Rosen & Barkin's 5-Minute Emergency Medicine Consult (340 page)

• Analgesics:
  
  • Morphine sulfate: 2–10 mg per dose (peds: 0.1–0.2 mg/kg IV/IM/SC q2–4h) IV/IM/SC
    
  • Fentanyl: 1–4 μg/kg (peds: 1–4 μg/kg IV) IV
    
• Sedatives:
  
  • Lorazepam: 1–2 mg IV
    
  • Midazolam: 2.5–5 mg (peds: 0.07 mg/kg) IV
    

FOLLOW-UP

• Strangulated hernias require immediate surgical intervention.
  
• Incarcerated hernias require admission for urgent surgical intervention.
  
• Intestinal obstruction
  
• Peritonitis
  
• Vomiting/dehydration
  
• Severe pain
  

After successful reduction has been achieved and patient asymptomatic

Referral to surgery with instructions to return if recurrent persistent pain, fever, vomiting

General surgery referral

• Failure to recognize signs and symptoms of an incarcerated or strangulated hernia
  
• Forcing reduction of incarcerated hernia
  
• Reintroducing strangulated bowel back into abdominal cavity
  

• Derici H, Unalp HR, Bozdag AD, et al. Factors affecting morbidity and mortality in incarcerated abdominal wall hernias.
  Hernia
  . 2007;11(4):341–346.
  
• Nicks BA. Hernias: Treatment & medication. Available at
  http://emedicine.medscape.com/article/775630-treatment
  . Updated on June 6, 2012. Accessed on February2013.
  
• Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibiotic prophylaxis for hernia repair.
  Cochrane Database Syst Rev
  . 2007;18(3):CD003769.
  
• Strange CD, Birkemeier KL, Sinclair ST, et al. Atypical abdominal hernias in the emergency department: Acute and non-acute.
  Emerg Radiol.
  2009;16(2):121–128.
  
• Wang KS, Committee on Fetus and Newborn, American Academy of Pediatrics, et al. Assessment and management of Inguinal Hernia in Infants.
  Pediatrics
  . 2012;130(4):768–773.
  

See Also (Topic, Algorithm, Electronic Media Element)

Abdominal Pain

CODES

• 553.00 Femoral hernia without mention of obstruction of gangrene, unilateral or unspecified(not specified as recurrent)
  
• 553.9 Hernia of unspecified site without mention of obstruction or gangrene
  
• 550.90 Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent)
  

BASICS

• Viral disease characterized by recurrent painful vesicular lesions of mucocutaneous areas
  
• Lips, genitalia, rectum, hands, and eyes most commonly involved
  
• Infection is characterized by 2 phases:
  
  • Primary
    , in which virus becomes established in a nerve ganglion;
    
  • Secondary
    , involves recurrence of disease at the same site
    
• Incubation period is ∼4 days from exposure
  
• Viral shedding occurs from 7–10 days (up to 23 days) in primary infection and 3–4 days in recurrent infections
  
• Neonatal infections can occur in utero, intrapartum (most common), or postnatal
  
  • Occur in 1/3,500 births per year in the US
    
• Human-to-human transmission
  
• 60–90% of population is infected with herpes simplex type 1 (HSV-1) or type 2 (HSV-2)
  
• More common in blacks than whites in ages <40 yr
  
• Females affected more than males
  

• HSV-1 or HSV-2 are DNA viruses of the Herpesviridae family
  
• Viral transmission may occur via respiratory droplets, contact with mucosa or abraded skin with infected secretions:
  
  • Recurrent mucosal shedding of HSV may transmit the virus
    
  • Rate of recurrence varies with virus type and anatomic site
    
• Both viruses infect oral or genital mucosa:
  
  • Most common for HSV-1 to cause oral infections and HSV-2 to cause genital infections
    

DIAGNOSIS

• Many primary infections go unrecognized and can only be detected by an elevated IgG Ab titer
  
• Clinically, infection presents with grouped 1–2 mm vesicles on an erythematous base
  
• Vesicles may be filled with clear or cloudy fluid or may appear as frank pustules
  

Orofacial infection:

• Primary infection:
  
  • Gingivostomatitis or pharyngitis:
    
    • Ulcerative exanthem involving gingival and mucous membranes
      
    • Fever, malaise, irritability, headache, myalgias, cervical adenopathy
      
    • Primary infection symptoms typically last 2--4 weeks unless secondarily infected and heal without scarring
      
    • Inability to eat owing to pain is a risk for dehydration
      
• Recurrent infection (recrudescence):
  
  • Usually involves lips, specifically the vermillion border
    
  • Commonly incited by sunlight, heat, stress, trauma (chapping, abrasions), or immunosuppression
    
  • Prodrome of itching, tingling, throbbing, or burning followed by erythema, papule/vesicle, ulcer, crust, and healing
    
  • Transmission can occur in the absence of recognizable lesions
    
  • Fewer constitutional symptoms
    
  • Many individuals have a rise in Ab titer and never experience recurrence
    
  • HSV-1 oral infections recur more often than genital HSV-1 infections. HSV-2 genital infections recur 6 times more frequently than HSV-1 genital infections
    

Skin infection:

• History of exposure to HSV-1 or HSV-2
  
• Abrupt onset of fever, edema, erythema, and localized tenderness
  
• Herpetic whitlow:
  
  • HSV-2 more common than HSV-1
    
  • Infection of pulp and lateral aspect of finger with single or multiple vesicles
    
  • May occur from autoinoculation with primary oral or genital infection or from direct inoculation from occupational exposure
    
  • Can last 3–4 wk
    
  • Recurrence possible
    
  • In young children, it is associated with HSV-1 inoculation through thumb sucking during gingivostomatitis
    
• Traumatic herpes:
  
  • Can occur following cosmetic procedures of face, surgical and dental interventions, sun exposure, or burns
    
• Herpes gladiatorum:
  
  • Mucocutaneous infection of athletes involving chest, face, and hands transmitted through traumatized skin (often wrestlers)
    
• Eczema herpeticum:
  
  • Association between atopic dermatitis and HSV infection
    
  • HSV-1 more common than HSV-2
    
  • Occurs in children and young adults with atopic dermatitis
    
  • Secondary staphylococcal infection commonly occurs
    
  • Higher risk if on steroids or infected with HIV
    
  • Varicelliform eruption with spread to surrounding skin
    
  • Fever, headache, and fatigue
    
• HSV-associated erythema multiforme:
  
  • Usually presents on palms and soles
    
  • Lasts 2–3 wk
    

Eye:

• Most common cause of corneal blindness
  
• Caused by extension of facial lesions or direct inoculation
  
• Acute onset of pain and photophobia
  
• Periauricular adenopathy, blurry vision, chemosis, and conjunctivitis
  
• May be unilateral or bilateral
  
• Dendritic lesions of cornea noted on fluorescein exam
  
• Different from herpes varicella zoster as dermatome not involved
  
• Hutchinson sign:
  
  • Vesicles on tip of nose may indicate ocular disease
    
  • Involvement of nasociliary nerve
    

CNS/encephalitis: