Rosen & Barkin's 5-Minute Emergency Medicine Consult (155 page)

Patients with isolated minor chest wounds and a normal CXR can be observed for 3 hr in the ED and have a repeat radiographic study; if no intrathoracic penetration is suspected, the patient can be discharged:

• CT chest may be an alternative to CXR, if no intrathoracic penetration is suspected; patient can be discharged without repeat radiograph.
  

• Ball CG, Williams BH, Wyrzykowski AD, et al. A caveat to the performance of pericardial ultrasound in patients with penetrating cardiac wounds.
  J Trauma
  . 2009;67:1123–1124.
  
• Duke MD, Guidry C, Guice J, et al. Restrictive fluid resuscitation in combination with damage control resuscitation: Time for adaptation.
  J Trauma Acute care Surg.
  2012;73:674–678.
  
• Haut ER, Kalish BT, Efron DT, et al. Spinal immobilization in penetrating trauma: More harm than good.
  J Trauma
  . 2010;68:115–121.
  
• Ivatury RR, Cayten CG, eds.
  The Textbook of Penetrating Trauma
  . Baltimore, MD: Williams & Wilkins; 1996.
  
• Moore EE, Knudson MM, Burlew CC, et al. Defining the limits of resuscitative emergency department thoracotomy: A contemporary Western Trauma Association perspective.
  J Trauma
  . 2011;70:334–339.
  
• Nandipati KC, Allamaneni S, Kakarla R, et al. Extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax: Experience at a community based level I trauma center.
  Injury.
  2011;42:511–514.
  

CODES

• 862.9 Injury to multiple and unspecified intrathoracic organs, with open wound into cavity
  
• 875.0 Open wound of chest (wall), without mention of complication
  
• 875.1 Open wound of chest (wall), complicated
  

BASICS

• Partial or complete obstruction of the common bile duct owing to gallstones, tumor, cyst, or stricture
  
• Increased intraluminal pressure in biliary tree
  
• Bacterial multiplication results in bacteremia and sepsis.
  
• Purulent infection of biliary tree, which may involve the liver and gallbladder
  
• Mirizzi syndrome is defined as common bile duct obstruction owing to extrinsic compression from gallbladder or cystic duct edema or stones.
  

• Bacterial sources of infection include:
  
  • Ascending duodenal source
    
  • Gallbladder infection
    
  • Portal venous seeding
    
  • Hematogenous spread with hepatic secretion
    
  • Lymphatic spread
    
• Bacterial organisms include:
  
  • Anaerobes (Bacteroides and Clostridium species)
    
  • Intestinal coliform (
    Escherichia coli
    )
    
  • Enterococcus
    
• AIDS sclerosing cholangitis characterized by:
  
  • Papillary stenosis
    
  • Sclerosing cholangitis
    
  • Extrahepatic biliary obstruction
    
  • Cytomegalovirus (CMV), Cryptosporidium, and microsporidia isolated, but causal role not established
    

DIAGNOSIS

• Charcot triad:
  
  • Classic presentation of fever and chills; right upper quadrant (RUQ) pain and jaundice found in only 50–70%
    
• Addition of shock and altered mental status denotes a more advanced form of biliary sepsis known as
  Reynolds pentad.
  
• Abdominal pain present in >70%—localizing to RUQ.
  
• AIDS sclerosing cholangitis presents with similar symptoms but with more chronic indolent course and near-normal serum bilirubin levels.
  

• Fever found in >90%
  
• Peritoneal findings found in 30%
  
• Clinically apparent jaundice may be absent in up to 40%.
  

• ECG in patients at risk for coronary artery disease
  
• CBC
  
• LFT
  
• Amylase, lipase
  
• Urinalysis
  
• Blood cultures
  
• Gallbladder US or hepatoiminodiacetic acid (HIDA) scan
  

• CBC:
  
  • Leukocytosis with left shift unless immunocompromised or severe sepsis
    
• LFTs consistent with cholestasis:
  
  • Elevated direct bilirubin and alkaline phosphatase
    
• Minimal elevation of transaminases (<200 IU/mL)
  
• Changes may lag symptom onset by 24–48 hr.
  
