alcohol. Look for postural BP change, shock; evidence of trauma/fracture. Investigations if persiste nt/recurrent: BP; FBC, clotting, LFT. Management resuscitate if needed (b p472); try to sto p bleeding: \200 Tilt head down, apply pressure to the soft fl eshy part of the nose for 15min Pack with nasal tampons leaving the attached ribbon visible to aid removal after 48h (irrigate with saline fi rst); if further bleeding refer to ENT for caute ry. In severe, persistent bleeding, continue resuscitation and refer urgently to ENT. OHFP.indb 460 OHFP.indb 460 30/05/2014 16:18 30/05/2014 16:18 461 ENT Sore throats (OHGP2 b p932) Think about serious peritonsillar or retropharyngeal abscess, l eukemia/ neutropenia; common viral URTI, tonsillitis, glandular fever. Ask about duration, coryzal symptoms, odynophagia, otalgia, night sweats, drug history. Look for pyrexia, enlarged tonsils pus, red throat, lymphadenopathy; fever, odynophagia, neck stiff ness dyspnoea suggest possible abscess. Management urgent FBC if possibility of neutropenia (eg chemotherapy, azathioprine); urgent ENT referral for drainage and IV antibiotics if abscess suspected; otherwise reassure, gar gle with soluble aspirin, regular analgesia (paracetamol and ibuprofen) over-the-counter medications (eg Diffl am see BNF). Consider antibiotics (eg phenoxymethylpencillin 500mg /6h PO) if persistent or pus seen over tonsils. Persistent consider alternative diagnosis including EBV serology; consider tonsillectomy in those with \211 5 disabling sore throats/year for 2yr. _OHFP.indb 461 _OHFP.indb 461 30/05/2014 16:18 30/05/2014 16:18 462 CHAPTER 15 Emergency department Groin lumpsp Worrying features testicular mass, painful lump, tenderness, vomiting, constip ation. Think about serious testicular cancer, testicular torsion, strangulated hernia; common lymp h node, inguinal hernia, femoral hernia, hydrocele, varicocele, spermatocele, epididymitis/ orchitis, ectopic testis, urogenital prolapse, saphena varix, groin abscess. See Fig. 15.4. Ask about location, onset, duration, change with time, pain, reducibility, other lumps, tr auma, skin changes, coughing, lifting, nausea, vomiting, constipation, weight loss, urinary incontinence; PMH previous lumps, cancer; 5: previous pregnancies, type of delivery; SH fo reign travel, IVDU, recent intercourse, condom usage; FH cancer. Look for see b p156 for fe male genital examination, b p155 for male. Management most lumps can be identifi ed from hi story and examina- tion; painful lumps need immediate referral to surgeons to exclude testi cular torsion or strangulated hernias. Testicular lumps need urgent (2wk) referral. Inguinal hernia Risk factors 4, increasing age, chronic cough, constipation, heavy lifting, previous abdominal surgery, ascites, obesity. Symptoms often asymptomatic apart from lump. Signs examine with the patient lying, then repeat standing up: scars, external genitalia, tenderness, reducibility (by patient and yourself ), cough impulse, check other side; only \200\230indirect \200\231 hernias extend into the scrotum. Management conservative weight loss, truss, high-fi bre diet, stop smoking, treat lung disease; surgery day surgery, eithe r open or laparoscopic. Complications irreducible hernia, strangulation. Femoral hernia As for inguinal hernia but more common in women and greater risk of irreduci bility and strangulation; surgical repair at earliest opportunity. 3Strangulated hernia An irreducible hernia where the blood supply has been compromised. Symptoms irreducible, painf ul lump near a hernial orifi ce (usually inguinal or femoral); may have nausea, vomiting, a bsolute constipation, abdo pain. Signs tender, red lump abdominal distension, peritonis m. Investigations blds FBC, U+E, glucose, amylase, CRP, G+S; AXR (exclude bowel obstruction ); erect CXR (exclude bowel perforation). Management request urgent senior review; NBM, ana lgesia (eg morphine 5mg IV PRN (titrate to pain) with cyclizine 50mg/8h IV), IV access and fl uids (b p381); book emergency theater. Saphena varix Dilated proximal long saphenous vein due to incompetent valves. Symptoms