Th Atl o E rg n y FOURTH EDITION M i in E itor K vin J. Knoo , md , ms Staff Physician Naval Medical Center, Portsmouth, Virginia Assistant Professor of Military and Emergency Medicine Uniformed Services University of the Health Sciences, Bethesda, Maryland L wr n B. St k, md Professor of Emergency Medicine and Pediatrics Vanderbilt University, Nashville, Tennessee Al n B. Storrow, md Vice Chairman for Research and Academic Affairs Associate Professor of Emergency Medicine Vanderbilt University, Nashville, Tennessee R. J on Thur n, md, faaem, cpps Chief Medical Officer TriStar Skyline and Hendersonville Medical Centers Adjunct Associate Professor of Nursing Vanderbilt University Medical Center, Nashville, Tennessee

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The Atlas of Emergency Medicine, Fourth Edition

Copyright © 2016 by McGraw-Hill E ucation. All right re erve . Printe in China. Except a per itte un er the Unite State Copyright Act of 1976, no part of thi publication ay be repro uce or i tribute in any for or by any ean , or tore in a ata ba e or retrieval y te , without the prior written per i ion of the publi her.

Previou e ition copyright © 2010, 2002, an 1997 by he McGraw-Hill Co panie , Inc.

1 2 3 4 5 6 7 8 9 0 DSS/DSS 20 19 18 17 16

ISBN 978-0-07-179725-2 MHID 0-07-179725-4

hi book wa et in Minion pro by Cenveo Publi her Service . he e itor were Brian Belval an Chri tie Naglieri. he pro uction upervi or wa Catherine H. Sagge e. Project anage ent wa provi e by Raghavi Khullar, Cenveo Publi her Service . RR Donnelley wa the printer an bin er.

Library of Congress Cataloging-in-Publication Data

T e atla of e ergency e icine / e itor , Kevin J. Knoop, Lawrence B. Stack, Alan B. Storrow, R. Ja on T ur an.—Fourth e ition. p. ; c . Inclu e in ex. ISBN 978-0-07-179725-2 (har cover : alk. paper)—ISBN 0-07-179725-4 (har cover : alk. paper) I. Knoop, Kevin J., e itor. II. Stack, Lawrence B., e itor. III. Storrow, Alan B., e itor. IV. T ur an, R. Ja on (Robert Ja on), e itor. [DNLM: 1. E ergency Me icine— etho —Atla e . 2. Critical Care— etho —Atla e . 3. E ergencie —Atla e . WB 17] RC86.7 616.02′5— c23 2015011035

McGraw-Hill E ucation book are available at pecial quantity i count to u e a pre iu an ale pro otion or for u e in corporate training progra . o contact a repre entative, plea e vi it the Contact U page at www. hprofe ional.co .

To MJ, Mimi and Stephen for your love and support of this and all life’s endeavors. To the providers who deliver emergency care 24/7 throughout the world for inspiring me to be a lifelong learner. To our patients for sharing their malady for others to learn and then use in improving care. KJK

To the patients and families who have allowed us to photography their examination findings of themselves and their family members I pray for God’s grace and blessing on you for allowing others to learn from your illness and injuries for the benefit of caring for others. LBS

To Julia, Robert, and Allison with deep gratitude for your patience, kindness, and love. ABS

To my wife Lauren, and children Kate and Ben: You are the greatest blessings of my life. To all those who have generously provided mentoring over the years, especially Drs. Knoop, Stack, and Storrow: I am deeply honored and humbled to have had the opportunity to work alongside each of you. RJT

CONTENTS

Contributor / xv AFFERENT PUPILLARY DEFECT Me ia Cre it / xvix (MARCUS GUNN PUPIL) 55 Forewor / xxxiii HORNER SYNDROME 57 Preface / xxxv THIRD-NERVE PALSY 58 SIXT H -NERVE PALSY 60

P rt 1 REGIONAL ANATOMY 1 Ch t r 3 Ch t r 1 FUNDUSCOPIC FINDINGS 61 HEAD AND FACIAL TRAUMA 3 David Effron ■ Beverly C. Forcier ■ Richard E. Wyszynski David W. Munter NORMAL FUNDUS 62 BASILAR SKULL FRACTURE 4 AGE-RELATED MACULAR DEGENERATION 63 DEPRESSED SKULL FRACTURE 7 EXUDATE 64 NASAL INJURIES 9 ROTH SPOTS 65 ZYGOMA FRACTURES 11 EMBOLI 66 LEFORT FACIAL FRACTURES 12 CENTRAL RETINAL ARTERY OCCLUSION 67 ORBITAL WALL FRACTURES 13 CENTRAL RETINAL VEIN OCCLUSION 69 MANDIBULAR FRACTURES 16 HYPERTENSIVE RETINOPATHY 70 EXTERNAL EAR INJURIES 19 DIABETIC RETINOPATHY 71 FRONTAL SINUS FRACTURE 21 VITREOUS H EMORRH AGE 73 TRAUMATIC EXOPHTHALMOS 23 RETINAL DETACH MENT 74 PENETRATING FACIAL TRAUMA 25 CYTOMEGALOVIRUS RETINITIS 75 UNCAL HERNIATION SYNDROME 26 PAPILLEDEMA 76 OPTIC NEURITIS 77 Ch t r 2 ANTERIOR ISCHEMIC OPTIC NEUROPATHY 78 OPHTHALMIC CONDITIONS 29 GLAUCOMA 79 SUBHYALOID HEMORRHAGE IN Frank Birinyi ■ Thomas F. Mauger ■ Andrew J. Hendershot SUBARACHNOID HEMORRHAGE 80 NEONATAL CONJUNCTIVITIS (OPHTHALMIA NEONATORUM) 30 Ch t r 4 BACTERIAL CONJUNCTIVITIS 32 OPHTHALMIC TRAUMA 81 VIRAL CONJUNCTIVITIS 33 Christopher S. Weaver Kevin J. Knoop ALLERGIC CONJUNCTIVITIS 35 ■ DACRYOCYSTITIS 36 CORNEAL ABRASION 82 DACRYOADENITIS 37 SUBCONJUNCTIVAL HEMORRHAGE 84 PTERYGIUM/PINGUECULA 38 CORNEAL FOREIGN BODY 85 HORDEOLUM/CHALAZION 39 HYPHEMA 86 SCLERIT IS 41 INTRAOCULAR FOREIGN BODY 88 EPISCLERITIS 42 IRIDODIALYSIS 89 ACUTE ANGLE-CLOSURE GLAUCOMA 43 LENS DISLOCATION 90 ANTERIOR UVEITIS (IRITIS) 45 PENETRATING GLOBE INJURY 92 SYMPATHETIC OPHTHALMIA 47 GLOBE RUPTURE 94 ANISOCORIA 48 TRAUMATIC CATARACT 95 HERPES ZOSTER OPHTHALMICUS 49 EYELID LACERATION 96 OCULAR HERPES SIMPLEX 50 CHEMICAL EXPOSURE 98 CORNEAL ULCER 52

vi ■ CONTENTS

Ch t r 5 CANINE SPACE ABSCESS 151 EAR, NOSE, AND THROAT LUDWIG ANGINA 152 CONDITIONS 99 PARAPHARYNGEAL SPACE ABSCESS 153 Edward C. Jauch ■ David R. White ■ Kevin J. Knoop Oral Con ition 154 OTITIS MEDIA 100 TRENCH MOUTH (ACUTE NECROTIZING BULLO US MYRINGIT IS 103 ULCERATIVE GINGIVITIS) 154 CHOLESTEATOMA 104 ACID TOOTH EROSION (BULIMIA) 155 TYMPANIC MEMBRANE PERFORATION 105 THRUSH (ORAL CANDIDIASIS) 156 OTITIS EXTERNA 106 ORAL HERPES SIMPLEX VIRUS (COLD SORES) 157 PREAURICULAR SINUS ABSCESS 107 APH TH OUS ULCERS (CANKER SORES) 158 MASTOIDITIS 108 ST RAWBERRY T O NGUE 159 AURICULAR PERICH ONDRITIS 109 TORUS PALATINUS 160 HERPES ZOSTER OTICUS GINGIVAL HYPERPLASIA 161 (RAMSAY HUNT SYNDROME) 111 BLACK H AIRY T O NGUE 162 FACIAL NERVE PALSY 113 ORAL CAVITY PIERCING COMPLICATIONS 163 ANGIOEDEMA 115 PHARYNGITIS 117 Ch t r 7 NASAL SEPTAL CONDITIONS 119 CHEST AND ABDOMEN 165 NASAL CELLULITIS 120 Stephen W. Corbett ■ Lawrence B. Stack ■ Kevin J. Knoop DIPHTHERIA 122 PERITONSILLAR ABSCESS 123 Che t an Ab o inal rau a 166 EPIGLOTTITIS 125 TRAUMATIC ASPHYXIA 166 UVULITIS 127 FLAIL CHEST 167 MUCOCELE (RANULA) 128 ST ERN O CLAVICULAR DISLO C AT IO N 168 SIALO ADEN IT IS 129 CLAVICLE FRACTURE 169 SIN USIT IS 132 TENSION PNEUMOTHORAX WITH NEEDLE THORACENTESIS 171 Ch t r 6 CARDIAC TAMPONADE WITH ORAL CONDITIONS 135 PERICARDIOCENTESIS 172 EMERGENCY DEPARTMENT TH ORACOTOMY 173 Edward C. Jauch ■ James W. H owell SEAT BELT INJURY 174 TOOTH SUBLUXATION 136 GREY TURNER SIGN AND CULLEN SIGN 175 TOOTH IMPACTION (INTRUSIVE LUXATION) 137 IMPALED FOREIGN BODY 176 TOOTH AVULSION 138 ABDOMINAL EVISCERATION 177 TOOTH FRACTURES 139 TRAUMATIC ABDOMINAL HERNIA 178 ALVEOLAR RIDGE FRACTURE 141 PELVIC FRACTURE 179 TEMPORAL MANDIBULAR JOINT DISLOCATION 142 TONGUE LACERATION 144 Nontrau atic Che t an Ab o inal VERMILION BORDER LIP LACERATION 145 Con ition 180 RESPIRATORY RETRACTIONS 180 O ontogenic infection 146 SUPERIO R VENA C AVA SYNDRO ME 181 GINGIVAL ABSCESS (PERIODONTAL ABSCESS) 146 SUPRACLAVICULAR ADENOPATHY 182 PERIAPICAL ABSCESS 147 JUGULOVENOUS DISTENSION 183 PERICORONAL ABSCESS 149 CAPUT MEDUSAE 184 BUCC AL SPACE ABSC ESS 150 ABDOMINAL H ERNIAS 185

CONTENTS ■ vii

UMBILICAL HERNIA 187 PEDICULOSIS 236 PATENT URACHAL DUCT 188 ANAL FISSURE 237 SIST ER MARY JO SEPH N O DE ANORECTAL ABSCESSES 238 (NODULAR UMBILICUS) 189 HEMORRHOIDS 240 ABDOMINAL DISTENSION 190 PROLAPSED RECTUM 243 ABDOMINAL WALL H EMATOMA 193 PILONIDAL ABSCESS 244 PECTUS DEFORMITIES 195 RECTAL FOREIGN BODY 245 ST O MA PRO LAPSE 197 MELENA 247 PRUNE BELLY (EAGLE-BARRETT) SYNDROME 198 Ch t r 10 Ch t r 8 GYNECOLOGIC AND OBSTETRIC UROLOGIC CONDITIONS 201 CONDITIONS 249 Jeffery D. Bondesson Suzanne Dooley Hash ■ Sean A. Lisse ■ Kevin J. Knoop