• Amylase and lipase normal or mildly elevated
  
• Urinalysis positive for bilirubin
  

• US detects the level of ductal obstruction and the presence of gallstone etiology.
  
• Radionuclide scanning (HIDA):
  
  • Indicates obstruction when tracer not found in duodenum within 1 hr
    
  • More sensitive than US in detecting obstruction in the 1st 24–48 hr before ductal dilation occurs
    
• CT scan and CRX:
  
  • Useful to rule out intestinal obstruction, perforation, or pneumonia
    
  • 20% gallstones radiopaque
    
• Magnetic resonance cholangiopancreatography (MRCP) is highly accurate for biliary obstruction but unnecessary if endoscopic retrograde cholangiopancreatography (ERCP) will be performed.
  

Emergency invasive biliary imaging and drainage by ERCP (or surgical/percutaneous if not available), if no response to medical treatment in 12–24 hr

• Acute cholecystitis
  
• Hepatitis or hepatic abscess
  
• Acute pancreatitis
  
• Right pyelonephritis
  
• Right lower lobe pneumonia or pulmonary embolism
  
• Perforated duodenal ulcer
  
• Appendicitis
  
• Sepsis with nonspecific elevation of LFTs
  
• Fitz-Hugh and Curtis syndrome
  

TREATMENT

Stabilize septic shock.

• Immediate IV fluid resuscitation for dehydration, hemodynamic compromise, and sepsis
  
• 80% respond to IV antibiotics within 1st 24 hr
  
• Vasopressors (dopamine) for hypotension refractory to volume replacement
  

• Broad-spectrum antibiotics for coliforms, anaerobes, and enterococcus such as:
  
  • Ampicillin/sulbactam + aminoglycoside (e.g., gentamicin)
    
  • Imipenem–cilastatin
    
  • Piperacillin/tazobactam + aminoglycoside (e.g., gentamicin)
    
  • For penicillin allergy:
    
    • Adults—use levofloxacin (Levaquin) and metronidazole
      
    • Pediatrics—use clindamycin and metronidazole
      
• Substitute aztreonam for aminoglycoside in renal insufficiency.
  
• NPO
  
• Nasogastric (NG) suctioning if protracted vomiting or ileus
  
• IV fluid (0.9% NS) replacement and maintenance
  
• Narcotic analgesia if hemodynamically stable and diagnosis reasonably established
  
• Immediate surgical and GI consultation
  
• Emergency invasive biliary drainage procedure (surgical, percutaneous, or ERCP) if no response to medical treatment in 12–24 hr
  

• Ampicillin/sulbactam: 3 g (peds: 200 mg/kg/24 h) IV piggyback (IVPB) q6h
  
• Aztreonam: 2 g (peds: 120 mg/kg/24 h) IVPB q6h
  
• Clindamycin: 600–900 mg (peds: 25–40 mg/kg/24 h) IVPB q6–8h
  
• Dopamine: 2–20 μg/min IVPB; titrate to maintain BP
  
• Gentamicin: 1.5–2 mg/kg (peds: 6–7 mg/kg/24 h) IVPB q8h; follow levels
  
• Imipenem–cilastatin: 500 mg (Peds 60–100 mg/kg/24 h) q6h
  
• Levaquin: 500 mg IVPB q24h; contraindicated in peds
  
• Hydromorphone: 0.5–2 mg IV (0.01–0.02 mg/kg), titrated to pain relief.
  
• Metronidazole: 500 mg (peds: 30 mg/kg/24 h) IVPB q6h
  
• Piperacillin/tazobactam: 3.375 mg (peds: 300 mg/kg/24 h) IVPB q6h
  
• Ondansetron: 4–8 mg IV, (0.15–0.3 mg/kg) IV (not to exceed 8 mg/dose IV), q4h PRN vomiting
  

FOLLOW-UP