Elias Coutavas, PhD

• Assistant Professor in Medicine

https://medicine.duke.edu/faculty/elias-coutavas-phd

Relationship between high consumption of marine fatty acids in early pregnancy and hypertensive disorders in pregnancy treatment example purchase haldol with mastercard. Hypertension in pregnancy: the management of hypertensive disorders during pregnancy (clinical guideline 107) medications restless leg syndrome purchase on line haldol. The relationship between calcium intake and pregnancy induced hypertension: up-to-date evidence medicine 44-527 purchase haldol master card. Calcium supplementation reduces the risk of pregnancyinduced hypertension in an Andes population symptoms 8 days past ovulation purchase haldol overnight delivery. Dietary calcium supplementation and prevention of pregnancy hypertension (letter) medicine dosage chart order cheap haldol line. Calcium supplementation during pregnancy may reduce preterm delivery in high-risk populations medications safe during breastfeeding purchase generic haldol. Calcium supplementation and the risk of preeclampsia in Ecuadorian pregnant teenagers. Calcium supplementation in nulliparous women for the prevention of pregnancyinduced hypertension, preeclampsia and preterm birth: an Australian randomized trial. World Health Organization randomized trial of calcium supplementation among low calcium intake pregnant women. Prevention of preeclampsia by linoleic acid and calcium supplementation: a randomized controlled trial. Rest during pregnancy for preventing pre-eclampsia and its complications in women with normal blood pressure. Exercise or other physical activity for preventing pre-eclampsia and its complications. Exercise and physical activity in the prevention of pre-eclampsia: systematic review. Increased breath markers of oxidative stress in normal pregnancy and preeclampsia. Effect of antioxidants on the occurrence of preeclampsia in women at increased risk: a randomized trial. Vitamin C and E supplementation in women at high risk for preeclampsia: a double-blind, placebo-controlled trial. Supplementation with vitamins C and E and the risk of preeclampsia and perinatal complications. World Health Organisation multicentre randomised trial of supplementation with vitamins C and E among pregnant women at high risk for pre-eclampsia in populations of low nutritional status from developing countries. Low dose aspirin prevents pregnancy-induced hypertension and preeclampsia in angiotensin-sensitive primigravidae. Antiplatelet agents for the prevention of preeclampsia: a meta-analysis of individual data. Early administration of low-dose aspirin for the prevention of severe and mild preeclampsia: a systematic review and meta-analysis. Aspirin for prevention of preeclampsia in women with historical risk factors: a systemic review. Low molecular weight heparin for the prevention of obstetric complications in women with thrombophilia. Prophylaxis of recurrent preeclampsia: low molecular weight heparin plus low-dose aspirin versus low-dose aspirin alone. The feasibility of a control population for a randomized controlled trial of seizure prophylaxis in the hypertensive disorders of pregnancy. Magnesium sulfate versus phenytoin for seizure prophylaxis in pregnancy-induced hypertension. Does magnesium sulfate affect the length of labor induction in women with pregnancy-associated hypertension? The effect of magnesium sulfate therapy on the duration of labor in women with mild preeclampsia at term: a randomized, doubleblind, placebo-controlled trial. Is magnesium sulfate prophylaxis really necessary in patients with severe preeclampsia? Is prophylactic administration of magnesium sulfate in women with pre-eclampsia indicated prior to labour? Prophylactic anticonvulsant therapy in hypertensive crises of pregnancy ­ the need for a large randomized trial. A randomized controlled trial of intravenous magnesium sulfate versus placebo in the management of women with severe pre-eclampsia. The Parkland Memorial Hospital protocol for treatment of eclampsia: evaluation of 245 cases. Which anticonvulsant for women with eclampsia: evidence from the Collaborative Eclampsia Trial. Magnesium sulfate versus diazepam in the management of eclampsia: a randomized controlled trial. Phenytoin versus magnesium sulfate in patients with eclampsia: preliminary results from a randomized trial. Poster presented at 15th Annual Meeting of the Society of Perinatal Obstetricians, Atlanta; January 23­28, 1995 (abstr 452). Individually determined postpartum magnesium sulfate therapy with clinical parameters to safely and cost-effectively shorten treatment for preeclampsia. Postpartum seizure prophylaxis: using maternal clinical parameters to guide therapy. A prospective randomized trial of magnesium sulfate in severe preeclampsia: use of diuresis as a clinical parameter to determine the duration of postpartum therapy. Abbreviated postpartum magnesium sulfate therapy for women with mild preeclampsia. The use of standard dose of magnesium sulfate in prophylaxis of eclamptic seizures: do body mass index alterations have any effect on success? Effect of maternal body mass index on serum magnesium levels given for seizure prophylaxis. Review: preeclampsia, acute atherosis of the spiral arteries and future cardiovascular disease: two new hypotheses. New additions include animal model observations that suggest explanations for changes in cerebral physiology during normal pregnancy and hypertensive complications. New findings in the human disease regarding volume status and the eclamptic convulsion are discussed and there is further clarification of that new but loosely thrown around term "posterior reversible encephalopathy syndrome" and in both areas our authors have made recent seminal contributions. In this regard discussions regarding prevention and management of cerebral symptoms, especially eclampsia, can be found in Chapters 12 and 20, the first reviewing trials with magnesium sulfate, the latter the treatment of impending or actual eclampsia. For many centuries, convulsions in the pregnant woman were the most recognizable event of what we now know to be a generalized disorder that affects virtually every organ system. In his first edition of Hypertensive Disorders in Pregnancy, Chesley chronicled the historical evolution of theories concerning causes of convulsions in women with eclampsia. Since the times of Hippocrates and Galen, the two main theories were either cerebral congestion ­ repletion, or cerebral anemia ­ depletion. Beliefs concerning repletion led to the widespread practice of phlebotomy during the 1700s and 1800s. And throughout much of the last century, as therapeutic measures were aimed at either halting or preventing convulsions, evidence began to accrue leading to insights into the cerebrovascular pathophysiology of eclampsia. For example, during the renaissance of neuroanatomy and pathology, intracranial hemorrhages and generalized cerebral edema were prominently emphasized. Neuroanatomical emphasis culminated in the seminal work of Sheehan and Lynch and their autopsy series of eclamptic women. By then, it was appreciated that women with fatal eclampsia frequently had brain abnormalities, but that these caused death in a minority of such cases. As deaths from eclampsia declined over the last half of the 20th century, interest in cerebral pathology waned also because there were few avenues from which to approach appropriate