Rosen & Barkin's 5-Minute Emergency Medicine Consult (103 page)

• Anderson IM, Haddad PM, Scott J. Bipolar disorder.
  BMJ.
  2012;345:e8508.
  
• Lukens TW, Wolf SJ, Edlow JA, et al. Clinical policy: Critical issues in the diagnosis and management of the adult psychiatric patient in an emergency department.
  Ann Emerg Med
  . 2006;47(1):79–99.
  
• Sachs GS, Dupuy JM, Wittman CW. The pharmacologic treatment of bipolar disorder.
  J Clin Psychiatry.
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See Also (Topic, Algorithm, Electronic Media Element)

(Topic, Algorithm, Electronic Media Element) Medical vs. Psychiatric

• Delirium
  
• Depression
  
• Dystonic Reaction
  
• Psychiatric Commitment
  
• Psychosis, Acute
  
• Psychosis, Medical vs. Psychiatric
  

CODES

• 296.00 Manic disorder, single episode, unspecified degree
  
• 296.50 Bipolar affective disorder, depressed, unspecified degree
  
• 296.80 Bipolar disorder, unspecified
  

BASICS

• Most bites are from provoked animals.
  
• Dog bite wounds:
  
  • Large dogs inflict the most serious wounds (pit bulls cause the most human fatalities).
    
  • Most fatalities in children (70%) due to bites to face/neck
    
  • Dogs of family or friends account for most bites.
    
• Cat bite wounds:
  
  • Majority from pets known to victim
    
  • 50% infection rate in those seeking care
    
  • Puncture wounds most frequent due to sharp thin teeth causing deep inoculation of bacteria
    
• Catscratch disease (CSD):
  
  • 3 of the following 4 criteria:
    
    • Cat contact, with presence of scratch or inoculation lesion of the skin, eye, or mucous membrane
      
    • Positive CSD skin test result
      
    • Characteristic lymph node histopathology
      
    • Negative results of lab studies for other causes of lymphadenopathy
      
• Rat bite wounds:
  
  • Occur in lab personnel or children of low socioeconomic class
    
  • Rat-bite fever (RBF), rare in US but high mortality rate
    
  • Rat bites rarely transmit rabies, and prophylaxis not routine
    

• Dog and cat bites:
  
  • Pasteurella multocida
    is the major organism in both:
    
    • Twice as likely to be found in cat bites than dog bites
      
    • Gram-negative aerobe found in up to 80% of cat infections
      
    • Infection appears in <24 hr
      
  • Staphylococcus
    or
    Streptococcus
    :
    
    • Infection appears in >24 hr
      
  • Other organisms include anaerobes and
    Capnocytophaga canimorsus
    (dogs).
    
• Catscratch disease:
  
  • Caused by
    Bartonella henselae
    
• Rat bites:
  
  • Caused by
    Spirillum minus
    and
    Streptobacillus moniliformis
    (RBF)
    

DIAGNOSIS

• Distribution of mammalian bites:
  
  • Dog bites represent 80–90% of all bites.
    
  • Cat bites represent 5–15% of all bites.
    
  • Human bites represent 2–5% of all bites (see “Human Bite” chapter).
    
  • Rat bites represent 2–3% of all bites.
    
• Dog bites:
  
  • Appearance:
    
    • Crush injuries (most common), tears, avulsions, punctures, and scratches
      
  • Low rates of infection compared with cat and human bites
    
  • Infections usually present with:
    
    • cellulitis
      
    • malodorous gray discharge
      
    • fever
      
    • lymphadenopathy
      
• Cat bites:
  
  • Appearance:
    
    • Puncture wounds (most common)
      
    • Abrasions
      
    • Lacerations
      
  • High infection rates (30–50%) due to deeper puncture wounds
    
• Catscratch disease:
  
  • From the bite/scratch of a cat, dog, or monkey
    
  • Small macule or vesicle that progresses to a papule:
    
    • Begins several days (3–10) after inoculation
      
    • Resolves within several days or weeks
      
    • Regional lymphadenopathy occurs 3 wk postinoculation
      
    • Tender
      
    • Nonsuppurative
      
    • Resolves after 2–4 mo
      
  • Low-grade fever, malaise, headache
    
• Rat-bite fever:
  
  • Does not have to involve a bite. Can occur from handling of rats
    
  • S. moniliformis
    :
    
    • Begins several days (2–10) after exposure
      
    • Common in US
      
    • Fever, rigors, migratory polyarthralgias, headaches, nausea, and vomiting
      
  • S. minus
    
    • Incubation period from 1–3 wk
      
    • More common in Asia
      
    • Arthritis not common
      

• Animal’s behavior, provocation, location, ownership
  
• Time since attack
  
• Past medical history: Conditions compromising immune function, allergies, and tetanus status
  

• Record the location and extent of all injuries.
  