TESTICULAR TORSION 202 Gynecologic Con ition 250 TORSION OF A TESTICULAR OR EPIDIDYMAL VAGINITIS 250 APPENDIX 204 CERVICAL POLYPS 252 ACUTE EPIDIDYMITIS 205 BART H O LIN GLAND ABSCESS 253 ORCHITIS 206 SPONTANEOUS ABORTION 254 HYDROCELE 208 GENITAL TRAUMA AND SEXUAL ASSAULT 255 TESTICULAR TUMOR 209 LICH EN SCLEROSUS 257 SCRO T AL ABSC ESS 210 LICH EN PLANUS 259 FOURNIER GANGRENE 211 VULVAR CANCER 260 PARAPHIMOSIS 213 URETHRAL PROLAPSE 261 PRIAPISM 214 UTERINE PROLAPSE 262 URETHRAL RUPTURE 215 CYSTOCELE 263 FRACTURE OF THE PENIS 216 RECTOCELE 264 PENILE TOURNIQUET 217 IMPERFORATE HYMEN 265 ST RADDLE INJURY 218 Ob tetric Con ition 266 BALANO PO ST H IT IS 219 ECTOPIC PREGNANCY 266 PENILE ZIPPER INJURY 221 MOLAR PREGNANCY (HYDATIDIFORM MOLE) 269 VARICOCELE 222 FAILED INTRAUTERINE PREGNANCY 270 THIRD-TRIMESTER BLUNT ABDOMINAL TRAUMA 271 Ch t r 9 EMERGENCY DELIVERY: IMMINENT VERTEX SEXUALLY TRANSMITTED INFECTIONS DELIVERY—CROWNING 273 AND ANORECTAL CONDITIONS 223 EMERGENCY DELIVERY: NORMAL Suzanne Dooley Hash ■ Brian R. Sharp DELIVERY SEQUENCE 274 Sexually ran itte Infection 224 BREECH DELIVERY 277 UMBILICAL CORD PROLAPSE IN SYPH ILIS 224 EMERGENCY DELIVERY 278 GONORRHEA 227 NUCHAL CORD IN EMERGENCY DELIVERY 279 CHLAMYDIA 229 SHOULDER DYSTOCIA IN EMERGENCY DELIVERY 280 GENITAL HERPES 230 POSTPARTUM PERINEAL LACERATIONS 281 LYMPH OGRANULOMA VENEREUM 232 INTRAUTERINE FETAL DEMISE 283 CHANCROID 233 CONDYLOMA ACUMINATA (GENITAL WARTS) 234

viii ■ CONT ENT S

Ch t r 11 GANGRENE 344 EXTREMITY TRAUMA 285 GAS GANGRENE (MYONECROSIS) 345 NECROTIZING FASCIITIS 346 Neha P. Raukar ■ George J. Raukar ■ Daniel L. Savitt CRYSTAL-INDUCED SYNOVITIS ACROMIOCLAVICULAR JOINT SEPARATION 286 (GOUT AND PSEUDOGOUT) 348 SH O ULDER DISLO CAT IO N 288 INGROWN TOENAIL (ONYCHOCRYPTOSIS) 350 ELBOW FRACTURES 290 LYMPH ANGITIS 351 ELBOW DISLOCATION 292 LYMPH EDEMA 352 BICEPS TENDON RUPTURE 293 OLECRANON AND PREPATELLAR BURSITIS 353 FOREARM FRACTURES 294 PALMAR SPACE INFECTION 354 FRACTURES OF THE DISTAL RADIUS 296 TENOSYNOVITIS 355 CARPAL AND CARPOMETACARPAL DISLOCATIONS 298 THROMBOPHLEBITIS 357 SCAPH O ID FRAC T URE 301 PARONYCHIA 358 CLENCHED FIST INJURY (FIGHT BITE) 302 SUBCLAVIAN VEIN THROMBOSIS 359 BO XER’S FRAC T URE 303 CERVICAL RADICULOPATHY 360 PERIPHERAL NERVE INJURY 304 DIGITAL CLUBBING 361 BENNETT AND ROLANDO FRACTURES 305 PHLEGMASIA DOLENS 362 BOUTONNIÈRE AND SWAN-NECK DEFORMITIES 307 DEEP VENOUS THROMBOSIS 363 HIGH-PRESSURE INJECTION INJURY 308 DUPUYTREN CONTRACTURE 365 GAMEKEEPER’S THUMB (SKIER’S THUMB) 309 ACH ILLES TENDONITIS 366 PHALANGEAL DISLOCATIONS 310 GANGLION (SYNOVIAL) CYST 367 MALLET FINGER AND JERSEY FINGER 312 RAYNAUD DISEASE 368 COMPARTMENT SYNDROME 314 ARTERIAL EMBOLUS 369 SUBUN GUAL H EMAT O MA 316 HIP DISLOCATION 317 HIP FRACTURE 318 Ch t r 13 KNEE EXTENSOR INJURIES 319 CUTANEOUS CONDITIONS 371 PATELLAR DISLOCATIONS 321 J. Matthew H ardin KNEE DISLOCATION 322 FEMUR FRACTURE 323 STEVENS-JOHNSON SYNDROME/TOXIC EPIDERMAL TIBIAL-FIBULAR FRACTURES 324 NECROLYSIS 372 FRACTURE BLISTERS 326 ERYTH EMA MULTIFORME 374 ACHILLES TENDON RUPTURE 327 DRUG ERUPTIONS 376 ANKLE DISLOCATION 328 FIXED DRUG ERUPTION 377 ANKLE FRACTURE 330 DISSECTING CELLULITIS OF THE SCALP 378 ANKLE SPRAIN 332 HIDRADENITIS SUPPURATIVA 379 CALCANEUS FRACTURE 333 PYOGENIC GRANULOMA 380 FRACTURES OF THE FIFTH METATARSAL BASE 334 PYODERMA GANGRENOSUM 382 LISFRANC FRACTURE-DISLOCATION 336 SEBORRHEIC DERMATITIS 383 AMPUTATIONS 338 PSORIASIS 384 PITYRIASIS ROSEA 386 ATOPIC DERMATITIS 388 Ch t r 12 NUMMULAR/XEROTIC ECZEMA 390 EXTREMITY CONDITIONS 341 DYSHIDROTIC ECZEMA 391 Robert J. Tubbs ■ Daniel L. Savitt ■ Selim Suner ID REACTION (DISSEMINATED ECZEMA) 392 CELLULITIS 342 ST ASIS DERMAT IT IS 393 FELON 343 LIVEDO RETICULARIS 394

CONTENTS ■ ix

VASCULITIS (LEUKOCYTOCLASTIC VASCULITIS) 396 NEONATAL MASTITIS 440 IDIOPATHIC THROMBOCYTOPENIC PURPURA 398 UMBILICAL GRANULOMA 441 THROMBOTIC THROMBOCYTOPENIC PURPURA 399 HYPERTROPHIC PYLORIC STENOSIS 442 URTICARIA AND DERMATOGRAPHISM 400 INTESTINAL MALROTATION WITH VOLVULUS 444 ALLERGIC CONTACT DERMATITIS 402 Ra he an Le ion 446 ERYTH EMA NODOSUM 403 ERYTH EMA INFECTIOSUM (FIFTH DISEASE) 446 ERYSIPELAS 404 ROSEOLA INFANTUM (EXTHANTHEM SUBITUM) 447 INFECTIVE ENDOCARDITIS 405 IMPETIGO 448 ERYTH EMA CH RONICUM MIGRANS 407 MEASLES 449 ROCKY MOUNTAIN SPOTTED FEVER 408 VARICELLA (CHICKENPOX) 450 DISSEMINATED GONOCOCCUS 409 HERPES ZOSTER 451 HOT TUB FOLLICULITIS/PSEUDOMONAS HAND, FOOT, AND MOUTH SYNDROME 452 HOT-FOOT SYNDROME 410 COLD PANNICULITIS (POPSICLE PANNICULITIS) 453 ECTH YMA GANGRENOSUM 411 HERPETIC GINGIVOSTOMATITIS 454 NONGENITAL HERPES SIMPLEX INFECTIONS 412 MENINGOCOCCEMIA 455 HERPES ZOSTER 413 URTICARIA 456 DERMATOPHYTE INFECTIONS 414 SUMMER PEN ILE SYNDRO ME 457 TINEA (PITYRIASIS) VERSICOLOR 416 STAPHYLOCOCCAL SCALDED SKIN SYNDROME 458 ONYCHOMYCOSIS 417 SCARLET FEVER (SCARLAT IN A) 459 INTERTRIGO 418 BLISTERING DISTAL DACTYLITIS 461 SCABIES 419 HENOCH-SCHÖNLEIN PURPURA 462 JAUNDICE 420 SERUM SIC KN ESS– LIKE REACT IO N 463 MELASMA 421 STRAWBERRY HEMANGIOMA 464 ABDOMINAL STRIAE (STRIAE ATROPH ICAE) 422 ORBITAL AND PRESEPTAL (PERIORBITAL) VITILIGO 423 CELLULITIS 466 UREMIC FROST 424 BRANCHIAL CLEFT CYST 469 AUTOIMMUNE BULLOUS DISEASES 425 THYROGLOSSAL DUCT CYST 470 SYST EMIC LUPUS ERYT H EMAT O SUS 426 CYSTIC HYGROMA 471 SWEET SYNDRO ME 427 CAT-SCRATCH DISEASE 472 PORPHYRIA CUTANEA TARDA 428 SQUAMOUS CELL CARCINOMA 429 General Con ition 473 BASAL CELL CARCINOMA 430 EPIGLOTTITIS 473 MELANOMA 431 RETROPHARYNGEAL ABSCESS 475 LIP LICKER’S DERMATITIS 432 BUTTON (DISC) BATTERY INGESTION 477 MEMBRANOUS (BACTERIAL) TRACHEITIS 478 NASAL FOREIGN BODY 479 P rt 2 SPECIALTY AREAS 433 PHYSEAL FRACTURES: SALTER-HARRIS Ch t r 14 CLASSIFICATION 480 PEDIATRIC CONDITIONS 435 TODDLER’S FRACTURE 481 DACTYLITIS (HAND-FOOT SYNDROME) 482 Brad Sobolewski Matthew R. Mittiga Javier A. Gonzalez del Rey ■ ■ HAIR TOURNIQUET 483 Newborn Con ition 436 FAILURE TO THRIVE 484 ERYTH EMA TOXICUM NEONATORUM 436 NURSING BOTTLE CARIES 485 SALMON PATCHES (NEVUS SIMPLEX) 437 NURSEMAID’S ELBOW NEONATAL JAUNDICE 438 (RADIAL HEAD SUBLUXATION) 486 NEONATAL MILK PRODUCTION (WITCH’S MILK) 439 ILEOCOLIC INTUSSUSCEPTION 488

x ■ CONT ENT S

INGUINAL HERNIA 490 IMMERSION INJURY (TRENCH FOOT) 543 PINWORM INFECTION (ENTEROBIASIS) 492 ULTRAVIOLET RADIATION EXPOSURE 544 LICE 493 LIGH TNING INJURIES 547 TRICHOTILLOMANIA 494 LARGE TERRESTRIAL ANIMAL ATTACKS 549 OCULOGYRIC CRISIS 495 CORAL SNAKE ENVENOMATION 550 SETTING-SUN PHENOMENON PIT VIPER ENVENOMATION 551 (SUNDOWNING) 496 TROPICAL SNAKE ENVENOMATIONS 554 KAWASAKI DISEASE 497 GILA MONSTER ENVENOMATION 556 BLACK WIDOW SPIDER ENVENOMATION 557 Ch t r 15 BROWN RECLUSE SPIDER ENVENOMATION 558 CHILD ABUSE 501 SCORPION ENVENOMATION 560 Kathi L. Makoroff ■ Daniel M. Lindberg ■ Marguerite M. Care TICKS 562 Phy ical Abu e 502 HYMENOPTERA ENVENOMATION 564 CATERPILLAR, MITE, AND CENTIPEDE CUTANEOUS FINDINGS 502 ENVENOMATION 566 CRANIAL FINDINGS 508 MIDDLE EAR SQUEEZE 568 FACIAL FINDINGS 511 MASK SQUEEZE 569 SKELET AL FIN DIN GS 514 STINGRAY ENVENOMATION 570 VISCERAL FINDINGS 517 SEA URCHIN ENVENOMATION 572 Sexual Abu e 519 COELENTERATE ENVENOMATION 574 CHILD SEXUAL ABUSE EXAM AND GENITAL MARINE DERMATITIS 577 FINDINGS 519 SC O RPIO N FISH ST IN G 578 INJURIES AND FINDINGS INDICATIVE OF CONE SNAIL ENVENOMATION 579 GENITAL OR ANAL TRAUMA 524 SEA SNAKE ENVENOMATION 580 MIMICS OF TRAUMA: STRADDLE INJURY 527 CEPHALOPOD ENVENOMATION 581 MIMICS OF TRAUMA: TOILET SEAT INJURIES 528 ERYSIPELOID 582 MIMICS OF TRAUMA: URETHRAL PROLAPSE 529 TOXICODENDRON AND OTHER PLANT MIMICS OF ERYTHEMA/BRUISING: LICHEN EXPOSURES 583 SC LERO SIS 530 SPO RO T RIC H O SIS 586 MIMICS OF ERYTHEMA/BRUISING: LABIAL ADH ESIONS 531 Ch t r 17 MIMICS OF ERYTHEMA/BRUISING: TOXICOLOGICAL CONDITIONS 587 PERIANAL STREPTOCOCCAL DISEASE 532 Saralyn R. Williams ■ Matthew D. Sztajnkrycer MIMICS OF ERYTHEMA/BRUISING: VENOUS ■ R. Jason Thurman POOLING 533 AMPHETAMINE TOXICITY 588 NEW DESIGNER DRUGS: “BATH SALTS” Ch t r 16 AND “SPICE” 590 ENVIRONMENTAL CONDITIONS 535 COCAINE TOXICITY 591 Ken Zafren ■ R. Jason Thurman ■ Ian D. Jones ANTICHOLINERGIC (ANTIMUSCARINIC) HIGH-ALTITUDE RETINAL HEMORRHAGE 536 TOXIDROME 594 HIGH-ALTITUDE PULMONARY EDEMA 537 CHOLINERGIC TOXIDROME 595 HIGH-ALTITUDE CEREBRAL EDEMA 538 OPIOID TOXICITY 597 HYPOTHERMIA 539 ACETAMINOPHEN POISONING 599 FROSTBITE 540 SALIC YLAT E PO ISO NING 600 PERNIO 542 TOXIC ALCOHOL INGESTION 602 CONTENTS ■ xi

