Rosen & Barkin's 5-Minute Emergency Medicine Consult (314 page)

• Albuterol: 2.5–5.0 mg nebulized
  
• Calcium gluconate: 10 mL of 10% solution applied topically. Consult poison center for instructions.
  
• Magnesium: 2 g IV over 20 min
  
• Methylene blue: 1–2 mg/kg slow IV (peds:
  Not
  recommended for <6 yr old; >6 yr old: 1 mg/kg IV/IM over 5 min)
  
• Hydroxocobalamin: 5 mg IV over 5 min, repeat once
  

FOLLOW-UP

• Airway compromise, respiratory difficulty (hypoxia)
  
• Significant systemic symptoms
  
• Admit patients with chemical burns to burn center.
  

• Patients who are well after a period of observation and consultation with poison control
  
• Superficial chemical burns owing to a toxin without potential for systemic toxicity (weak acid/alkali)
  

Psychiatric or social work referral for victims of chemical terrorist attacks.

• Decontaminate stable victims on site when possible.
  
• Protect medical providers (pre-hospital and ED) with appropriate personal protective equipment.
  
• Provide specific antidotes for exposures when indicated.
  
• Victims who can walk and talk are minimally contaminated.
  

• Clarke SF, Chilcott RP, Wilson JC, et al. Decontamination of multiple casualties who are chemically contaminated: A challenge for acute hospitals.
  Prehosp Disast Med
  . 2008;23(2):175–181.
  
• Freyberg CW, Arquilla B, Fertel BS, et al. Disaster preparedness: Hospital decontamination and the pediatric patient—Guidelines for hospitals and emergency planners.
  Prehosp Disaster Med
  . 2008;23(2):166–172.
  
• Goldfrank LR, Flomenbaum NE, Howland MA, et al.
  Goldrank’s Toxicologic Emergencies
  . 8th ed. New York, NY: McGraw-Hill; 2006;1764–1774.
  
• Streets KW, Johnson DA. Development and Implementation of a Multidisciplinary Emergency Department Hazmat Team.
  International Nursing Library
  . 2011;
  http://hdl.handle.net/10755/162923
  

See Also (Topic, Algorithm, Electronic Media Element)

• Chemical Weapons Poisoning
  
• Cyanide Poisoning
  
• Radiation Injury
  

CODES

• V87.09 Contact with and (suspected) exposure to other hazardous metals
  
• V87.2 Contact with and (suspected) exposure to other potentially hazardous chemicals
  
• V87.39 Contact with and (suspected) exposure to other potentially hazardous substances
  

BASICS

Blunt trauma to head resulting in a variety of injuries ranging from closed head injury to death

Blunt trauma to head may cause several types of closed head injuries:

• Concussion: Transient (LOC) or amnesia with normal head CT
  
• Subdural hematoma: Tearing of subdural bridging veins and bleeding into the subdural space
  
• Epidural hematoma: Dural arterial injury, especially the middle meningeal artery often associated with a skull fracture:
  
  • Classically, transient LOC followed by a lucid interval, then rapid demise
    
• Subarachnoid hemorrhage: Bleeding into the subarachnoid space following trauma
  
• Cerebral contusion: Focal injuries to the brain characterized as coup (beneath area of impact) or contrecoup (area remote from impact)
  
• Intracerebral hemorrhage: Mass intracranial lesion with bleeding into the brain parenchyma
  
• Diffuse axonal injury: Microscopic injuries scattered throughout the brain in a patient in deep coma
  

DIAGNOSIS

• Evidence of trauma to head includes:
  
  • Scalp laceration, cephalohematoma, or ecchymosis
    
  • Raccoon eyes: Bilateral ecchymosis of orbits associated with basilar skull fractures
    
  • Battle sign: Ecchymosis behind the ear at mastoid process associated with basilar skull fracture
    
  • Hemotympanum
    
  • Cerebral spinal fluid rhinorrhea or otorrhea
    
• Evidence of increasing intracranial pressure includes:
  
  • Decreasing level of consciousness, falling score on Glasgow Coma Scale
    
  • Cushing response, bradycardia, HTN, and diminished respiratory rate
    
  • Dilated pupils associated with decorticate or decerebrate posturing
    

• Mechanism
  
• LOC or amnesia for event
  
• Use of anticoagulants
  
• Headache, visual changes, or hearing loss
  
• Focal neurologic complaints
  
• Associated neck pain
  

• Evaluation of head for hematoma, Battle sign, raccoon eyes
  
• Complete neurologic exam
  
• Exam of neck/cervical spine
  

• Imaging indicated for patients with any of the following:
  
  • LOC or amnesia of events
    
  • Progressive headache
    
  • Alcohol or drug intoxication
    
  • Unreliable history or dangerous mechanism
    
  • Post-traumatic seizure
    
  • Repeated vomiting
    
  • Signs of basilar skull fracture
    
  • Possible skull penetration or depressed skull fracture
    
  • Glasgow Coma Scale score <15
    
  • Focal neurologic findings
    
• Patients on Coumadin, heparin, or other anticoagulants and those with a history of bleeding dyscrasias must undergo imaging.
  
  • If initial head CT is negative and <4 hr post injury, patient must be monitored and repeat head CT 4–6 hr post injury, or earlier if clinical deterioration.
    
• Alcoholics have an increased risk for bleeding, low threshold for imaging
  

• Older patients (>60–65 yr of age) are at higher risk of intracranial hemorrhage.
  
• Many are on anticoagulation, take a careful hx.
  
• Have a low threshold for obtaining CT scan.
  

• Rapid check of blood glucose level
  
• CBC, platelet count, and coagulation parameters
  
• Type and cross-match for surgical candidates.
  
• Baseline electrolytes, BUN, and creatinine levels
  
• Blood alcohol level if indicated
  

• CT or MRI of head as indicated
  
• Cervical spine radiographs or helical CT when indicated
  

Lumbar puncture if question of subarachnoid blood on head CT

• Penetrating head trauma
  
• Any condition that alters mental status that may have produced a fall and caused external evidence of head trauma (e.g., hypoglycemic episode, seizure)
  

TREATMENT

• Blunt head trauma patients with risk for intracranial lesion must go to a trauma center:
  
  • High-risk patients include those with depressed consciousness, focal neurologic signs, multiple trauma, or palpable depressed skull fractures.
    
• Moderate-risk patients should go to a hospital with availability of prompt neurosurgical consultation:
  
  • Moderate-risk patients include those with progressive headache, alcohol or drug intoxication, unreliable history, post-traumatic seizure, repeated vomiting, post-traumatic amnesia, signs of basilar skull fracture.
    
• Protect and manage the airway, including intubation:
  
  • Routine hyperventilation without signs of cerebral herniation should be avoided.
    
• If evidence of cerebral herniation (see Signs and Symptoms) or progressive neurologic deterioration in a normotensive patient, initiate measures to decrease intracranial pressure:
  
  • Mild hyperventilation to keep ETCO
    ₂
    about 30–35 mm Hg:
    
    • 20 breaths/min in adults
      
    • 25 breaths/min in children
      
    • 30 breaths/min in infants <1 yr
      
  • Elevating head of bed 20–30°
    
• Cervical spine precautions must be maintained in all patients.
  
• Cautions:
  
  • Avoid hypotension (systolic BP <90 mm Hg); use IV crystalloid solutions to maintain BP.
    
  • Avoid hypoxia (oxygen saturation <90%); administer 100% oxygen.
    
  • Check blood glucose level.