Rosen & Barkin's 5-Minute Emergency Medicine Consult (198 page)

• Fever:
  
  • Abrupt in onset rising to 39°C or higher
    
  • 2–7 days duration
    
  • Biphasic (“saddleback”) curve, returning to almost normal after 2–7 days
    
  • Associated with frontal or retro-orbital headache
    
• Rash:
  
  • Generalized maculopapular rash occurs with onset of fever in 50% of patients.
    
  • After 3–4 days, rash becomes diffusely erythematous.
    
  • Faded areas appear.
    
  • Areas of desquamation may appear.
    
  • After defervescence of fever, scattered petechiae may develop over trunk, extensor surfaces of limbs, and axillae.
    
  • Palms and soles spared
    
• Musculoskeletal:
  
  • Arthralgias and myalgias after onset of fever
    
  • Severe lumbar back pain
    
• GI:
  
  • Anorexia
    
  • Nausea and vomiting
    
  • Abdominal pain (sometimes severe)
    
  • Altered taste
    
  • Hepatomegaly/ascites
    
  • GI bleeding
    
• Miscellaneous:
  
  • Epistaxis
    
  • Gingival bleeding
    
  • Hemoptysis
    
  • Hypotension
    
  • Narrowed pulse pressure (<20 mm Hg)
    
  • Retro-orbital pain
    

• Primarily a clinical diagnosis
  
• Suspect in endemic areas
  
• Suspect in patients with history of travel
  

• CBC:
  
  • Thrombocytopenia
    
  • Elevated hematocrit
    
• Electrolytes, BUN, creatinine:
  
  • Elevated BUN
    
  • Hyponatremia
    
• Liver function tests:
  
  • Elevated aspartate transaminase (AST; or serum glutamic-oxaloacetic transaminase [SGOT])
    
• Coagulation profiles:
  
  • Prolonged INR, prothrombin time (PT), and partial thromboplastin time (PTT)
    
  • Low fibrinogen:
    
    • D
      -dimer
      
  • Virus isolation or detection of dengue virus–specific antibodies (available in only a few labs) through hemagglutination inhibition (HI) assay
    

CXR:

• Pleural effusions
  

Tourniquet test:

• Inflate BP cuff to median BP in patient’s extremity.
  
• Test is positive when 3 or more petechiae appear per square centimeter.
  

• Viral illness, nonspecific
  
• Influenza
  
• Rubella
  
• Measles
  
• Malaria
  
• Rocky Mountain spotted fever
  
• Typhoid
  
• Kawasaki disease
  
• Scarlet fever
  
• Erythema infectiosum
  
• Mononucleosis
  
• Roseola infantum
  
• Secondary syphilis
  
• Enterovirus
  
• West Nile virus
  
• HIV
  
• Leptospirosis
  
• Chikungunya fever
  
• Toxic shock syndrome
  
• Hepatitis
  
• Appendicitis
  
• Meningitis
  

TREATMENT

• IV access
  
• IV crystalloids for hypotension
  
• O
  ₂
  and monitor for unstable patients
  

• Treatment is supportive.
  
• IV fluids
  
• Acetaminophen (Tylenol) for fever
  
• Analgesics for pain
  
• Platelet transfusion for severe thrombocytopenia
  
• DIC therapy, if necessary
  

• Neonatal dengue can occur by vertical transmission if mother infected 0–8 days before delivery:
  
  • Infants may develop DHF or DSS because of passive maternal immunity.
    
• DHF and DSS most common in children 7–12 yr of age
  

FOLLOW-UP

• ICU admission for the following:
  
  • Hypotension
    
  • DIC
    
  • Thrombocytopenia
    
  • Hemoconcentration
    
• Regular admission for the following:
  
  • 15 yr of age or younger
    
  • All patients with previous dengue exposure
    
  • Any patient where close follow-up is not available
    

• Close follow-up guaranteed
  
• Tolerating PO
  
• Pain controlled
  

• Consider dengue in patients presenting with fever and rash who recently traveled to endemic regions.
  
• Chikungunya fever is an emerging infectious disease also seen in travelers and must be considered in the differential:
  
  • Found in Asia and Africa
    

• Halstead SB: Dengue.
  Lancet.
  2007;370:1644–1652.
  
• Istúriz RE, Gubler DJ, Brea del Castillo J. Dengue and dengue hemorrhagic fever in Latin America and the Caribbean.
  Infect Dis Clin North Am
  . 2000;14(1):121–140.
  
• Pincus LB, Grossman ME, Fox LP. The exanthem of dengue fever: Clinical features of two US tourists traveling abroad.
  J Am Acad Dermatol
  . 2008;58(2):308–316.
  
• Simmons CP, Farrar JJ, Nguyen vV, et al. Dengue.
  N Engl J Med.
  2012;366:1423–1432.
  
• Wilder-Smith A, Schwartz E: Dengue in travelers.
  N Engl J Med
  . 2005;353:924–932.
  

CODES

061 Dengue

BASICS

• Primary teeth:
  
  • Eruption begins between 6–10 mo of age and concludes by 30 mo
    
  • Eruption is bilaterally symmetric
    
  • 20 total teeth
    
• Permanent teeth:
  
  • Begin to erupt at age 6
    
  • 32 total (4 central and 4 lateral incisors, 4 canines, 8 premolars, 12 molars)
    
  • Number from 1–32 starting with upper right 3rd molar (1) to upper left 3rd molar (16) and lower left 3rd molar (17) to lower right 3rd molar (32)
    
  • Better and often easier to describe the involved tooth anatomically
    
• Most commonly injured teeth:
  
  • Maxillary central incisors, maxillary lateral incisors, and the mandibular incisors
    
• Tooth fractures:
  
  • Fractures of the crown are classified as uncomplicated (involve only the enamel or both the enamel and dentin) or complicated (involves the neurovascular pulp)
    
  • Fractures can be classified using the
    Ellis classification system
    
  • Class I fracture (uncomplicated fracture):
    
    • Involves only the superficial enamel
      
    • Fracture line appears chalky white
      
    • Painless to temperature, air, percussion
      
  • Class II facture (uncomplicated fracture):
    
    • Involves enamel and dentin
      
    • Fracture line will appear ivory or pale yellow compared to whiter enamel
      
    • May be sensitive to heat, cold, or air
      
    • Not tender
      
  • Class III fracture (complicated fracture):
    
    • True dental emergency
      
    • Involves enamel, dentin, and pulp
      
    • Pulp has pinkish, red, fleshy hue
      
    • Frank bleeding or a pink blush after wiping tooth surface indicates pulp violation
      
    • May be exquisitely painful or desensitized (with associated neurovascular disruption)
      
• Luxation injuries
  
  • Involve the supporting structures
    
    • Includes the periodontal ligament (PDL) and alveolar bone
      
• Several types of injuries exist:
  
  • Concussed teeth:
    
    • Tooth neither loose nor displaced
      
    • Sensitivity with chewing or percussion
      
  • Subluxed teeth:
    
    • Tooth is loose but not displaced
      
    • Bleeding from gingival sulcus
      
    • Sensitivity with chewing or percussion
      
    • PDL is damaged
      
  • Intrusion:
    
    • Tooth is driven into socket
      
    • Alveolar socket fractured
      
    • PDL compressed
      
  • Avulsed tooth:
    
    • Total displacement from alveolar ridge
      
    • PDL severed
      
  • Extrusion:
    
    • Partial central dislocation from socket
      
    • PDL damaged
      
  • Lateral luxation:
    
    • Nonaxial displacement of the tooth
      
    • PDL damaged
      
    • Associated with alveolar socket fracture
      
• Alveolar bone fractures:
  
  • Fractures of tooth-bearing portions of mandible or maxilla
    
  • Bite malocclusion, painful bite, tooth mobility en bloc
    
  • Diagnosed clinically or radiographically