TRICYCLIC ANTIDEPRESSANT POISONING 604 Ch t r 19 POISONING BY Β-BLOCKER AND CALCIUM CLINICAL FORENSIC MEDICINE 671 CHANNEL BLOCKER AGENTS 606 William S. Smock ■ Lawrence B. Stack INHALANT ABUSE 608 METHEMOGLOBINEMIA 610 GUNSHOT WOUNDS 672 CELLULAR ASPHYXIANTS 612 Pattern Injurie of Do e tic Violence, VANCOMYCIN-INDUCED RED MAN SYNDROME 614 A ault, an Abu e 679 BO T ULISM 615 SHARP-FORCE-PATTERN INJURIES 679 ANTICOAGULANTS 616 BLUNT-FORCE-PATTERN INJURIES 682 CAUSTIC INGESTION 618 STRANGULATION INJURIES 684 HYDROFLUORIC ACID BURNS 620 THERMAL-PATTERN INJURIES 686 ARSENIC POISONING 622 IRON POISONING 624 Ch t r 20 LEAD POISONING 625 HIV CONDITIONS 689 MERCURY POISONING 627 St ephen P. Raffanti ■ Anna K. Person MUSHROOM INGESTION 629 CARDIAC GLYCOSIDE PLANT PRIMARY HIV INFECTION 690 INGESTION 631 IMMUNE RECONSTITUTION INFLAMMATORY HOUSEPLANTS WITH CALCIUM OXALATE SYNDRO ME (IRIS) 691 CRYSTALS 633 ORAL HAIRY LEUKOPLAKIA 692 JIMSONWEED INGESTION 634 CANDIDIASIS ASSOCIATED WITH HIV 693 PEYOTE INGESTION 635 KAPOSI SARCOMA 695 TOXALBUMIN INGESTION 636 TOXOPLASMA GONDII INFECTION 697 LEVAMISOLE-INDUCED VASCULITIS 637 PNEUMOCYSTIS 699 CRYPTOCOCCAL INFECTIONS 700 HISTOPLAMOSIS 702 Ch t r 18 CYTOMEGALOVIRUS INFECTIONS 703 WOUNDS AND SOFT TISSUE HERPES ZOSTER 704 INJURIES 639 EOSINOPHILIC FOLLICULITIS 706 HERPES SIMPLEX VIRUS 707 Chan W. Park Michael L. Juliano Dana Woodhall ■ ■ SCABIES 708 WOUND CLEANING AND IRRIGATION 640 MOLLUSCUM CONTAGIOSUM 710 WOUND ASSESSMENT 642 DERMATOPHYTE (TINEA) INFECTIONS 711 WOUND FOREIGN BODIES 644 THROMBOCYTOPENIA 712 TRAUMATIC WOUNDS 646 DRUG REACTIONS 713 EAR LACERATIONS 650 ACUTE NECROTIZING ULCERATIVE GINGIVITIS 714 LIP LACERATIONS 651 TENDON LACERATIONS 652 ANIMAL BITE WOUNDS 654 Ch t r 21 FISHHOOK INJURIES 656 TROPICAL MEDICINE 715 SIMPLE WO UN D C LO SURES 658 Seth W . Wright ■ Andrew N. Pfeffer COMPLEX WOUND CLOSURES 661 FREE-LIVING AMEBA INFECTION 716 WOUND CARE COMPLICATIONS 664 ANEMIA IN TH E TROPICS 717 BURN S 666 ANTH RAX 718 ELECTRICAL INJURY 668 ASCARIASIS 720 DECUBITUS ULCERS 670 CHAGAS DISEASE 721 xii ■ CONT ENT S

CHOLERA 722 LARYNGEAL MASK AIRWAY 787 CUTANEOUS LARVA MIGRANS 724 LIGH TED STYLETS AND WANDS 789 CYSTICERCOSIS 725 DIGITAL (TACTILE) INTUBATION 792 DENGUE FEVER 727 INTUBATING LARYNGEAL AIRWAY (ILA) 793 DRACUNCULIASIS 729 KING LARYNGEAL TUBE 795 ELEPH ANTIASIS 730 BLIND NASOTRACHEAL INTUBATION 796 EPIDEMIC MENINGITIS 732 NASAL FLEXIBLE FIBEROPTIC INTUBATION 799 GOITER 733 CRICOTHYROTOMY (SELDINGER TECHNIQUE) 801 HYDATID CYST 734 OPEN CRICOTHYROTOMY 803 LEECH BITES 735 LEISH MANIASIS 737 Ch t r 23 LEPROSY 739 LEPTOSPIROSIS 741 ECG ABNORMALITIES 805 MALARIA 742 James V. Ritchie ■ Michael L. Juliano ■ R. Jason Thurman MUMPS 744 Part 1: St- Abnor alitie 806 MYCETOMA 745 ACUTE ANTERIOR MYOCARDIAL INFARCTION 806 MYIASIS 747 ACUTE INFERIOR MYOCARDIAL INFARCTION 807 NONTUBERCULOSIS MYCOBACTERIA ACUTE RIGH T VENTRICULAR MYOCARDIAL INFECTIONS 749 INFARCTION 808 PROTEIN-ENERGY MALNUTRITION— ACUTE POSTERIOR MYOCARDIAL INFARCTION 809 KWASH IORKOR AND MARASMUS 750 LEFT MAIN LESION 810 RABIES 752 SGARBO SSA CRIT ERIA FO R AMI IN SET T ING SCH IST O SO MIASIS 753 OF LBBB 811 TETANUS 755 SUBENDO C ARDIAL ISCH EMIA 812 TRACHOMA 757 HYPERACUTE T WAVES 813 TRADITIONAL MEDICINE IN THE TROPICS 758 WELLENS WAVES 814 TROPICAL SPOROTRICHOSIS 760 “CEREBRAL” T WAVES 815 TUBERCULOSIS 761 EARLY REPOLARIZATION 816 TUNGIASIS 764 LEFT VENTRICULAR ANEURYSM 817 PERICARDITIS 818 Ch t r 22 Part 2: Con uction Di turbance 819 AIRWAY 765 FIRST-DEGREE AV BLOCK 819 St even J. Whit e ■ Richard M. Levitan ■ Kevin H igh TYPE 1 SECOND-DEGREE AV BLOCK Lawrence B. Stack ■ (MOBITZ I, WENCKEBACH) 820 AIRWAY MAXIM ONE 766 TYPE 2 SECOND-DEGREE AV BLOCK (MOBITZ II) 821 AIRWAY MAXIM TWO 767 THIRD-DEGREE (COMPLETE) AV BLOCK 822 AIRWAY MAXIM THREE 768 T INTERVAL PROLONGATION 823 AIRWAY MAXIM FOUR 769 RIGH T BUNDLE BRANCH BLOCK 824 AIRWAY MAXIM FIVE 770 LEFT BUNDLE BRANCH BLOCK 825 LARYNGOSCOPIC OROTRACHEAL INTUBATION 772 LEFT ANTERIOR FASCICULAR BLOCK 826 BOUGIE-ASSISTED INTUBATION 781 LEFT POSTERIOR FASCICULAR BLOCK 827 VIDEO-ASSISTED INTUBATION—GLIDESCOPE 784 TRIFASCICULAR BLOCK 828 VIDEO-ASSISTED INTUBATION—STORZ C-MAC 785 ASH MAN PH ENOMENON 829 VIDEO-ASSISTED INTUBATION—McGRATH MAC Part 3: Rhyth Di turbance 830 EDL 786 JUNCTIONAL RHYTHM 830 CONTENTS ■ xiii

VENTRICULAR RHYTHM 831 SUBXIPHOID CARDIAC (SUBCOSTAL VIEW) 877 PACED RHYTHM 832 PARASTERNAL LONG-AXIS VIEW (PSLA) 879 ATRIAL FIBRILLATION 833 PARASTERNAL SHORT-AXIS VIEW (PSSA) 881 ATRIAL FLUTTER 834 APICAL FOUR-CH AMBER VIEW (AP4) 883 MULTIFOCAL ATRIAL TACHYCARDIA 835 SUBXIPH O ID LO N G-AXIS (IVC) 885 SUPRAVENTRICULAR TACHYCARDIA (SVT) 836 LUNG ULTRASOUND 887 SVT WITH ABERRANCY 837 ABDOMINAL AORTA ULTRASOUND 890 VENTRICULAR TACHYCARDIA 838 DEEP VENOUS THROMBOSIS ULTRASOUND 894 VENTRICULAR FLUTTER 839 ULTRASOUND-GUIDED RESUSCITATION 897 TORSADES DE POINTES 840 GALLBLADDER ULTRASOUND 899 Part 4: Structural Abnor alitie 841 RENAL AND BLADDER ULTRASOUND 903 PREGNANCY ULTRASOUND 907 DEXTROCARDIA 841 PROCEDURAL GUIDANCE: LEFT VENTRICULAR H YPERTROPH Y 842 ULTRASOUND-GUIDED VENOUS ACCESS 911 RIGH T VENTRICULAR HYPERTROPHY 843 PROCEDURAL GUIDANCE: LEFT ATRIAL H YPERTROPH Y 844 THORACENTESIS/PARACENTESIS 914 RIGH T ATRIAL HYPERTROPHY 845 OCULAR ULTRASOUND 916 HYPERTROPHIC CARDIOMYOPATHY 846 SOFT TISSUE ULTRASOUND 920 BRUGADA SYNDRO ME 847 WOLFF-PARKINSON-WHITE SYNDROME 848 Ch t r 25 Part 5: ECG Abnor alitie of MICROSCOPIC FINDINGS 923 Noncar iac Origin 849 Brett Bechtel HYPOTHERMIA 849 URINALYSIS 924 HYPOKALEMIA 850 SYNOVIAL FLUID ANALYSIS FOR CRYSTALS 926 HYPERKALEMIA 851 GRAM STAIN 928 PULMONARY EMBOLISM 853 DARK-FIELD EXAMINATION 929 PERICARDIAL EFFUSION 854 VAGINAL FLUID WET MOUNT 930 DIGOXIN EFFECT, TOXICITY 855 POTASSIUM HYDROXIDE MOUNT 931 TRICYCLIC ANTIDEPRESSANT EFFECT 856 STOOL EXAMINATION FOR FECAL LEUKOCYTES 932 LIMB LEAD REVERSAL 857 SKIN SCRAPING FOR DERMATOSES AND LOW VOLTAGE 858 INFESTATIONS 933 CEREBROSPINAL FLUID EXAMINATION: INDIA INK Ch t r 24 PREPARATION 934 EMERGENCY ULTRASOUND 859 WRIGHT STAIN—THIN SMEAR FOR MALARIA 935 Jeremy S. Boyd ■ Jordan D. Rupp ■ Robinson M. Ferre FERNING PATTERN FOR AMNIOTIC FLUID 936 PERIPHERAL BLOOD SMEAR FOR SCHISTOCYTES EMERGENCY ULTRASOUND: INTRODUCTION 860 AND BLAST CELLS 937 TRAUMA ULTRASOUND 863 TAPE TEST FOR ENTEROBIAS VERMICULARIS PERICARDIAL (SUBXIPHOID VIEW) 864 EGGS 938 RIGHT UPPER QUADRANT (POUCH OF MORISON) 866 TZANCK PREPARATION 940 LEFT UPPER QUADRANT (PERISPLENIC VIEW) 868 SUPRAPUBIC 870 THORAX (RIGHT AND LEFT) 873 INDEX 941 CARDIAC ULTRASOUND 876 CONTRIBUTORS