investigation. These technologies, combined with reproducible animal models to better study cerebral blood flow and its alterations, have allowed a heretofore unknown look at cerebrovascular pathology provoked by the preeclampsia syndrome. And finally, we review hypertensive effects on cerebral perfusion in both pregnant and nonpregnant animal models from which we draw a composite description of the effects of the preeclampsia syndrome on the brain. Clinical aspects of the preeclampsia syndrome are discussed in Chapters 2 (clinical spectrum), 12 (prevention), and 20 (management). The classical microscopic vascular lesions consist of fibrinoid necrosis of the arterial wall and perivascular microinfarcts and hemorrhages. Thus, while gross intracerebral hemorrhage was seen in up to 60% of eclamptic women, it was fatal in only half. They may appear anywhere on the gyral surface and are most common in the occipital lobes and least common in the temporal lobes. Other frequently described major macroscopic lesions include subcortical edema, multiple nonhemorrhagic areas of "softening" throughout the brain, hemorrhagic areas in the white matter, and hemorrhage in the basal ganglia or pons, often with rupture into the ventricles. Such lesions may also be seen in the frontal and inferior temporal lobes, as well as the basal ganglia and thalamus. Such women may develop signs of impending life-threatening transtentorial herniation. Common findings are hyperintense T2 lesions in the subcortical and cortical regions of the parietal and occipital lobes, with occasional involvement of basal ganglia and/or brainstem. The radiograph on the left shows slit-like effaced ventricles as well as sharply demarcated gray­white interface, both indicating parenchymal swelling. The radiograph on the right taken 10 days later shows diminished edema manifest by larger ventricles and loss of gray­white interface demarcation. Vasogenic edema is associated with increased hydrostatic pressure and ensuing capillary leak, while cytotoxic edema is associated with ischemia and cell death with infarction. This issue is critical because the former is usually reversible and the latter may not be. This case demonstrates the occasional atypical distribution of signal abnormalities away from the parieto-occipital region. Intuitively, however, they are more likely found in women who have more severe disease and who have neurological symptoms. Much of this is because of the various challenges associated with in vivo studies of cerebral blood flow in human pregnancy (see below). And while central nervous system histopathology is mainly based on autopsy data as discussed, most hemodynamic data are invariably from surviving women. Although this presents some difficulty in relating histopathological with hemodynamic findings, an accurate picture is emerging. When taken clinically, data taken from the past several decades include pathological and neuroimaging findings that have led to two general theories to explain cerebral abnormalities associated with eclampsia. Importantly ­ and as emphasized throughout this edition ­ endothelial cell dysfunction that characterizes the preeclampsia syndrome may play a key role in both theories. The first theory suggests that in response to acute severe hypertension cerebrovascular overregulation leads to vasospasm. Finally, the reversible cerebral vasoconstriction syndrome has been reported to be associated with preeclampsia,30 but whether this causes eclampsia is not known. The second theory is that eclampsia represents a form of hypertensive encephalopathy such that sudden elevations in systemic blood pressure exceed the normal cerebrovascular autoregulatory capacity. This mechanism has gained much attention over the last decade, especially since it was described as reversible posterior leukoencephalopathy syndrome. The white matter shows mild, diffuse vacuolization with minimal inflammatory reaction characterized by scattered macrophages. Thus, autoregulation is a physiological protective mechanism that prevents brain ischemia during drops in pressure and prevents capillary damage and edema from hyperperfusion during pressure increases. For example, during acute hypertension at mean pressures above the autoregulatory limit ­ about 160 mm Hg in the otherwise healthy patient ­ the myogenic vasoconstriction of vascular smooth muscle is overcome by excessive intravascular pressure and forced dilatation of cerebral vessels occurs. Its clinical, pathological, as well as neuroimaging features reflect the rapid and dynamic fluctuations in cerebral blood flow and water content. The arterial boundary zones, located at the territorial limits of the major arteries, are commonly affected sites. In the human, the most frequently affected region in the cortex is at the parieto-occipital sulci, which represent the boundary zone of the anterior, middle, and posterior cerebral arteries. This has been described in the thrombotic microangiopathy syndromes ­ hemolytic uremic syndrome and thrombotic thrombocytopenic purpura ­ as well as with systemic lupus erythematosus, with immunosuppressive drug toxicity, or with the use of certain chemotherapeutic agents that include methotrexate and cisplatin. In the cerebral circulation, the development of the sausage-string pattern is linked to the development of vascular damage, specifically in the dilated regions of the vessel as they fail to maintain myogenic vasoconstriction, with resulting endothelial hyperpermeability and extravasation of macromolecules into the brain parenchyma. While it is tempting to hypothesize that the upper limit of cerebral autoregulation is reduced with the preeclampsia syndrome, evidence for this is lacking. It seems much more likely that perivascular edema develops at a much lower capillary hydrostatic pressure, possibly as a function of endothelial activation known to accompany the preeclampsia syndrome. That said, failure of autoregulatory mechanisms may occur in response to either an acute and/or relatively large blood pressure increase, which seems more (A) 3. Thus, it is possible that it is the acuteness of the blood pressure rise or relative change in pressure from baseline in the setting of endothelial dysfunction that disrupts the delicate balance between capillary and cerebral perfusion pressures in eclampsia. Understanding cerebral hemodynamic changes associated with pregnancy and preeclampsia is challenging, necessitating the use of animal models in some instances. Thus, the following sections will review both animal and clinical studies on changes in cerebral hemodynamics during pregnancy and preeclampsia. Animal Studies Many women who develop eclampsia do so at pressures that are considerably lower than those reported for posterior reversible encephalopathy syndrome or hypertensive encephalopathy. The curves were determined using laser Doppler to measure relative changes in cerebral blood flow during constant infusion of phenylephrine to raise mean arterial pressure. Notice there is no difference in autoregulation or the pressure at which breakthrough occurred. In nonpregnant animals, water content was similar at basal pressure (black bars) and after autoregulatory breakthrough (gray bars). In late-pregnant animals, however, acute hypertension that caused autoregulatory breakthrough caused a significant increase in water content (p < 0. Thus, under these conditions, pregnancy alone predisposes the brain to edema formation.

