Rosen & Barkin's 5-Minute Emergency Medicine Consult (265 page)

Evaluate vital signs:

• Collect relevant information that could help psychosocial evaluation.
  

• ABCs
  
• Administer supplemental oxygen for hypoxia.
  
• IV fluid bolus for signs of dehydration
  

• Treatment should be directed to correction of the underlying cause of fatigue:
  
  • Identify and treat any infectious process.
    
  • Correct metabolic and hematologic disturbances.
    
  • Diagnose progressive neurologic disease and acute psychiatric crisis.
    
  • Initiate workup for endocrine and neoplastic disease.
    
  • Stop any offending medications or toxins.
    
• Most cases will not have identifiable cause, so reassurance and close follow-up is required.
  
• Recommend appropriate diet, exercise regimen, and consistent sleep cycles.
  

Medication should be reserved for treatment of the underlying cause of symptoms.

FOLLOW-UP

• Underlying disease requiring IV medication or monitoring
  
• Failure to thrive as outpatient
  
• Unable to provide for self
  

• Able to care for self
  
• Serious disturbances have been excluded.
  
• Adequate follow-up is arranged.
  

Most patients who are evaluated for fatigue in the ED should be referred:

• When the cause of a patient’s fatigue symptoms have been clearly identified, referral should be directed to the appropriate specialist.
  
• When the cause of a patient’s fatigue symptoms are not clearly identified, a primary care referral is indicated.
  

• Fatigue is a subjective symptom complex, and a complete history and physical exam are needed.
  
• Beware of patients with unreliable history and physical exam. The elderly, children, intoxicated, and those with decreased mental ability may all have life-threatening disease and present with a complaint of fatigue.
  

• Kitai E, Blumberg G, Levy D, et al. Fatigue as a first-time presenting symptom: Management by family doctors and one year follow-up.
  Isr Med Assoc J.
  2012;14(9):555–559.
  
• Manzullo EF, Escalante CP. Research into fatigue.
  Hematol Oncol Clin North Am
  . 2002;16(3):619–628.
  
• Mawle AC. Chronic fatigue syndrome.
  Immunol Invest
  . 1997;26(1–2):269–273.
  
• Morrison RE, Keating HJ 3rd. Fatigue in primary care.
  Obstet Gynecol Clin North Am
  . 2001;28(2):225–240, v–vi.
  
• Nemec M, Koller MT, Nickel CH, et al. Patients presenting to the emergency department with non-specific complaints: The Basel Non-specific Complaints (BANC) study.
  Acad Emerg Med.
  2010;17(3):284–292.
  

CODES

• 729.1 Myalgia and myositis, unspecified
  
• 780.71 Chronic fatigue syndrome
  
• 780.79 Other malaise and fatigue
  

BASICS

• Problems may present in 1 or several of the components of “feeding”:
  
  • Getting food into oral cavity: Appetite, food-seeking behavior, ingestion
    
  • Swallowing food: Oral and pharyngeal phases
    
  • Ingestion and absorption: Esophageal swallowing, GI phase
    
• Acute feeding problems may be a component of acute systemic disease:
  
  • Infection, bowel obstruction
    
• Chronic feeding problems may result from underlying neuromuscular, cardiovascular, or behavioral issues:
  
  • Cerebral palsy, prematurity, congenital heart disease, chronic neglect
    
• Minor feeding difficulties reported in 25–50% of normal children:
  
  • Mainly colic, vomiting, slow feeding, and refusal to eat
    
• More severe problems observed in 40–70% of infants born prematurely or children with chronic medical conditions.
  

• Several distinct areas of pathology—but overlap is common
  
• Structural abnormalities:
  
  • Naso-oropharynx:
    
    • Cleft lip/palate
      
    • Choanal atresia
      
    • Micrognathia and/or Pierre Robin sequence
      
    • Macroglossia
      
    • Tonsillar hypertrophy
      
    • Retropharyngeal mass or abscess
      
  • Larynx and trachea:
    
    • Laryngeal cleft or cyst
      
    • Subglottic stenosis
      
    • Laryngo- or tracheomalacia
      
    • Tracheoesophageal fistula
      
  • Esophagus:
    
    • Esophageal strictures, stenosis, or web
      
    • Tracheoesophageal compression from vascular ring/sling
      
    • Esophageal mass or tumor
      
    • Foreign body
      
• Neurologic conditions:
  