and signs single, soft, compressible, bluish lump below the inguinal ligament, disappears on ly ing, cough impulse present. Management high saphenous vein ligation. OHFP.indb 462 OHFP.indb 462 30/05/2014 16:18 30/05/2014 16:18 463 GROIN LUMPS Groin abscess Common in IVDU after injection in groin with dirty needles; manage as for ski n abscess (b p421), but consider DVT, endocarditis, HIV and atypical infections. Scrotal lump Separate from testis Within testis Cystic Solid Cystic Solid Hydrocele Tumor, orchitis Epididymal cyst Epididymitis Fig. 15.4 Diff erential diagnosis of a scrotal lump. 3Testicular torsion This is an emergency \200\223 if you suspect torsion, get a senior rev iew immedi- ately as testicular tissue will become necrotic in hours. Symptoms lower abdomi nal pain, swollen/painful testis, nausea, vomiting. Signs iHR, high riding/horizontal-lying testis, thickened spermatic cord (early sign), \200\223ve Prehn \200\231s sign (elevating testis does not relieve pain: if +ve more suggestive of epididymitis), absent cremasteric refl ex. Diff erential diagnosis epididymo-orchitis, hydrocele, testicular tumor. Managemen t request urgent senior review; diagnosis may be confi rmed on Doppler USS but this should not delay emergency surgical exploration; NBM, analgesia (eg morphine 5mg IV PRN (titrate t o pain) with cyclizine 50mg/8h IV), IV access and fl uids (b p381); book emergency theater. Complications testicular necrosis, infertility, contralateral torsion if not fi xed. Hydrocele Fluid in the tunica vaginalis surrounding the testis. Symptoms and signs enlarged \200\230testicle \200\231, soft, non-tender, smooth, well- defi ned, transilluminable. In vestigations can be secondary to a testicular tumor, USS if in doubt. Management conservati ve if asymptomatic; surgical intervention involves eversion and suturing of the tunica vagi nalis; aspiration sclerosant is an alternative in patients unsuitable for surgery, but a ssociated with recurrence. Spermatocele (epididymal cyst) Benign cystic accumulation of sperm within the head of the e pididymis. Symptoms and signs soft, small, well-defi ned, spherical, transilluminable, sepa rate (superior) to the testis; painless, but may be uncomfortable. Management transscrotal excision, only if symptomatic. Varicocele Varicose veins within the spermatic cord, associated with subfertility. Symptoms and signs soft, tubular lumps like a \200\230bag of worms \200\231 above the testicle, re solves on lying, cough impulse present; may be uncomfortable. Management usually none; surg ical ligation can improve fertility. _OHFP.indb 463 _OHFP.indb 463 30/05/2014 16:18 30/05/2014 16:18 464 CHAPTER 15 Emergency department Ectopic testis Embryological failure of testis to descend through inguinal canal. Symptoms and signs usually diagnosed in childhood; smooth, well-defi ned, spherical mass between ing uinal ring and scrotum, empty scrotal sac on the same side. Management surgical orchidopexy to reduce cancer risk. Epididymitis/orchitis Infection of epididymis/testis after UTI or STI; may mimic testicular torsion. Causes Chlamydia species, N. gonorrhea, E. coli, viral eg mumps. Symptoms and sig ns acute testicular swelling and pain, tender, enlarged testis urethral discharge, fever. Management exclude testicular torsion (b p463) and assess for STI (b p465) and UTI (urine dipstick/M,C+S); most infections will respond to doxycycline 100mg/12h PO and analgesia. Testicular cancer Symptoms painless lump felt within testicle, diff erence in size of testi cles. Signs hard, non-transilluminable, irregular surface to testicle, may have a 2 \232 hy drocele. Investigations blds FBC, LFT, A-FP, B-hCG, LDH; imaging scrotal USS, CXR and CT fo r staging; biopsy. Management surgical removal with radiotherapy and/or chemotherapy. Progn osis 98% 5yr survival. Urogenital prolapse Risk factors multiple childbirth, vaginal deliveries, large babies, hea vy lifting, age, chronic cough, constipation, obesity. Symptoms vaginal lump, dragging sens ation, urinary frequency/urgency, urinary incontinence, constipation, intercourse problems. Signs PV