Median time to a croup score of < or = 1 was shorter for children treated with dexamethasone (2 hr) or budesonide (3 hr) compared to those who received placebo (8 hr) (p < 0 symptoms 0f kidney stones buy discount haldol 1.5 mg line. Croup scores for both steroid groups were significantly lower than the placebo group by 1 hour and remained so subsequently treatment for ringworm purchase haldol toronto. The authors conclude that oral dexamethasone and budesonide are both effective in reducing symptoms and duration of hospitalization in children with croup medicine zalim lotion order generic haldol line. Answer Oral dexamethasone and nebulized budesonide have no significant difference in efficacy on croup score reduction if tolerated by the child medicine prescription drugs generic 5 mg haldol free shipping. Expert comment the quality of the re-evaluation before discharge from the emergency department and the advice given to the parents is key to ensuring safety for these children symptoms ibs 1.5mg haldol amex. Several studies have examined whether smaller doses could be used especially in milder croup symptoms 7 dpo bfp order genuine haldol on line, as a dose of 0. Thereafter ongoing observation and repeated review by an experienced clinician are mandatory because the effects can be short lived. Adrenaline can and should be repeated if the severity of symptoms recurs but only with a view to re-evaluating need for airway intervention. The evidence demonstrates that steroids are of clinical use in all severities of croup, and that oral dexamethasone is equal to and perhaps superior to the alternate treatment of choice nebulized budesonide. On the milder spectrum there is now no evidence to support the use of antibiotics, salbutamol inhaler use, or humidified air, and these treatments should be discouraged. The child with severe croup is significantly ill and requires a multidisciplinary team approach to optimize management. The key to management is to anticipate problems and mobilize key senior clinicians as soon as possible. Red flags include current severity of symptoms, poor response to adrenaline or repeated requirement, previous airway symptoms, and young age. Remember that it is a distressing event for the parent to witness, and as with all emergencies, a designated nurse or doctor should support the parents, as they are likely to remain at the bedside right until or even sometimes during intubation. The effects of steam inhalation on nasal patency and nasal symptoms with patients with the common cold. A randomised controlled trial of mist in the acute treatment of moderate crop Acad Emerg Med 2002; 9:873­9. The effect of humidified air in mild to moderate croup: evaluation using crop scores and respiratory induction plethysmography. Controlled delivery of high versus low humidity versus mist therapy for croup in emergency departments. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial. His running partners assure you that he has trained consistently for the race over the last few months and had taken on regular hypertonic fluids throughout the race until he collapsed. The marathon course has remained dry throughout the day with an ambient temperature of 24 °C. While you prepare for his arrival you consider the specific potential causes of collapse in a marathon runner. The majority can be treated in the pre-hospital setting but some will need immediate intensive treatment and hospitalization. Presenting symptoms may include fatigue, muscle cramps, dizziness, vomiting, diarrhoea, abdominal pains, and feeling hot or cold. Learning point Differential diagnosis of the collapsed marathon runner (See Table 26. Exercise-associated collapse the participant is unable to walk or stand unaided Conscious level is unaffected. Temperature and biochemical markers may be abnormal initially but will normalise quickly Treat with oral hydration and nursing in the Trendelenberg position 2. Temperature remains <40 °C and overall neurological function remains; however, there are now symptoms such as headaches, nausea, irritability and mild confusion. Again, the body is still able to dissipate heat but due to these compensatory mechanisms, there is a profound tachycardia and orthostatic hypotension. The methods of recording temperatures vary from department to department with a range of measuring techniques utilized. Commonly tympanic, axillary, or oral thermometers have been the mainstay of measurement; however, in the higher acuity patient, core temperatures via the rectal and oesophageal route can also be utilized. Despite its potential practical and social inconveniences alternative methods should not be used. To facilitate this some marathon field teams have hand-held point-of-care sodium-monitoring devices for this purpose. Learning point Exertional hyponatraemia Fluid balance remains a constant challenge for the marathon runner. The treating clinician must thus be alert to sodium levels and their rate of change. Mild symptoms: Bloating / oedema Nausea and vomiting Headache Cerebral oedema / hyponatraemic encephalopathy. Confirm diagnosis with near-patient rapid testing or urgent laboratory measurement 2. Seizures should be treated with standard anti-convulsant medications although these may be ineffectual if hyponatraemia persists 6. He has no significant medical history and had trained for 3 months appropriately for the event but subsequently had run faster than anticipated, eventually having to stop to walk at mile 21 before collapsing. Learning point Exertional heat stroke Definition Life-threatening illness, induced by strenuous exercise, comprising core temperature > 40 °C and central nervous system dysfunction. The aim is to achieve rapid cooling, ideally within 30­60 minutes of collapse, and prolonged pre-hospital times without cooling should be avoided (See Table 26. Answer Total-body immersion in ice-cold water is the quickest and most effective cooling method. Where this is unavailable, a combination of other techniques such as ice packs may be used. Active cooling should be stopped at 39 °C to avoid hypothermia but rectal temperature monitoring should continue to detect rebound hyperthermia. Some teams use immersion in cold tubs or place the patient over a cold tub and ladle cold water over the skin. The wet towels need to be rotated frequently and a fan will increase heat loss by evaporation. Case progression the patient is given cold intravenous crystalloid via peripheral cannulae and is stripped and cooled using towels soaked in ice water. Laboratory results reveal hypernatraemia with early renal impairment: sodium 148 mmol/L, potassium 4. These results suggest the patient is significantly volume-depleted and does require intravenous