Brett Bechtel, MD, FAAEM, FACEP Robinson M. Ferre, MD, FACEP Staff Phy ician A i tant Profe or Lour e E ergency Depart ent Director, E ergency Ultra oun Pa ucah, Kentucky Depart ent of E ergency Me icine Chapter 25 Van erbilt Univer ity Na hville, enne ee Frank Birinyi, MD, FACEP Chapter 24 A junct A i tant Profe or he Ohio State Univer ity Beverly C. Forcier, MD Atten ing Phy ician Ophthal ology Mount Car el We t Ho pital Clevelan Height , Ohio Mount Car el Ea t Ho pital Chapter 3 Colu bu , Ohio Chapter 2 Javier A. Gonzalez del Rey, MD Director, Pe iatric Re i ency Progra Jeffery D. Bondesson, MD A ociate Director, Divi ion of E ergency Me icine Atten ing Phy ician Profe or, Univer ity of Cincinnati Depart ent of Pe iatric E ergency Depart ent Cincinnati Chil ren’ Ho pital Me ical Center Kai er San Diego Me ical Center Cincinnati, Ohio San Diego, California Chapter 14 Chapter 8 J. Matthew Hardin, MD, FAAD Jeremy S. Boyd, MD, RDMS Der atologi t A i tant Profe or Na hville, enne ee A i tant Progra Director Chapter 13 Fellow hip Director, E ergency Ultra oun Depart ent of E ergency Me icine Andrew J. Hendershot, MD Van erbilt Univer ity Clinical A i tant Profe or of Ophthal ology Na hville, enne ee Havener Eye In titute Chapter 24 he Ohio State Univer ity Wexner Me ical Center Colu bu , Ohio Marguerite M. Care, MD Chapter 2 A i tant Profe or Depart ent of Ra iology, Divi ion of Neurora iology Kevin High, RN, EMT, MPH, MHPE, CFRN Cincinnati Chil ren’ Ho pital Me ical Center Clinical A ociate Cincinnati, Ohio rau a Re u citation Manager Chapter 15 Depart ent of E ergency Me icine Van erbilt Univer ity School of Me icine Stephen W. Corbett, MD, PhD Na hville, enne ee Profe or Chapter 22 Depart ent of E ergency Me icine Lo a Lin a Univer ity Me ical Center James W. Howell, DDS Lo a Lin a, California Fellow Chapter 7 Depart ent of Oral an Maxillofacial Surgery College of Dental Me icine Suzanne Dooley-Hash, MD Me ical Univer ity of South Carolina A i tant Profe or Charle ton, South Carolina Univer ity of Michigan Me ical School Chapter 6 Ann Arbor, Michigan Chapter 9 an 10 Edward C. Jauch, MD, MS Profe or, Director, Divi ion of E ergency Me icine David Effron, MD, FACEP Profe or, Depart ent of Neuro cience A i tant Profe or of E ergency Me icine A ociate Vice Chair, Re earch, Depart ent of Me icine Ca e We tern Re erve Univer ity, Metro Health Me ical Center Me ical Univer ity of South Carolina Clevelan , Ohio Charle ton, South Carolina Chapter 3 Chapter 5 an 6 xvi ■ CONT RIBUT ORS

Ian D. Jones, MD David W. Munter, MD, MBA A i tant Profe or of E ergency Me icine an Infor atic A i tant Clinical Profe or Me ical Director A ult E ergency Depart ent Depart ent of E ergency Me icine Van erbilt Univer ity School of Me icine Ea tern Virginia Me ical School Na hville, enne ee Norfolk, Virginia Chapter 16 Chapter 1 Michael L. Juliano, MD, FACEP, CDR, MC, USN Chan W. Park, MD, FAAEM Depart ent Chair of E ergency Me icine Director of Si ulation E ucation Naval Me ical Center Port outh Co-Director of Inter i ciplinary A vance Fellow hip in Clinical Port outh, Virginia Si ulation Chapter 18 an 23 Durha VA Me ical Center, North Carolina A junct A i tant Profe or Kevin J. Knoop, MD, MS Divi ion of E ergency Me icine Staff Phy ician Duke Univer ity Me ical Center Naval Me ical Center, Port outh, Virginia Durha , North Carolina A i tant Profe or of Military an E ergency Me icine Chapter 18 Unifor e Service Univer ity of the Health Science Bethe a, Marylan Anna K. Person, MD Chapter 2, 3, 4, 8, 10, 14, 15, an 24 A i tant Profe or of Me icine A ociate Progra Director, ID Fellow hip Progra Daniel M. Lindberg, MD Divi ion of Infectiou Di ea e A ociate Profe or of E ergency Me icine an Pe iatric Van erbilt Univer ity Univer ity of Colora o School of Me icine Na hville, enne ee Aurora, Colara o Chapter 20 Chapter 15 Andrew N. Pfeffer, MD Sean A. Lisse, MD A i tant Profe or of E ergency Me icine Univer ity of Michigan Me ical School Van erbilt Univer ity Ann Arbor, Michigan Na hville, enne ee Chapter 10 Chapter 21 Kathi L. Makoroff, MD, MEd Stephen P. Raffanti, MD, MPH A ociate Profe or of Pe iatric Profe or of Me icine Mayer on Center for Safe an Healthy Chil ren Divi ion of Infectiou Di ea e Cincinnati Chil ren’ Ho pital Me ical Center Van erbilt Univer ity Cincinnati, Ohio Me ical Director Chapter 15 Van erbilt Co prehen ive Care Center Thomas F. Mauger, MD Na hville, enne ee Chapter 20 Profe or an Chair an Depart ent of Ophthal ology George J. Raukar, MD Havener Eye In titute Orthope ic Surgery he Ohio State Univer ity Pri a-Care Colu bu , Ohio Fall River, Ma achu ett Chapter 2 Chapter 11 Matthew R. Mittiga, MD Neha P. Raukar, MD, MS A i tant Profe or A i tant Profe or of E ergency Me icine Univer ity of Cincinnati Depart ent of Pe iatric Brown Univer ity Cincinnati Chil ren’ Ho pital Me ical Center Provi ence, Rho e I lan Divi ion of E ergency Me icine Chapter 11 Cincinnati, Ohio Chapter 14 James V. Ritchie, MD, CAPT, MC, USN A i tant Profe or Military an E ergency Me icine Unifor e Service Univer ity of the Health Science Bethe a, Marylan Chapter 23 CONTRIBUTORS ■ xvii

Jo rd an D . Ru pp, MD Matthew D. Sztajnkrycer, MD, PhD, FACEP A i tant Profe or A ociate Profe or of E ergency Me icine Depart ent of E ergency Me icine Depart ent of E ergency Me icine Mayo Clinic Van erbilt Univer ity Roche ter, Minne ota Na hville, enne ee Staff oxicologi t Chapter 24 Minneapoli , MNMN Poi on Control Sy te Chapter 17 Daniel L. Savitt, MD, FACEP A ociate Profe or of E ergency Me icine R. Jason Thurman, MD, FAAEM, CPPS A ociate Profe or of Me icine Chief Me ical Officer Alpert Me ical School of Brown Univer ity riStar Skyline an Hen er onville Me ical Center Rho e I lan Ho pital A junct A ociate Profe or of Nur ing Provi ence, Rho e I lan Van erbilt Univer ity Me ical Center Chapter 11 an 12 Na hville, enne ee Chapter 6, 16, 17, 20, an 23 Brian R. Sharp, MD A i tant Profe or Robert J. Tubbs, MD A ociate Re i ency Progra Director A i tant Profe or Depart ent of E ergency Me icine Depart ent of E ergency Me icine Univer ity of Wi con in School of Me icine an Public Health Alpert Me ical School of Brown Univer ity Ma i on, Wi con in Provi ence, Rho e I lan Chapter 9 Chapter 12 William S. Smock, MD, MS Christopher S. Weaver, MD Profe or A ociate Profe or E ergency Me icine E ergency Me icine Univer ity of Loui ville School of Me icine In iana Univer ity School of Me icine Loui ville, Kentucky In ianapoli , In iana Chapter 19 Chapter 4 Brad Sobolewski, MD, MEd David R. White, MD A i tant Profe or A ociate Profe or, Depart ent of Otolaryngology Univer ity of Cincinnati Depart ent of Pe iatric Me ical Univer ity of South Carolina Cincinnati Chil ren’ Ho pital Me ical Center Charle ton, South Carolina Divi ion of E ergency Me icine Chapter 5 Cincinnati, Ohio Chapter 14 Steven J. White, MD, FACEP, FAAP A i tant Profe or of E ergency Me icine an Pe iatric Lawrence B. Stack, MD Van erbilt Univer ity Profe or of E ergency Me icine an Pe iatric Na hville, enne ee Van erbilt Univer ity Chapter 22 Na hville, enne ee Chapter 1, 5, 7, 9, 19, 22, an 25 Saralyn R. Williams, MD, FACMT, FACEP A ociate Profe or of Clinical Me icine Alan B. Storrow, MD Depart ent of Me icine an E ergency Me icine Vice Chair an for Re earch an Aca e ic Affair Van erbilt Univer ity A ociate Profe or of E ergency Me icine Na hville, enne ee Van erbilt Univer ity Chapter 17 Na hville, enne ee Chapter 11, 12, 13, 18, an 21 Dana Woodhall, MD Me ical Epi e iologi t, Para itic Di ea e Branch Selim Suner, MD, MS, FACEP Divi ion of Para itic Di ea e an Malaria Profe or of E ergency Me icine, Surgery an Engineering Center for Global Health Alpert Me ical School of Brown Univer ity LCDR US Public Health Service Provi ence, Rho e I lan Chapter 18 Chapter 12 Seth W. Wright, MD, MPH Profe or of E ergency Me icine Van erbilt Univer ity Na hville, enne ee Chapter 21 xviii ■ CONTRIBUTORS

Eric Wu, MD Ken Zafren, MD, FAAEM, FACEP, FAWM E ergency Me icine Re i ent Clinical A i tant Profe or Van erbilt Univer ity Divi ion of E ergency Me icine Na hville, enne ee Stanfor Univer ity Me ical Center Chapter 1 Palo Alto, California Richard E. Wyszynski, MD, FACS Chapter 16 Staff Phy ician Lorain In titute Clevelan Clinic Foun ation Clevelan , Ohio Chapter 3 MEDIA CREDITS

