Rosen & Barkin's 5-Minute Emergency Medicine Consult (585 page)

• If primarily medical etiology, admission to medical service, criteria dictated by specific medical condition
  
• If primarily psychiatric etiology (e.g., schizophrenia), admit to psychiatric service if:
  
  • Danger to self or others
    
  • Inability to care for self
    
  • Deranged thought pattern that can be threat to self or others
    
  • 1st episode: Evaluation and stabilization
    
  • Laws for involuntary hospitalization vary by state.
    

• Stable medical condition
  
• Not suicidal/homicidal
  
• Able to care for self
  
• Capable of making medical decisions
  

• Insurance coverage determines inpatient and outpatient psychiatric disposition options.
  
• Case management or social services necessary for psychiatric disposition.
  

• If psychosis is primarily psychiatric, confirm follow-up appointment with mental health provider within 1–2 wk.
  
• Reassess risk/benefit of continuing on antipsychotic medication at follow-up.
  

• Patients with psychosis may not be able to explain their symptoms in a typical way. Get collateral and maintain a high degree of suspicion.
  
• Important to rule out organic causes prior to ascribing psychosis to a psychiatric disorder.
  

• Baldwin P, Browne D, Scully PJ, et al. Epidemiology of first-episode psychosis: Illustrating the challenges across diagnostic boundaries through the Cavan-Monaghan study at 8 years.
  Schizophr Bull.
  2005;31(3):624–638.
  
• Fraser S, Hides L, Philips L, et al. Differentiating first episode substance induced and primary psychotic disorders with concurrent substance use in young people.
  Schizophr Res.
  2012;136:110–115.
  
• Freudenreich O, Schulz SC, Goff DC. Initial work-up of a first-episode psychosis: A conceptual review.
  Early Interv Psychiatry
  . 2009;3:10–18.
  
• Goulet K; Deschamps B, Evoy F, et al. Use of brain imaging (computed tomography and magnetic resonance imaging) in first-episode psychosis: Review and retrospective study.
  Can J Psychiatry.
  2009;54(7):493–501.
  
• Ray WA, Chung CP, Murray KT, et al. Atypical antipsychotics and the risk of sudden cardiac death.
  N Engl J Med
  . 2009;360(3):225–235.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Agitation, Management of
  
• Psychosis, Acute
  
• Schizophrenia
  

CODES

• 292.9 Unspecified drug-induced mental disorder
  
• 298.9 Unspecified psychosis
  
• 780.1 Hallucinations
  

BASICS

• Transfer of kinetic energy to the lung, causing direct damage to the lung parenchyma, resulting in both hemorrhage and edema in the absence of a pulmonary laceration
  
• Mortality rate is 10–25%.
  
• Independent risk factor for:
  
  • Acute respiratory distress syndrome
    
  • Pneumonia
    
  • Long-term respiratory dysfunction
    

• Development of pulmonary contusion:
  
  • Takes place in 2 stages:
    
    • 1st stage, which is related to the direct injury, results in disruption of the alveolocapillary membrane, which leads to extravasation of blood into the interstitial and alveolar space.
      
    • 2nd stage is related to the indirect worsening of the injury as a result of measures that occur during the resuscitation of the patient, in particular, administration of IV fluids.
      
• Leads to:
  
  • Increased intrapulmonary shunting
    
  • Increased resistance to airflow
    
  • Decreased lung compliance
    
  • Increased respiratory work
    
  • Hypoxemia and acidosis
    
  • Respiratory failure
    

• Blunt or penetrating thoracic trauma
  
• Sudden deceleration–compression
  
• Fall from height
  
• Motor vehicle accident
  
• Assault
  
• Missile
  

DIAGNOSIS

• Blunt or penetrating thoracic trauma by any mechanism
  
• Mechanism as described by patient, family or emergency medical services personnel:
  
  • Seat belt use
    
  • Steering wheel damage
    
  • Air bag deployment
    
• Chest pain
  
• Dyspnea
  
• Hemoptysis
  

• Auscultation:
  
  • Initially normal or diminished breath sounds
    
  • Progresses to crackles, rales, absent breath sounds
    
• Localized ecchymosis, edema, erythema, and tenderness of chest wall
  
• Bony deformities, crepitus, point tenderness, and paradoxical movements associated with rib fractures
  
• Ecchymosis from seat belt, aka “seat belt sign”
  
• Ecchymosis from steering wheel impact
  
• Splinting respirations
  
• Cyanosis, tachycardia, hypotension
  
• Dyspnea, tachypnea
  

CXR:

• Radiographic findings may not appear until 6–12 hr post injury.
  
• Patchy alveolar infiltrates to frank consolidation.
  
• Associated intrathoracic injury:
  
  • Rib fractures
    
  • Pneumothorax, hemothorax
    
  • Widened mediastinal silhouette
    

Arterial blood gas may reveal hypoxemia and elevated alveolar–arterial gradient.

• Chest radiograph:
  
  • Percentage of contusion can help predict the need for intubation:
    
    • <18%: Usually will not need intubation
      
    • >28%: Usually leads to intubation
      
• Thoracic CT is useful in detecting pulmonary injury and associated intrathoracic injuries not identified on CXR:
  
  • Studies that have shown injury size on CT can also assist with prognosis.
    
  • >20% of the total lung volume is predictive of the need of assisted ventilation.
    
• US has been studied and could prove to be a fast, sensitive method for diagnosing pulmonary contusion.
  

• Adult respiratory distress syndrome
  
• CHF
  
• Hemothorax
  
• Noncardiogenic causes of pulmonary edema
  
• Pneumonia, abscess, or other infectious process
  
• Pneumothorax
  
• Pulmonary laceration, infarction, or embolism
  

TREATMENT

Thoracic trauma with significant mechanism or pre-existing pulmonary disease should be routed to the nearest available trauma center.

• Manage airway and resuscitate as indicated.
  
  • Stabilize associated chest wall injuries (open chest, flail chest)
    
• IV line, O
  ₂
  , continuous cardiac monitoring, and pulse oximetry
  
• Control airway:
  
  • Endotracheal intubation indications:
    
    • Severe hypoxemia (PaO
      ₂
      <60 mm Hg on room air, <80 mm Hg on O
      ₂
      )
      
    • Significant underlying lung disease
      
    • Impending respiratory failure
      
  • Early intubation and institution of positive end expiratory pressure:
    
    • Correct hypoxemia and acidosis.
      
    • Decrease the work of breathing.
      

• Maintain adequate oxygenation and ventilation.
  
• Monitor O
  ₂
  saturation and respiratory rate.
  
• In conscious and alert patients, O
  ₂
  administration via face mask is 1st-line therapy.
  
• If patient cannot maintain a PaO
  ₂
  >80 mm Hg on high-flow oxygen:
  
  • Continuous positive airway pressure via mask
    
  • Nasal bilevel positive airway pressure (BiPAP)
    
  • Early endotracheal intubation and mechanical ventilation
    
• In patients with severe unilateral injuries with significant hemoptysis or air leaks, consider selective bronchial intubation.