Urgent Care Emergencies (eBook)

Avoiding the Pitfalls and Improving the Outcomes

Deepi G. Goyal, Amal Mattu (Herausgeber)

eBook Download: EPUB

2024 | 1. Auflage
192 Seiten
Wiley (Verlag)
978-1-394-20570-7 (ISBN)

Infos

Newly updated reference highlighting high-risk aspects of common, seemingly minor medical illnesses and injuries

Urgent Care Emergencies is a concise, quick reference designed to help healthcare professionals avoid pitfalls in challenging and fast-paced clinical settings. This text focuses on caring for patients with seemingly minor acute illnesses and injuries that may carry substantial morbidity if not appropriately recognized and managed. The text covers a wide range of emergencies that may be encountered in urgent care centers, clinics, or other acute care settings. It focuses on the most commonly encountered complaints and conditions, including genitourinary issues, common infections, orthopedic injuries, wounds, back pain, head and neck problems, and skin complaints. This new edition also includes additional chapters on the importance of effective patient communication, pharmacologic pitfalls, special issues in the care of pediatric and geriatric patients, and a special chapter focused on legal pitfalls.

As healthcare continues to evolve, this Second Edition serves as an essential resource for clinicians in urgent care and emergency departments. Each chapter is authored by experienced acute care clinicians and includes clinical wisdom that readers can apply directly to the care of their own patients.

Written by a team of highly qualified authors, Urgent Care Emergencies stresses important topics such as

• Seemingly minor orthopedic injuries with a high risk for limb-threatening vascular injury
• The limitations of radiographic imaging in the evaluation of subarachnoid hemorrhage
• The potential life-threatening complications of local anesthetics
• The importance of considering necrotizing fasciitis or Fourniere gangrene in seemingly minor soft tissue infections
• Red flags in pediatric back pain
• Key factors in evaluating sore throat to prevent morbidity and speed resolution

This updated edition of Urgent Care Emergencies is an essential at-your-fingertips reference for any physician, advanced practice provider, and other medical professional working in a setting that manages acute unscheduled medical concerns.

Deepi G. Goyal, MD, is Associate Professor of Emergency Medicine, Mayo Clinic, Rochester, MN, USA.

Amal Mattu, MD, is Professor of Emergency Medicine, University of Maryland School of Medicine, Edgewater, MD, USA.

Textauszug

CHAPTER 1
HEENT Pitfalls

Laura J. Bontempo and Sarah K. Sommerkamp

Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA

Introduction

Emergencies affecting the head, eyes, ears, nose, and throat (HEENT) constitute a large component of chief complaints seen in urgent care centers. The majority of these patients have benign conditions that can be managed on an outpatient basis. However, some seemingly innocuous complaints can portend more serious diseases that pose a significant risk of morbidity and possibly mortality. As with most diseases, the key to differentiating between minor and dangerous conditions is the history and physical examination. A huge spectrum of pathology can manifest in the head and neck. In this chapter we present key facts, highlight pitfalls in diagnosing these conditions, and offer pearls intended to facilitate their management.

Eye

Pitfall | Failure to identify red flag symptoms leads to inappropriate or unrecognized need to transfer patients requiring emergency evaluation

A wide variety of eye complaints are encountered by urgent care providers. Identifying the emergent conditions that require emergency department (ED) or emergent ophthalmologic care is crucial. Red flags include a severely painful red eye, acute vision loss, anisocoria, and photophobia [1]. An acute red eye may represent acute angle glaucoma, endophthalmitis, uveitis, or keratitis. Visual acuity should be documented on these patients. Acute monocular visual loss may signify another dangerous condition, such as central retinal artery occlusion, central retinal vein occlusion, retinal detachment, or a central nervous system process (stroke, transient ischemic attack [TIA], or multiple sclerosis). Patients with concern for these diagnoses should be referred to an ED or for emergent ophthalmologic follow‐up. After identifying which patients need a higher level of care, there are still many eye conditions that can effectively be cared for in the urgent care setting.

Corneal abrasion, ulcers, and foreign bodies

Differentiation between corneal abrasions, corneal ulcers, and corneal foreign bodies (FBs) can be difficult. The majority of patients with any of these conditions present with eye pain and a gritty or FB sensation. Patients with suspected corneal epithelial defects should have a full eye examination. Use of a slit lamp is preferred to the Wood's lamp. The instillation of analgesic and/or cycloplegic drops will significantly relieve the patient's symptoms and increase their ability to tolerate the examination, but these drops should not be used if globe rupture is suspected. Globe rupture can occur after trauma or a penetrating FB and should be suspected if there is buckling of the sclera or if there appears to be fluid draining from the orbit. This is a true ophthalmologic emergency, and no pressure or foreign material should be introduced into the eye of this patient. Fluorescein staining is mandatory for the evaluation of a corneal defect and to assess for ulcers or dendritic lesions seen with herpes simplex virus (HSV) keratitis. Varicella zoster virus (VZV) should be suspected in patients with a vesicular rash on the forehead or nose and should be referred to ophthalmology [2]. In patients with herpes virus infection concerns (HSV or VZV), steroids should only be used if directed by ophthalmology. Defects in the epithelial surface appear as a stain that does not clear with blinking. The size and position of any defect(s) should be documented. Punctate defects, which appear in a circular pattern, are sometimes seen in contact lens wearers, particularly after prolonged wear. Larger defects with a crater formation are ulcers.