Eftitan Akam Keith Batts, MD Me ical Stu ent Staff Phy ician Van erbilt Univer ity School of Me icine Bon Secour Health Center Na hville, enne ee Suffolk, Virginia Wael Alrifai, MD Judith C. Bausher, MD Clinical Fellow of Neonatology A ociate Profe or of Pe iatric an E ergency Me icine Van erbilt Chil ren’ Ho pital, DO Univer ity of Cincinnati College of Me icine Pe iatric Neonatology Atten ing Phy ician, Divi ion of E ergency Me icine Na hville, enne ee Chil ren’ Ho pital Me ical Center Cincinnati, Ohio Edward S. Amrhein, DDS, CAPT, DC, USN Hea , Dental Depart ent Brett Bechtel, MD, FAAEM, FACEP Director, Oral & Maxillofacial Surgery Re i ency Staff Phy ician Naval Me ical Center Lour e E ergency Depart ent Port outh, Virginia Pa ucah, Kentucky Donald Arnold, MD, MPH William Beck, CRA A ociate Profe or of E ergency Me icine an Pe iatric Clinic Photographer, Flori a Eye Clinic Depart ent of Pe iatric Alta onte Spring , Flori a Divi ion of E ergency Me icine Van erbilt Univer ity School of Me icine John G. Benitez, MD, MPH Na hville, enne ee A junct Profe or in E ergency Me icine A junct Profe or in Me icine Thomas Babcock, MD Van erbilt Univer ity School of Me icine Longview E ergency Me icine A ociate enne ee Poi on Control Center Goo Shepher Me ical Center Na hville, enne ee Longview, exa Debbie Bennes, MS, MLT, ASCP Matthew Backer, Jr., MD, RADM, MC, USNR (RET) Mayo Clinic Atten ing Phy ician Roche ter, Minne ota Depart ent of Ob tetric an Gynecology Naval Me ical Center Lynne Bentsen, RN San Diego, California Bonaire Jo h n D . Baker, MD Marion Berg, MD Chief of Ophthal ology A i tant Profe or of E ergency Me icine Chil ren’ Ho pital of Michigan Depart ent of E ergency Me icine Clinical Profe or of Ophthal ology Van erbilt Univer ity Me ical Center Wayne State Univer ity School of Me icine Na hville, enne ee Detroit, Michigan Gianina Best, MD Raymond C. Baker, MD Phy ician, E ergency Depart ent Profe or of Pe iatric Lebanon Co unity Ho pital Univer ity of Cincinnati College of Me icine Lebanon, Oregon Pe iatrician, Divi ion of Pe iatric Alexandra Bingnear Chil ren’ Ho pital Me ical Center Cincinnati, Ohio MSN Stu ent Van erbilt Univer ity School of Nur ing Kevin S. Barlotta, MD, FAAEM, FACEP Na hville, enne ee A ociate Profe or of E ergency Me icine Frank Birinyi, MD, FACEP Me ical Director Critical Care ran port Univer ity of Alaba a A junct A i tant Profe or Bir ingha , Alaba a he Ohio State Univer ity Atten ing Phy ician William Barsan, MD Mount Car el We t Ho pital Profe or an Chair Mount Car el Ea t Ho pital Depart ent of E ergency Me icine Colu bu , Ohio Univer ity of Michigan Ann Arbor, Michigan xx ■ MEDIA CREDITS

Jake Bl o ck, MD Catherine Burger, MD A ociate Profe or of Ra iology an Ra iological Science A i tant Profe or of E ergency Me icine A ociate Profe or of Orthopae ic Surgery an Rehabilitation Depart ent of E ergency Me icine A ociate Profe or of E ergency Me icine Van erbilt Univer ity School of Me icine Depart ent of Ra iology Na hville, enne ee Van erbilt Univer ity Me ical Center Na hville, enne ee Sean P. Bush, MD Staff E ergency Phy ician an Enveno ation Con ultant Allison Bollinger, MD A ociate Profe or of E ergency Me icine Mi le enne ee E ergency Phy ician Lo a Lin a Univer ity Me ical Center an School of Me icine Na hville, enne ee Lo a Lin a, California Jeffery D. Bondesson, MD William E. Cappaert, MD Atten ing Phy ician Depart ent of E ergency Me icine E ergency Depart ent Metro Health Me ical Center Kai er San Diego Me ical Center Clevelan , Ohio San Diego, California Mike Cardwell, MS Thomas Bottoni, MD Sacra ento, California Staff E ergency Phy ician Naval Me ical Center Marguerite M. Care, MD Port outh, Virginia A i tant Profe or Depart ent of Ra iology, Divi ion of Neurora iology Jeremy S. Boyd, MD, RDMS Cincinnati Chil ren’ Ho pital Me ical Center A i tant Profe or Cincinnati, Ohio A i tant Progra Director Fellow hip Director, E ergency Ultra oun Rachel Champion, MD Depart ent of E ergency Me icine Depart ent of Me icine Van erbilt Univer ity Divi ion of Der atology Na hville, enne ee Van erbilt Univer ity School of Me icine Na hville, enne ee Robert L. Brandt, Jr., MD Wright State Phy ician Health Center Frances S. Cheng, MD, PhD Fairborn, Ohio Yale Un iver ity New Haven, Connecticut Francisco Bravo Puccio, MD Univer i a Peruana Richard A. Chole, MD, PhD Cayetano Here ia, Li a, Peru Lin burg Profe or an Hea Depart ent of Otolaryngology Wa hington Univer ity School of Me icine James Paul Brewer, MD St. Loui , Mi ouri Re i ent Depart ent of E ergency Me icine Ju dy Ch ri st en sen Van erbilt Univer ity School of Me icine Me ical Illu trator Na hville, enne ee Graphic Divi ion Staff E ucation an raining Suzanne Bryce, MD Naval Me ical Center Chief Re i ent San Diego, California Van erbilt E ergency Depart ent Na hville, enne ee Jaso n Ch u , MD A i tant Profe or of Clinical Me icine Robert G. Buckley, MD, MPH, CAPT, MC, USN Colu bia Univer ity College of Phy ician an Surgeon Co an ing Officer an Deputy Director St. Luke’ -Roo evelt Ho pital Center Captain Ja e A. Lovell Fe eral Health Care Center New York, New York North Chicago, Illinoi Walter Clair, MD, MPH Steven D. Burdette, MD Divi ion of Car iova cular Me icine Wright State Phy ician Internal Me icine Van erbilt Heart Va cular In titute Dayton, Ohio Van erbilt Univer ity Me ical Center Na hville, enne ee MEDIA CREDITS ■ xxi

Richard A. Clinchy III, PhD, NREMT-P Herbert L. DuPont, MD A erican College of Preho pital Me icine Baylor St. Luke’ Me ical Center Ft. Walton Beach, Flori a Hou ton, exa Timothy Coakley, MD, FAAEM E. Lee Edstrom, MD International actical Me ical Solution , Inc. Surgeon in Chief Virginia Beach, Virginia Divi ion of Pla tic Surgery Rho e I lan Ho pital Stephen W. Corbett, MD, PhD A i tant Profe or of Surgery Profe or Depart ent of E ergency Me icine Brown Univer ity Lo a Lin a Univer ity Me ical Center Provi ence, Rho e I lan Lo a Lin a, California David Effron, MD, FACEP Robin T. Cotton, MD A i tant Profe or of E ergency Me icine Profe or Depart ent of Otolaryngology an Maxillofacial Surgery Ca e We tern Re erve Univer ity, Metro Health Me ical Center Chil ren’ Ho pital Me ical Center Clevelan , Ohio Cincinnati, Ohio Thomas Egnatz, CRA Barbara R. Craig, MD, CAPT, MC, USN he Glick Eye In titute Me ical Con ultant for Chil Abu e an Neglect In ianapoli , In iana National Naval Me ical Center Bethe a, Marylan Mark Eich, MD Staff Phy ician Brice Critser, CRA Naval Ho pital Director of Diagno tic I aging Jack onville, Flori a Univer ity of Iowa Ho pital an Clinic Depart ent of Ophthal ology Eugene Eiland, MD Univer ity of Iowa Chief Re i ent Iowa City, Iowa Van erbilt E ergency Depart ent Na hville, enne ee James Dahle, MD, MAJ, USAF, MC Atten ing Phy ician Edward Eitzen, MD, MPH Naval Me ical Center Chief, Preventive Me icine Depart ent Port outh, Virginia US Ar y Me ical Re earch In titute of Infectiou Di ea e River i e E ergency Phy ician Fort Detrick, Marylan Newport New , Virginia Colora o Spring , Colora o Sheila Dawling, PhD James P. Elrod, MD, PhD Aegi Science Corporation Staff He opathologi t Na hville, enne ee St. ho a Ho pital Na hville, enne ee Mohamud Daya, MD Depart ent of E ergency Me icine David Eschenbach, MD Oregon Health & Science Univer ity Profe or Portlan , Oregon Depart ent of Ob tetric an Gynecology Univer ity of Wa hington Suzanne Dooley-Hash, MD Seattle, Wa hin gton A i tant Profe or Univer ity of Michigan Me ical School Sarah M. Escott, MD Ann Arbor, Michigan Greenville, North Carolina Steve Downie, MD Katherine Farmer, MD Staff E ergency Phy ician Brown Univer ity Bapti t Ho pital of Southea t exa Provi ence, Rho e I lan Beau ont, exa Me ical Director Robinson M. Ferre, MD, FACEP Neighbor E ergency Center A i tant Profe or Port Arthur, exa Director, E ergency Ultra oun Depart ent of E ergency Me icine Van erbilt Univer ity Na hville, enne ee xxii ■ MEDIA CREDIT S

James F. Fiechtl, MD, RMSK Russell C. Gilbert, MD A i tant Profe or of E ergency Me icine CAP , Me ical Corp , USN Van erbilt Bone an Joint Pul onary an Critical Care Me icine Franklin, enne ee US Naval Ho pital, Gua John Fildes, MD, FACS Javier A. Gonzalez del Rey, MD Atten ing Surgeon Director, Pe iatric Re i ency Progra Divi ion of rau a A ociate Director, Divi ion of E ergency Me icine Depart ent of Surgery Profe or, Univer ity of Cincinnati Depart ent of Pe iatric Cook County Ho pital Cincinnati Chil ren’ Ho pital Me ical Center Chicago, Illinoi Cincinnati, Ohio Jeffrey Finkelstein, MD Jef f rey Go s h e, MD Chief, Divi ion of Acute Care Clevelan Clinic Main Ca pu Chair an, Depart ent of E ergency Me icine Clevelan , Ohio Wilfor Hall Me ical Center Atten ing Phy ician Melissa Gray, WEMT Joint Military Me ical Center NOLS Wil erne Me icine In titute E ergency Me icine Re i ency Lan er, Wyo ing San An ton io, exa Rob Greidanus, MD Andreas Fischer, RN Peace Country Health Region Spokane, Wa hington Alberta, Cana a Jason W. Fischer, MD, MSc Ralph A. Gruppo, MD Pe iatric E ergency Me icine Cincinnati Chil ren’ Ho pital Me ical Center he Ho pital for Sick Chil ren hro bo i Center oronto, Ontario, Cana a Cincinnati, Ohio Beverly C. Forcier, MD Peter Hackett, MD Ophthal ology In titute of Altitu e Me icine Clevelan Height , Ohio elluri e, Colora o Lo ui s C. Frazi er, MD Hope K. Haefner, MD Chief Re i ent Profe or Depart ent of E ergency Me icine Ob tetric & Gynecology Van erbilt Univer ity School of Me icine Von Voigtlan er Ho pital Na hville, enne ee Ann Arbor, Michigan Luanne Freer, MD, FACEP, FAWM H. Hunter Handsfield, MD Me ical Director, Yellow tone National Park Profe or E eritu of Me icine Yellow tone National Park, Wyo ing Univer ity of Wa hington Center for AIDS an S D Seattle, Wa hin gton Sara-Jo Gahm, MD E ergency Phy ician J. Matthew Hardin, MD, FAAD Everett, Wa hington Der atologi t Na hville, enne ee Elena Geraymovych, MD A i tant Profe or, Ophthal ology Carson Harris, MD Univer ity of exa Health Science Center at San Antonio Director San An ton io, exa E ergency Me icine oxicology Service Region Ho pital W. Brian Gibler, MD Saint Paul, Minne ota Profe or of E ergency Me icine Univer ity of Cincinnati College of Me icine Ben Heavrin, MD Cincinnati, Ohio Mi le enne ee E ergency Phy ician Na hville, enne ee Jeffrey S. Gibson, MD *