fluid replacement therapy. Assuming normal renal function before the race started, patients frequently show rapid improvement in their biochemistry once they have access to adequate hydration and the exercise has stopped. Many clinicians will instinctively reach for antipyretics when faced with patients with a raised temperature. The blind treatment of absolute numbers can be ineffectual or in some cases even detrimental. It is recommended by the World Health Organisation for reducing fevers in all age ranges due to its antipyretic and analgesic properties without any significant anti-inflammatory effects. This is of course understandable considering the effectiveness of other cooling techniques. They are not expected to work on a healthy hypothalamus that has been overloaded, as in the case of heat stroke. Paradoxically antipyretics may actually be deleterious and potentially aggravate bleeding tendencies, especially in patients who develop hepatic, hematologic, or renal complications. There is a focus on understanding the physiology and prevention of heat illnesses. Research into acclimatization has identified a preferred regime of 7­14 days with 2 hours of daily exertion to sweating. Recreational runners intending to run in very hot and/or humid environments should be aware of this. Key to success is very rapid cooling, managing the airway if necessary - the priority is cooling so a patient who is very agitated may need a general anaesthetic to make this possible. The validity of devices that assess body temperature during outdoor exercise in the heat. Immersion and Cold-Water Immersion Provide Similar Cooling Rates in Runners With Exercise-Induced Hyperthermia. Effects of large volume, ice-cold intravenous fluid infusion on respiratory function in cardiac arrest survivors. Cooling intravenous fluids by refrigeration: implications for therapeutic hypothermia. Consensus Statement of the 2nd International Exercise-Associated Hyponatraemia Consensus Development Conference, New Zealand, 2007. The child has no medical history of note, is not on any medications, and is up to date with her immunizations. You note there are 2 petechiae < 2 mm distributed on the chest above the nipples and a few petechiae beside each eye. Medical and public awareness of the signs and symptoms of meningococcal disease has increased following recent public campaigns. Approximately half of children presenting with meningococcal disease are missed at first presentation to a doctor. Clinical tip definition Petechia: Non-blanching spots on the skin < 2 mm in diameter. Arch Dis Child 2001; 85(3):218­22 270 Challenging Concepts in Emergency Medicine Learning point Causes of non-blanching rash See Table 27. Not all children require immediate antibiotics but if you are uncertain it is advisable to give antibiotics rather than delay for senior review or blood test results. Petechiae start to spread Rash becomes purpuric Signs of bacterial meningitis Signs of meningococcal septicaemia the young person appears to be ill to the healthcare professional. They also quote that there is a 95 % chance that only 0­5 % of children with such a rash will have meningococcal disease. They enrolled consecutive infants and children presenting to the paediatric emergency department. None of the patients with petechiae found only above the nipple line (163 patients 39. They are probably caused by raised venous and capillary pressure resulting from coughing, vomiting, or crying. Answer A child that appears well with a petechial rash limited to the face and chest above the nipples is highly unlikely to have meningococcal disease. However, it is worth remembering that in the early stages the rash may not be widespread and may be blanching. Although occurring less frequently, more than 2 petechiae can sometimes be present in well babies. Probably the most common cause of a non-blanching rash in a well child is a self-limiting viral infection, though this is often a diagnosis of exclusion. Her neurological exam is grossly normal, but you note there are a few more petechiae on her abdomen. Five paediatric departments enrolled 264 consecutive patients over a period of 24 months. Conducted a cohort study of 411 patients and found that an abnormal leukocyte count of < 5000 or > 15 000 was a good predictor of the seriousness of the illness; with a sensitivity of 1. They concluded that abnormal leucocyte count and coagulation profiles are predictive though not diagnostic of serious invasive bacteraemia. It was concluded that that procalcitonin was the best performing marker in this population but was better for ruling out serious infection rather than ruling it in. Case progression the child remains in the observation unit whilst awaiting the blood results. She eats and drinks but remains quiet, coughs and retches a few times but does not vomit. The mother comes and informs you that there appear to be more petechiae on her face and neck. Despite the blood results not being back you administer an intravenous dose of ceftriaxone 80 mg/kg. Distinguishing those children who present with serious illness and those who present with a self-limiting problem can cause a diagnostic challenge to emergency physicians. All these issues, together with the fact that physicians may have had limited exposure to sick children, can lead to a situation in which the subtle signs of ill health are missed. Recognition of these challenges has lead to the investigators to look for clinical features or laboratory tests which may be of diagnostic value and aid the formulation of clinical decision rules in order to try to standardize the assessment of these children. The Thompson systematic review8 highlighted 2 decision rules which were able to rule out meningitis and meningococcal disease. The first12 was able to identify 35 % who did not require a lumbar puncture despite signs of meningitis (see Table 27. In one prospective study4 of 264 infants with fever and skin haemorrhages, 5 clinical variables were found to distinguish between meningococcal disease and other condition (see Table 27. The presence of two or more features gives a 97 % probability of identifying a patient with meningococcal disease and a false positive rate of 12 %. Whilst this suggests that large, widely distributed lesions are of greatest concern, any petechial rash must be considered to be a potential marker of serious infection. In such cases it is difficult to decipher retrospectively if these children were misdiagnosed or had a coexisting infection or an infection which progressed to meningitis. The prior use of antibiotics poses a number of diagnostic challenges as it may affect the way in which a child presents and/or the results of investigations.