exclude masses, prolapse may be seen on asking patient to \200\230bear down \200 \231 during speculum examination. Treatment weight loss, stop smoking, treat constipation, pelvic fl oor exercises; interventional ring pessaries;1 surgery hysterectomy, pelvic fl oo r repair. Table 15.10 Types of urogenital prolapse Uterine prolapse First degree cervix remains within vagina Second degree cervix visible at introitus Third degree procidentia; uterus protruding from vagina Prolapse of the vaginal wall after hysterectomy; may contain small intestine or omen tum Urethra bulges onto the lower anterior vaginal wall Bladder wall bulges on the anterior vaginal wall Rectal wall bulges into the middle posterior vaginal wall Intestinal loops he rniate into the upper posterior vaginal wall Vault prolapse Urethrocele Cystocele Rectocele Enterocele 1 Review every 6mth to replace, check for bleeding/ulceration and symptoms. Prescribe topic al estrogen to reduce the risk of ulceration. OHFP.indb 464 OHFP.indb 464 30/05/2014 16:18 30/05/2014 16:18 465 GROIN LUMPS Sexually transmitted infections (STIs) Until recently known as venereal disease (after Venu s, the Roman goddess of love) patients may present to the emergency department or their GP complaining of symptoms of an STI. These patients should always be given information about and encouraged to attend the local sexual health clinic, ideally with any current partner. Since coinfection with multiple STIs is common, these clinics off er comprehensive screenin g, sexual health advice and contact tracing where necessary. Some common infections include : \200 Gonorrhea (Neisseria gonorrhoeae) Symptoms usually appear 1 \200\22314d after expo sure and include yellow/green discharge with dysuria in both sexes. Diagnosis involves Gram staining and culture of high vaginal or urethral swabs, and PCR. Usually sensitive to ceph alosporins, as increasingly resistant to fl uoroquinolones (ciprofl oxacin, levofl oxacin). \200 Chlamydia (Chlamydia trachomatis serovars D-K) Symptoms usually appear 1 \200\2233w k after exposure and include watery/white discharge dysuria in both sexes. Infection can often go unnoticed (especially in women). Diagnosis involves antigen detection or PCR, usi ng live cells acquired from endocervical (5) or urethral (4) swabs using a special swab and transportation medium. Usually sensitive to tetracyclines or macrolides. Lymphogranuloma venerum (Chlamydia trachomatis serovars L1 \200\2233) Increasingly common amongst homosexual men in Europe. Primary infection is ma rked by the appearance of a painless ulcer at the inoculation site after 3 \200\22312d; sec ondary disease appears after up to 6mth, with tender unilateral lymphadenopathy, or proctit is in anal inoculation. Diagnosis is either serological or with PCR. Usually sensitive to t etracyclines or macrolides. Syphilis (Treponema pallidum) Symptoms can take up to 3mth to appear. Primary disease cause s a painless genital ulcer. Secondary disease causes perianal plaques, a non-itchy rash and fl u-like symptoms. Diagnosis is serological, usually using a combination of a nontreponem al screening test (eg VDRL), with confi rmation using a treponemal specifi c test (eg FTA-A BS). Treatment is with IM benzylpenicillin. Genital herpes (herpes simplex virus, usually type 2) Symptoms usually appear 2 \200\2237d after exposure, causing itching, tingling or small fl uid-fi ll ed vesicles in genital area. Diagnosis is clinical, supported by PCR where necessary. Episo des can be treated with antivirals (eg aciclovir), but this does not \200\230cure \200\231 the disease (see also b p415). \200 Genital warts (human papillomavirus, especially type s 6, 11) Small fl eshy tags or larger caulifl ower-shaped lesions. Diagnosis is clinical, s upported by PCR testing where necessary. Always ensure a recent cervical smear in aff ected women. Treatment is with topical keratolytic or cryotherapy. Likely to recur (see also b p 421). Pubic lice (Pthirus pubis) Symptoms take 1 \200\22314d after exposure and include pruritus in hairy infected areas in both sexes. Diagnosis is by light