*Decea e MEDIA CREDITS ■ xxiii

Thomas R. Hedges III, MD Jennifer Jagoe, MD Director, Neuro-Ophthal ology Service Hanover, Marylan Co-Director, Electrophy iology Service New Englan Eye Center Timothy Jahn, MD, LCDR, MC, USNR Bo ton, Ma achu ett Atten ing Phy ician Depart ent of E ergency Me icine Lawrence E. Heiskell, MD, FACEP, FAAFP Naval Ho pital Depart ent of E ergency Me icine Great Lake , Illinoi Naval Ho pital wentynine Pal wentynine Pal , California Thea L. James, MD IS M A i tant Profe or of E ergency Me icine Rancho Mirage, California Bo ton Univer ity School of Me icine Bo ton, Ma achu ett Andrew J. Hendershot, MD Clinical A i tant Profe or of Ophthal ology Alison Jarman, MD Havener Eye In titute he Northern Ho pital he Ohio State Univer ity Wexner Me ical Center Melbourne, Au tralia Colu bu , Ohio Edward C. Jauch, MD, MS Robert W. Hickey, MD Profe or, Director, Divi ion of E ergency Me icine A ociate Profe or of Pe iatric Profe or, Depart ent of Neuro cience Chil ren’ Ho pital of Pitt burgh of UPMC A ociate Vice Chair, Re earch, Depart ent of Me icine Pitt burgh, Penn ylvania Me ical Univer ity of South Carolina Charle ton, South Carolina Briana M. Hill, MD Rapi City Me ical Center, LLP Ian D. Jones, MD Der atology Depart ent A i tant Profe or of E ergency Me icine an Infor atic Rapi City, South Dakota Me ical Director A ult E ergency Depart ent Van erbilt Univer ity School of Me icine Barbara Hoffman, MD Na hville, enne ee Dalla , exa Michael L. Juliano, MD, FACEP, CDR, MC, USN Robert S. Hoffman, MD Depart ent Chair of E ergency Me icine Profe or Naval Me ical Center Port outh E ergency Me icine an Me icine (Clinical Phar acology) Port outh, Virginia New York Univer ity School of Me icine New York, New York Arthur M. Kahn, MD, FACS A i tant Profe or of Surgery King Holmes, MD, PhD UCLA School of Me icine Profe or Atten ing Surgeon Depart ent of Global Health an Me icine Ce ar -Sinai Me ical Center Univer ity of Wa hington Lo Angele , California Seattle, Wa hin gton Beverly Hill , California Edmund A. Hooker, MD Nicholas C. Kanaan, MD A ociate Profe or, Depart ent of Health Service A ini tration Me orial Ho pital of Sweetwater County Xavier Univer ity Rock Spring , Wyo ing Cincinnati, Ohio Lo ui se Kao , MD Chris Imray, PhD In ianapoli , In iana Profe or of Va cular Surgery Coventry, UK David Kaplan, MD Staff Atten ing Phy ician Meg Jack, MD Depart ent of E ergency Me icine Car on ahoe E ergency Phy ician he Miria Ho pital Car on City, Neva a Provi ence, Rho e I lan Liudvikas Jagminas, MD Lee Kaplan, MD Vice Chair an Director of Clinical Operation Clinical Profe or of Der atology Yale Un iver ity Univer ity of California, San Diego New Haven, Connecticut San Diego, California xxiv ■ MEDIA CREDIT S

Rebecca A. Kasl, MD David P. Kretzschmar, DDS, MS Depart ent of Neurological Surgery Chief, Depart ent of Oral an Maxillofacial Surgery Van erbilt Univer ity School of Me icine 2n Me ical Group Na hville, enne ee Bark ale AFB, Loui iana A i tant Profe or Tomisaku Kawasaki, MD Depart ent of Surgery Director Loui iana State Univer ity Me ical Center Japan Kawa aki Di ea e Re earch Center New Orlean , Loui iana okyo, Japan Win ton-Sale , North Carolina Rudy J. Kink, MD James L. Kretzschmar, DDS, MBS, LTCOL, USAF Pe iatric E ergency Me icine Fellow OIC Flight Dental Clinic LeBonheur Chil ren’ Me ical Center Hollo an AFB, New Mexico Me phi , enne ee Jeffrey Kuhn, MD, CAPT, MC, USN (RET) Jo rg e Kl ei s i n ger, MD Depart ent of Otolaryngology—Hea an Neck Surgery Director Naval Me ical Center Vi ión Soli aria Port outh, Virginia Juan Jo é Ca telli, Chaco, Argentina Maria de Lourdes Ladino, MS-IV Mimi Knoop Me ical Stu ent Hoopla Skateboar Van erbilt Univer ity School of Me icine Santa Barbara, California Na hville, enne ee Kevin J. Knoop, MD, MS Michael J. Lambert, MD, RDMS, FAAEM Staff Phy ician Depart ent of E ergency Me icine Naval Me ical Center, Port outh, Virginia A vocate Chri t Me ical Center A i tant Profe or of Military an E ergency Me icine Oak Lawn, Illinoi Unifor e Service Univer ity of the Health Science Bethe a, Marylan Shannon Langston, MD A i tant Profe or of E ergency Me icine Stephen J. Knoop Van erbilt Univer ity School of Me icine Herpetologi t Na hville, enne ee Virginia Aquariu an Marine Science Center Virginia Beach, Virginia Patrick W. Lappert, MD Lappert Pla tic Surgery Shannon Koh, MD Ma i on, Alaba a Depart ent of Internal Me icine Univer ity of Pitt burgh Hillary J. Larkin, PA-C Pitt burgh, Penn ylvania Director, Me ical Sexual A ault Service Depart ent of E ergency Me icine Matthew Kopp, MD Ala e a Sexual A ault Re pon e ea A i tant Profe or of E ergency Me icine Highlan General Ho pital UEMF Co pliance Director Oaklan , California Depart ent of E ergency Me icine he Warren Alpert Me ical School Lo renz F. Lassen, MD , FACS Brown Univer ity Otolaryngology, Lakeview Me ical Center Provi ence, Rho e I lan Suffolk, Virginia Rosalynne Korman, MD Adam Laverty UC Irvine Depart ent of Pe iatric A a Laverty Photography Orange, California Utila, Hon ura Paul J. Kovalcik, MD Alexis Lawrence, MD Colorectal Surgeon Brown Univer ity We tern Branch North Depart ent of E ergency Me icine Che apeake, Virginia Provi ence, Rho e I lan MEDIA CREDITS ■ xxv

Laurie Lawrence, MD C. Bruce MacDonald, MD A i tant Profe or of E ergency Me icine A i tant Profe or, Depart ent of Otolaryngology Depart ent of E ergency Me icine Bo ton Univer ity School of Me icine Van erbilt Univer ity School of Me icine Bo ton, Ma achu ett Na hville, enne ee Mark L. Madenwald, MD, LT, MC, USNR Lo ui s La Vo pa, MD Chief Re i ent Staff Phy ician E ergency Me icine Depart ent E ergency Me icine Depart ent Naval Me ical Center Naval Ho pital Port outh, Virginia Agana, Gua Kathi L. Makoroff, MD, MEd Harold Lee, MD A ociate Profe or of Pe iatric Eugene & Marilyn Glick Eye In titute Mayer on Center for Safe an Healthy Chil ren Depart ent of Ophthal ology Cincinnati Chil ren’ Ho pital Me ical Center In iana Univer ity School of Me icine Cincinnati, Ohio In ianapoli , In iana William K. Mallon, MD, FACEP, DTMH, FACEP, FAAEM Stephen J. Leech, MD, RDMS Profe or of Clinical E ergency Me icine A i tant Clinical Profe or Keck School of Me icine Depart ent of E ergency Me icine Univer ity of Southern California Univer ity of Central Flori a School of Me icine Lo Angele , California Flori a State Univer ity School of Me icine Orlan o, Flori a Scott Manning, MD Profe or an Chief of Pe iatric Otolaryngology William Leininger, MD Univer ity of Wa hington, Seattle Chil ren’ Ho pital Depart ent of Ob tetric an Gynecology Seattle, Wa hin gton Naval Me ical Center San Diego, California Robin Marshall, MD E ergency Me icine Atten ing Richard C. Levy, MD Naval Me ical Center Profe or E eritu of E ergency Me icine Port outh, Virginia Depart ent of E ergency Me icine Univer ity of Cincinnati Ian T. McClure, MD Cincinnati, Ohio Staff E ergency Phy ician Sutter General Ho pital Daniel M. Lindberg, MD Sacra ento, California A ociate Profe or of E ergency Me icine an Pe iatric Univer ity of Colora o School of Me icine Kathy McCue, MD Aurora, Colara o Staff E ergency Phy ician Ala ka Native Me ical Center Anne W. Lucky, MD Anchorage, Ala ka Volunteer Profe or of Der atology an Pe iatric Univer ity of Cincinnati College of Me icine Megan McGraw Letson, MD Director, Der atology Clinic In uring the Chil ren Chil Abu e Fellow Chil ren’ Ho pital Me ical Center Cincinnati Chil ren’ Ho pital Me ical Center Cincinnati, Ohio Colu bu , Ohio Jo su a Lu f t i g, PA- C Timothy D. McGuirk, DO, CAPT, MC, USN Me ical Sexual A ault Service Depart ent Hea Depart ent of E ergency Me icine E ergency Me icine Ho pital Ala e a Sexual A ault Re pon e ea Okinawa, Japan Highlan General Ho pital a pa, Flori a Oaklan , California Patrick H. McKenna, MD, FACS, FAAP Binh Ly, MD Profe or Chief, Divi ion of Pe iatric Urology A ociate Clinical Profe or Me ical Director, Surgical Specialty Clinic A erican Fa ily Univer ity of California, San Diego Chil ren’ Ho pital LaJolla, California Univer ity of Wi con in School of Me icine Ma i on Wi con in xxvi ■ MEDIA CREDIT S

Jare d J. McKi n n ey, MD David W. Munter, MD, MBA A i tant Profe or A ociate Clinical Profe or Depart ent of E ergency Me icine Depart ent of E ergency Me icine Van erbilt Univer ity Me ical Center Ea tern Virginia Me ical School A i tant E ergency Me ical Service Director Norfolk, Virginia Na hville Fire Depart ent Na hville, enne ee Douglas Nilson, MD Sen ior Re i en t Sheila McMorrow-Jones, MD Brown Univer ity E ergency Me icine, Pe iatric Rho e I lan Ho pital Depart ent of Pe iatric Re i ency Progra in E ergency Me icine Van erbilt Univer ity Provi ence, Rho e I lan Na hville, enne ee Christopher B. Noel, MD Jo h n L. Meade, MD Depart ent of E ergency Me icine Stat oc Con ulting, Inc. Van erbilt Univer ity Gulf Breeze, Flori a Na hville, enne ee Vineet Mehan, MD Daniel F. Noltkamper, MD Atten ing Phy ician, Provi ence Ho pital, E ergency Depart ent Greater Wa hington Pla tic Surgery A ociate , LLC Colu bia, South Carolina Annan ale, Virginia James J. Nordlund, MD Larry B. Mellick, MD, MS, FAAP, FACEP Profe or of Der atology Profe or of Pe iatric an E ergency Me icine Depart ent of Der atology Georgia Regent Univer ity Ho pital Univer ity of Cincinnati Augu ta, Georgia Cincinnati, Ohio James J. Mensching, DO Michael J. Nowicki, MD Operational Me ical Director Pe iatric Ga troenterology E ergency Me ical Depart ent Univer ity of Mi i ippi Me ical Center Naval Me ical Center Jack on, Mi i ippi Brockton, Ma achu ett John O’Boyle, MD, CAPT, MC, USN Marc Mickiewicz, MD Director, Profe ional E ucation E ergency Phy ician at Su ner Naval Me ical Center Gallatin, enne ee Port outh, Virginia Shawn Miller Gerald O’Malley, DO Okinawa Nature Photography Atten ing E ergency Phy ician Depart ent of E ergency Me icine Benjamin Milligan, MD Albert Ein tein Me ical Center CHA Ca bri ge Ho pital Ca pu Phila elphia, Penn ylvania Ca bri ge, Ma achu ett James O’Malley, MD Sherman Minton, MD (Deceased) Provi ence Ala ka Regional Me ical Center Profe or E eritu Anchorage, Ala ka In iana Univer ity School of Me icine In ianapoli , In iana John E. O’Mara, MD Swe i h Heart an Va cular In titute Matthew R. Mittiga, MD Seattle, Wa hin gton A i tant Profe or Univer ity of Cincinnati Depart ent of Pe iatric Alan E. Oestreich, MD Cincinnati Chil ren’ Ho pital Me ical Center Profe or of Ra iology an Pe iatric Divi ion of E ergency Me icine Univer ity of Cincinnati College of Me icine Cincinnati, Ohio Chief, Section of Diagno tic Ra iology Staff Ra iologi t Aubrey Mowery, MPH, RN, CHES Chil ren’ Ho pital Me ical Center MSN Stu ent in Pe iatric Pri ary Care Cincinnati, Ohio Van erbilt Univer ity School of Nur ing Na hville, enne ee MEDIA CREDITS ■ xxvii