The clinical utility of serological markers in the evaluation of the acute scrotum treatment 4 sore throat order haldol 1.5mg free shipping. She has 2 wounds to her anterior tibial surface medicine kit for babies trusted haldol 10 mg, one is a simple linear wound and the other has a skin flap treatment arthritis purchase haldol with a visa. She has a history of type 2 diabetes mellitus symptoms 10 weeks pregnant buy 5mg haldol otc, peripheral vascular disease symptoms 2dp5dt cost of haldol, and hypertension treatment 1st degree burns order haldol no prescription, and is taking metformin, gliclazide, and amlodipine, with no known drug allergies. Pretibial lacerations are commonly seen in elderly females with multiple comorbidities such as peripheral vascular disease, diabetes, and cardiac failure. The complex physiology of this patient group not only influences wound healing but also the ability to rehabilitate. The combination of complex medical needs and the relatively poor blood supply to the shin2 means relatively trivial wounds may lead to significant morbidity. The aim of any wound management is to reduce the risk of infection, encourage healing, and provide the best cosmetic outcome for the patient whilst causing minimal distress. Skin-flap lacerations are prone to poor wound healing due to the decreased blood supply to the flap. This is problematic as frequently their input will be sought if the wound is particularly complex or requires referral on to plastic surgery. It is therefore essential that they remain up-to-date regarding current evidence and practice. Learning point Assessment and classification of pretibial wounds Pretibial lacerations incorporate a range of injuries from small, superficial lacerations to full thickness degloving injuries. It is important to assess the wound fully in the first instance as this will influence the first aid care delivered and the ongoing management. Case 11 Pretibial laceration 109 Clinical tip First aid for pretibial lacerations Whilst the patient is awaiting full assessment it is recommended that the wound be covered in moist, saline-soaked gauze4 to prevent the flap drying out and shrinking. Patients should have their pain assessed at triage using a validated score as recommended by the College of Emergency Medicine5 before any intervention is performed. Expert comment It is essential to assess wounds carefully to get the best results. Appropriate assessment will allow the best method for managing a wound to be chosen. All wounds should be assessed for skin viability, presence of haematoma or active bleeding, skin loss (as opposed to skin retraction), and skin quality. Viable skin has an intact blood supply but it may be difficult to assess if it is bruised. Skin retraction may be identified by gently pulling on the skin edges to redrape it and correctly position it. Case progression On initial assessment of the patient she appears quite comfortable. You remove the wet gauze and consider the wound; it appears quite dirty and requires irrigation. Clinical question: Does sterile saline significantly reduce the risk of bacterial infection compared with tap water, when irrigating simple lacerations? Not only is it easy, cheap, and accessible, but the larger volumes used help with debridement and decolonization. However, it is important, as with any procedure, to ensure the patient has adequate analgesia to ensure that the procedure is effective. Answer There is no evidence that using tap water to cleanse wounds increases the infection rate, and some evidence it reduces it. The skin appears pale and you are not certain if there is skin loss or if the skin is under tension from the clot as there is a large gap between the skin edge of the flap and the skin on the lower leg. Any organized clot or haematoma which sits between the skin flap and the base of the wound will prevent healing as it will increase tension in the wound and may compromise the blood supply to the flap. It has been suggested that any haematoma can be removed in the emergency department using local anaesthetic and a Yankauer suction catheter 9 connected to wall suction. The technique involves using any overlying laceration as an entry port or making a stab incision if the wound is not broken. The suction catheter is then moved to and fro within the haematoma to break up the clot and allow its removal, and the cavity is then irrigated with normal saline. An alternative technique which has been described for traumatic subcutaneous heamatomas (not specifically in the pretibial region),10 suggests using a 50-ml syringe connected to a 16-gauge cannula. The plunger is pulled back until a 10-ml syringe can fit between the withdrawn plunger and syringe base. The cannula and syringe is then pulled back and forward into the haematoma, breaking it up and draining it. This technique has the advantage of not requiring or creating a large entry point; however, the small calibre of the cannula means complete removal is unlikely. Expert comment Often pretibial haematomas are well organized and adherent by the time patients present. The methods described earlier may be effective but it is essential to give adequate analgesia and use local anaesthesia to ensure the patient is not distressed. If pain is not controlled then regional or general anaesthesia should be employed. Case progression the haematoma is removed, but once the flap is laid down over the wound there is still a 6 mm gap between the 2 skin edges. You consider whether you should attempt to bridge the gap with sutures or adhesive tapes or leave the flap in the current position and apply a dressing to the wound. Case 11 Pretibial laceration Expert comment 111 In my practice, I thoroughly evacuate any haematoma, stop any bleeding (with pressure or with bipolar diathermy-sutures can be used if diathermy is not available), and then debride any obviously severely damaged tissue. A good dressing using non-adherent materials will protect the wound to allow healing. Sutures and steristrips rarely provide any further support and may cause undue tension or blistering and may also cut through tissue. To date, only one randomized controlled trial has looked specifically at the comparison of sutures or closure with adhesive tapes. Significantly slower healing in patients with flap lacerations treated with sutures (p < 0. The difficulties these wounds present with regards to closure has led some to suggest novel methods of management;14 for example, the use of adhesive tapes laid parallel to wound edges prior to closure with deep reinforced sutures followed by a gentle localised compression dressing. This technique negates the dead space in the wound and prevents tearing of fragile skin. The average healing time was 26 days for the 112 patients with flap lacerations, and 16 days for the 35 linear laceration patients, which was reported to be shorter than the time quoted in the contemporary literature. Case 11 Pretibial laceration 113 Expert comment Early mobilization is routine for such injuries whether they have been dressed or skin-grafted. However, it is important to note that caution needs to be applied for those lacerations crossing a joint. Patients should also be reminded to elevate their legs when resting to avoid oedema. Case progression You decide to attempt to approximate the wound with adhesive strips. The patient is admitted to the observation ward for a multidisciplinary team assessment and pain control. On the observation ward, the nursing staff ask about what the instructions are for wound care and mobilization and what attention the wound will require on