Rosen & Barkin's 5-Minute Emergency Medicine Consult (589 page)

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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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MEDICATION
  • Alteplase: 100 mg (peds: N/A) IV over 2 hr
  • Enoxaparin: 1 mg/kg (peds: 0.75 mg/kg) SC q12h
  • Reteplase: 10 U (peds: N/A) IV bolus q30min × 2
  • Streptokinase: 250,000 U (peds: 3,500–4,000 U/kg) IV bolus over 30 min, then 100,000 U (peds: 1,000–1,500 U/kg) IV maintenance over 24 hr
  • Unfractionated heparin:
    • Bolus: 80 U/kg (peds: 75 U/kg) IV over 10 min
    • Maintenance: 18 U/kg (peds: 20 U/kg) IV drip
    • Do not use TBW to calculate dose in obese patients.
  • Warfarin: 5 mg (peds: 0.05–0.34 mg/kg/d) PO per day, adjust for INR goal 2–3
  • Rivaroxaban: 15 mg BID × 3wks then 20mg QD
FOLLOW-UP
DISPOSITION
Admission Criteria
  • Admit all patients with PE for continued anticoagulation and observation.
  • Clinically stable patients with a high suspicion for PE, no contraindication to anticoagulation, and a lack of V/Q scanning or angiographic availability may be anticoagulated and studied when resources are available in the morning.
PEARLS AND PITFALLS
  • Clinical presentation is variable and nonspecific, making diagnosis difficult in many cases.
  • Patients with malignancy are at higher risk for Coumadin failure and recurrent PE even with therapeutic INR.
ADDITIONAL READING
  • Kline JA, Courtney DM, Kabrhel C, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria.
    J Thromb Haemost.
    2008;6(5):772–780.
  • Stein P, Fowler S, Goodman LR, et al. Multidetector computed tomography for acute pulmonary embolism.
    N Eng J Med
    . 2006;354:2317–2327.
  • Stein PD, Woodward PK, Weg JG, et al. Diagnostic pathways in acute PE: Recommendations of the PIOPED II investigators.
    Am J Med
    . 2006;119:1048–1055.
  • van Belle A, Büller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography.
    JAMA.
    2006;295(2):172–179.
See Also (Topic, Algorithm, Electronic Media Element)
  • Chest Pain
  • Dyspnea
CODES
ICD9
  • 415.11 Iatrogenic pulmonary embolism and infarction
  • 415.19 Other pulmonary embolism and infarction
  • 673.20 Obstetrical blood-clot embolism, unspecified as to episode of care or not applicable
ICD10
  • I26.99 Other pulmonary embolism without acute cor pulmonale
  • O88.219 Thromboembolism in pregnancy, unspecified trimester
PURPURA
Richard E. Wolfe
•
Ashley L. Greiner
BASICS
DESCRIPTION
  • Skin lesionscaused by extravasation of blood into the skin or subcutaneous tissue
  • Can be caused by fragile capillaries, poor dermal support, and/or platelet dysfunction
  • The resultant lesions do not blanch completely with pressure (as seen when pressing down through a glass slide)
  • Nomenclature varies by the size of the lesions:
    • Petechiae (≤4 mm)
    • Purpuric lesions (5–10 mm)
    • Ecchymoses (>10 mm)
  • Color determined by depth and time of onset:
    • Red if superficial and recent onset
    • Purple if deep
    • Deep purple, brown, orange, or blue-green with later presentations
  • Nonpalpable purpura:
    • Simple hemorrhage or microvascular occlusion with ischemic hemorrhage
    • Generally due to a platelet disorder:
      • Diminished production
      • Altered distribution
      • Increased destruction
      • Abnormal function
  • Palpable purpura:
    • Generally due to vasculitis:
      • Autoimmune, small-vessel leukocytoclastic vasculitis
      • Hypersensitivity to various antigens
      • Formation of circulating immune complexes deposited in walls of postcapillary venules; activate complement that is chemotactic for polymorphonuclear leukocytes
      • Released enzymes damage vessel walls and cause leakage of blood
      • Vasculitic lesions may not be palpable in immunocompromised patients
ETIOLOGY
  • Nonpalpable purpura:
    • Viral:
      • Echovirus
      • Coxsackie
      • Measles
      • Parvovirus B19
    • Drugs:
      • Acetaminophen
      • Allopurinol
      • Anticoagulants
      • Aspirin
      • Digoxin
      • Furosemide
      • Gold salts
      • Lidocaine
      • Methyldopa
      • Nonsteroidal anti-inflammatory drugs
      • Penicillin G
      • Phenylbutazone
      • Quinidine
      • Quinine
      • Rifampin
      • Steroids
      • Sulfonamides
      • Thiazides
    • Nutritional deficiencies:
      • Vitamin K deficiency
      • Vitamin C deficiency (Scurvy)
    • Bone marrow disease
    • Hypersplenism
    • Idiopathic thrombocytopenic purpura (ITP)
    • Disseminated intravascular coagulation (DIC)
    • Thrombotic thrombocytopenic purpura
    • Liver or renal insufficiency
    • Thrombocytopenia (<50,000 plt/cc)
    • Thrombocytosis (>1,000,000 plt/cc)
    • Spiking elevations of intravascular pressure (childbirth, vomiting, paroxysmal coughing)
    • Hemophilia
    • Solar purpura (only on sun-exposed areas)
    • Post-transfusion
  • Palpable purpura:
    • Viral:
      • Echovirus type 9
      • Coxsackie
      • Hepatitis B
    • Streptococcal pharyngitis
    • Drugs:
      • Allopurinol
      • Anti-influenza vaccines
      • Cephalosporins
      • Gold
      • Heparin
      • Hydralazine
      • Iodides
      • Levamisole
      • Metoclopramide
      • Penicillin G
      • Phenylbutazone
      • Phenytoin
      • Quinidine
      • Quinine
      • Streptomycin
      • Sulfonamides
      • Thiazides
      • Ticlopidine
    • Malignancies
    • Autoimmune and connective tissue diseases
    • Gonococcus
    • Meningococcus
    • Pseudomonas
      (ecthyma gangrenosum)
    • Rocky Mountain spotted fever
    • In immunocompromised hosts:
      Candida
      ,
      Aspergillus
    • Occlusion due to organisms living in vessels (generally immunocompromised hosts): Mucormycosis, aspergillosis, and disseminated strongyloidiasis
    • Occlusion due to microvascular platelet plugs (heparin necrosis)
    • Cold-related gelling or agglutination (cryoglobulinemia)
    • Local or systemic coagulation abnormalities: Scarlet fever,
      Vibrio vulnificus
      bacteremia; “malignantchickenpox” and “black measles” (both rare in US); Coumadin necrosis
    • Embolization: Cholesterol, crystal, thrombus (atrial myxoma, septic endocarditis, multiple myeloma)
Pediatric Considerations
  • Henoch–Schönlein purpura
  • Hemolytic uremic syndrome
  • Kawasaki disease
  • Neonatal:
    • Extramedullary erythropoiesis in rubella and cytomegalovirus (blueberry muffin baby)
    • Purpura fulminans (protein C and S deficiency)
    • Maternal ITP
    • Wiskott–Aldrich syndrome
DIAGNOSIS
SIGNS AND SYMPTOMS
  • Palpable or nonpalpable, nonblanching lesions
  • Size:
    • Petechiae (≤4 mm)
    • Macular (5–10 mm)
    • Ecchymoses (>1 cm)
  • Shape:
    • Round lesions: Caused by leukocytoclastic emboli
    • Irregular (retiform) lesions: Caused by infectious emboli
    • Annular or erythema multiforme (target lesions)
  • Distribution:
    • Generalized: Consider DIC and meningococcemia
    • Dependent: Most common. Seen in the lower extremities (increased hydrostatic force)
    • Acral: Found in the extremities only
    • Oral/mucous membranes: Consider ITP
  • Hypotension
  • Altered mental status
  • Gingival hemorrhage
  • Epistaxis
  • Hematuria
  • Fever
  • Malaise
  • Arthralgias/hemarthroses
  • Myalgias
  • Purpura fulminans:
    • Large, irregular ecchymoses
    • Fever
    • Shock
    • DIC
  • Pseudomonas
    (ecthyma gangrenosum):
    • Begins as edematous, erythematous papules
    • Bullae formation in girdle region
  • Disseminated gonococcal infection:
    • Usually <10 lesions, purpuric papules, or vesicopustules on the extensor surface of hands, dorsal aspect of ankles and toes
    • Fever
    • Arthralgias
  • Meningococcemia:
    • Small areas of skin infarction cause retiform purpura
    • May involve head, palms, soles, mucous membranes, including conjunctivae
    • Fever
    • Headache
  • Rocky Mountain spotted fever:
    • After 4–7 days of generalized symptoms, erythematous macules on distal extremities including palms and soles, then petechial
    • Fever
    • Headache
  • Henoch–Schönlein purpura:
    • Appears on extensor aspects of lower extremities and buttocks
    • Fades in about 5 days
    • Fever
    • Arthralgias
    • Abdominal pain
    • Hematuria
  • Kawasaki disease:
    • Purpura is rare
    • Fever, plus 4 of the following: Polymorphous exanthem, peripheral extremity changes, bilateral conjunctivitis, changes of lips and mouth, unilateral cervical lymphadenopathy
  • Levamisole adulterated cocaine:
    • Retiform, necrotic purpura involving the ears/face but can occur anywhere
    • Neutropenia
    • Recurrent symptoms with continued abuse

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