Edward C. Oldfield III, MD Stephen P. Raffanti, MD, MPH Profe or of Me icine Profe or of Me icine Director, Infectiou Di ea e Divi ion Divi ion of Infectiou Di ea e Ea tern Virginia School of Me icine Van erbilt Univer ity Norfolk, Virginia Me ical Director Van erbilt Co prehen ive Care Center Lauren G. Oliveira, DO Na hville, enne ee Naval Me ical Center Port outh Port outh, Virginia Mark E. Ralston, MD Depart ent of Pe iatric Sheryl Olson, RN Naval Ho pital Oak Harbor Flight Nur e Oak Harbor, Wa hington Wil erne Me icine In tructor Wil erne Wi e Michael Redman, PA-C Manitou Spring , Colora o Staff, E ergency Me icine Fort Leonar Woo Ar y Co unity Ho pital Jare d M. Orro ck, MD Fort Leonar Woo , Mi ouri Mayo Clinic Roche ter, Minne ota Keven Reed, OD Orange Park Eye Center Edward J. Otten, MD Orange Park, Flori a Profe or of E ergency Me icine an Pe iatric Director, Divi ion of oxicology Nichole Rice, RN, MPA, PA-C Univer ity of Cincinnati College of Me icine Che apeake E ergency Phy ician Cincinnati, Ohio Che apeake, Virginia Max Palatnik, MD William H. Richardson, MD Depart ent of E ergency Me icine Pal etto Health E ergency Phy ician Van erbilt Univer ity Colu bia, South Carolina Na hville, enne ee David Ritchie, MD James Palma, MD, LCDR, MC, USN E ergency Me icine Re i ent Ultra oun Fellow Van erbilt Univer ity Pal etto Health Richlan Na hville, enne ee Colu bia, South Carolina Jim Ritchie, MD, FACEP James Palombaro, MD, LCDR, MC, USNR Re i ency Progra Coor inator Atten ing Phy ician PCEA Chogoria Ho pital Depart ent of Ob tetric an Gynecology Chogoria, Kenya Naval Me ical Center San Diego, California James V. Ritchie, MD, CAPT, MC, USN A i tant Profe or Lauri A. Paolinetti, PA-C Military an E ergency Me icine Sexual A ault Exa iner Unifor e Service Univer ity of the Health Science Depart ent of E ergency Me icine Bethe a, Marylan Ala e a Sexual A ault Re pon e ea Highlan General Ho pital Michael Ritter, MD Oaklan , California Laguna Beach, California Dallas E. Peak, MD Gregory K. Robbins, MD, MPH A i tant Profe or of Clinical E ergency Me icine Ma achu ett General Ho pital Depart ent of E ergency Me icine Bo ton, Ma achu ett In iana Univer ity School of Me icine Karen Rogers, MD In ianapoli , In iana Centra E ergency Phy ician Lara L. Philips, MD Lynchburg General Ho pital Depart ent of E ergency Me icine Lynchburg, Virginia ho a Jeffer on Univer ity Phila elphia, Penn ylvania xxviii ■ MEDIA CREDIT S

Jan et Gael Ro h de Daniel L. Savitt, MD, FACEP Chair an, Guyana Bapti t Mi ion (Retire ) A ociate Profe or of E ergency Me icine Georgetown, Guyana A ociate Profe or of Me icine Alpert Me ical School of Brown Univer ity Timothy Root, MD Rho e I lan Ho pital o oka Eye A ociate Provi ence, Rho e I lan Or on Beach, Flori a Robert Schnarrs, MD Tal Rubinstein, MD he Hague Center Cole Eye In titute Norfolk, Virginia Clevelan Clinic Clevelan , Ohio Charles J. Schubert, MD Cincinnati Chil ren’ Ho pital Me ical Center Donald L. Rucknagel, MD, PhD Cincinnati, Ohio Profe or of Pe iatric an Internal Me icine Univer ity of Cincinnati College of Me icine Gary Schwartz, MD Co prehen ive Sickle Cell Center A i tant Profe or Chil ren’ Ho pital Me ical Center Depart ent of E ergency Me icine Cincinnati, Ohio Van erbilt Univer ity Me ical Center Na hville, enne ee Richard M. Ruddy, MD Divi ion of E ergency Me icine Susan Scott Cincinnati, Ohio Kailua, Honolulu Jo rd an D . Ru pp, MD Eric M. Sergienko, MD, MPH A i tant Profe or CAP , Me ical Corp , US Navy Depart ent of E ergency Me icine Depart ent of Defen e Liai on OPHPR Van erbilt Univer ity Center for Di ea e Control an Prevention Na hville, enne ee Atlanta, Georgia Stephan E. Russ, MD Jef f Servo s s A i tant Profe or of E ergency Me icine US Fi h an Wil life Service Depart ent of E ergency Me icine Van erbilt Univer ity Me ical Center Binita R. Shah, MD, FAAP Na hville, enne ee Profe or of Pe iatric an E ergency Me icine SUNY Down tate Me ical Center Brad Russell, MD Director E eritu , Pe iatric E ergency Me icine E ergency Phy ician King County Ho pital Center Na hville, enne ee Brooklyn, New York Warren K. Russell, MD Kara N. Shah, MD, PhD Morton Ho pital Divi ion of Der atology E ergency Depart ent Cincinnati Chil ren’ Ho pital Me ical Center aunton, Ma achu ett Cincinnati, Ohio Cybele Sabino Lisboa, BSc (Biol.) Robert A. Shapiro, MD Curator of Reptile , A phibian an Invertebrate Chil ren’ Ho pital Me ical Center Fun ação Parque Zoológico e São Paulo Cincinnati, Ohio São Paulo, Brazil Virender K. Sharman, MD John C. Sakles, MD Fellow Profe or Divi ion of Dige tive Di ea e an Nutrition E ergency Me icine Univer ity of South Carolina School of Me icine Univer ity of Arizona Colu bia, South Carolina uc on, Arizona Phoenix, Arizona Katrina Santos Vongsy, MD Craig Sheedy, MD National Naval Me ical Center Depart ent of E ergency Me icine Bethe a, MD Van erbilt Univer ity Na hville, enne ee MEDIA CREDITS ■ xxix

Nakul Shekhawat, MD, MPH Hannah F. Smitherman, MD Yp ilanti, Michigan Fort Worth, exa Rees W. Sheppard, MD, FACS Bill Smock, MD A i tant Director of Pe iatric Ophthal ology Police Surgeon Chil ren’ Ho pital Me ical Center Loui ville Metro Police Depart ent Volunteer A ociate Profe or Loui ville, Kentucky Univer ity of Cincinnati College of Me icine Cincinnati, Ohio Shannon Snyder, MD Na hville, enne ee Richard Sherbahn, MD A vance Fertility Center of Chicago Aaron L. Sobol, MD Gurnee, Illinoi Laurel Ri ge Eyecare Uniontown, Penn ylvania Anita P. Sheth, MD Volunteer A i tant Profe or Brad Sobolewski, MD Co-Director, Divi ion of Pe iatric Der atology Pe iatric E ergency Me icine Cincinnati Chil ren’ Ho pital Me ical Center Cincinnati Chil ren Ho pital Me ical Center Univer ity of Cincinnati College of Me icine Cincinnati, Ohio Cincinnati, Ohio Emily R. Stack Hanyuan Shi Brentwoo , enne ee Me ical Stu ent Lawrence B. Stack, MD Van erbilt Univer ity Na hville, enne ee Profe or of E ergency Me icine an Pe iatric Van erbilt Univer ity Paul R. Sierzenski, MD Na hville, enne ee Chri tiana Care Health Sy te Philip E. Stack, MD Newark, Delaware Angel Me ical Center Arun D. Singh, MD Franklin, North Carolina Director Walter E. Stamm, MD (Deceased) Depart ent of Ophthal ic Oncology Cole Eye In titute, Clevelan Clinic Profe or of Me icine Clevelan , Ohio Divi ion of Allergy an Infectiou Di ea e Univer ity of Wa hington Kenneth Skahan, MD Seattle, Wa hin gton A i tant Profe or James F. Steiner, DDS Divi ion of Infectiou Di ea e Univer ity of Cincinnati Cincinnati, Ohio Cincinnati, Ohio Claire Stevens, PA Stuart Skinner, MD Depart ent of Neurology Divi ion of Infectiou Di ea e , Univer ity of Sa katchewan Pri ary Infection Clinic Sa katchewan, Cana a Univer ity of Wa hington Seattle, Wa hin gton Clay B. Smith, MD Kristin L. Stevens, MD A i tant Profe or Depart ent of E ergency Me icine, Pe iatric an Internal Me icine Minneapoli , Minne ota Van erbilt Univer ity Me ical Center Alan B. Storrow, MD Na hville, enne ee Vice Chair an for Re earch an Aca e ic Affair Timothy L. Smith, MD, MPH, FACS A ociate Profe or of E ergency Me icine Profe or an Director Van erbilt Univer ity Oregon Sinu Center Na hville, enne ee Depart ent of Otolaryngology—Hea an Neck Surgery Richard T. Strait, MD Oregon Health an Science Univer ity Cincinnati Chil ren’ Ho pital Me ical Center Portlan , Oregon Cincinnati, Ohio xxx ■ MEDIA CREDITS

Selim Suner, MD, MS, FACEP Paul J. Turek, MD Profe or of E ergency Me icine, Surgery an Engineering he urek Clinic Alpert Me ical School of Brown Univer ity San Franci co, California Provi ence, Rho e I lan George W. Turiansky, MD Matthew D. Sztajnkrycer, MD, PhD, FACEP Depart ent of Der atology A ociate Profe or of E ergency Me icine Unifor e Service Univer ity of the Health Science Depart ent of E ergency Me icine Mayo Clinic Bethe a, Marylan Roche ter, Minne ota Staff oxicologi t Jan i ce U n derwo o d Minneapoli , MNMN Poi on Control Sy te A vance Health E ucation Center, Inc. Hou ton, exa Gary Tanner, MD Ha pton Roa Eye A ociate -- Oy ter Point Dileep C. Unnikrishnan, MD Newport New , Virginia Long Branch, New Jer ey Martin Terry, PhD Andrew H. Urbach, MD Pre i ent, Cactu Con ervation In titute Profe or of Pe iatric A ociate Profe or Univer ity of Pitt burgh School of Me icine Depart ent of Biology, Geology, Phy ical Science Me ical Director for Clinical Excellence an Service Sui Ro State Un iver ity Chil ren’ Ho pital of Pitt burgh of UPMC Alpine, exa Pitt burgh, Penn ylvania Cyril Thomas, PA-C Richard P. Usatine, MD San Diego, California Profe or, Der atology an Cutaneou Surgery Profe or, Fa ily an Co unity Me icine Mary Ann Thompson Arildsen, MD, PhD A i tant Director, Me ical Hu anitie E ucation Van erbilt Univer ity Me ical Center Univer ity of exa Health Science Center at San Antonio Na hville, enne ee Me ical Director, Skin Clinic, Univer ity Health Sy te San An ton io, exa R. Jason Thurman, MD, FAAEM, CPPS Chief Me ical Officer Gerard Van Houdt, MD riStar Skyline an Hen er onville Me ical Center Lour e Me ical Center E ergency Depart ent A junct A ociate Profe or of Nur ing Pa co, Wa hington Van erbilt Univer ity Me ical Center Na hville, enne ee Cathleen M. Vossler, MD Princeton E ergency Phy ician , PA Alexander J. Towbin, MD Univer ity Me ical Center of Princeton at Plain boro Depart ent of Ra iology & Me ical I aging Plain boro, New Jer ey Cincinnati Chil ren’ Ho pital Me ical Center Cincinnati, Ohio Arden H. Wander, MD Profe or of Clinical Ophthal ology * Robert S. Trieff, MD Univer ity of Cincinnati Cincinnati, Ohio Alexander T. Trott, MD Jo h n n y Wei , BS Profe or of E ergency Me icine Van erbilt Univer ity School of Me icine Univer ity of Cincinnati College of Me icine Na hville, enne ee Cincinnati, Ohio Jo h n J. Wei t er, MD , Ph D Robert J. Tubbs, MD Retina Con ultant of Greater Bo ton A i tant Profe or Peabo y, Ma achu ett Depart ent of E ergency Me icine Alpert Me ical School of Brown Univer ity David R. White, MD Provi ence, Rho e I lan A ociate Profe or, Depart ent of Otolaryngology Me ical Univer ity of South Carolina Charle ton, South Carolina