discharge. Non-adherent dressings are recommended and although it has been found that dry dressings and paraffin-gauze dressings are used,1 neither are ideal as they both cause trauma on removal, and paraffin dressings are thought to allow the migration of granulating cells through the dressing leading to prolonged inflammation and troublesome removal. One of the advantages of such dressings is that they can remain in place for 1 week. It has also been suggested17 that the direction of the flap be drawn on the dressing so as the dressing can be removed in that direction in order to cause minimal disturbance. The risks of keeping this patient group immobilized with bed rest are greater than any benefit it may confer to wound healing. There was no difference in post-operative haematoma, bleeding, graft infection, or donor-site healing between the comparison groups. Case progression the patient is discharged home the next day with analgesia and a temporary care package. A week later the district nurse calls you to say that she has come to review the wound but she is concerned about how it appears and she thinks it might be infected. When the patient returns it is apparent that the flap has lifted from the base and appears necrotic and there is surrounding erythema. You are concerned that the patient should have been referred to a plastic surgeon at initial presentation. Clinical question: What is the evidence for early skin grafting in pretibial lacerations? Skin grafting, whether performed early or late, is usually performed by plastic surgeons under general anaesthetic. Disadvantages of this are the risks associated with a general anaesthetic in this often frail group, the necessity to transfer patients to another unit, and the creation of an additional wound in the donor site. In a survey of A&E departments,1 it was found that 19 out of 22 emergency medicine consultants would refer to a plastic surgeon if they felt the wound was severe or not healing, and anecdotally this is still the practice in many departments today. However this requires a surgeon competent in the harvesting of skin grafts to be available together with the space and support staff required for such a procedure within the emergency department. To date there has only been 1 study comparing primary excision and grafting with conservative treatment. Answer Pretibial injuries which result in flap lacerations should be treated by primary excision and grafting which can be easily carried out under local anaesthetic. While this one study suggests improved healing rates in early grafted injuries, it is unlikely that plastic surgery units will accept all injuries and we will still need to be considerate about which wounds we refer immediately or arrange for specialist follow-up. Expert comment the decision to skin graft a pretibial laceration should be made by someone competent to perform the procedure. Clinicians competent in the procedure require a suitable theatre environment to perform such surgery and suitable equipment. Modern practice usually requires meshing of the skin to increase the area covered and to reduce post-operative haematoma formation while larger skin grafts are probably best taken with a powered dermatome. The choice of anaesthetic may be influenced by the size of the injury and the premorbid condition of the patient. In addition to local anaesthetic and general anaesthetic, one can also consider regional anaesthetic. Learning point Criteria for referral to a plastic surgeon Pretibial lacerations are common and although there are no agreed national or specialty guidelines for referral for skin grafting, the following groups should be considered for review by the plastic surgery team: Large haematoma with active bleeding Skin loss greater than 15 cm2 Complex flap or multiple skin lacerations Large areas of non-viable skin Case 11 Pretibial laceration 115 As in all healthcare matters, prevention is better than cure and it is likely that the prevention of pretibial lacerations would be considered in any falls prevention programme, but at present no studies have considered assessing a prevention policy although they have been proposed. Clinical tip Skin tear risk prevention16 There are a number of interventions which have been suggested which may prevent pretibial lacerations. The skin on the pretibial region is thin and therefore at risk of injury and hence the use of emollients, stockings, or special leg protectors may provide some protection. There are environmental considerations which may reduce the risk of falls such as ensuring good lighting and sensible placement of furniture. Such measures, together with education of the elderly population and those who care for them may reduce such injuries and therefore the complications associated with them. A Final Word from the Expert Pre-tibial lacerations can have a significant effect on patients and can take a very long time to heal. Early effective treatment can reduce healing time, reduce risks of infection, and allow patients to return to normal activity sooner. It is essential to assess patients effectively and liaise with the plastic surgery team to identify those who would most benefit from surgery as early as possible. The use of sutures or adhesive tapes for the primary closure of pretibial lacerations. Mobilisation versus Bed Rest after Skin Grafting Pretibial Lacerations: A Meta-Analysis. Lower limb skin loss: simple outpatient management with meshed skin grafts with immediate mobilization. He initially describes his pain as 7 out of 10, but after paracetamol and codeine at the triage, and entonox whilst waiting for you, he tells you that the pain has reduced to a pain score of 4. Examination reveals an obviously deformed tender distal left wrist, but thankfully no other associated injuries to the elbow or shoulder in particular. His range of movement at the wrist remains minimal but you feel this is limited by the pain and swelling more than the fracture positions. There are no overlying wounds so you are confident that this is a closed fracture. He concludes that the wrist can then be placed in a plaster cast, and the patient safely discharged to the orthopaedic fracture clinic as an outpatient. The classic mechanism is the fall on outstretched arm classically in an osteoporotic middle-aged or elderly woman. This mechanism occurs frequently from a backwards fall on the palm of an outstretched hand. Volar Barton fracture: this is an intra-articular fracture of the distal radius, which involves the volar margin of the carpal surface and is associated with dislocation of the radiocarpal joint. These fractures also usually occur from a fall onto an outstretched arm, leading to dorsiflexion stress, during which the volar radiocarpal ligaments avulse the volar lip of the radius from the metaphysis. You are uncomfortable with this management plan due to the nature of the fracture and the age of the patient, and are unsure whether a fracture that is displaced in the volar direction instead of the dorsal direction runs more risk of a median nerve palsy. Expert comment the younger the patient, the greater the need to ensure as adequate a reduction as possible for a distal radius fracture. This is particularly important in a fracture sustained to the wrist of the dominant arm. In adolescents with metaphyseal/epiphyseal involvement, the reduction often locks in easily as with a joint reduction. The reality remains, however, that in modern emergency healthcare, and increasingly in the future, out-of-hours specialty emergency care is becoming less and less available unless limb- or life-threatening.

