Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

Rosen & Barkin's 5-Minute Emergency Medicine Consult (146 page)

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult

4.36Mb size Format: txt, pdf, ePub

Read Book Download Book

ads

ALERT
For patients presenting between 3 and 4.5 hr of onset, there are additional exclusion criteria:

MEDICATION
First Line

Alteplase (tPA): 0.9 mg/kg IV; max. 90 mg, with 10% of dose given as bolus and remainder infused over 60 min
Aspirin: 81–325 mg PO/PR
Labetalol: 10–20 mg IV bolus, repeat q10min max. 300 mg; follow with continuous infusion 0.5–2 mg/min

Second Line

Pediatric Considerations

Heparin or low-molecular-weight heparin is often used in children with ischemic stroke
May call 1-800-NOCLOTS for pediatric stroke consultation and guidance

FOLLOW-UP
DISPOSITION
Admission Criteria

Discharge Criteria

Patients who present with completed strokes that are days to weeks old may be discharged if they are able to function independently or have adequate social support
Patients with multiple prior strokes who experience relatively minor new episodes may also be treated on outpatient basis if similar criteria are met and stroke is completed

FOLLOW-UP RECOMMENDATIONS

PEARLS AND PITFALLS

Always note pre-hospital observations
Onset of symptoms is crucial to determining treatment with tPA
- Include additional exclusion criteria between 3 and 4.5 hr
Avoid aggressive BP correction due to risk of hypoperfusion and extension of stroke
Door to needle goal is <60 min

ADDITIONAL READING

Clinical Policy: Use of intravenous tPA for the management of acute ischemic stroke in the emergency department.
Ann Emerg Med.
2013;61:225–243.
Freundlich CL, Cervantes-Arslanian AM, Dorfman DH. Pediatric stroke.
Emerg Med Clin N Am
. 2012;30:805–828.
Fulgham JR, Ingall TJ, Stead LG, et al. Management of acute ischemic stroke.
Mayo Clin Proc
. 2004;11:1459–1469.
Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professional from American Heart Association/American Stroke Association Stroke Council.
Stroke
. 2013;44:870–947.
Lees KR, Bluhmki E, von Kummer R, et al. Time to treatment with intravenous alteplase and outcomes of stroke: An updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials.
Lancet
. 2010;375:1695–1703.
Leira EC, Ludwig BR, Gurol ME, et al. The types of neurological deficits might not justify withholding treatment in patients with low National Institutes of Health Stroke Scale scores.
Stroke
. 2012;43:782--786.
Perry JM, McCabe KK. Recognition and initial management of acute ischemic stroke.
Emerg Med Clin North Am
. 2012;30:637–657.
www.ninds.nih.gov/doctors

See Also (Topic, Algorithm, Electronic Media Element)

CODES
ICD9

ICD10

CERVICAL ADENITIS
Julie Zeller
BASICS
DESCRIPTION

Acute bacterial infection of a cervical lymph node
- Often arising after a prior bacterial infection of the head or neck area
Primarily a pediatric disease:
- Becoming more common in adults owing to immunocompromised disease states (HIV, cancer, transplant patients)
Any cervical node can become infected:
- >80% of childhood cervical lymphadenitis involves the submandibular or deep cervical nodes
- Jugulodigastric node located just below the angle of the mandible is common site
- Cervical nodes act as the final common pathway for lymphatic drainage of all areas of the head and neck
- Initial lymphadenopathy results after bacterial invasion of regional areas of the head and neck
- Local lymph nodes swell secondary to hyperplasia of sinusoidal cells and infiltration of lymphocytes
- If the infection is not contained, the bacteria enter the lymph system and proliferate (lymphadenitis)
- Pus forms when neutrophils are incited, and an abscess develops when host defenses are unable to clear infection
- Clinically manifests as warm, tender, swollen, erythematous node

ETIOLOGY

∼70% of cases are a result of group A β-hemolytic Streptococcal infection
- 20% Staphylococcal infection
- 10% related to viral infection or other bacteria
Infections secondary to community-acquired MRSA (CA-MRSA) have increased in frequency
Children have one of the highest rate of CA-MRSA colonization and invasive disease
Mycobacteria TB:
- Scrofula or tuberculous lymphadenitis
- Rarely seen
- Usually a chronic lymphadenitis in the posterior cervical nodes
- Purified protein derivative (PPD) is usually strongly reactive
- Treatment is nonsurgical
Atypical mycobacteria (nontuberculous)
Mycobacterium avium
complex:
- More commonly seen
- Usually a chronic lymphadenitis in the submandibular or anterior cervical nodes
- PPD test results are unreliable
- Treatment is primarily surgical
Bartonella henselae
(catscratch disease):
- Subacute lymphadenitis
- Fever and mild systemic symptoms occur in only ∼3% of patients
- Has indolent course but usually spontaneously resolves after 4–6 wk
Anaerobes:
- Consider when associated with infections of the teeth or gingiva
Rare organisms:
- Gram-negative bacilli
- Yersinia pestis
- Group B streptococcus
- Francisella tularensis
- Alpha-streptococcus
- Anthrax

Pediatric Considerations

One of the most common causes of a neck mass in a child
Overall, group A Streptococcus and
Staphylococcus aureus
most common causes
In neonates, group B Streptococcus and
S. aureus
most common
Group B
Streptococcal cellulitis
–adenitis syndrome:
- Infants are usually 3–7 wk of age, male, febrile, with submandibular or facial cellulitis, and an ipsilateral otitis media
- 94% incidence of concurrent bacteremia
S. aureus
associated with more indolent course and higher frequency of suppuration
Viral infections generally result in bilateral lymphadenopathy

Geriatric Considerations

Consider malignancy over infection in this population, especially in the absence of fever, leukocytosis, etc.
Fixed, nontender, hard node most likely not cervical adenitis

DIAGNOSIS