  • Cerebral palsy
    
  • Muscular dystrophies
    
  • Mitochondrial disorders
    
  • Arnold–Chiari malformation
    
  • Myasthenia gravis
    
  • Brainstem injury
    
  • Pervasive developmental disorder (autism spectrum disorders)
    
  • Infant botulism
    
  • Brainstem glioma
    
  • Polymyositis/dermatomyositis
    
• Prematurity
  
• Immune disorders:
  
  • Allergy
    
  • Eosinophilic esophagitis
    
  • Celiac disease
    
• Congenital heart disease:
  
  • Precorrection: Fatigue, respiratory compromise, increased metabolic needs
    
  • Postcorrection: Any/all of the above, recurrent laryngeal nerve injury
    
• Chronic aspiration
  
• Conditioned dysphagia:
  
  • Gastroesophageal reflux (GER)
    
  • Prolonged tube or parenteral feeding early in life
    
• Metabolic disorders:
  
  • Hypothyroidism
    
  • Inborn errors of metabolism
    
• Acute illness or event:
  
  • Sepsis
    
  • Pharyngitis
    
  • Intussusception
    
  • Malrotation
    
  • Shaken baby syndrome
    
• Behavioral issues:
  
  • Poor environmental stimulation
    
  • Dysfunctional feeder–child interaction
    
  • Selective food refusal
    
  • Rumination
    
  • Phobias
    
  • Conditioned emotional reactions
    
  • Depression
    
  • Poverty (inadequate food available)
    

DIAGNOSIS

Common presentations:

• Caregiver concerns regarding feeding or postfeeding behavior
  
• Poor weight gain/failure to thrive
  
• Recurrent or chronic respiratory illness
  

• Onset of problem
  
• Length of meals (often prolonged)
  
• Food refusal/oral aversion
  
• Independent feeding (if >8 mo):
  
  • Neuromuscular problems decrease ability to get food to the mouth
    
• Failure to thrive/poor weight gain
  
• Recurrent pneumonia/respiratory distress:
  
  • Most aspiration episodes are silent in infants
    
  • Recurrent pneumonia or wheezing may be primary symptoms of chronic aspiration
    
  • Chronic lung disease
    
• Recurrent vomiting or gagging:
  
  • If yes, when
    
• Diarrhea, rectal bleeding
  
• Onset of irritability or lethargy during feeding, colic
  
• Duration of feeding highly variable, especially in breast-fed infants—for all ages, feeding times >30 min on a regular basis is cause for concern:
  
  • Full-term healthy infant usually has 2–3 oz of formula every 2–3 hr.
    
  • Breast-fed baby eats 10–20 min on each breast every 2–3 hr.
    
  • As child gets older, duration and frequency may decrease.
    
  • 1 mo old normally eats 4 oz every 4 hr.
    

• Vital signs, including oximetry
  
• Weight, length, head circumference:
  
  • Comparison with prior measurements; plotting growth curve
    
  • Slow velocity of growth
    
  • Impaired nutritional status. Severe cases may show emaciation, weakness, apathy.
    
• General physical exam—especially note:
  
  • Affect and social responsiveness
    
  • Dysmorphism (facial asymmetry, tongue and jaw size, etc.)
    
  • ENT—oropharyngeal inflammation, infection, or anatomic abnormality
    
  • Cardiovascular status (murmur, tachycardia, tachypnea, retractions)
    
  • Pulmonary—tachypnea, color change, evidence of aspiration
    
  • Abdominal exam—bowel sounds, distension, tenderness, masses
    
  • Neurologic—tone, coordination, alertness
    
  • Skin: Allergic rash or atopy:
    
    • Loss of subcutaneous fluid or fat is often most apparent around the eyes, which will appear “sunken” in most dehydrated or malnourished infants
      
    • Edema, however, may occur with protein deficiency (kwashiorkor).
      
• Observation of feeding: Neuromuscular tone, posture, position; patient motivation; oral structure and function; efficiency of oral intake:
  
  • Ability to handle oral secretions
    
  • Pace of feeding
    
  • Noisy airway sounds after swallowing
    
  • Gagging, coughing, or emesis during feeding
    
  • Respiratory distress with feeding
    
  • Oximetry during feeding may be helpful
    
  • Onset of fatigue or irritability
    
  • Duration of feeding