Rosen & Barkin's 5-Minute Emergency Medicine Consult (165 page)

• Cautions:
  
  • Follow standard pre-hospital guidelines for trauma management (ABCs).
    
  • Do not remove penetrating foreign bodies.
    
  • Do not attempt to replace eviscerated bowel; cover with moist saline dressings.
    
  • Obtain history regarding mechanism of injury, vehicular damage, and seat belt use.
    
• Controversies:
  
  • Use of intravenous crystalloid resuscitation is still considered the standard of care.
    

• Refer to topic on abdominal trauma.
  
• ABCs should precede abdominal evaluation.
  
• Aggressive management with IV crystalloid resuscitation and blood replacement as needed.
  

• Early surgical consultation; surgery is definitive treatment.
  
• Cover eviscerated bowel in moist saline gauze, in a nondependent position.
  
• Administer broad-spectrum antibiotics to cover gram-negative aerobic and anaerobic bacteria.
  
• The efficacy of multiple-agent and single-agent antibiotic regimens is similar.
  
• Ensure tetanus prophylaxis.
  

• Ampicillin: 2 g (peds: 50 mg/kg) IV q6h + gentamicin 2 mg/kg (peds: 2.5 mg/kg) IV q8h
  +
  metronidazole 500 mg IV q6h (peds: Use clindamycin 25–40 mg/kg IV q24h div. q6–q8h)
  
• Aztreonam: 2 g IV q8h (peds: 90–120 mg/kg IV q24h div. q6–q8h)
  +
  clindamycin 900 mg IV q8h (peds: Use clindamycin 25–40 mg/kg IV q24h div. q6–q8h)
  
• Cefoxitin: 2 g IV q8h (peds: 40 mg/kg IV q6h)
  
• Piperacillin/tazobactam: 4.5 g (peds: 75 mg/kg) IV q8h
  

FOLLOW-UP

• Colon injuries require admission for surgical repair or monitoring.
  
• All penetrating foreign bodies must be removed to prevent sepsis.
  
• Patients with abdominal ecchymosis require hospital admission and observation because of potential for undiagnosed hollow viscus injury.
  

• Patients in whom serious abdominal injury is not suspected and with completely normal abdominal exam, normal hemodynamic status, and no other injury may be considered for discharge with appropriate precautions.
  
• If there is any doubt about the possibility of colon injury, the patient should be admitted and observed.
  

Patients may initially present with paucity of symptoms:

• Observation and serial exams are indicated if mechanism suggests significant blunt abdominal trauma.
  

• Cleary RK, Pomerantz RA, Lampman RM. Colon and rectal injuries.
  Dis Colon Rectum
  . 2006;49(8):1203–1222.
  
• Goldberg JE, Steele SR. Rectal foreign bodies.
  Surg Clin North Am
  . 2010;90(1):173–184.
  
• Greer LT, Gillern SM, Vertrees AE. Evolving colon injury management: A review.
  Am Surg
  . 2013;79(2):119–127.
  
• Steele SR, Maykel JA, Johnson EK. Traumatic injury of the colon and rectum: The evidence vs dogma.
  Dis Colon Rectum
  . 2011;54(9):1184–1201.
  
• Williams MD, Watts D, Fakhry S. Colon injury after blunt abdominal trauma: Results of the EAST Multi-Institutional Hollow Viscus Injury Study.
  J Trauma
  . 2003;55(5):906–912.
  

CODES

• 863.40 Injury to colon, unspecified site, without mention of open wound into cavity
  
• 863.42 Injury to transverse colon, without mention of open wound into cavity
  
• 863.50 Injury to colon, unspecified site, with open wound into cavity
  

BASICS

• Light coma:
  
  • Responds to noxious stimuli
    
• Deep coma:
  
  • Does not respond to pain
    
• Unresponsiveness:
  
  • Loss of either arousability or cognition:
    
    • Loss of arousal
      
    • Arousal is primarily a brainstem function.
      
    • Impairment of the reticular activating system
      
    • Loss of cognition
      
    • Requires dysfunction of both cerebral hemispheres
      
  • Stupor:
    
    • Deep sleep, although not unconsciousness
      
    • Exhibits little or no spontaneous activity
      
    • Awaken with stimuli
      
    • Little motor or verbal activity once aroused
      
• Obtundation:
  
  • Mental blunting with mild or moderate reduction in alertness
    
• Delirium:
  
  • Floridly abnormal mental status
    
  • Irritability
    
  • Motor restlessness
    
  • Transient hallucinations
    
  • Disorientation
    
  • Delusions
    
• Clouding of consciousness:
  
  • Disturbance of consciousness
    
  • Impaired capacity to think clearly or perceive, respond to, and remember current stimuli
    

• Diffuse brain dysfunction (69%):
  
  • Lack of nutrients:
    
    • Hypoglycemia
      
    • Hypoxia
      
  • Poisoning:
    