Fifty per cent of the first group became immunized to RhD-positive blood cells whereas none of the second group developed antibodies administering medications 6th edition purchase haldol 1.5 mg with amex. A Final Word from the Expert Vaginal bleeding in early pregnancy may culminate in the loss of a pregnancy and causes significant anxiety for patients and their partners medications made from plants cheap haldol 1.5mg otc. The emergency physician should approach this vulnerable group with expediency and sensitivity treatment pink eye purchase discount haldol. Ectopic pregnancy is a potentially life-threatening diagnosis and should be considered in any woman of childbearing age medications for bipolar buy generic haldol on line, remembering that the problem may present atypically treatment 001 - b cheap 5 mg haldol mastercard. If an ectopic is suspected symptoms uterine fibroids buy haldol, ideally a transvaginal ultrasound scan should be performed by a qualified practitioner at first presentation to enable a risk assessment to be performed and a clear follow-up plan devised involving the gynaecology team. Ongoing management decisions related to a diagnosed ectopic pregnancy should rest with the gynaecology team, but for those patients who are discharged home clear safety netting is required. Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis. Implementation of probabilistic decision rules improves the predictive values of algorithms in the diagnostic management of ectopic pregnancy. Transvaginal Ultrasonography by Emergency Physicians Decreases Patient Time in the Emergency Department. Outcome analysis of a protocol including bedside endovaginal sonography in patients at risk for ectopic pregnancy. Treatment of cornual heterotopic pregnancy via selective reduction without feticide drug. Methotrexate in local treatment of cervical heterotopic pregnancy with successful perinatal outcome: Case report. Successful management of post-in-vitro fertilization cervical heterotopic pregnancy. A randomised trial comparing single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured tubal pregnancy. A review of the clinical effectiveness and costeffectiveness of routine anti-D prophylaxis for pregnant women who are rhesus-negative. They are unable to recall any history of trauma and report that other than a mild coryzal illness he has been well. He has no past history of note, is not on any regular medications and his immunizations are up-to-date. These range from a change in gait which is difficult for the assessing clinician to see, to a child who is totally non-weight-bearing. A change in gait can cause significant anxiety to parents particularly as it often occurs in the absence of a history of trauma. Stormy perinatal course or prematurity, cerebellar signs, developmental regression, unsteady gait Slipped upper femoral epiphysis I: 10. Cerebral palsy cerebral palsy, cerebral tumours, prevalence: > 2 per spinal tumours 100012 Malignancy. Appendicitis: abdominal pain, nausea and vomiting, loss of appetite, low-grade fever, diarrhoea, dysuria or frequency Rheumatological disease. Remember the cause may be in the bone (hip, knee, shaft), the brain (neurological), or the blood (leukaemia, vitamin D deficiency). He is reluctant to bear any weight on the right side and is noted to have a mild limp on walking. On undressing him, the legs appear normal, there are no signs of trauma, there is no joint swelling, and he has a full range of movements of his joints, although there is slight discomfort on rotating his right hip. There is no sign of any focal tenderness over the spine or legs, and he is neurologically intact. You suspect the child has transient synovitis but want to rule out septic arthritis. Clinical question: What investigations may assist in differentiating transient synovitis from septic arthritis and when should they be performed as part of the initial assessment of a limping child? In this age group, patients may present within a few hours of the onset of limp or a few days later. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. In this case, as the limp was of short onset with no other adverse features, it was reasonable to wait and review the child. Expert comment Most children have a minor limp and few cannot completely weight bear. A child who is unable to weight bear at all must not be discharged without a further assessment, investigation, and a careful follow-up plan. A child with a persistent limp, a fever, or evidence of being systemically unwell also requires further investigation. Blood culture should be performed in the febrile child, blood film in persistent limp with no other cause, and a metabolic work up may be indicated by the history. An ultrasound will help to exclude a hip effusion, although it may be useful in other conditions, depending on the operator. The doctor suggests giving regular ibuprofen until the review as if this seems to resolve the problem then a simple inflammatory process may be the cause. His mother says he was unsettled overnight and appears lethargic this morning but there were no specific symptoms that she could describe. Examination of his limbs reveals a right hip that is warm and tender to touch with restricted movement. Clinical question: Is there a role for plain radiographic imaging in addition to ultrasound when assessing the limping child? Children can be managed expectantly if the clinical picture fits with this diagnosis, but repeat X-ray may be required to confirm the diagnosis. While radiography is of use if the pain appears to be in the lower limb, in the hip radiographic abnormalities are less likely. If there is hip involvement an ultrasound will identify an effusion, which may then prompt aspiration for Gram stain and culture. The echogenicity of the fluid may indicate the cause of the effusion as haemorrhages and exudates are usually echogenic, transudates less so. However, if hip ultrasound is not available out of hours, assessment of the clinical picture with blood laboratory investigations will aid the clinician in suspecting the diagnosis. Where there was hip joint pain, an ultrasound scan had sensitivity of 100 % compared with 26. Out of 127 patients 4 had false-negative results; all these were done within the first 24 hrs from symptom onset, which was statistically significant (p 0. The sensitivity was a little higher (36 %) in those above 9 yrs old urgent and non-urgent pathology Data from various sources (see references) Case