Rosen & Barkin's 5-Minute Emergency Medicine Consult (550 page)

• Dysrhythmias for cardiac monitoring
  
• Intractable vomiting
  
• Refractory hypotension
  
• Evidence of end-organ damage (e.g., hepatic dysfunction, acidosis) or concern for potential for end-organ damage
  
• Altered mental status
  

• Baseline mental status
  
• Tolerating oral fluids
  
• Normal cardiac activity
  
• Delayed sequelae not anticipated
  

Lower threshold to admit children:

• Tend to eat more concentrated parts of plants
  
• Lower lethal dose
  
• Symptoms less specific
  

Follow-up with medical toxicologist or primary care physician

• Death from unintentional plant exposures is rare.
  
• Intentional exposures from herbal remedies, attempted abuse or therapeutic misadventures can be deadly.
  
• Contact your regional poison center if concerned about a patient ingesting a potentially poisonous plant: 1-800-222-1222
  

A special thanks to Dr. Harry Karydes, who contributed to the previous edition.

• Froberg B, Ibrahim D, Furbee RB. Plant poisoning.
  Emerg Med Clin North Am
  . 2007;25(2):375–433.
  
• Nelson LS, Shih RD, Balick MJ.
  Handbook of Poisonous and Injurious Plants
  . 2nd ed. New York, NY: Springer; 2007:21–34.
  
• Palmer ME, Betz JM. Plants. In: Goldfrank LR, Flomenbaum NE, Lewin NA, et al., eds.
  Goldfrank’s Toxicologic Emergencies
  . 9th ed. Chicago, IL: McGraw-Hill Medical; 2011:1537–1560.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Acidosis
  
• Cyanide Poisoning
  
• Digoxin Poisoning
  

CODES

988.2 Toxic effect of berries and other plants eaten as food

BASICS

• Normal conditions:
  
  • Pleural space contains 0.1–0.2 mL/kg (30 mL in an adult) of clear, low-protein fluid that facilitates movement of the pulmonary parenchyma within the thoracic space.
    
  • Fluid formation and reabsorption are governed by hydrostatic and oncotic forces.
    
  • Normally, the sum of these forces results in movement of fluid into the pleural space from the parietal surface and reabsorption at the visceral surface.
    
  • Lymphatics help remove any excess fluid.
    
• Alteration of any of the above factors results in abnormal fluid accumulation.
  
• Classification:
  
  • Transudative effusion:
    
    • An ultrafiltrate of serum, containing low protein and cells
      
    • Results from increase in hydrostatic pressure and/or decrease in oncotic pressure
      
    • Pleural surface is not involved in the primary pathologic process.
      
  • Exudative effusion:
    
    • Contains high protein and cells
      
    • Results from pathologic disease of the pleural surface leading to membrane permeability and/or disruption of lymphatic reabsorption
      

• Transudative effusions:
  
  • Congestive heart failure (CHF)
    
  • Peritoneal dialysis
    
  • Cirrhosis with ascites
    
  • Pulmonary embolism
    
  • Acute atelectasis
    
  • Nephrotic syndrome
    
  • Myxedema
    
  • Hypoproteinemia
    
  • Superior vena cava syndrome
    
  • Meigs syndrome:
    
    • Triad of ascites, benign ovarian tumor, and pleural effusion
      
• Exudative effusions:
  
  • Pulmonary or pleural infection:
    
    • Bacterial, viral, fungal, tuberculosis (TB), parasitic
      
  • Primary lung cancer
    
  • Mesothelioma
    
  • Metastasis (often from breast cancer, ovarian cancer, or lymphoma)
    
  • Pericarditis
    
  • Pulmonary embolism
    
• Intra-abdominal disorders:
  
  • Pancreatitis, hepatitis, cholecystitis
    
  • Subdiaphragmatic abscess
    
  • Esophageal rupture
    
  • Peritonitis
    
  • Meigs syndrome
    
• Rheumatologic disease:
  
  • Systemic lupus erythematosus
    
  • Rheumatoid arthritis
    
  • Sarcoidosis
    
• Trauma:
  
  • Hemothorax
    
  • Chylothorax
    
• Drugs:
  
  • Drug-induced lupus
    
  • Nitrofurantoin, methysergide, dantrolene, amiodarone, bromocriptine
    
  • Crack cocaine
    

DIAGNOSIS

• Small effusions are often asymptomatic.
  