• Document any swelling, crush injuries, or devitalized tissue.
  
• Note the range of motion of affected areas.
  
• Note the status of tendon and nerve function.
  
• Document any signs of infection, including regional adenopathy.
  
• Document any joint or bone involvement.
  

• Aerobic and anaerobic cultures from any infected bite wound
  
• Cultures not routinely indicated if wounds not clinically infected
  
• Catscratch disease:
  
  • Presence of elevated titers of
    B. (Rochalimaea) henselae,
    or
    
  • Positive reaction to catscratch antigen (CSA):
    
    • Inject 0.1 mL CSA IM
      
    • Induration at the site 48–72 hr later equal to or exceeding 5 mm is positive
      

Plain radiograph indications:

• Fracture
  
• Suspect foreign body (e.g., tooth)
  
• Baseline film if a bone or joint space has been violated in evaluating for osteomyelitis
  
• For infection in proximity to a bone or joint space
  

• Human bite injuries: Human teeth cause crush injuries and animal teeth cause more punctures and lacerations.
  
• Bite injuries from other animals
  
• CSD-caused lymphadenopathy:
  
  • Reactive hyperplasia (leading cause of lymphadenopathy in children <16 yr)
    
  • Infection, chronic lymphadenitis, drug reaction, malignancy, and congenital conditions
    

TREATMENT

Apply pressure to any bleeding wound

• Achieve hemostasis on any bleeding wound.
  
• Airway stabilization if bite located on face or neck
  

• Wound irrigation:
  
  • Copious volumes of normal saline irrigation with an 18G plastic catheter tip aimed in the direction of the puncture.
    
  • Avoid injection of saline through tissue planes due to force of irrigation.
    
• Débridement:
  
  • Remove foreign material, necrotic skin tags, or devitalized tissues.
    
  • Do not débride puncture wounds.
    
  • Remove any eschar present so underlying pus may be expressed and irrigated.
    
• Wound closure:
  
  • Closing wounds increases risk of infection and must be balanced with scar formation and effect of leaving wound open to heal secondarily.
    
  • Do not suture infected wounds or wounds >24 hr after injury.
    
  • Repair of wounds >8 hr: Controversial
    
  • Close facial wounds (warn patient of high risk of infection).
    
  • Infected wounds, those presenting >24 hr after the event, and deep hand wounds should be left open.
    
  • May approximate the wound edges with Steri-Strips and perform a delayed primary closure.
    
• Antibiotic indications:
  
  • Infected wounds
    
  • Cat bites
    
  • Hand injuries
    
  • Severe wounds with crush injury
    
  • Puncture wounds
    
  • Full-thickness puncture of hand, face, or lower extremity
    
  • Wounds requiring surgical débridement
    
  • Wounds involving joints, tendons, ligaments, or fractures
    
  • Immunocompromised patients
    
  • Wounds presenting >8 hr after the event
    
• Elevate injured extremity
  
• Tetanus prophylaxis
  
• Rabies immunoprophylaxis:
  
  • Not required if rabies not known or suspected
    
  • Rodents (squirrels, hamsters, rats, mice) and rabbits rarely transmit the disease.
    
  • Skunks, raccoons, bats, and foxes represent the major reservoir for rabies.
    
  • See “Rabies” chapter for treatment guidelines.
    
• Catscratch disease:
  
  • Analgesics
    
  • Apply local heat to affected nodes.
    
  • Avoid lymph node trauma.
    
  • Disease usually self-limiting
    
  • Antibiotics controversial, consider if severe disease is present or immunocompromised victim
    
• Rat-bite fever:
  
  • High mortality (10%)
    
  • IV penicillin or doxycycline