Rosen & Barkin's 5-Minute Emergency Medicine Consult (151 page)

• Albuterol using nebulizer: 2.5 mg in 2.5 mL NS (peds: 0.1–0.15 mg/kg/dose)
  
• Atropine: 2 mg IM or IV (5–6 mg in severely poisoned adults; peds: 0.02–0.08 mg/kg), then q5–10min titrate to clinical effect
  
• Cyanide antidote kit:
  
  • Inhale amyl nitrite ampule for 30 sec qmin until sodium nitrite given.
    
  • Sodium nitrite: 10 mL of 3% solution or 300 mg IV over 3–5 min (peds: 0.15–0.33 mL/kg):
    
    • Monitor methemoglobin levels to keep <30%.
      
  • Sodium thiosulfate: 50 mL IV of 25% solution or 12.5 g (peds: 1.65 mL/kg)
    
• Diazepam: 5–10 mg IV over 3–5 min (peds: 0.2–0.4 mg/kg up to 10 mg over 2–3 min)
  
• Hydroxocobalamin: 5 g IV
  
• Pralidoxime chloride (2-PAM, Protopam): 1–2 g IV over 20–30 min or 600 mg IM (diluted with water or saline to concentration of 300 mg/mL) given with 1st 3 atropine doses (peds: 25–50 mg/kg/dose IV), repeat in 2 hr if muscle weakness has not been relieved, and in 4–6-hr intervals if necessary. Continuous infusion of 500 mg/h has been used for organophosphate poisoning
  

FOLLOW-UP

• ICU admission for symptomatic patients with significant exposure
  
• Hospital admission to monitor for developing complications for blister, choking, lacrimating agents, incapacitating agents
  

Riot control exposures:

• Observe in ED for 6 hr and discharge if symptoms resolve.
  

Must perform adequate decontamination

• Davis K, Aspera G. Exposure to liquid sulfur mustard.
  Ann Emerg Med
  . 2001;37:653–656.
  
• Keyes DC. Chemical warfare agents. In: Dart RC, Caravati EM, McGuigan MA, et al., eds.
  Medical Toxicology
  . 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:1777–1794.
  

CODES

• 987.5 Toxic effect of lacrimogenic gas
  
• 987.7 Toxic effect of hydrocyanic acid gas
  
• 987.9 Toxic effect of unspecified gas, fume, or vapor
  

BASICS

• One of the most frequent chief complaints in the ED
  
• Often the presenting symptom of a high-risk etiology:
  
  • Acute coronary syndrome
    
  • Pulmonary embolism
    
  • Aortic dissection
    
• Assume life threatening until proven otherwise.
  
• Categorization may suggest the underlying etiology, but the presentation of chest pain can be extremely variable and vague.
  
• Thoracic pain:
  
  • May involve the myocardium, pericardium, the ascending aorta, pulmonary artery, mediastinum, and esophagus
    
  • Pain is deep, visceral, and poorly localized.
    
  • Characteristics vary from severe and crushing to mild, burning, or indigestion.
    
• Epigastric pain:
  
  • May involve the descending aorta, diaphragmatic muscles, gallbladder, pancreas, duodenum, and stomach
    
  • Pain is generally referred to the xiphoid region and in the back.
    
• Pleuritic pain:
  
  • Inflammation or trauma to the ribs, cartilage, muscles, nerves, pleural or pericardial surface
    
  • Pain increased by breathing, laughing, coughing, sneezing
    
  • Tenderness to palpation may be present.
    
  • Diaphragmatic pleurisy:
    
    • Sharp shooting pains in the epigastrium, lower retrosternal area, or shoulder intensified by thoracic movement
      
• Chest wall pain:
  
  • Inflammation of skin and SC structures of the chest wall
    
  • Pain is reproduced by:
    
    • Palpation
      
    • Horizontal flexion of the arms
      
    • Extension of the neck
      
    • Vertical pressure on the head
      

• Thoracic:
  
  • Acute coronary syndrome
    
  • Pericarditis
    
  • Myocarditis
    
  • Stress-induced cardiomyopathy
    
  • Cardiac syndrome X
    
  • Stimulant use
    
  • Thoracic aortic dissection
    
  • Esophagitis
    
  • Esophageal spasm
    
  • GERD
    
  • Esophageal hyperalgesia
    
  • Abnormal motility patterns and achalasia
    
  • Esophageal rupture and mediastinitis
    
• Epigastric:
  
