Rosen & Barkin's 5-Minute Emergency Medicine Consult (705 page)

Analgesia

FOLLOW-UP

• Patients with confirmed torsion must be admitted for scrotal exploration and bilateral orchiopexy.
  
• Flow studies that are inconclusive and technical failures mandate further investigation by surgical exploration of the scrotum.
  
• Admission for urgent surgical exploration of an acute scrotum is mandatory if there is any potential delay in obtaining a flow study:
  
  • Patients in whom apparent spontaneous detorsion has occurred should undergo elective exploration for bilateral orchiopexy.
    

• Patients with negative scrotal exploration and those with normal flow studies can be discharged with appropriate urologic follow-up.
  
• Parameters for return to ED must be discussed because of the possibility of recurrent torsion.
  
• Patients with an obvious diagnosis other than testicular torsion can be referred for care.
  

• Testicular torsion can mimic acute appendicitis in children.
  
• Remember that “time is testicle”; emergent workup and consultation are required.
  
• Maintain a high index of suspicion for testicular torsion in all age groups even though peak incidence is in adolescents and neonates.
  
• If testicular torsion is diagnosed early, a near 100% salvage rate for the testicle is possible. Orchiopexy is not a guarantee against future torsion, although it does reduce the odds.
  

• Baldisserotto M. Scrotal emergencies.
  Pediatr Radiol
  . 2009;39:516–521.
  
• Beni-Israel T, Goldman M, Chaim S, et al. Clinical predictors for testicular torsion as seen in the pediatric ED.
  Am J Emerg Med.
  2010;28:786–789.
  
• Drlík M, Kočvara R. Torsion of spermatic cord in children: A review.
  J Pediatr Urol.
  2013;9:259–266.
  
• Gatti JM, Murphy JP. Acute testicular disorders.
  Pediatr Rev
  . 2008;29:235–241.
  
• Schmitz D, Safranek S. Clinical inquiries. How useful is a physical exam in diagnosing testicular torsion?
  J Fam Pract
  . 2009;58:433–434.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Epididymitis/Orchitis
  
• Hydrocele
  

CODES

• 608.20 Torsion of testis, unspecified
  
• 608.21 Extravaginal torsion of spermatic cord
  
• 608.22 Intravaginal torsion of spermatic cord
  

BASICS

• Rare disease in US but still prevalent in 3rd-world countries
  
• About 30 cases per year in US
  
• One-half of the cases involve people >50 yr of age
  
• Majority of cases in US occur in the unvaccinated, >10 yr since last booster or IVDUs
  
• 500,000–1,000,000 cases worldwide
  
• High mortality rates even with treatment
  
• Incubation period:
  
  • Inoculation to the appearance of the 1st symptoms:
    
    • 48 hr to 3 wk or more
      
  • Period of onset:
    
    • <7 days—poor prognosis
      
    • Very poor prognosis if <48 hr from 1st symptom to initial reflex spasm
      
• Neonatal tetanus:
  
  • Due to infected umbilical stump
    
  • Symptom onset in 2nd week of life when maternal antibodies decrease
    
  • Rare in US but common in 3rd-world countries
    
  • Worldwide, accounts for over one-half of all tetanus infections
    

• Clostridium tetani:
  
  • Slender, motile, heat-sensitive, anaerobic gram-positive rod with a terminal spherical spore
    
  • Spore characteristics
    
  • Resistant to oxygen, moisture, temperature extremes
    
  • Can survive indefinitely until it germinates
    
  • Ubiquitous in soil and feces
    
• When inoculated into a wound or devitalized tissue or injected IV as a contaminant of street drugs, the spores germinate under anaerobic conditions and produce 2 toxins.
  
• Toxins:
  
  • Tetanolysin:
    
    • Damages tissue
      
    • Does not cause clinical manifestations of tetanus infection
      
  • Tetanospasmin:
    
    • Powerful neurotoxin
      
    • Disrupts the release of neurotransmitters such as γ-aminobutyric acid (GABA)
      
    • Responsible for the clinical manifestations
      
• Muscle spasms
  
• Autonomic instability
  
• Uncontrolled motor activity
  

DIAGNOSIS

• Most common type accounting for about 80% of all cases
  
• Initial presentation:
  
  • Muscle stiffness and pain
    
  • Trismus (initial)
    
  • Risus sardonicus (characteristic facial appearance)
    
• Systemic symptoms:
  
  • Irritability
    
  • Restlessness
    
  • Diaphoresis
    
• Later manifestations:
  
  • Muscle group rigidity
    
  • Sudden burst of tonic contractions of muscle groups causing:
    
    • Opisthotonos
      
    • Flexion and adduction of the arms
      
    • Clenching of fists
      
    • Extension of the lower extremities
      
  • Diaphragmatic spasm or paralysis:
    
    • May compromise respiration
      
• Hypersympathetic state (most common cause of death):
  
  • Begins in the 2nd week
    
  • Dysrhythmias
    
  • BP changes
    
  • Diaphoresis
    
  • Hyperthermia
    

• Less common form of disease, accounting for about 17% of all cases
  
• Typical localized spasms around area of initial infection may:
  
  • Be mild
    
  • Persist for months before resolving
    
  • Evolve to generalized form (13%)
    

• Rare variant of disease
  
• Follows head injury or otitis media
  
• Spasm of lower cranial and facial muscles:
  
  • Cranial nerve (CN) palsies, CN VII most common
    
• May progress to generalized tetanus
  

• Generalized form of tetanus occurring during the 1st weeks of life
  
• Often caused by infection of umbilical stump
  
• Clinical manifestations:
  
  • Irritability
    
  • Poor suck
    
  • Facial grimacing
    
  • Muscle spasms with touch
    
• Very high mortality rate (50–100%)
  
• Incubation period 1–2 wk
  

• Investigate source of infection.
  
• Acute skin wound not necessary to contract infection
  
• >25% of infections occurred in the absence of known acute trauma.
  
• Infections can occur from abscesses, ulcers, and gangrene.
  
• Elicit tetanus immunization status.
  

• Perform complete physical exam focusing on cardiovascular and respiratory status, neurologic and CN exam.
  
• Diagnosis of tetanus is clinical:
  
  • Suspect in all cases of trismus
    
  • No wound recalled in one-fifth of cases
    
  • Full tetanus immunization almost eliminates diagnosis.
    

Often of limited or no benefit for diagnosis but useful for ruling out other etiologies or assessing complications of disease

• CBC
  
• Electrolytes, BUN, creatinine, glucose, calcium:
  
  • For hypocalcemia
    
• Strychnine level
  
• ABG, pulse oximetry:
  
  • For oxygenation status
    
• Wound culture for
  C. tetani:
  
  • Positive only about 30% of time
    
• C. tetani
  titers:
  
  • Will be useful only after the fact
    
• CSF analysis:
  
  • Normal in tetanus
    
  • Exclude meningitis/encephalitis