Rosen & Barkin's 5-Minute Emergency Medicine Consult (563 page)

Dermatologic

• Mees lines:
  
  • Arsenic
    
  • Thallium
    
  • Chemotherapy agents
    
  • Radiation
    
• Bullae:
  
  • Barbiturates
    
  • Carbon monoxide
    
  • Captopril
    
• Flushed or red appearance:
  
  • Anticholinergics
    
  • Disulfiram reactions
    
  • Niacin
    
  • Boric acid
    
  • Scombroid poisoning
    
  • Monosodium glutamate
    
  • Carbon monoxide (frequently postmortem)
    
  • Cyanide (rare)
    
  • Vancomycin
    
• Blue skin:
  
  • Ergotamines
    
  • Methemoglobinemia from:
    
    • Nitrite
      
    • Nitrate
      
    • Dapsone
      
    • Aniline dye
      
    • Phenazopyridine
      
    • Benzocaine
      
    • Chloroquine
      
  • Pseudocyanosis from:
    
    • Chlorpromazine
      
    • Amiodarone
      
    • Minocycline
      
    • Silver (argyria)
      
    • Gold (chrysiasis)
      

Depends on ingested substance:

• CBC
  
• Electrolytes, BUN, creatinine, glucose
  
• Urinalysis
  
• Arterial blood gas, venous blood gas
  
• Carboxyhemoglobin, methemoglobin levels
  
• Toxicology screen
  
• Aspirin and Acetaminophen level
  
• Prothrombin time
  
• Liver function tests
  

• Anion gap acidosis:
  Mnemonic:
  A CAT MUD PILES (encompasses a limited number of common causes):
  
  • A
    lcohol ketoacidosis
    
  • C
    O/cyanide
    
  • A
    cetaminophen in fulminant hepatic failure
    
  • T
    oluene
    
  • M
    ethanol
    
  • U
    remia
    
  • D
    iabetic ketoacidosis
    
  • P
    araldehyde, phenformin/metformin
    
  • I
    ron, isoniazid
    
  • L
    actic acidosis
    
  • E
    thylene glycol
    
  • S
    alicylates, sodium azide, hydrogen sulfide
    
• Increased osmolar gap:
  
  • Methanol
    
  • Ethylene glycol
    
  • Isopropyl alcohol
    
  • Ethanol
    
  • Acetone
    
  • Glycerol
    
  • Mannitol
    
  • Glycine
    

TREATMENT

ABCs

Depends on ingested substance (see Poisoning; Poisoning, Gastric Decontamination)

• Obtain appropriate lab tests.
  
• Recognize signs and symptoms and lab clues to the toxidromes.
  

• Boyer EW, Shannon M. The serotonin syndrome.
  N Engl J Med
  . 2005;352:1112–1120.
  
• Nelson L, Lewin N, Howland MA, et al.
  Goldfrank’s Toxicologic Emergencies.
  9th ed. New York, NY: McGraw-Hill; 2010.
  
• Weatherald J, Marrie TJ. Pseudocyanosis: Drug-induced skin hyperpigmentation can mimic cyanosis.
  Am J Med
  . 2008;121(5):385–386.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Poisoning
  
• Poisoning, Gastric Decontamination
  

CODES

• 971.0 Poisoning by parasympathomimetics (cholinergics)
  
• 971.1 Poisoning by parasympatholytics (anticholinergics and antimuscarinics) and spasmolytics
  
• 971.2 Poisoning by sympathomimetics [adrenergics]
  

BASICS

• Caused by poliovirus infection
  
• Incubation period 7–14 days
  
• Duration <1 wk
  
• Clinical manifestations are defined as follows:
  
  • Subclinical (i.e., not apparent) 90–95%
    
  • Abortive poliomyelitis 4–8%:
    
    • Clinically indistinct from many other viral infections (fever, myalgias, malaise)
      
    • Only suspected to be polio during an epidemic
      
  • Nonparalytic poliomyelitis 1–2%:
    
    • Differs from abortive poliomyelitis by the presence of meningeal irritation
      
    • Course similar to any aseptic meningitis
      
  • Paralytic poliomyelitis 0.1%, which is further subdivided:
    
    • Spinal paralytic poliomyelitis (frank polio)
      
    • Bulbar paralytic poliomyelitis (10% of paralytic polio): Paralysis of muscle groups innervated by cranial nerves; involves the circulatory and respiratory centers of the medulla with high mortality
      
    • Mixed bulbospinal poliomyelitis
      
  • Postpoliomyelitis syndrome:
    
    • New onset of increased muscle weakness, pain, and focal or generalized atrophy
      
    • Occurs 8–70 yr after the active illness, usually in the previously affected limb
      
    • Risk factors include age at time of infection, extent of recovery and female sex (increased risk with better recovery)
      
    • Gradual progression
      

• Polioviruses:
  
  • Picornaviruses
    
  • Small, nonenveloped RNA viruses of the enterovirus genera
    
  • 3 subtypes: 1, 2, 3
    
• Fecal–oral route transmission
  
  • Enters through oral cavity
    
  • Replicates in pharynx, GI tract, and lymphatics
    
• Humans are the only natural host and reservoir
  
• Poliovirus selectively destroys motor and autonomic neurons
  
• Natural (wild) virus has been completely eliminated in US since 1979
  
• Oral poliovirus vaccine (OPV):
  
  • Accounts for only poliomyelitis seen in US
    
    • 8–10 cases/yr of vaccine-associated paralytic poliomyelitis (VAP): Neurovirulent conversion of vaccine virus; decreased since widespread use of inactivated poliovirus vaccine (IPV)
      
    • VAP occurs in poorly immunized regions by acquiring properties of wild-type virus.
      
    • There has been a recent increase in some third word countries
      

DIAGNOSIS

• Primarily asymptomatic
  
• Viral symptoms: Fever, headache, malaise. Respiratory symptoms: Sore throat, fatigue GI symptoms: Nausea, vomiting
  
• Nonparalytic aseptic meningitis: Stiff neck, and or back
  
• Muscle pain and weakness
  
• Progressive weakness for <1 wk:
  
• Dysphagia and dysarthria with bulbar involvement
  

• Vaccination history
  
• History of prior polio infection
  
• Recent exposure to individual vaccinated with OPV
  
• Recent travel to endemic countries (Nigeria, Pakistan, India, Afghanistan)
  
• Comorbid conditions affecting immunocompetence especially B-lymphocyte disorders (e.g., hypogammaglobulinemia and agammaglobulinemia)
  

• Fever (37°C –39°C)
  
• Headache, photophobia
  
• Nuchal rigidity
  
• Neurologic changes:
  
  • Muscle soreness that becomes severe muscle spasm, progressing rapidly to spotty flaccid weakness and paralysis
    
  • Asymmetric paralysis more prominent in the lower than the upper extremities
    
  • Urinary retention (50% of paralytic cases)
    
  • Reflexes initially hyperactive, then absent
    
  • Apprehensive and irritable, occasionally drowsy
    
  • No sensory loss associated with the motor deficit