progression the blood tests reveal white cell count 11. He is referred urgently to the orthopaedic team who take him to theatre for aspiration. He is started on intravenous antibiotics and the question of concomitant steroids is raised. Learning point Organisms that cause septic arthritis in children First 2 months of life Group B streptococcus S. The duration of intravenous antibiotics is guided by clinical improvement and normalizing inflammatory markers. In children with an acute hematogenous septic arthritis, a short total course of 10 days of antimicrobials is sufficient in uncomplicated cases. Prospective randomized controlled trial 201139 of 49 children with septic arthritis treated with antibiotics and randomized to receive dexamethasone 0. Future advances Although hip ultrasonography is sensitive for the detection of joint effusion, it is not as good at picking up other causes of hip problems such as pelvic musculoskeletal problems. However, where it is readily available and the child is cooperative, it is an option. Careful history and examination are required to ascertain the site of the pathology, remembering that the cause may not always be in the lower limbs, but may involve other systems. Assessment of the gait is an essential part of this; non-weight-bearing children require careful further consideration. Ultrasound is a useful modality, even if it is to rule out a hip effusion so that other causes can be considered. Acute non-traumatic hip pathology in children: incidence and presentation in family practice. Epidemiology, etiology, and clinical features of septic arthritis in children younger than 2 months. Incidence and prevalence of juvenile arthritis in an urban population of southern Germany: a prospective study. Office for National Statistics, Cancer Statistics registrations: Registrations of cancer diagnosed in 2008, England. Screening for sickle cell disease and thalassaemia: a systematic review with supplementary research. Seven year follow up of children presenting to the accident and emergency department with irritable hip. Septic arthritis of the hip in children: poor results after late and inadequate treatment. Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. Managing children with acute non-traumatic limp: the utility of clinical findings, laboratory inflammatory markers and X-rays. The role of ultrasound in differentiating septic arthritis from transient synovitis of the hip in children. Experimental septic arthritis in rabbits treated by a combination of antibiotic and steroid drugs. Double-blind, randomized, placebo-controlled study of dexamethasone therapy for hematogenous septic arthritis in children. Magnetic resonance imaging as the primary imaging modality in children presenting with acute non-traumatic hip pain. He was hammering some metal rods at work about 3 hrs earlier and thinks that something may have gone into his right eye. He is otherwise well and has no significant medical history or any allergies and is fully immunized against tetanus. On examination his right eye is swollen, slightly red and inflamed, and is watering profusely. The other eye is normal in appearance and the triage nurse has documented a visual acuity of 6/6 in his left eye. It is extremely well innervated from the ophthalmic division of the trigeminal nerve and thus very sensitive to pain. Corneal injuries cause severe pain and blepharospasm making it difficult to open and examine the eye adequately initially. Often a drop of topical anaesthesia is needed before the eye can be opened for examination. Corneal inflammation usually produces a characteristic circumcorneal injection sparing the palpebral conjunctiva, rather than diffused injections see in conjunctival inflammation. Expert comment Any injury to the eye involving glass or metal should raise the question of a penetrating foreign body. Patients hammering or drilling often assume they have dust in their eye when it may be a penetrating fragment of metal from the hammer, etc. The only way to be completely sure there is not a penetrating foreign body is to directly visualize it and remove it from the surface of the cornea. The back of the eye has no pain sensation so the pain of penetrating injury may be similar to that of a corneal foreign body and the pain will be abolished by local anaesthetic applied to the cornea. Case progression Initially, the patient is in a lot of discomfort and is unable to keep his eye open for long enough to be examined properly. You decide to instil a single drop of a local anaesthetic 1 % tetracaine into the right eye to relieve the pain and allow a thorough examination. A detailed examination of the eye reveals circumcorneal injection of the sclera, a symmetric pupil that reacts to light normally, and a normal anterior chamber. The eye is then examined with a slit lamp after instilling a drop of fluoroscein dye using a blue filter. A corneal abrasion, which stains green, is seen along with an embedded metallic corneal foreign body. This can be performed with either a concentrated fluoroscein strip or 2 % fluoroscein drops placed in the region of the corneal injury. Clinical question: What is the best imaging modality in the presence of a suspected intraocular foreign body? The sensitivity of detection was unaffected by hyphema but was determined by the type of glass, size, and location. Expert comment the most appropriate imaging modality for a suspected intraorbital foreign body will depend on the skills and resources within a given facility. The small size of such foreign bodies together with poor patient cooperation make the procedure challenging and hence the use of ultrasound is currently limited to specialists using an ultrasound biomicroscope at present. A drop of local anaesthetic is instilled in each eye and the metallic foreign body is carefully removed under direct visualization using the slit lamp for magnification and a 25-gauge needle. Expert comment On the day of injury, corneal foreign bodies are usually fairly easy to remove. After a day or so they may become embedded due to corneal overgrowth and rubbing the eye. The majority of these are magnetic, and particles containing iron oxidize to set up an inflammatory reaction within the eye (siderosis). Case progression Having removed the metallic foreign body, you re-examine the eye and notice that there is a residual rust ring that you have only been able to remove partially.

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