Table 1.1 Treatment of conjunctivitis, corneal abrasions, ulcers, and foreign bodies [3–6].

Indication	Contact lenses	Antibiotic	Dose	Duration of therapy

Abrasion or FB

No

Trimethoprim/polymyxin B

1–2 drops q 3 h

Continue until symptom free for >24 h

Conjunctivitis

No

Trimethoprim/polymyxin B

1 drop q 6 h

5–7 d

Abrasion or conjunctivitis Not from FB

No

Erythromycin

Ointment 0.5″ q 2–4 h

Continue until symptom free for >24 h/5–7 d

Abrasion or FB

Yes

Ciprofloxacin

Day 1–2: q 2 h when awake; days 3–7: q 4 h

Until evaluation by ophthalmologist

Conjunctivitis

Yes

Ciprofloxacin

1–2 drops q 6 h

5–7 d

Abrasion or FB

Yes

Moxifloxacin

1 drop q 6–8 h

Until evaluation by ophthalmologist

Conjunctivitis

Yes

Moxifloxacin

1 drop q 6–8 h

7 d

Ulcer

NA

Moxifloxacin

1–2 drops q 1 h

Until evaluation by ophthalmologist

VZV

NA

Antiviral: acyclovir or ganciclovir

IV/oral/topical

Ophthalmologist evaluation needed

FB, foreign body; IV, intravenous; NA, not applicable; q, every; VZV, varicella zoster virus.

Parallel vertical abrasions should raise suspicion for an FB under the lid. When this type of injury is detected, the patient's eyelid should be everted to allow further assessment. Without treatment, and over time, the vertical abrasions will coalesce and form an ulcer. An FB may be superficially lodged directly on the corneal surface. In many cases FBs can be removed with a cotton swab or by irrigation, but if that procedure is unsuccessful, removal with a needle or burr may be necessary and should be done only by someone with specific training. Metal FBs may lead to the development of a rust ring, which should be removed by an ophthalmologist [3]. Emergent ophthalmologic consultation is indicated for globe rupture or intraocular foreign body. Following removal of the superficial FB, patients should be treated with antibiotic drops (not ointment) as per Table 1.1. An FB consisting of vegetation should be treated with a fluoroquinolone [4]. Perforating or intraocular FBs will require systemic antibiotics and transfer [3].

KEY FACT | Patients with corneal abrasions, ulcers, and corneal foreign bodies should all be treated with antibiotics.

The immediate treatment of corneal abrasions, ulcers, and FBs is similar (Table 1.1). Simple abrasions that are smaller than 3 mm do not require follow‐up as long as an FB is not present, the patient's visual acuity is normal, and symptoms resolve within 24 hours [7]. However, if there is any doubt, referral to an ophthalmologist is reasonable. All other defects should be seen by an ophthalmologist within 24 hours. Antibiotics, which may be prescribed as either ointment or drops, should be administered to all patients with epithelial defects. Ointment is generally preferred (particularly for children) because it stays in place longer and lubricates the eye. However, ointments are not well tolerated by most adults because they obscure vision. Contact lens wearers with corneal abrasions require antipseudomonal antibiotic coverage and should be advised to refrain from wearing their contact lenses until they are cleared to do so by an ophthalmologist. All patients with corneal ulcers also require antipseudomonal antibiotic coverage.

Patients with painful corneal abrasions may require systemic analgesia. Ophthalmic nonsteroidal anti‐inflammatory drugs (NSAIDs) may be prescribed but are expensive. Topical anesthetics such as tetracaine when used for the first 24 hours have been shown to improve analgesia, but should be used with caution as repeated use may be associated with the development of ulcers [8]. Eye patching has not been shown to be effective in accelerating healing. In fact, because it might worsen the infection and thus lengthen the time to recovery, patching is not recommended [9].

Conjunctivitis

Commonly known as “pink eye,” conjunctivitis presents with an irritated, erythematous conjunctiva with discharge. Visual acuity should be minimally affected, if at all. The etiology may be infectious or noninfectious (allergic/chemical). Infectious causes are most commonly bacterial or viral, and it may be difficult to differentiate between the two. Generally, a thin watery discharge from the eye accompanied by symptoms of an upper respiratory infection is more likely to be viral in etiology. This pathology is self‐limiting and patients do not require treatment with antibiotics. Symptom relief with cool compresses, artificial tears, and anticipatory guidance regarding duration of symptoms and handwashing are paramount to good patient care. Purulent drainage is more commonly caused by a bacterial source [10]. While bacterial conjunctivitis may improve on its own, topical antibiotics are recommended. Topical antibiotics typically shorten the...

Produkt-Details

• Erscheint lt. Verlag: 6.12.2024
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete ► Notfallmedizin
• Schlagworte: common infections, orthopedic injuries • Emergency Care • emergency patient communications • Emergency Room • genitourinary complaints • HEENT examination • urgent care • urgent care back pain, urgent care dermatology • urgent wounds
• ISBN-10: 1-394-20570-8 / 1394205708
• ISBN-13: 978-1-394-20570-7 / 9781394205707