Rosen & Barkin's 5-Minute Emergency Medicine Consult (332 page)

Patients with hemothoraces requiring tube thoracostomies should be admitted for monitoring and thoracostomy tube management to the trauma, cardiothoracic, or general surgery service. The admitting unit should be experienced in managing chest tube equipment.

• Patients with isolated small hemothoraces (detected incidentally on US or CT imaging) may be considered for discharge after 4–6 hr of observation if there is no evidence of continued bleeding, the patient is not hypoxic, and is asymptomatic.
  
• Patients with asymptomatic blunt chest trauma and normal initial chest radiographs do not require repeat films prior to discharge.
  

• Because the pleural cavity of an average 70 kg man can hold over 4 L of blood, an exsanguinating hemorrhage can occur without any evidence of external blood loss.
  
• Auscultation and percussion of a supine trauma patient with substantial hemothorax may produce equivocal findings due to distribution of blood along the entire posterior aspect of pleural space.
  
• Without a clear history of trauma, CXR may be incorrectly read as pneumonia.
  
• If there is a concurrent diaphragmatic injury, a hemothorax may have an intra-abdominal origin.
  
• Prepare for autotransfusion early, as most blood loss occurs on initial chest tube insertion.
  
• In the supine trauma patient, a common error in chest tube insertion is placement too anterior and superior, making complete drainage difficult.
  
• Be sure all chest tube fenestrations are within the thoracic cavity.
  
• Prophylactic antibiotics administered with chest tube insertion do not decrease the risk of pneumonia or empyema.
  

• Ali HA, Lippmann M, Mundathaje U, et al. Spontaneous hemothorax: A comprehensive review.
  Chest
  . 2008;124(5):1056–1065.
  
• McEwan K, Thompson P. Ultrasound to detect haemothorax after chest injury.
  Emerg Med J
  . 2007;24(8):581–582.
  
• Parry GW, Morgan WE, Salama FD. Management of haemothorax.
  Ann R Coll Surg Engl
  . 1996;78(4):325–326.
  
• Vukich DJ, Markovchick V. Thoracic trauma. In: Rosen P, et al., eds.
  Emergency Medicine: Concepts and Clinical Practice.
  6th ed. St. Louis, MO: Mosby; 2006:391–392.
  

CODES

• 511.89 Other specified forms of effusion, except tuberculous
  
• 860.2 Traumatic hemothorax without mention of open wound into thorax
  
• 860.3 Traumatic hemothorax with open wound into thorax
  

BASICS

Vasculitis

Mechanism:

• Increased serum IgA:
  
  • Circulating IgA complexes
    
  • Glomerular mesangial deposition of IgA
    
• Although cause is undefined, there are many associated conditions:
  
  • Infections
    
  • Group A streptococcus
    
  • Mycoplasma
    
  • Viral: Varicella, Epstein–Barr (EB)
    
  • Drugs: Penicillin, tetracycline, aspirin, sulfonamides, erythromycin
    
  • Allergens: Insect bites, chocolate, milk, wheat
    
• Peak incidence: School-aged children and young adults
  
• More common in whites
  
• Males > females
  
• Occurs more often in winter/spring
  
• Multisystem involvement can lead to life-threatening or long-term complications:
  
  • Intussusception
    
  • Proliferative glomerulonephritis
    
  • Chronic renal failure:
    
  • More common in older children and adults (13–14%)
    
  • Intracranial hemorrhage
    

DIAGNOSIS

• General:
  
  • Well-appearing child, despite nature and extent of rash
    
  • Recent or current upper respiratory tract infection
    
  • Malaise
    
  • Low-grade fever
    
  • Hypertension, if associated renal failure
    
  • Children <3 mo may have only skin manifestations
    
  • Children <2 yr of age may have facial edema alone as presenting symptom
    
• Skin:
  
  • Purpuric rash:
    
    • Presenting sign in 50% of patients
      
    • 100% of patients develop purpura
      
    • 1st appears as pink rounded papules that blanch
      
    • Progresses to 2–3 cm circular palpable purpura within 24 hr; may be discrete or confluent
      
    • Rash begins in gravity-dependent areas of legs and buttocks, which may extend to upper extremities and trunk
      
    • Symmetric distribution
      
    • May involve lower back
      
    • Rarely involves the face
      
    • Rash recurs in up to 40% of patients (within 6 wk).
      
