Rosen & Barkin's 5-Minute Emergency Medicine Consult (48 page)

• Patient may be uncooperative or violent.
  
• Secure IV access.
  
• Protect from self-induced trauma.
  

• ABCs
  
• Establish IV 0.9% NS access.
  
• Cardiac monitor
  
• Naloxone, dextrose (or Accu-Chek), and thiamine if altered mental status
  

• Decontamination:
  
  • Administration of activated charcoal
    
  • Whole-bowel irrigation with polyethylene glycol solution for body packers
    
• Hypertensive crisis:
  
  • Initially administer benzodiazepines if agitated.
    
  • α-blocker (phentolamine) as second-line agent
    
  • Nitroprusside for severe, unresponsive hypertension
    
  • Avoid β-blockers, which may exacerbate hypertension.
    
• Agitation, acute psychosis:
  
  • Administer benzodiazepines.
    
• Hyperthermia:
  
  • Benzodiazepines if agitated
    
  • Active cooling if temperature >40°C:
    
    • Tepid water mist
      
    • Evaporate with fan.
      
  • Paralysis:
    
    • Indicated if muscle rigidity and hyperactivity contributing to persistent hyperthermia
      
    • Nondepolarizing agent (e.g., vecuronium)
      
    • Avoid succinylcholine.
      
    • Intubation; mechanical ventilation
      
  • Apply cooling blankets.
    
• Rhabdomyolysis:
  
  • Administer benzodiazepines.
    
  • Hydrate with 0.9% NS.
    
  • Maintain urine output at 1–2 mL/min.
    
  • Hemodialysis (if acute renal failure and hyperkalemia occur)
    
• Seizures:
  
  • Maintain airway.
    
  • Administer benzodiazepines.
    
  • Phenobarbital if unresponsive to benzodiazepines
    
  • Phenytoin contraindicated
    
• Hypotension:
  
  • May be late finding due to catecholamine depletion
    
  • Initially bolus with isotonic crystalloid solution
    
  • If no response, administer norepinephrine.
    
  • Dopamine may not be effective
    

• Activated charcoal: 1–2 g/kg up to 100 g PO
  
• Dextrose: D
  ₅₀
  W 1 amp: 50 mL or 25 g (peds: D
  ₂₅
  W 2–4 mL/kg) IV
  
• Diazepam (benzodiazepine): 5–10 mg (peds: 0.2–0.5 mg/kg) IV
  
• Lorazepam (benzodiazepine): 2–6 mg (peds: 0.03–0.05 mg/kg) IV
  
• Nitroprusside: 1–8 μg/kg/min IV (titrated to BP)
  
• Phenobarbital: 15–20 mg/kg at 25–50 mg/min until cessation of seizure activity
  
• Phentolamine: 1–5 mg IV over 5 min (titrated to BP)
  
• Vecuronium: 0.1 mg/kg IVP
  

FOLLOW-UP

• Hyperthermia
  
• Persistent altered mental status
  
• Hypertensive crisis
  
• Seizures
  
• Rhabdomyolysis
  
• Persistent tachycardia
  

• Asymptomatic after 6 hr observation
  
• Absence of the above admission criteria
  

Patients may need referral for chemical dependency rehab and detoxification.

• Admit patients with severe or persistent symptoms.
  
• Monitor core temperature:
  
  • Hyperthermia >40°C may be life threatening.
    
  • Treat with aggressive sedation and active cooling.
    
  • Recognize rhabdomyolysis and hyperkalemia.
    
  • Avoid physical restraints in agitated patients if possible.
    
• Consider associated emergency conditions:
  
  • Patients with chest pain should be evaluated for acute coronary syndromes and treated accordingly.
    
  • Consider infection in altered patients with fever and history of IV drug use.
    
  • Methamphetamine abuse frequently associated with traumatic injury
    
• Benzodiazepines are 1st-line therapy in symptomatic methamphetamine intoxication
  

• Callaway CW, Clark RF. Hyperthermia in psychostimulant overdose.
  Ann Emerg Med
  . 1994;24:68–75.
  
• Carvalho M, Carmo H, Costa VM, et al. Toxicity of amphetamines: an update.
  Arch Toxicol
  . 2012;86:1167–1231.
  
• Gray SD, Fatovich DM, McCoubrie DL, et al. Amphetamine-related presentations to and inner-city tertiary emergency department: A prospective evaluation.
  Med J Aust
  . 2007;186:336.
  
• Prosser JM, Nelson LS. The toxicology of bath salts: a review of synthetic cathinones.
  J Med Toxicol
  . 2012;8:33--42.
  
• Turnipseed SD, Richards JR, Kirk JD, et al. Frequency of acute coronary syndrome in patients presenting to the emergency department with chest pain after methamphetamine use.
  J Emerg Med
  . 2003;24(4):369–373.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Sympathomimetic Poisoning
  
• Tricyclic Antidepressant Poisoning
  

CODES

• 969.72 Poisoning by amphetamines
  
• 969.73 Poisoning by methylphenidate
  
• 969.79 Poisoning by other psychostimulants
  

BASICS

• Partial amputations have tissue connecting the distal and proximal parts and are treated by revascularization.
  
• Complete amputations have no connecting tissue and may be treated by replantation.
  
• Both of the above are treated the same from an emergency standpoint.
  

Traumatic amputations may result from machinery, powered hand tools, household appliances, lawnmowers, getting caught between objects, motor vehicle collisions, crush injuries, blast injuries, gunshot wounds, knives, degloving injuries to digits (ring avulsions), and animal bites.

DIAGNOSIS

• Exact time of injury is critical, as ischemia time predicts success for replantation:
  
  • Irreversible muscle necrosis begins at 6 hr of ischemia.
    
  • The temperature and amount of muscle present in the tissue predicts the tolerable ischemia time.
    
  • Amputated digits have little muscle and can tolerate more ischemia time:
    
    • Warm ischemia time of 8–12 hr
      
    • Cool ischemia time of as much as 24 hr
      
  • Amputated limbs have more muscle mass and can tolerate less ischemia time:
    
    • Warm ischemia time of 4–6 hr
      
    • Cold ischemia time of 10–12 hr
      
• Mechanism of injury:
  
  • Clean-cut or “guillotine” amputations have better prognosis for replantation than crush or avulsion injuries.
    
• Comorbid illnesses that hinder successful replantation:
  
  • Diabetes, peripheral vascular disease, rheumatologic disease, smoking
    
• Handedness
  
• Social history, including occupation and major hobbies
  

• Assessment and documentation of injured extremity is crucial.
  
• Signs of neurologic compromise:
  
  • Loss of sensation and 2-point discrimination
    
  • Loss of active range of motion
    
• Signs of vascular compromise in partial amputations:
  
  • Distal part dusky or cyanotic
    
  • Delayed capillary refill (>2 sec)
    
  • Diminished or absent pulses (Doppler or palpation)
    
  • Ribbon sign (twisting of the artery in the amputated digit or limb)
    
  • Use Allen test in hand injuries.
    
  • Pulse oximetry may be helpful.
    
• Soft tissue: Assess skin, muscle, tendon, and nail bed integrity.
  
• Identify exposed bone and fractures (gross deformity, tenderness, crepitus).