microscopy. Treatment is with parasiticidal topical preparation which should be repeated at 7d to kill lice emerging from surviving eggs (see also b p416). _OHFP.indb 465 _OHFP.indb 465 30/05/2014 16:18 30/05/2014 16:18 466 CHAPTER 15 Emergency department y Burns emergency g If airway involved \200\223 CALL anesthetist If no respiratory eff ort \200\223 CALL ARRE ST TEAM If no palpable pulse \200\223 CALL ARREST TEAM Airway Breathing Circulation 3Call for senior help early if patient deteriorating or >10% burns. Airway/C-spine \200 A pply collar, sandbags, and tape if C-spine injury is possible \200 Look for burns to the face and neck, singed eyebrows, facial hair or nasal hairs, soot around the nostrils or in the sputum, facial swelling Listen for snoring noises, stridor, hoarse voice \200 Intubation if inhalation injury sus pected to prevent airway obstruction. Breathing \200 15l/min O2 if SOB or sats <94% \200 Count RR; rapid breathing suggests inhalation injury \200 Monitor O2 sats and RR \200 Escharotomy if circumferential chest burns are restricting breathing. Circulation \200 V enous access, send bloods for FBC, U+E, glucose, clotting, G+S \200 carboxyhaemoglobin (COHb) \200\223 try the blood g as machine Give 0.9% saline 1l STAT \200 Give morphine IV (eg 10mg titrated to pain) and cyclizine 5 0mg IV \200 Monitor HR with defi brillator ECG leads and BP for signs of shock. Disabilit y \200 Assess GCS and check glucose \200 Look/feel for pupil refl exes, limb tone and p lantar refl exes. Exposure \200 Measure the extent of 2nd-/3rd-degree burn, see Fig. 15.5 \200 Cover the burn with cling fi lm as analgesia, avoid creams \200 Check temp. Furth er resuscitation \200 Obtain history and examine the patient \200 Calculate fl uid requ irements and adjust rate accordingly (see \200\230Burns fl uid resuscitation \200\231) Catheterise to monitor urine output \200 CXR for trauma and as a baseline (signs of inhal ation injury after 24h) \200 ABG if respiratory distress \200 Monitor circulation of al l limbs with burns \200 Call for senior help \200 Reassess, starting with A, B, C \200 g , , , Serious complications \200 Hypovolaemia b p472 \200 Carbon monoxide poisoning b p469 \200 Inhalation injury b p469 Coexisting trauma b p434 \200 Limb ischaemia b p446 \200 Restriction of breathing b p27 0 OHFP.indb 466 OHFP.indb 466 30/05/2014 16:18 30/05/2014 16:18 467 BURNS EMERGENCY Measuring the burn Burn sizes are expressed as a percentage of the skin surface covered by 2nd- or 3rd-degree burns. 1st-degree burns (erythema only) are not counted. The Lund and Br owder chart1 in Fig. 15.5 works for children and adults: A A 1 1 2 2 2 2 13 1 /1 2 1 /1 2 13 1/1 2 1/1 2 2 /1 2 2 /1 2 1 1 /1 4 1/1 4 1/1 4 1/1 4 B B B B C C C C 1 /3 4 1 /3 4 1/3 4 1 /3 4 Relative percentage of body surface area affected by growth Area A (1/2 of head) B (1/2 of one thigh) C (1/2 of one leg) <1yr 91/2 23/4 21/2 1yr 81/2 31/4 21/2 5yrs 61/2 4 23/4 10yrs 51/2 41/4 3 15yrs 41/2 41/2 31/4 Adult 31/2 43/4 31/2 Fig. 15.5 Lund and Browder chart. 1 The palm (not including fi ngers) of a patient \200\231s hand is about 0.75 \200\2231% of t heir body surface area and this can be used for smaller burns. Alternatively the \200\230r ule of nines \200\231 can be used for adults: Head 9% Each arm 9% Each leg 18% Trunk front 18% Trunk back 18% Perineum 1% Burns \202 uid resuscitation The burn size is used to calculate fl uid requirement for re suscitation using the following formula: \200 (4 x weight (kg)) x percentage of burn = vo lume over 24h (ml) Give half over the fi rst 8h after injury (ie over 6h if presented at 2h ): \200 (Volume over 24h (ml) 2) 8 = rate per hour (ml) The other half is given ove r 16h: \200 (Volume over 24h (ml) 2) 16 = rate per hour (ml) So for a 70kg man with 30% burns the rate is 525ml/h for the fi rst 8h then 263ml/h for the next 16h. This is onl y a guide, monitor the volume status and urine output to maintain volume (b p380). 