Rosen & Barkin's 5-Minute Emergency Medicine Consult (426 page)

FOLLOW-UP

• All are admitted:
  
  • Airway encroachment and obstruction can be progressive and unpredictable
    
• ICU or closely monitored setting due to unpredictable progression of symptoms
  

• This is a clinical diagnosis with unpredictable progression:
  
  • Early specialty consultation is necessary for possible assistance with airway management or drainage
    
• Early transfer to higher level of care if the illness acuity exceeds the clinician’s level of expertise or if the facility is not adequately equipped for such management
  

• Mother is susceptible to all aspects and complications as nongravid patients
  
• Focus: Airway management, oxygenation, treatment of sepsis if present
  

Chronic comorbid conditions, chronic medications, less physiologic reserve can all complicate the presentation and treatment

• Asphyxia
  
• Spread into thoracic cavity:
  
  • Empyema
    
  • Mediastinitis
    
  • Lung abscess
    
• Pericarditis
  
• Internal jugular vein thrombosis
  
• Carotid artery erosion and/or infection
  
• Sepsis/bacteremia
  
• Subphrenic abscess
  

Pearls:

• Prepare to manage airway immediately
  
• Consult appropriate medical specialists as soon as possible, whether for transfer to a higher level of care, or to the operating suite for “double setup” management
  
• Video laryngoscopy is intuitive and easy to use, provides rapid, safe, high probability intubation success
  

Pitfalls:

• Failure to appreciate the progressive nature, unpredictable rate, extent of advancement
  
• Diagnostic testing and/or imaging should not delay definitive airway management or other therapy
  

• Candamourty R, Venkatachalam S, Babu MR, et al. Ludwig’s Angina—An emergency: A case report with literature review.
  J Nat Sci Biol Med
  . 2012;3(2):206–208.
  
• Ludwig BJ, Foster BR, Saito N, et al. Diagnostic imaging in nontraumatic pediatric head and neck emergencies.
  Radiographics.
  2010;30(3):781–799.
  
• Mckellop JA, Bou-Assaly W, Mukherji SK. Emergency head & neck imaging: Infection and inflammatory processes.
  Neuroimaging Clin N Am
  . 2010;20:651–661.
  
• Tobias JD, Ross AK. Intraosseous infusions: A review for the anesthesiologist with a focus on pediatric use.
  Anesth Analg.
  2010;110:391–401
  
• Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management.
  Ann Emerg Med.
  2012;59:165–175.e1.
  
• Wolfe MM, Davis JW, Parks SN. Is surgical airway necessary for airway management in deep neck infections and Ludwig angina?
  J Crit Care
  . 2011:26:11–14.
  

CODES

528.3 Cellulitis and abscess of oral soft tissues

BASICS

• Dislocation of the lunate relative to the radius and distal row of metacarpals, most are volar but can be dorsal.
  
• Usually from high-energy hyperextension with ulnar deviation of the wrist.
  

• Implies disruption of all 4 perilunate ligaments and radiocarpal ligament (Mayfield classification, stage IV)
  
• In volar dislocations, median nerve injury occurs in the carpal tunnel.
  
• Associated fractures of the radial styloid, scaphoid, capitate, and triquetrum are common and, if present, should raise suspicion of an occult perilunate ligamentous injury.
  

DIAGNOSIS

Frequently missed injury.

• Often from fall or motor vehicle accident.
  
• Pain and tenderness in the wrist.
  

• Mass or swelling in the wrist, either dorsally or volarly, depending on direction of dislocation.
  
• Gross deformity can be masked by swelling.
  
• May display signs of median nerve injury.
  

• Clinical exam is frequently not diagnostic.
  
• Assess skin integrity and neurovascular status, including 2-point discrimination.
  
• Radiographs as outlined below.
  

• Radiographic imaging to include 3 views of the wrist.
  
• Lateral view most useful:
  
  • Disruption of the normal imaginary longitudinal line through the centers of the radius, lunate, and capitate indicates dislocation or subluxation.
    
  • In volar dislocations, the lunate is frequently tilted with the opening of the “cup” toward the palm (spilled teacup sign)
    
• Posteroanterior (PA) view:
  
  • The dislocated lunate has a triangular (as opposed to the usual quadrangular) appearance.
    
  • Disruption of a smooth and continuous arc formed by the radiocarpal row suggests lunate dislocation.
    

Radiograph can be difficult to interpret unless full ossification is present.

Other fractures are common.

• Lunate fracture.
  
• Perilunate dislocation.
  
• Scapholunate dissociation.
  
• Scaphoid fracture.
  

TREATMENT

• Dress open wounds.
  
• Immobilize in neutral position.
  

Immobilize in position of comfort with a volar or “sugar tongs” splint.

• Identify multiple trauma or other injuries.
  
• Contact a hand surgeon for immediate reduction and possible operative intervention.
  
• Closed reduction can be difficult or unstable.
  
• Open reduction and internal fixation are frequently required.
  

Although serious injury is unusual, children with wrist pain should be splinted and referred for ongoing evaluation of possible occult fractures.

Analgesics:

• Morphine:
  
  • Pediatrics: 0.05–0.20 mg/kg IV up to 1.5 mg. Use preservative-free formulation q4h
    
  • Adults: 4–8 mg IV
    
• Acetaminophen with hydrocodone:
  
  • Pediatrics >12 yo: 2.5--10 mg hydrocodone every 4--6 h to max 60 mg/24 h or 4 g acetaminophen/24 h.
    
  • Adults: 5--10 mg hydrocodone ever 4--6 h as needed not to exceed 60 mg/24 h or 4 g acetaminophen/24 h
    
• Acetaminophen with codeine (adults):
  
  • Pediatrics: 0.5–1 mg/kg/dose based on codeine content PO q4–6h; do not exceed 5 doses of 10–15 mg/kg/24 h of acetaminophen
    
  • Adults: 30–60 mg/dose PO q4–6h; do not exceed 4 g/24 h of acetaminophen
    
• Hydrocodone and acetaminophen:
  
  • Pediatrics <12 yr old: 0.1–0.2 mg/kg based on hydrocodone content PO q4–6h; do not exceed 5 doses of 10–15 mg/kg/24 h of acetaminophen
    
  • Pediatrics >12 yr old: 750 mg apap PO q4h, not to exceed 10 mg hydrocodone per dose
    
  • Adults: Do not exceed 4 g/24h of acetaminophen PO q4–6h
    

NSAIDs:

• Ibuprofen:
  
  • Pediatrics: 5–10 mg/kg q6–8h, max. dose 40 mg/kg/d PO div. TID/QID
    
  • Adults: 600 mg PO q6h
    
• Naproxen:
  
  • Pediatrics >2 yr old: 2.5 mg/kg/d PO BID (not to exceed 10 mg/kg/d)
    
  • Adults: 250–500 mg PO BID
    
• Acetaminophen with codeine (pediatrics):
  
  • Patients may metabolize codeine at variable speeds: poor metabolizers which may lead to under-response, or "ultra-fast" metabolizers which can lead to high levels of morphine, hence undesirable side effects such asapnea and death.
    

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