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 (ISBN-13: 9780511275746)




ACETAMINOPHEN POISONING

HENAN SEDIK, M.D., F.A.A.P.

HISTORY AND PHYSICAL

■ History of ingestion:

  ➢ Tylenol® preparations

  ➢ Over-the-counter analgesics/cold remedies

■ Toxic dose >150 mg/kg in acute ingestion

   ➢ Stage I (0.5–24 h):

    • Nausea

    • Vomiting

    • Diaphoresis

    • Pallor

    • Malaise

  ➢ Stage Ⅱ (24–72 h): latent period: initial symptoms resolve; hepatic dysfunction develops

  ➢ Stage Ⅲ (3–7 d):

    • Progressive hepatic encephalopathy: jaundice, confusion, hyperammonemia, & bleeding diathesis

TESTS

■ Acetaminophen level: 4 h after ingestion

■ Plot level on Rumack and Matthew’s semilogarithmic nomogram

■ Liver function tests

■ Serum toxicology screen for co-ingestions

DIFFERENTIAL DIAGNOSIS

■ Accidental vs. intentional

■ Chronic ingestions

■ Other hepatotoxins

■ Viral hepatitis/hepatic disease

■ Reye’s

MANAGEMENT

GI decontamination

■ Antidote: N-acetylcysteine (NAC)

SPECIFIC THERAPY

■ Decontamination:

  ➢ Gastric lavage: within first hour after ingestion.

  ➢ Avoid ipecac unless toxic co-ingestion

  ➢ Activated charcoal:

    • All patients w/in 4 h of ingestion

    • Consider beyond 4 h for co-ingestions or delayed absorption of acetaminophen (e.g., ingestion of sustained-release preparations or agent that slows gut motility)

N-acetylcysteine (NAC):

  ➢ Antidote

  ➢ Most efficacious if administered w/in 8 h of ingestion

  ➢ Use if:

    • 4-hour level >150 mcq/mL

    • Patient presents 6–8 h after ingestion: give initial dose while level pending

  ➢ Oral dose: loading dose 140 mg/kg, then 70 mg/kg q4h for 17 doses, diluted 1:4 in a carbonated beverage, PO or NG

  ➢ Side effects: nausea, vomiting

  ➢ Repeat dose if patient vomits within 1 h; use antiemetics

  ➢ Ⅳ NAC (not FDA approved in U.S.) recommended for:

    • Pts who cannot tolerate oral NAC due to intractable vomiting & for whom further delay will result in decreased efficacy

    • Pts whose medical condition precludes enteral use of NAC (e.g., corrosive ingestion, GI bleeding or obstruction)

    • Fulminant hepatic failure

    • Pregnancy

FOLLOW-UP

■ Serum acetaminophen level in “minimal risk of hepatic toxicity” range on nomogram (or ingestion <140 mg/kg): sent home

■ Potential hepatotoxicity: admitted for antidote therapy

■ Repeat monitoring of acetaminophen levels at 4 h intervals

NAC should not be discontinued if subsequent levels fall below possible hepatic toxic zone

■ Monitor liver function and coagulation profile

COMPLICATIONS AND PROGNOSIS

Complications

■ Fulminant hepatic failure

■ Renal failure

■ Anaphylaxis with Ⅳ NAC

Prognosis

■ No toxicity with ingestion of single dose <150 mg/kg

■ Hepatocellular necrosis: may resolve with ICU care

■ Fulminant hepatic failure: may require transplant


ACNE VULGARIS

PAULINE SHEEHAN, M.D.

HISTORY AND PHYSICAL

■ 85% teenagers & young adults affected

History

■ Risk factors: relative with severe disease, hyperandrogenism

Physical signs

■ Disorder of pilosebaceous unit; prominent on face, chest & back

■ Noninflammatory lesions:

  ➢ Microcomedones

  ➢ Open comedones (blackheads)

  ➢ Closed comedones (whiteheads)

■ Inflammatory lesions:

  ➢ Papules

  ➢ Pustules

  ➢ Cysts

  ➢ Nodules

TESTS

■ Free & total testosterone & DHEA-S, LH, FSH, prolactin in females who:

  ➢ Fail traditional therapy

  ➢ Evidence of hyperandrogenism

DIFFERENTIAL DIAGNOSIS

■ Rash caused by systemic or topical steroids, anticonvulsants, isoniazid

■ Folliculitis

■ Acne rosacea

MANAGEMENT

■ Goal: to prevent scarring and emotional sequelae

■ Noticeable improvement: 6–8 wk

■ Proper usage & dosage of medications important

■ Avoid creams, lotions, cosmetics, hair care products containing oil (use oil-free, non-comedogenic, water-based products)

■ Picking & excessive scrubbing can lead to scarring

SPECIFIC THERAPY

■ Depending on type, severity & distribution of lesions

■ Generally begin w/ topical therapy with keratolytic agent alone or w/ topical antibiotic; then progress to systemic therapy w/ oral antibiotics, OCPs, antiandrogens

■ Non-inflammatory:

  ➢ Benzoyl peroxide:

    • gels, creams, lotions, soaps, shaving creams, washes

    • Start w/ water-based gel or cream

    • Lower concentrations less irritant

  ➢ Tretinoin:

    • Creams, gels, solutions

    • Start with lowest concentrations; work up as tolerated

    • Apply thin layer every other night, wash off in am

  ➢ May add azelaic acid:

    • Anti-inflammatory, comedolytic; fades hyperpigmentation

    • Less potent than tretinoin but tolerated better

  ➢ May add adapalene gel: similar effect as tretinoin but less local irritation

  ➢ Tazarotene gel: for acne & psoriasis

■ Moderate inflammatory:

  ➢ As for non-inflammatory; then consider:

    • Topical clindamycin, tetracycline, or erythromycin

    • Add oral therapy PRN: tetracycline, doxycycline, minocycline

    • Second-line oral therapy: erythromycin, amoxicillin, cephal-exin

■ Severe inflammatory:

  ➢ As for moderate inflammatory; then consider:

    • Increase frequency & dosage of oral antibiotics

    • Consider intralesional steroids, isotretinoin (only for severe recalcitrant acne)

    • Oral contraceptives, hormonal therapy (spironolactone)

FOLLOW-UP

■ Re-evaluate in 6–8 wk

■ Adjust therapy accordingly

■ Continue antibiotics for 3 mo & reconsider therapy

■ Judicious use of antibiotics important

COMPLICATIONS AND PROGNOSIS

■ Scarring

■ Hyper- or hypopigmentation

■ Beware psychological impact


ACUTE ABDOMINAL PAIN

JAIME BELKIND-GERSON, M.D.

HISTORY AND PHYSICAL

History

■ Type, character, & radiation of pain

■ Previous abdominal pain

■ Vomiting, diarrhea, bowel function

■ ? GI bleeding

■ Cough, fever

■ Precipitating events, diet

■ Intake of drugs or toxins

■ Trauma

■ Past surgical history

Physical signs

■ Fever

■ Pharyngitis

■ Evidence of pneumonia, costovertebral angle tenderness

■ Location & character of pain

■ Presence or absence of bowel sounds

■ Liver, spleen size

■ Peritoneal signs

■ Rectal exam (test for blood)

■ Pelvic exam/testicular exam

TESTS

CBC

■ Urinalysis

■ Abdominal flat plate and upright films

■ Amylase, lipase, ALT/AST, bilirubins, glucose

■ Stool culture and tests for ova and parasites

BUN/creatinine

■ Pregnancy test

■ Toxicology screen

■ Chest x-ray

■ Abdominal ultrasound

■ In selected cases, GI contrast studies and/or CT

DIFFERENTIAL DIAGNOSIS

■ Trauma:

  ➢ Duodenal hematoma

  ➢ Pancreatitis

  ➢ Liver or spleen laceration

■ Intra-abdominal medical disorders:

  ➢ Constipation

  ➢ Gastroenteritis

  ➢ Peptic ulcer disease

  ➢ UTI

  ➢ Pelvic inflammatory disease (PID)

  ➢ Pancreatitis

■ Intra-abdominal surgical disorders:

  ➢ Appendicitis

  ➢ Intussusception

  ➢ Complicated pancreatitis

  ➢ Obstruction from previous surgery

■ Extra-abdominal disorders:

  ➢ Pneumonia

  ➢ Psychogenic pain

  ➢ Testicular or ovarian torsion

  ➢ Pregnancy

  ➢ PID

■ Systemic disorders:

  ➢ Lead poisoning

  ➢ Sickle cell anemia

  ➢ Diabetic ketoacidosis

  ➢ Porphyria

■ Surgical disorder suggested by:

  ➢ Pain that wakes child at night

  ➢ Severe pain

  ➢ Fever, vomiting (particularly bilious or feculent)

  ➢ Rebound tenderness

  ➢ Lack of bowel sounds

  ➢ Abdominal distention

  ➢ Failure to pass flatus

MANAGEMENT

General measures

■ Avoid analgesics

NPO with Ⅳ fluid & electrolyte replacement

NG tube for relief of GI obstruction

■ Consider surgical and/or gastroenterologist consult

SPECIFIC THERAPY

■ Varies according to etiology

■ Prompt attention to potential surgical cases is high priority

FOLLOW-UP

■ Frequent contact w/ pt discharged with diagnosis of abdominal pain

COMPLICATIONS AND PROGNOSIS

■ Varies according to etiology:

  ➢ Dehydration

  ➢ Electrolyte imbalances

  ➢ Sepsis

  ➢ Intestinal perforation, intestinal obstruction, & hemorrhage

Prognosis

■ Very good for most medical disorders (e.g., infectious diarrhea, gastroenteritis, constipation)

■ Excellent for surgical disorders treated in a timely manner (e.g., appendicitis, intussusception, testicular torsion, obstruction due to adhesions, ectopic pregnancy)


ACUTE ASTHMA

SUZANNE F. STEINBACH, M.D.