• Dyspnea, pleuritic chest pain, and/or cough
  
• Tachypnea, hypoxia, decreased breath sounds, and/or dullness to percussion
  

• Underlying primary pathologic process (CHF, pneumonia, pulmonary embolus, pancreatitis) is often the source of complaints.
  
• Dyspnea on exertion or at rest
  
• Cough with large effusion
  
• Pleuritic chest pain with inflammation of pleura
  
• Empyema: Fever, fatigue, weight loss
  

• Decreased breath sounds
  
• Decreased tactile fremitus
  
• Increased egophony for large effusions
  
• Dullness to chest percussion
  
• Pleural friction rub
  
• Examine for the primary cause of pleural effusion.
  

• Cardiac monitor and pulse oximetry
  
• CBC, comprehensive metabolic panel, coagulation panel
  
• Chest radiography
  
• Search for underlying cause
  

• CBC
  
• Electrolytes, BUN/creatinine, glucose, serum lactate dehydrogenase (LDH), serum protein
  
• Pulse oximetry or arterial blood gas
  
• Coagulation panel
  
• Pleural fluid analysis to determine if transudative or exudative effusion:
  
  • Check pleural protein and LDH levels.
    
  • Light criteria: Fluid is likely exudative if 1 or more of the following criteria are met:
    
    • Pleural fluid protein/serum protein >0.5
      
    • Pleural fluid LDH/serum LDH >0.6
      
    • Pleural fluid LDH >2/3 upper limit of normal serum LDH
      
• If effusion is transudative, no further fluid analysis is usually necessary.
  
• Determining etiology of exudative effusion:
  
  • Initial testing: Cell count with differential, Gram stain and culture, acid fast bacilli stain, pH, glucose, and cytology
    
  • Based on clinical scenario consider: Triglycerides, amylase, albumin, creatinine, adenosine deaminase, and tumor markers.
    
  • RBC and Hct:
    
    • 5,000–100,000/mm
      ³
      nonspecific
      
    • >100,000/mm
      ³
      suggestive of malignancy, trauma, or pulmonary embolus
      
    • Pleural fluid Hct >0.5 serum Hct is by definition a hemothorax.
      
    • Other causes: Malignancy, TB, aortic rupture
      
    • Heparinize and chill hemorrhagic samples to be sent for cytology.
      
  • WBC:
    
    • 1,000–10,000/mm
      ³
      nonspecific
      
    • >10,000/mm
      ³
      suggestive of parapneumonic effusion, empyema, pancreatitis, rheumatologic, malignancy, or TB
      
  • Glucose:
    
    • Glucose <60 mg/dL suggestive of complicated parapneumonic effusion/empyema, malignancy, esophageal rupture, or rheumatologic disease
      
  • Triglyceride:
    
    • Triglycerides >100 mg/dL suggestive of chylothorax, disruption of thoracic duct
      
  • Amylase:
    
    • Amylase >200 IU/L suggestive of pancreatitis, esophageal rupture, malignancy, TB, or empyema
      
  • pH:
    
    • Send in a chilled heparinized arterial blood gas syringe.
      
    • pH < 7 suggests complicated parapneumonic effusion or empyema
      
  • Cytology identifies malignant cells.
    

• Chest radiograph:
  
  • Upright chest film:
    
    • Blunting of the costophrenic angle
      
    • Requires at least 200–250 mL of fluid
      
    • Presence of subpulmonic effusions may be indicated by loss of supradiaphragmatic vascular markings or an increased space between the gastric bubble and pulmonary parenchyma.
      
  • Lateral decubitus film:
    
    • Can identify as little as 5–10 mL of fluid.
      
    • Suspect a loculated effusion or alternative diagnosis if effusion fails to layer.
      
• US:
  
  • Has similar sensitivity to lateral decubitus film and can detect as little as 5–10 mL of fluid.
    
  • Can differentiate simple effusions from loculated fluid collections.
    
  • Improves patient safety and decreases risk of pneumothorax for thoracentesis
    
• CT chest with IV contrast:
  
  • Most sensitive study for detecting pleural fluid collections and identifying loculated effusions.
    
  • Useful for determination of underlying lung process such as masses and pleural thickening