1 Reprod uced from Lund, C.C., Browder, N.C. Surg Gynaecol Obstet 1944 79:352. _OHFP.indb 467 _OHFP.indb 467 30/05/2014 16:18 30/05/2014 16:18 468 CHAPTER 15 Emergency department Burns Worrying features HR >100, systolic BP <100mmHg, RR >30, O2 sats <92%, signs of inhalation injury, full thickness or circumferential burn, fi res indoors, explosions, >10% skin invol vement. Think about life/limb threatening see b p466; most likely cutaneous burns, chemical/electri cal burn, carbon monoxide poisoning, non-accidental injury, associated injuries (fractures, wounds, eye/ear trauma). Ask about mechanism of burn, time of burn, explosions, smoke, cau se of fi re, place where fi re occurred, duration of exposure, immediate treatment, falls/j umping out of windows, trauma, breathing diffi culty, pain; PMH cardiac or respiratory prob lems, previous burns/trauma; DH allergies, tetanus status; SH smoking (COHb result), housin g (do they have somewhere to go?) Obs temp, RR, BP, HR, O2 sats. Look for soot around nostr ils/mouth, facial burns, swelling, singed facial hair, nostril hair or eyebrows, stridor, h oarse voice, degree of burn (see Table 15.11), color, sensation, blistering, extent of burn , location of burn, circumferential burns, other trauma. Depth of burn is assessed by the a ppearance, blanching, sensation and bleeding when pricked with a needle; it can be diffi cu lt to assess especially as diff erent depths may be close together so that a patient may re port pain in an area of full thickness burn. Always get a senior \200\231s opinion. Investi gations blds COHb if fi re occurred inside; consider ABG, CXR. Table 15.11 Classifying burn severity Depth Super \201 cial Partial dermal Deep dermal Full thickness Degree Color 1st Red 2nd 3rd White, brown, black, leathery No No No Pink, blisters Bright red, mottled No Yes Slow Blanching Sensation Bleeding Yes Yes Yes Yes Yes Yes Treatment Major burns (>10% skin surface) resuscitate as per protocol (b p467). Minor burns cool with running cold water for 10 \200\22320min as soon as possible after the injury. Of f er analgesia (b p86) and cover the burn with cling fi lm until management has been determ ined. The following should be referred to plastics for assessment: \200 All burns to the face, hand, or genitalia unless small and superfi cial \200 All deep dermal/full thicknes s burns larger than a postage stamp. Ask for their advice on dressings (often minimal as so me dressings alter the appearance of the burn). Other burns should be cleaned with water an d dressed. OHFP.indb 468 OHFP.indb 468 30/05/2014 16:18 30/05/2014 16:18 469 BURNS Dressings If referring straight to plastic surgery cover the burn in cling fi lm. Otherwise aim to keep the burn covered with a sterile and non-adherent dressing: \200 Silver sulfa diazine cream (eg Flamazine ) silver has antibiotic eff ects to reduce the risk of infecti on; it should be pasted on 3 \200\2235mm thick \200 Paraffi n impregnated gauze (eg Jelon et ) this is a non-adherent dressing; it can be applied over silver sulfadiazine cream Sterile gauze and crepe bandages can be used on top of Jelonet \200 Polythene bag/glove this can be placed over a burn to the hand treated with silver sulfadiazine cream Paraffi n wax/Vaseline can be applied often for areas diffi cult to dress The burn should be reviewed and redressed in 2 3d. \200 The burn should be reviewed and redressed in 2 \200\2233d. Tetanus Burns can cause inoculation with tetanus; manage in the same way as wounds (b p437). 3Inhalation injury Inhalation of smoke can cause delayed obstruction of the airway. Symptom s breathlessness, hoarse voice, dysphagia, confusion. Signs singed facial hair or eyebrows, soot around the nostrils or palate, facial/neck burns, stridor, drooling, swelling near th e airways, wheeze. Investigations dPEFR; blds iCOHb (see Carbon monoxide poisoning ); ABG acidosis, hypoxia, hypercapnia; ECG exclude dysrhythmia/ ischaemia; CXR ARDS after 24h. Man agement symptoms or signs of inhalation injury should prompt early intubation, high-fl ow h umidifi ed O2, salbutamol. Complications pulmonary oedema, ARDS, upper airway obstruction. 