Rosen & Barkin's 5-Minute Emergency Medicine Consult (558 page)

• Local anesthetic:
  
  • 1% lidocaine with epinephrine 1:100,000
    
  • Max. dose: 7 mg/kg–500 mg
    
• Consider procedural sedation in stable awake patients
  
• No indication for antibiotics in a clean procedure
  

FOLLOW-UP

• Tension pneumothorax
  
• Chest tube required
  

• <15% collapse, no expansion while in the ED or successful aspiration with catheter removed:
  
  • Discharge with follow-up in 24 hr and 1 wk for chest radiograph to assure re-expansion.
    
• Reliable patients with the thoracic vent and successful aspiration or secured catheter and Heimlich valve:
  
  • Discharge with 24 and 48 hr follow-up.
    
  • At 48 hr follow-up:
    
    • Clamp catheter, observe for 2 hr, and repeat chest radiograph.
      
    • Remove thoracic vent or catheter if no re-expansion.
      
    • Observe for 2 hr and repeat chest radiograph.
      
    • If no re-expansion, discharge with 24 hr and 1 wk follow-up.
      
• Discharge instruction should include prompt return for new onset of chest pain or dyspnea.
  
• Patients without re-expansion at 1 wk require a cardiothoracic surgery consult.
  

Pulmonary medicine and/or chest surgery

• Delay in chest decompression in the unstable patient leading to rapid hemodynamic compromise
  
• Avoid poor tube placement involving kinks or improper depth, which may necessitate repeating the procedure.
  
• Avoid placement of catheter or tube too low on the lateral chest wall, which may lead to iatrogenic abdominal injuries.
  
• Failure to detect associated mediastinal or lower neck injuries
  
• If pneumomediastinum is detected, evaluate for esophageal pathology
  

• Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: An American College of Chest Physicians Delphi consensus statement.
  Chest
  . 2001;119:590–602.
  
• Gaudio M, Hafner JW. Simple aspiration compared to chest tube insertion in the management of primary spontaneous pneumothorax.
  Ann Emerg Med
  . 2009;54:458–460.
  
• Hassani B, Foote J, Borgundvaag B. Outpatient management of primary spontaneous pneumothorax in the emergency department of a community hospital using a small-bore catheter and a Heimlich valve.
  Acad Emerg Med
  . 2009;16:513–518.
  
• Soldati G, Testa A, Sher S, et al. Occult traumatic pneumothorax: Diagnostic accuracy of lung ultrasonography in the emergency department.
  Chest
  . 2008;133:204–211.
  
• MacDuff A, Arnold A, Harvey J, et al. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010.
  Thorax
  . 2010;65(suppl 2):ii18–ii31.
  
• Zehtabchi S, Rios Cl. Management of emergency department patients with primary spontaneous pneumothorax: Needle aspiration or tube thoracostomy?
  Ann Emerg Med
  . 2008;51:91–100.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Chest Pain
  
• Dyspnea
  

CODES

• 512.0 Spontaneous tension pneumothorax
  
• 512.81 Primary spontaneous pneumothorax
  
• 512.89 Other pneumothorax
  

BASICS

• Poisoning may be intentional or unintentional.
  
• Patients with change in mental status without clear cause should have poisoning (intoxication, overdose) considered in differential diagnosis.
  

• Intentional:
  
  • Depression
    
  • Suicide
    
  • Homicide
    
  • Recreational drug abuse
    
• Unintentional (accidental):
  
  • Common cause in children
    
  • Therapeutic error (e.g., double dose)
    
  • Recreational drug experimentation
    

• Accidental ingestions—typically young children (1–5 yr)
  
• Consider child abuse if inconsistent or suspicious history.
  

DIAGNOSIS

• Neurologic:
  
  • Lethargy
    
  • Agitation
    
  • Coma
    
  • Hallucinations
    
  • Seizures
    
• Respiratory:
  
  • Tachypnea, bradypnea, apnea
    
  • Inability to protect airway
    
• Cardiovascular:
  
  • Dysrhythmias
    
  • Conduction blocks
    
• Vital signs:
  
  • Varies depending on toxic substance
    
  • Hyperthermia, hypothermia
    
  • Tachycardia, bradycardia
    
  • Hypertension, hypotension
    

Selected Toxidromes (see Poisoning, Toxidromes)

• Anticholinergic:
  
  • Altered mental status (confusion, delirium, lethargy)
    
  • Dry skin and mucous membranes
    
  • Fixed dilated pupils
    
  • Tachycardia
    
  • Hyperthermia
    
  • Flushing
    
  • Urinary retention
    
• Cholinergic:
  
  • Secretory overdrive (salivation, lacrimation, urination, diaphoresis)
    
  • Miosis
    
  • Bronchospasm, wheezing
    
• Opiate:
  
  • CNS and respiratory depression
    
  • Miosis
    
• Sympathomimetic:
  
  • CNS excitation
    
  • Seizures
    
  • Tachycardia
    
  • Hypertension
    
  • Diaphoresis
    

• A complete set of vital signs, including core temperature
  
• A complete physical exam, including eyes, skin, odors
  

• Electrolytes, BUN/creatinine, glucose
  
• Calculate anion gap: Na + (Cl + HCO
  ₃
  ):
  
  • Normal anion gap: 8–12
    
  • Use mnemonic
    A CAT MUD PILES
    for elevated anion gap acidosis:
    
    • Alcoholic ketoacidosis
      
    • Cyanide, carbon monoxide
      
    • Aspirin, other salicylates
      
    • Toluene
      
    • Methanol, metformin
      
    • Uremia
      
    • Diabetic ketoacidosis
      
    • Paraldehyde, phenformin
      
    • Iron, isoniazid
      
    • Lactic acidosis from other causes
      
    • Ethylene glycol
      
    • Starvation ketosis
      
• Serum osmol gap:
  
  • Calculate osmol gap if elevated anion gap acidosis from potential toxic alcohol.
    
  • Most sensitive
    early
    in poisoning
    
  • Normal osmol gap does not completely rule out toxic alcohol ingestion.
    
  • Calculated osmolality = 2(Na
    ⁺
    ) + glucose/18 + BUN/2.8 + ethanol (in mg/dL)/4.6.
    
  • Osmol gap = measured osmolality – calculated osmolality.
    
  • Use mnemonic
    ME DIE A
    when osmol gap >10:
    
    • Methanol
      
    • Ethanol
      
    • Diuretics (mannitol, glycerin, sorbitol)
      
    • Isopropyl alcohol
      
    • Ethylene glycol
      
    • Acetone
      
• Pregnancy test
  
• Acetaminophen level for suicidal ingestions
  
• Toxicology screen
  

• ECG for dysrhythmias or QRS/QT changes
  
• CT of head for altered mental status not clearly due to toxin
  
• Chest radiograph if suspected aspiration or pneumonia
  

• Causes of altered mental status
  
• Intracranial mass, bleeding
  
• Infection, sepsis
  
• Endocrine abnormalities
  
• Hypothermia
  
• Hypoxia
  
• Metabolic abnormalities
  
• Psychogenic