Rosen & Barkin's 5-Minute Emergency Medicine Consult (158 page)

Initiate IV access for patients with nausea or vomiting.

IV fluid bolus if vomiting or hypotensive

• IV hydration with 0.9% NS if vomiting
  
• NPO
  
• Parenteral NSAIDs (ketorolac) may lessen biliary spasm, but may exacerbate peptic causes of pain.
  
• Narcotic analgesics (hydromorphone) with antiemetic (ondansetron):
  
  • Administer for refractory pain once diagnosis is reasonably established.
    
  • Morphine sulfate may lead to spasm at sphincter of Oddi (clinical significance not well established).
    
• Anticholinergics (glycopyrrolate) have no proven benefit in the treatment of acute biliary pain.
  

• Ketorolac: 60 mg IM or 30 mg (peds: Start 0.5 mg/kg for 1st dose up to 1 mg/kg/24h) IV q6h. In elderly: 30 mg IM or 15 mg IV
  
• Hydromorphone: 0.5–2 mg IV (0.01–0.02 mg/kg), titrated to pain relief.
  
• Ondansetron: 4–8 mg IV (0.15–0.3 mg/kg) IV (not to exceed 8 mg/dose IV), q4h PRN vomiting.
  

FOLLOW-UP

Admission and surgical or gastroenterologic consultation for evidence of:

• Acute cholecystitis
  
• Acute cholangitis
  
• Common duct obstruction
  
• Gallstone pancreatitis
  

• Lack of clinical, lab, or radiographic evidence of cholecystitis, cholangitis, common duct obstruction, or pancreatitis
  
• Resolution of all pain and tenderness
  
• Ability to tolerate oral fluids
  

• General surgery referral for all cases of biliary colic with documented cholelithiasis or for radiographic finding of a “Porcelain gallbladder” (due to increased risk of gallbladder carcinoma).
  
• GI referral for choledocholithiasis.
  

Surgical follow-up for patients with symptomatic gallstones

• Alternative causes of upper abdominal pain may be falsely attributed to incidental finding of gallstones.
  
• An ultrasound is more sensitive and specific for cholelithiasis.
  
• Radionuclide scanning (HIDA) is highly diagnostic of cystic duct obstruction and cholecystitis.
  
• CT scans may miss gallstones if the stones are not radiopaque.
  

• Antevil JL, Buckley RG, Johnson AS, et al. Treatment of suspected symptomatic cholelithiasis with glycopyrrolate: A prospective, randomized clinical trial.
  Ann Emerg Med
  . 2005;45:172–176.
  
• Jackson PG, Evans SR. Biliary system. In: Townsend CM Jr, ed.
  Sabiston Textbook of Surgery
  . 19th ed. Philadelphia, PA: WB Saunders; 2012:1476–1514.
  
• Silen W, ed. The colics.
  Cope’s Early Diagnosis of the Acute Abdomen
  . 22nd ed. Oxford, UK: Oxford University Press; 2010:145–153.
  
• Strasberg SM. Acute calculous cholecystitis.
  N Eng J Med
  . 2008;358:2804–2811.
  
• Vassiliou MC, Laycock WS.
  Biliary Dyskinesia. Surg Clin North Am.
  2008;88(6):1253–1272.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Cholangitis
  
• Cholelithiasis
  

CODES

• 574.20 Calculus of gallbladder without mention of cholecystitis, without mention of obstruction
  
• 574.21 Calculus of gallbladder without mention of cholecystitis, with obstruction
  
• 574.90 Calculus of gallbladder and bile duct without cholecystitis, without mention of obstruction
  

BASICS

• 3rd leading cause of death in US
  
• A disease characterized by airflow obstruction due to several processes:
  
  • Emphysema: Irreversible alveolar destruction with loss of airway elastic recoil. Represents accelerated aging of the lung
    
  • Chronic bronchitis: Airway inflammation without alveolar destruction
    
  • Reactive airway disease: Reversible bronchospasm, mucous plugging, and mucosal edema
    
• COPD affects ∼10% of the population and 50% of smokers.
  
• Increased incidence of hypertension, diabetes, heart failure, and cardiovascular disease in those with COPD
  
• Frequent exacerbations lead to:
  
  • Greater mortality
    
  • Faster decline in lung function
    
  • Worse quality of life
    
  • Increased risk of hospitalization
    
• Medical Research Council (mMRC) dyspnea scale
  
  • Grade 0: Only breathless with strenuous exercise
    
  • Grade 1: Short of breath when hurrying or walking up a slight hill
    
  • Grade 2: Walk slower than people of same age due to dyspnea or have to stop for breath when walking on level ground
    
  • Grade 3: Stop for breath after 100 m on level ground
    
  • Grade 4: Too breathless to leave the house or breathless when dressing/undressing
    
• GOLD guidelines
  
  • Group A
    
    • No more than 1 exacerbation/yr
      
    • FEV1 >80% predicted
      
    • mMRC of 0 or 1
      
  • Group B
    
    • mMRC of 2 or more
      
    • FEV1 50–80% of predicted
      
  • Group C
    
    • mMRC < 2
      
    • ≥2 exacerbations/yr
      
    • FEV1 30–49% of predicted
      
  • Group D
    
    • High symptom burden
      
    • mMRC ≥ 2
      
    • High risk for exacerbations
      
    • FEV1 < 30% of predicted
      

α
₁
-Antitrypsin deficiency

• Smoking is the overwhelming cause:
  
  • COPD develops in 15% of smokers.
    
• Air pollution
  
• Airway hyper-responsiveness
  
• α
  ₁
  -Antitrypsin deficiency
  
• Autoimmunity may play a role
  
• Acute exacerbations:
  
  • Viral infections
    
    • >50% of exacerbations associated with recent cold symptoms
      
    • Decreased immunity may make the host more susceptible to a COPD exacerbation
      
    • Rhinovirus
      
    • Respiratory syncytial virus (RSV)
      
  • Bacterial infections
    
    • Bacteria isolated in 40–60% of sputum during acute exacerbation
      
    • Most common:
      
      • Haemophilus influenzae
        
      • Moraxella catarrhalis
        
      • Streptococcus pneumoniae
        
    • More likely if:
      
      • Increased dyspnea
        
      • Increased sputum volume
        
      • Purulent sputum
        
  • Pollutants
    
    • Changes to immunity
      
    • Increased airway inflammation
      
  • Seasonal variations
    
    • More common and more severe in winter
      

DIAGNOSIS

• Dyspnea on exertion
  
• Cough
  
• Sputum production
  
• Fatigue
  
• Wheezing
  
• Orthopnea
  
• Altered mental status
  

• Wheezing
  
• Retractions
  
• Decreased air movement
  
• Cyanosis
  
• Prolonged expiratory phase
  
• Barrel chest
  
• Lower-extremity edema
  
• Jugular venous distension
  
• S3 and S4 gallops
  
• Altered mental status secondary to carbon dioxide narcosis
  

• CBC:
  
  • Elevated hematocrit may indicate chronic hypoxemia.
    
  • Increased neutrophils and elevated WBC may indicate infection.
    
• Arterial blood gas:
  
  • Retaining carbon dioxide
    
  • Acidosis
    
  • Oxygenation
    
• β-Natriuretic peptide:
  
  • Differentiate between COPD and CHF
    
• Sputum sample
  
• Theophylline level as needed