3Carbon monoxide poisoning This must be considered in all patients involved in fi re-relate d injuries. Symptoms headache, vomiting, malaise, lethargy, dysrhythmias. Signs often none, O2 sats will be falsely high, cherry-red lips (rare). Results COHb available on some gas a nalysers \200\223 seek advice. >30% is con- sidered serious; very heavy smokers may have a COHb of up to 15%; ABG may show metabolic acidosis; ECG to exclude dysrhythmia/ischaemia. Management 15l/min O2 by tight fi tting mask and reservoir for >24h (use humidifi ed O2); c onsider mannitol, ventilation, hyperbaric O2. Complications cerebral oedema, pulmonary oede ma, MI, dysrhythmia. 3Chemical burns These can be severe, especially if alkalis are involve d. They should be washed in running water for at least 20min; larger burns may need fl uid replacement as for thermal burns (b p467). Toxbase (b p493) will give advice on the treatme nt of specifi c chemical burns. 3Electrical burns These can cause dysrhythmias, cardiac dam age and severe muscle damage resulting in renal failure or compartment syndrome. ECG in all patients; blds FBC, U+E, iCK; urine dipstick if severe or high voltage (>1000V) for blood (actually detecting myoglobinuria). _OHFP.indb 469 _OHFP.indb 469 30/05/2014 16:18 30/05/2014 16:18 470 CHAPTER 15 Emergency department Anaphylaxis in adults (OHCM9 b p806) p y If airway involved \200\223 CALL anesthetist If no respiratory eff ort \200\223 CALL ARRE ST TEAM If no palpable pulse \200\223 CALL ARREST TEAM Airway Breathing Circulation 3Call for senior help early if anaphylaxis suspected. \200 Sit patient up unless hypotens ive, then lay fl at with legs elevated \200 15l/min O2 in all patients \200 Monitor pul se oximeter, BP, defi brillator ECG leads if unwell \200 Request full set of observations \200 Take brief history if possible/check drug chart/ask ward staff \200 Examine patie nt: look for early signs of anaphylaxis (see box) \200 Establish likely cause and stop fu rther exposure (eg IV antibiotics) \200 Adrenaline, 1:1000 solution, 0.5ml (0.5mg) intram uscular: repeat after 5min if no improvement Large-bore venous access, take bloods if time permits: \200 FBC, U+E, mast cell tryptase (see \200\230Investigations \200\231) IV infusion of 1l 0.9% saline STAT \200 Consider nebulised b-agonist for bronchospasm: salbutamol 5mg, or \200 adrenaline 1:1000 solution, 5ml (5mg) Re-assess \200 Consider adjuncts to treatment: antihistamine, eg chlorphenamine 10mg slow IV \200 hydrocortisone 200mg slow IV Ensure senior help has been requested. Intramuscular adrenaline should be given if the diag nosis of anaphylaxis is likely but not if the symptoms are mild or the patient is well. Early signs of anaphylaxis Urticaria \200 Bronchospasm/stridor \200 Vomiting and/or diarrhea Flushing \200 Abdominal pain \200 Sense of impending doom. OHFP.indb 470 OHFP.indb 470 30/05/2014 16:18 30/05/2014 16:18 471 ANAPHYLAXIS IN ADULTS 3Anaphylaxis Worrying signs BP <90mmHg systolic, dO2 sats, chest tightness, stridor. Common precipitants Drugs Penicillins, anesthetic drugs, contrast media, blood products Latex, stings, eggs, fi sh, s trawberries, nuts Environmental Symptoms chest tightness, wheeze, breathlessness, itching, swelling, anxiety/fear/agitation , GI disurbance (vomiting, abdominal pain, diar- rohea). Signs see box; later hypotension, tachycardia, tongue/periorbital swelling, wheeze, cyanosi s. Treat all patients with physical signs. Investigations 3if you suspect anaphylactic shoc k commence treatment (see b p470): seconds count. Subsequently check for serum mast cell tryptase to confi rm gl obal mast cell degranulation (send three samples of clotted blood: one during the reaction once adrenaline has been given, one 1h post-reaction, and one 6 \200\22324h post-reaction). Follow-up by immunologist; consider adrenaline for self-injection (eg EpiPen \200\232). Adrenaline (epinephrine) preparations 1:1000 1:10,000 Preparation \200\223 1ml ampoule. Give 0.5ml (0.5mg) IM 1mg in 1ml Preparation \200\223 1 0ml syringe in cardiac arrest drugs, or 10ml ampoule 1mg in 10ml Intramuscular adrenaline should be given if the diagnosis of anaphylaxis is likely but not if the symptoms are mild or the patient is well. _OHFP.indb 471 _OHFP.indb 471 30/05/2014 16:18 30/05/2014 16:18 472 CHAPTER 15 Emergency department y Hypotension emergency yp g If airway involved \200\223 CALL anesthetist If no respiratory eff ort \200\223 CALL ARRE ST TEAM If no palpable pulse \200\223 CALL ARREST TEAM Airway Breathing Circulation 3Call for senior help early if patient deteriorating Systolic <100mmHg: \200 Lay patient fl at and elevate the legs if dizzy \200 15l/min O2 if SOB or sats <94% \200 Monitor pu lse oximeter, BP, defi brillator ECG leads if unwell \200 Request full set of observation s and ECG \200 Take brief history if possible/check notes/ask ward staff \200 Examine p atient: condensed RS, CVS, abdo and neuro exam \200 Establish likely cause of shock \200 Large-bore venous access, take bloods: FBC, U+E, CRP, D-dimer, cardiac markers, blood cultures IV infusion of 1l 0.9% saline STAT \200 Treat most likely cause, see following sections \200 Arterial blood gas, but don \200\231t leave the patient alone \200 Consider request ing urgent CXR, portable if too unwell \200 Call for senior help \200 Reassess, startin g with A, B, C \200 Life-threatening causes Hypovolaemic/haemorrhagic shock (b p478) \200 Septic shock (b p480) \200 Cardiogenic sh ock (tamponade/tension pneumothorax/heart failure) (b p479) \200 Anaphylactic shock (b p4 70) \200 Neurogenic shock (spinal shock) (b p481). OHFP.indb 472 OHFP.indb 472 30/05/2014 16:18 30/05/2014 16:18 473 HYPOTENSION (SYSTOLIC <100mmHG) Hypotension (systolic <100mmHg) yp g) Worrying features dGCS, idHR, stridor, dO2 sats, blee ding, chest pain, diz- ziness, durine output, renal failure, severe back pain, non-blanchin g rash. ( y Think about life-threatening shock (hypovolaemic/haemorrhagic, septic, cardiogenic, anaphyl actic, neurogenic), dysrhythmia (brady- or tachyarrhythmia); other postural hypotension, va sovagal episode, Addison \200\231s disease/adrenal insuffi ciency, drugs (B-blockers, ACEi, Ca2+ channel blockers, diuretics, nitrates). Ask about assess severity shortness of breath , dGCS, feeling faint/ dizzy on standing, what is timecourse, and what BP does patient usua lly run (inspect recent obs charts); consider cause palpitations, chest pain, blood loss (h aematemesis, melaena, PV bleeding), trauma, abdominal/back/loin pain, diarrhea, vomiting, p olyuria, fever, sweats, cough, urinary symptoms, itch/urticaria, spinal trauma or anestheti c, weight loss, skin darkening; PMH AAA, gastroduodenal ulcers, pregnancy, diabetes insipid us and DM, infections (urinary, chest, cardiac, blood), immunocompromise, angina, MI, previ ous DVT/PE, Addison \200\231s disease, postural hypotension; DH cardiac medications (B-bloc kers, ACEi, Ca2+ channel blockers, diuretics, nitrates), blood transfusions, antibiotics, a nticoagulants, recent anesthetics, steroids (?withdrawal), allergies (?anaphylaxis); FH PE/ DVT, Addison \200\231s/autoimmune disease; SH smoking, alcohol, recreational drug abuse. Ob s HR, BP, postural BP, RR, sats, temp, GCS, fl uid balance. Look for volume status (b p380) , pulse rate/rhythm/volume, evidence of diarrhea or vomiting, source of bleeding (limbs, ch est, abdomen, back, mouth, PR, PV), palpable abdominal aortic aneurysm, abdominal guarding or tenderness, warm peripheries or fever, fl ushed appearance, sweating, urticaria, dyspnoe a, focal signs in the chest (consolidation, tension pneumo- thorax, or pulmonary oedema), c alf swelling or tenderness, wasting of small muscles of the hands or iskin pigmentation. In vestigations serial BP repeat BP manually to confi rm diagnosis and check bilateral BP; ECG dysrhythmia, evidence of LVH/strain/MI; blds FBC, U+E, glucose, G+S (X-match if hemorrhage ), CRP; consider D-dimer, cardiac markers, clotting, blood cultures, mast cell tryptase; ur ine dipstick and M,C+S, consider catheter; CXR consolidation, mediastinal widening; do not request if you suspect tension pneumothorax \200\223 perform immediate needle decompressio n (b p279); pelvic X-ray in trauma; CT chest may be nec- essary if aortic dissection suspec ted. Consider also central venous pressure monitoring via a central line, continuous arteri