  • Dissection of the descending aorta
    
  • Peptic ulcer disease
    
  • Pancreatitis
    
  • Cholecystitis
    
  • Splenic rupture
    
  • Hepatic injury
    
  • Subdiaphragmatic abscess
    
• Pleuritic pain:
  
  • Pulmonary embolism
    
  • Pneumothorax
    
  • Pneumonia
    
  • Costochondritis
    
• Diaphragmatic pleurisy:
  
  • Splenic rupture
    
  • Hepatic injury
    
  • Subdiaphragmatic abscess
    
• Esophageal rupture
  
• Intercostal myositis
  
• Intercostal neuralgia
  
• Pectoralis minor strain
  
• Pericarditis
  
• Pleuritis
  
• Pneumonitis
  
• Rib fractures
  
• Acute chest syndrome of sickle cell
  
• Chest wall twinge syndrome:
  
  • Brief episodes of sharp anterior chest pain lasting 30 sec–3 min, aggravated by deep breathing and relieved by shallow respirations
    
• Chest wall pain:
  
  • Chest wall hematoma
    
  • Chest wall laceration
    
  • Herpes zoster
    
  • Thrombophlebitis of the thoracoepigastric vein
    
  • Xiphisternal arthritis
    
  • Adiposis dolorosa
    
  • Breast abscess, fibroadenosis, carcinoma
    

DIAGNOSIS

• Coronary artery disease:
  
  • Pressure
    
  • Squeezing pain
    
  • Radiation to arm, jaw
    
  • Shortness of breath
    
  • Diaphoresis
    
  • Nausea
    
  • Vomiting
    
  • Weakness
    
  • Fatigue especially in women or elderly
    
  • Signs of CHF
    
  • Anxiety
    
• Aortic dissection:
  
  • Sudden onset of pain with maximal intensity early
    
  • Tearing pain
    
  • Radiation to back and/or flank
    
  • HTN
    
  • Diastolic murmur of aortic insufficiency
    
  • Difference in upper-extremity pulses
    
  • Syncope
    
  • Nausea
    
  • Vomiting
    
  • Associated neurologic changes (i.e., visual changes)
    
• Pulmonary embolism:
  
  • Pleuritic pain
    
  • Shortness of breath
    
  • Anxiety
    
  • Diaphoresis
    
  • Tachypnea
    
  • Tachycardia
    
  • Low-grade fever
    
  • Syncope
    
  • Localized rales
    
  • Wheezing
    
• Acute pericarditis:
  
  • Substernal pain
    
  • Varies with respiration
    
  • Increased with recumbency
    
  • Relieved by leaning forward
    
  • Anxiety
    
  • Anorexia
    
  • Fever
    
  • Pericardial friction rub
    
• Pneumothorax:
  
  • Pleuritic pain
    
  • Shortness of breath
    
  • Anxiety
    
  • Tachypnea
    
  • Decreased unilateral breath sounds
    
  • Can be spontaneous (young), or associated with very minor trauma (elderly)
    

• The history is the most important tool to distinguish between the various etiologies.
  
• Have the patient define the key features:
  
  • Duration
    
  • Location:
    
    • Retrosternal
      
    • Subxiphoid
      
    • Diffuse
      
  • Frequency:
    
    • Constant
      
    • Intermittent
      
    • Sudden vs. delayed onset
      
  • Precipitating factors:
    
    • Exertion
      
    • Stress
      
    • Food
      
    • Respiration
      
    • Movement
      
  • Timing:
    
    • Context of onset of pain (i.e., at rest, exertional)
      
    • Duration of pain
      
  • Quality:
    
    • Burning
      
    • Squeezing
      
    • Dull
      
    • Sharp
      
    • Tearing
      
    • Heavy
      
  • Associated symptoms:
    
    • Shortness of breath
      
    • Diaphoresis
      
    • Nausea
      
    • Vomiting
      
    • Jaw pain
      
    • Back pain
      
    • Radiation
      
    • Palpitations
      
    • Syncope
      
    • Fever
      
    • Weakness: Generalized vs. focal
      
    • Fatigue