• Abdominal:
  
  • Abdominal pain:
    
    • 70–80% of cases
      
    • Colicky to severe
      
    • Abdominal findings may precede the rash by 4 wk.
      
  • GI bleeding:
    
    • 75% of cases
      
    • Occult to severe blood loss
      
    • Intussusception (ileoileal or ileocolic)
      
• Renal-genitourinary:
  
  • Asymptomatic hematuria:
    
    • Occurs in 80% of cases
      
  • Scrotal pain
    
  • Testicular swelling
    
  • Renal failure
    
• Extremities:
  
  • Arthritis:
    
    • 70–80% of cases
      
    • Migratory periarticular pain
      
    • Most frequent in knees and ankles
      
    • Angioedema
      
• Neurologic:
  
  • Headache
    
  • Seizure
    
  • Altered mental status
    
  • Focal deficits +/- visual abnormalities and verbal disability
    

• Constitutional symptoms:
  
  • Fever
    
• Rash:
  
  • Location, timing, duration, and progression of rash
    
• Associated symptoms:
  
  • Abdominal pain, vomiting, and seldom facial edema
    
  • Timing, duration, and progression of symptoms
    
• Progression of symptoms:
  
  • Timing, duration, and progression of symptoms
    

• General appearance:
  
  • Level of responsiveness, vital signs (high BP)
    
• Cardiovascular:
  
  • Quality of heart tones
    
  • Perfusion (pulses, capillary refill)
    
• GI:
  
  • Abdominal distention, tenderness, palpable masses, bloody stools
    
• Genitourinary:
  
  • Testicular swelling, tenderness
    
• Skin:
  
  • Location
    
  • Blanching vs. nonblanching
    
  • Erythematous or purplish raised lesions (papules, purpura) vs. macular lesions (petechia)
    
  • Hemorrhagic bullous evolution seldom described in children
    
• Neurologic:
  
  • Level of consciousness
    
  • Presence of focal deficits
    

Exclude life-threatening causes of petechia, purpura, severe abdominal pain, hematuria, and CNS findings, if appropriate.

• CBC:
  
  • Platelet count normal
    
  • WBC often elevated
    
• PT, PTT (if bleeding or in shock; or if unsure of diagnosis and concerned about possibility of coagulopathy)
  
• Electrolytes (if hypertension or urinalysis abnormal)
  
• BUN, creatinine (if hypertension or urinalysis abnormal):
  
  • May be elevated in cases with serious renal complications
    
• Urinalysis:
  
  • Hematuria is common
    
  • Proteinuria is suggestive of glomerulonephritis
    
• Cultures to exclude common infections
  

• Abdominal imaging studies:
  
  • Indicated if abdominal pain or GI bleeding
    
  • Flat and upright abdominal films of limited use
    
  • Abdominal US, barium enema, or CT scan may be necessary to rule out intussusception.
    
• Testicular US:
  
  • Indicated in patients with testicular pain and swelling
    
• Head CT:
  
  • Indicated if CNS findings to exclude bleed
    

Lumbar puncture, as clinically indicated

• Abdominal pain:
  
  • Gastroenteritis
    
  • Appendicitis
    
  • Inflammatory bowel disease
    
  • Intussusception
    
  • Meckel diverticulum
    
• Arthralgia:
  
  • Acute rheumatic fever
    
  • Polyarthritis nodosa
    
  • Juvenile rheumatoid arthritis
    
  • Systemic lupus erythematosus
    
• Rash:
  
  • Infection:
    
    • Meningococcemia
      
    • Bacterial sepsis: Streptococcal or staphylococcal
      
    • Rocky Mountain spotted fever
      
    • Infectious mononucleosis
      
    • Bacterial endocarditis
      
    • Viral exanthem
      
  • Trauma/child abuse
    
  • Functional platelet disorders
    
  • Thrombocytopenia
    
  • Vasculitis
    
  • Erythema nodosum
    
  • Drugs/toxins
    
• Renal disease:
  
  • Acute glomerulonephritis
    
• Testicular swelling:
  
  • Incarcerated hernia
    
  • Orchitis
    
  • Testicular torsion