Rosen & Barkin's 5-Minute Emergency Medicine Consult (541 page)

• Observe/manage airway for respiratory distress
  
• Normal saline (NS) hydration for hypotension/dehydration
  

• ABCs
  
• Fluid resuscitation: 1 L (peds: 20 mL/kg) NS bolus for signs of volume depletion or if patient is unable to tolerate oral solutions
  

• Antipyretics/analgesics:
  
  • Acetaminophen
    
  • Ibuprofen
    
  • Topical analgesics (e.g., Chloraseptic spray)
    
• GAS infection:
  
  • Often mild and self-limited:
    
    • Antibiotic therapy accelerates symptom relief (fever and pain) by 1–2 days
      
  • Goal of antibiotic treatment is to reduce the incidence of acute rheumatic fever, symptoms, and suppurative complications
    
• Antibiotics:
  
  • Penicillin V: Antibiotic of choice for GAS pharyngitis
    
  • Cephalosporins or macrolides are an acceptable alternative treatment for nonresponders and penicillin-allergic patients
    
• Corticosteroids:
  
  • In conjunction with antibiotics, corticosteroids have a 3-fold increase in the likelihood of symptom resolution at 24 hr
    
  • Number needed to treat: 3.3–3.7
    
  • Avoid in diabetics and immunocompromised patients
    
• Potential complications of streptococcal infection:
  
  • Suppurative complications:
    
    • Peritonsillar/retropharyngeal abscess
      
    • Lemierre disease
      
    • Otitis media/mastoiditis
      
  • Nonsuppurative complications:
    
    • Acute rheumatic fever:
      
      • Rare in industrialized countries, but still the leading cause of cardiac death within 1st 5 decades of life
        
      • Sequelae of GAS; not proven in association with group C or G
        
    • Acute poststreptococcal glomerulonephritis
      
    • Sydenham chorea
      
    • Reactive arthritis
      
    • PANDAS: Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection:
      
      • Sudden onset of symptoms similar to obsessive–compulsive disorder
        
      • Caused by an autoimmune reaction affecting the basal ganglia
        
      • Uncommon and controversial
        
• Diphtheria:
  
  • Goals of therapy:
    
    • Prevent airway obstruction
      
    • Treat infection
      
  • Penicillin or macrolide antibiotic
    
  • Complications:
    
    • Exotoxin-mediated myocarditis and neuritis (cranial neuropathies)
      
• Gonococcal pharyngitis:
  
  • 3rd-generation cephalosporin plus macrolide for possible
    Chlamydia
    coinfection
    

• Penicillin G:
  
  • <27 kg: Benzathine penicillin G (Bicillin LA): 0.6 million U IM × 1
    
  • >27 kg: Benzathine penicillin G (Bicillin LA): 1.2 million U IM × 1
    
• Penicillin V:
  
  • <12 yr: 25–50 mg/kg/d PO div. q6–8h × 10 days
    
  • >12 yr: 250–500 mg PO q6–8h × 10 days
    
• Amoxicillin:
  
  • 50 mg/kg PO QD, (max. 1 g) × 10 days
    

• Macrolides:
  
  • Azithromycin: 20 mg/kg/d × 3 days (max. 500 mg per dose)
    
  • Erythromycin: 40–50 mg/kg PO div. q6h × 10 days (max. 500 mg per dose)
    
• Oral cephalosporins:
  
  • Cephalexin: 20 mg/kg/dose PO BID × 5 days (max. 500 mg per dose)
    
• Steroids:
  
  • Dexamethasone: 0.6 mg/kg IM/PO × 1 (max. 10 mg)
    
  • Prednisone: 40–60 mg PO × 1
    
• Special conditions:
  
  • Suspected gonococcal pharyngitis:
    
    • Ceftriaxone: 125–250 mg IM × 1
      

FOLLOW-UP

• Airway compromise
  
• Severe dehydration
  
• Suspected child abuse
  

Able to tolerate oral intake

• If symptoms do not improve within 72 hr
  
• Patients are no longer contagious after 24 hr of antibiotic treatment
  
• Mononucleosis patients should avoid contact sports
  

• Use the modified Centor criteria to make the decision to test for GAS pharyngitis
  
• Children with negative RADT need follow-up throat culture
  
• Acute rheumatic fever is a more common complication of GAS pharyngitis in nonindustrialized nations
  
• Evaluate for high-risk complications of bacterial pharyngitis (e.g., peritonsillar abscess, retropharyngeal abscess, Lemierre disease)
  

• Hayward G, Thompson M, Heneghan C, et al. Corticosteroids for pain relief in sore throat: Systemic review and meta-analysis.
  BMJ.
  2009;339:b2976.
  
• Kociolek LK, Shulman ST. In the clinic. Pharyngitis.
  Ann Intern Med.
  2012;157:ITC3-1–ITC3-16.
  
• McIsaac WJ, Kellner JD, Aufricht P, et al. Empirical validation of guidelines for the management of pharyngitis in children and adults.
  JAMA
  . 2004;291:1587–1595.
  
• Wessels MR. Clinical practice. Streptococcal pharyngitis.
  N Engl J Med.
  2011;364:648–655.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Epiglottitis
  
• Mononucleosis
  
• Peritonsillar Abscess
  
• Retropharyngeal Abscess
  
• Rheumatic Fever
  

CODES

• 034.0 Streptococcal sore throat
  
• 054.79 Herpes simplex with other specified complications
  
• 462 Acute pharyngitis
  

BASICS

• Phencyclidine (PCP) is a dissociative anesthetic structurally related to ketamine:
  
  • Causes decreased perception of pain and agitation
    
• Half-life of 21–24 hr, but may be longer in overdose
  
• Enterohepatic recirculation—recirculated into the stomach
  

• Drug of abuse:
  
  • Frequently encountered as an adulterant of marijuana
    
• Street names for PCP include:
  
  • Angel dust
    
  • Wicky stick
    
  • Wicky weed
    
  • Wacky weed
    
  • Wet
    
  • Illy
    
  • Embalming fluid
    
  • Sherman
    

Exposure in toddlers reported via passive exposure

DIAGNOSIS

• CNS:
  
  • Altered mental status
    
  • Agitation
    
  • Bizarre/violent behavior
    
  • Belligerence
    
  • Coma
    
  • Seizures
    
  • Nystagmus (vertical, horizontal, or rotatory)
    
• Cardiovascular:
  
  • HTN
    
  • Tachycardia
    
• Musculoskeletal:
  
  • Traumatic injury (decreased pain perception)
    
  • Rhabdomyolysis (due to vigorous muscular contraction)
    
• Vital signs:
  
  • Hyperthermia
    

How was the PCP consumed?

• Smoked with marijuana
  
• Ingested
  

• Agitation
  
• Coma
  
• Hypertension
  
• Tachycardia
  
• Diaphoresis
  
• Nystagmus (vertical, horizontal, or rotatory)
  
• Hyperthermia
  
• Vigorous muscular contraction
  

• Clinical diagnosis based on presentation supported by urine toxicology screen:
  
  • Dextromethorphan and ketamine may give false positive.
    
• Careful physical exam for occult trauma
  
• Exclude other causes of altered mental status.