    • Ethanol
      
    • Isopropyl alcohol
      
    • Ethylene glycol
      
    • Methanol
      
    • Salicylates
      
    • Sedative-hypnotics
      
    • Narcotics
      
    • Anticonvulsants
      
    • Isoniazid
      
    • Heavy metals
      
    • Opiates
      
    • Benzodiazepines
      
    • Anticholinergics
      
    • Lithium
      
    • Phencyclidine
      
    • Cyanide
      
    • Carbon monoxide
      
    • Isoniazid
      
  • Infection:
    
    • Bacterial/tuberculous/syphilitic meningitis
      
    • Encephalitis
      
    • Falciparum meningitis
      
    • Typhoid fever
      
    • Rabies
      
  • Endocrine disorders:
    
    • Myxedema coma
      
    • Thyrotoxicosis
      
    • Addison disease
      
    • Cushing disease
      
    • Pheochromocytoma
      
  • Metabolic disorders:
    
    • Hepatic encephalopathy
      
    • Uremia
      
    • Porphyria
      
    • Wernicke encephalopathy
      
    • Aminoacidemia
      
    • Reye syndrome
      
    • Hypercapnia
      
  • Electrolyte disorders:
    
    • Hypernatremia, hyponatremia
      
    • Hypercalcemia, hypocalcemia
      
    • Hypermagnesemia, hypomagnesemia
      
    • Hypophosphatemia
      
    • Acidosis, alkalosis
      
  • Temperature regulation:
    
    • Hypothermia
      
    • Heat stroke
      
    • Neuroleptic malignant syndrome
      
    • Malignant hyperthermia
      
  • Uremia
    
  • Postictal state, status epilepticus
    
  • Psychiatric
    
  • Shock
    
  • Fat embolism
    
  • Hypertensive encephalopathy
    
• Supratentorial lesions (19%):
  
  • Hemorrhage (15%):
    
    • Intraparenchymal hemorrhage
      
    • Epidural hematoma
      
    • Subdural hematoma
      
    • Subarachnoid hemorrhage
      
  • Infarction (2%):
    
    • Thrombotic arterial occlusion
      
    • Embolic arterial occlusion
      
    • Venous occlusion
      
  • Tumor or abscess (2%):
    
    • Hydrocephalus
      
    • Herniation
      
    • Hemorrhage from erosion into adjacent blood vessels
      
• Subtentorial lesions (12%):
  
  • Infarction
    
  • Hemorrhage
    
  • Tumor
    
  • Basilar migraine
    
  • Brainstem demyelination
    

Eclampsia

DIAGNOSIS

Ongoing disturbance of consciousness

• No spontaneous eye opening
  
• Lack of response to painful stimuli
  
• No motor activity
  
• Regular cardiorespiratory function
  
• Glasgow Coma Scale (GCS) scoring:
  
  • Eye opening (E):
    
    • Spontaneously: 4
      
    • To verbal command: 3
      
    • To pain: 2
      
    • No response: 1
      
  • Best motor response (M) to verbal command:
    
    • Obeys: 6
      
  • Best motor response to painful stimulus:
    
    • Localizes to pain: 5
      
    • Withdraws to pain: 4
      
    • Flexion—abnormal: 3
      
    • Extension—abnormal: 2
      
    • No response: 1
      
  • Best verbal response (V):
    
    • Oriented and converses: 5
      
    • Disoriented and converses: 4
      
    • Verbalizes: 3
      
    • Vocalizes: 2
      
    • No response: 1
      
  • GCS = E + M + V
    
• Hypothermia:
  
  • Infection, hypoglycemia, myxedema coma, alcohol and sedative-hypnotic poisoning
    
• Fever:
  
  • Infection, thyrotoxicosis, anticholinergics, sympathomimetics, neuroleptic malignant syndrome, hypothalamic hemorrhage
    
• HTN
  
• Structural lesion, hypertensive encephalopathy
  
• Hypotension
  
• Mydriasis:
  
  • Organophosphates
    
• Miosis:
  
  • Narcotics
    
  • Anticholinergics
    
  • Pontine lesion
    
• Loss of pupillary reflexes or unequal pupils:
  
  • Structural lesions
    
• Evidence of head trauma
  
• Nuchal rigidity:
  
  • Meningitis
    
  • Subarachnoid hemorrhage
    
• Decorticate posturing:
  
  • Flexion of elbows and wrists
    
  • Adduction and internal rotation of shoulders
    
  • Supination of the forearms
    
  • Suggests severe damage above the midbrain
    
• Decerebrate posturing:
  
  • Extension of elbows and wrists
    
  • Adduction and internal rotation of shoulders
    
  • Pronation of the forearms
    
  • Suggests damage at the midbrain or diencephalon
    
• Asymmetric movements:
  
  • Structural lesions
    
  • Persistent twitching of an extremity:
    
    • Status epilepticus