HISTORY AND PHYSICAL

History

■ Presence/duration: cough, wheeze, shortness/labored/rapid bre-athing

■ Home therapy: # & frequency of steroids, bronchodilator doses

■ Previous attacks:

  ➢ Use of steroids

  ➢ ER/hospital/ICU care

  ➢ Intubation

■ Best baseline peak expiratory flow (PEF)

■ Trigger exposures

Physical signs

■ Respiratory rate

■ Oxygen sat

■ Ability to speak

■ Retractions

■ Trachea midline, crepitus

■ Air entry, inspiratory to expiratory ratio (I:E), wheeze, asymmetries

■ Mental status

TESTS

■ PEF

CXR:

  ➢ Asymmetric exam

  ➢ Poor response to therapy

ABG: poor response to therapy

DIFFERENTIAL DIAGNOSIS

■ Bronchiolitis

■ Laryngotracheobronchitis (croup)

■ Foreign body aspiration

■ Vocal cord dysfunction

■ Airway compression

■ Anaphylaxis

MANAGEMENT

What to do first

■ Assess severity:

  ➢ Mild:

    • Mild tachypnea

    • Normal mental status and color

    • Speaks in sentences

    • ± mild retractions

    • PEF >80%

    • O2 sat >95%

    • PaCO2 <35

    • ± end-expiratory wheeze (E)

    • Good response

  ➢ Moderate:

    • Moderate tachypnea & retractions

    • Normal mental status

    • Speaks in phrases

    • Pale

    • PEF: 50–80%

    • O2 sat: 91–95%, PaCO2 <42

    • E or inspiratory (I) & E wheeze

    • Incomplete response to therapy

  ➢ Severe:

    • Severe tachypnea or apnea

    • Depressed or agitated mental status

    • ± severe retractions

    • Single word or short phrases

    • ± cyanotic

    • Decreased aeration

    • PEF <50

    • O2 sat <91, PaCO2 >41

    • Poor response to therapy

General measures

■ Reassure

■ Educate

■ Hydrate; avoid overhydration

■ O2: O2 sat >90%

■ Bronchodilators:

  ➢ Inhaled albuterol

  ➢ Ipratropium bromide

  ➢ SQ epinephrine/terbutaline

  ➢ Ⅳ terbutaline

■ Corticosteroids

SPECIFIC THERAPY

■ Mild:

  ➢ Albuterol 0.02 mL/kg (max, 1.0 mL) in NS nebulized or 2–4 puffs w/ spacer q20 min up to 3×, then q4 h at home, taper

  ➢ Consider oral steroids: 1–2 mg/kg (max, 60 mg/d) divided bid for 3–10 d

■ Moderate/severe:

  ➢ O2 to keep O2 sat >90%

  ➢ Albuterol 0.03 mL/kg (max, 1.0) in NS nebulized w/ ipratropium q20 min up to 3× or 4–8 puffs with spacer q20 min up to 4 h

  ➢ Steroids PO or Ⅳ: 2–4 mg/kg/day: in extremis or no response to 1st dose or incomplete response to 2nd dose of albuterol

■ In extremis, can’t do PEF, deteriorates suddenly:

  ➢ Epinephrine 1:1,000, 0.01 mg = mL/kg sq (max, 0.3–0.5 mL), repeat q15 min × 3

  ➢ Terbutaline 1:1,000, 0.01 mg = mL/kg sq (max, 0.25 mL)

Side effects and complications of treatment

■ O2: hypoventilation in chronic CO2 retainers

■ Beta-2 agonists: tachycardia, anxiety, tremor, head/abdominal pain, arrhythmias

■ Ipratropium: migratory anisocoria, tremor

■ Steroids: GI upset, acne, hyperglycemia, hypertension, weight gain, hypokalemia, psychosis

Contraindications:

Absolute

■ Sedation, mucolytic drugs

Relative

■ Chest physiotherapy; antibiotics (OK for pneumonia, sinusitis)

FOLLOW-UP

■ Assess after bronchodilator therapy & 1 h later

■ Poor response (persistent severe asthma): transfer to ER or ICU with O2, albuterol, steroids:

  ➢ SQ epinephrine/terbutaline

  ➢ Continuous albuterol nebs, 0.5 mg/kg/h

  ➢ MgSO4 25 mg/kg (max, 2.0 g) q6h

  ➢ Heliox 70/30

  ➢ Terbutaline Ⅳ: 10 mcg/kg over 10 min then 0.2 mcg/kg/min, titrate up to max 8 mcg/kg/min; monitor EKG, cardiac enzymes

■ Incomplete response (persistent moderate asthma):

  ➢ Repeat albuterol q20 min × 3 or space to qh × 3–4 h

  ➢ Corticosteroids

  ➢ ER or hospital >3 h

■ Good response (mild asthma):

  ➢ Space albuterol q2 h

  ➢ Consider steroids

■ Discharge: <2 signs in moderate category, PEF >80%

■ Follow-up 2–3 days

■ Persistent asthma (see “Chronic Asthma” entry): begin or step up preventive therapy


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