*Decea e MEDIA CREDITS ■ xxxi

Stephen J. White, MD, FACEP, FAAP Eric Wu, MD A i tant Profe or of E ergency Me icine an Pe iatric E ergency Me icine Re i ent Van erbilt Univer ity Van erbilt Univer ity Na hville, enne ee Na hville, enne ee Saralyn R. Williams, MD, FACMT, FACEP Richard E. Wyszynski, MD, FACS A ociate Profe or of Clinical Me icine Staff Phy ician Depart ent of Me icine an E ergency Me icine Lorain In titute Van erbilt Univer ity Clevelan Clinic Foun ation Na hville, enne ee Clevelan , Ohio Alex Wilson Li ly Yu, MS4 Nova Scotia Mu eu of Natural Hi tory Van erbilt Univer ity Halifax, Nova Scotia, Cana a Na hville, enne ee Andrew Wong, MD Scott W. Zackowski, MD A i tant Clinical Profe or of E ergency Me icine Chief of Service, Annie Penn Ho pital A ociate Me ical Director Depart ent of E ergency Me icine—Green boro Region Univer ity of California, Irvine Wake Fore t Univer ity, School of Me icine Irvine, California Green boro, North Carolina Dana Woodhall, MD Ken Zafren, MD, FAAEM, FACEP, FAWM Me ical Epi e iologi t, Para itic Di ea e Branch Clinical A i tant Profe or Divi ion of Para itic Di ea e an Malaria Divi ion of E ergency Me icine Center for Global Health Stanfor Univer ity Me ical Center LCDR US Public Health Service Palo Alto, California Jo h n Wo rre l l , MD Richard Zienowicz, MD Profe or of Ra iology Atten ing Phy ician Depart ent of Ra iology Divi ion of Pla tic Surgery Van erbilt Univer ity Me ical Center A ociate Profe or of Surgery Na hville, enne ee Brown Univer ity Provi ence, Rho e I lan Seth W. Wright, MD, MPH Profe or of E ergency Me icine Van erbilt Univer ity Na hville, enne ee FOREWORD

Within a given e ical pecialty, typically two or three ajor hi expan ion of topic an iagno e ha a e thi text- textbook help efine the brea th an epth of a i cipline. book a ajor re ource in ultiple e ical environ ent for hi Atlas of Emergency Medicine, for the fiel of e ergency clinician worl wi e. care, i one of the e efining work . Fir t appearing in 1997, hi 4th e ition of the Atla , for the fir t ti e, al o provi e the 4th E ition of the Atla i now publi he in ultiple for- acce to vi eo to help i prove the iagno tic capabilitie of eign language an available electronically, which ake it the clinician an co ple ent the tatic photographic i age . univer ally available an i portant for patient care acro he e itor are to be congratulate for continuing to expan the globe. A any acute iagno e are a e vi ually, an the cope an e ia of thi ajor work, while continuing to any phy ician are vi ual learner , the Atlas of Emergency earch for better photographic repre entation of i ea e pro- Medicine erve a an out tan ing e ucational an refer- ce e for thi late t e ition. ence tool for the e ical tu ent, re i ent, an particularly For e per onally, thi Atlas of Emergency Medicine the practicing e ergency phy ician. It i a u eful a junct in 4th Edition repre ent the incre ibly ucce ful ger ination preparation for the pictorial ection of certification te t . hi of an i ea tarte a a conver ation between an e ergency Atla al o erve a a valuable re ource for other a bulatory e icine atten ing phy ician an a very talente e ergency care pecialtie uch a pe iatrician , general interni t , fa - e icine re i ent (the enior e itor of thi Atla , Dr. Knoop) ily phy ician , phy ician a i tant , an nur e practitioner , uring an overnight hift in the Univer ity of Cincinnati by provi ing an approach e igne by e ergency phy ician Me ical Center e ergency epart ent, now over 20 year for patient with e ergent con ition . ago. he critical gap in the E ergency Me icine textbook of he 4th E ition of the Atlas of Emergency Medicine ha the early 1990’ wa the lack of a co prehen ive an practi- been co pletely revi e by the four e itor a well a expert cal pictorial atla available for real-ti e iagno i of patient e ergency phy ician contributor fro acro the pecialty. pre enting to e ergent care etting . hi book ha not only It now contain 1500 full color photograph , electrocar io- bri ge thi gap, but al o now provi e the conci e iagno tic gra , an ra iograph , 500 newly cho en for thi 4th E ition. an treat ent infor ation nece ary for the e ergency phy- he chapter are arrange logically by organ y te , pecial ician or other practitioner to anage the patient an care- population , an clinical proble . Environ ental con i- fully i po ition the in real ti e, at the be i e. I believe tion , toxicology, electrocar iographic abnor alitie , foren ic thi i portant Atlas of Emergency Medicine, now a cla ic in e icine, airway proce ure , tropical e icine, icro copic it 4th E ition, will re ain a ain tay for the ho pital e er- iagno e , an e ergency ultra oun are o e of the pecial gency epart ent an outpatient clinic librarie , a well a ection that greatly expan the u efulne of thi Atla for the have a ajor pre ence in the avvy clinician’ per onal refer- practicing clinician caring for patient with e ergencie . A ence collection long into the future. clinical u ary, anage ent an i po ition approache , an pearl for photographic ti uli of a particular iagno- W. Brian Gibler, MD i ake thi text a full purpo e reference. he i pre ive Profe or of E ergency Me icine able of Content an exhau tive In ex of the 4th E ition Depart ent of E ergency Me icine provi e a co prehen ive ability to acce the i portant pho- Univer ity of Cincinnati College of Me icine tograph , iagra , an ra iograph nece ary to quickly help Cincinnati, Ohio care for the patient pre enting with an e ergent con ition. PREFACE

The Atlas of Emergency Medicine, 4th E ition Preface Secon , after exten ive review an critique, hun re of “ he life o hort, the craft o long to learn” new an replace ent i age have been a e . We have been Hippocrate fortunate to raw upon new ource of photograph avail- able on the Internet or through electronic channel unavail- We have a pa ion for i proving patient care. Our journey able to u previou ly. hi ha ub tantially trengthene the with The Atlas of Emergency Medicine began with uperb content an i a re in er of how uch the worl of e ia entor who in tille in u a rive to beco e excellent cli- ha change . Gone are the ay of anually orting through nician an e ucator . We i covere i aging wa a pow- thou an of li e or print . here have been ra ical change erful tool to take the learner “to the be i e” an e tabli h in the way we acce e ical knowle ge over the pa t two per anence, in a fa hion unlike any other i actic technique. eca e . Regar le of the for , however, an i age aintain In 1994, uch by chance, collegial networking brought three a potent ean to teach an learn. of u together to pur ue an aggre ive goal of pro ucing the hir , we are aking an initial ove into vi eo. Many chap- o t co prehen ive ource of high-quality e ergency care ter inclu e link to hort vi eo further eluci ating fin ing an i age available. While there were o e initial etractor , provi ing a powerful e iu to expan upon tatic i age . our fir t three e ition receive wi e prea prai e an have he au ience for thi text i all who provi e e ergency been tran late into three foreign language , fla h car , an e ical care, inclu ing clinician , e ucator , re i ent , electronic ver ion . We are eeply hu ble an honore to nur e , preho pital caregiver , an e ical tu ent . Many pre ent our fourth iteration. have al o foun it extre ely u eful a a review for written E ergency care i efine by ti e an the e ergency boar exa ination containing pictorial que tion . Other epart ent i the o t iver e elting pot of acute con i- healthcare worker , uch a interni t , fa ily phy ician , tion in the ho pital. Diagno tic accuracy, progno tic pre ic- pe iatrician , nur e practitioner , an phy ician a i tant tion, an the treat ent pathway rely heavily on vi ual clue . will fin the Atlas a u eful gui e in i entifying an treating We e ire to axi ize thi kill for the benefit of our patient . any acute con ition , where vi ual clue ignificantly gui e, We al o trongly believe the vi ual experience, while o e- i prove, an expe ite iagno i a well a treat ent. ti e ownplaye within the hectic an ti e-pre ure envi- We thank the any contributor an rea er who have ron ent of o ern e icine, i critical to i eal e ucation. helpe ake thi e ition po ible. We are e pecially grateful I age can teach fa ter an with greater i pact than any for the any contribution fro two great e ucator in e er- page of text or hour of lecture. gency e icine who hare our pa ion: Davi Effron, MD, We continue our pur uit of the e goal with a ub tan- an Larry Mellick, MD. Al o, pecial thank to Anne Sy or, tially up ate , expan e , an i prove fourth e ition of The PhD, our McGraw-Hill e itor for her tirele co it ent, Atlas of Emergency Medicine. Nearly all of our change an organizational ability an focu . La tly, an o t i por- a ition co e fro rea er ugge tion an critici , all tantly, we expre our eepe t gratitu e to our patient who receive with incere gratitu e. were willing to be a “great ca e” in the Atlas, thu ulti ately Fir t, we have change the for at to greatly re uce text paving the way for i prove e ergency care. an allow for ore i age . Hence, the text i ore conci e, provi ing e ential infor ation. Each chapter ite i now Kevin J. Knoop, md, ms organize into: Clinical Summary, inclu ing a ifferential Lawrence B. Stack, md iagno i where appropriate, followe by Management and Alan B. Storrow, md Disposition, an , finally, Pearls. We have, a in the pa t, R. Ja on hur an, md en eavore to provi e relevant “pearl ” repre enting tip for iagno i , anage ent, or unique a pect of a con ition if- ficult to fin in a typical text. PART 1

Regional Anatomy Chapter 1 HEAD AND

Scan QR code or go FACIAL T RAUMA to www.ematlas.com for video related to David W. Munter chapter

Exposed Galea. Partial forehead degloving injury after a motor vehicle crash. Galea overlying the frontal bone is demonstrated just prior to repair. (Photo contributor: Lawrence B. Stack MD)

3 BASILAR SKULL FRACTURE

Clinical Summary positive. The fluid can be placed on filter paper and a “halo” or double ring may be seen. The skull “base” comprises the frontal bone, occiput, occipital condyles, clivus, carotid canals, petrous portion of the tem- poral bones, and the posterior sphenoid wall. A basilar skull Management and Disposition fracture is basically a linear fracture of the skull base. Trauma Identify underlying brain injury, which is best accomplished resulting in fractures to this area typically does not have local- by CT. CT is also the best diagnostic tool for identifying the izing symptoms. Indirect signs of the injury may include vis- fracture site, but fractures may not always be evident. Evi- ible evidence of bleeding from the fracture into surrounding dence of open communication, such as a CSF leak, mandates soft tissue, such as a Battle sign or “raccoon eyes.” Bleeding neurosurgical consultation and admission. Otherwise, the into other structures—including hemotympanum or blood decision for admission is based on the patient’s clinical con- in the sphenoid sinus seen as an air-fluid level on computed dition, other associated injuries, and evidence of underlying tomography (CT)—may also be seen. Cerebrospinal fluid brain injury as seen on CT. The use of antibiotics in the pres- (CSF) leaks may also be evident and noted as clear or pink ence of a CSF leak is controversial because of the possibility of rhinorrhea. If CSF is present, a dextrose stick test may be selecting resistant organisms.

FIGURE 1.1 ■ Battle Sign. Ecchymosis in the postauricular area develops when the fracture line communicates with the mastoid air cells, resulting in blood accumulating in the cutaneous tissue. This FIGURE 1.2 ■ Battle Sign. A striking Battle sign is seen in this patient had sustained injuries several days prior to presentation. patient with head trauma. This finding may take hours to days to (Photo contributor: Frank Birinyi, MD.) develop. (Photo contributor: David Effron, MD.)

4 BASILAR SKULL FRACTURE (CONTINUED) ■ 5

Pearls 1. Clinical manifestations of basilar skull fracture may take several hours to fully develop. 2. There should be a low threshold for head CT in any patient with head trauma, loss of consciousness, change in mental status, severe headache, visual changes, or nausea or vomiting. 3. The use of filter paper or a dextrose stick test to determine if CSF is present in rhinorrhea is not 100% reliable.

FIGURE 1.5 ■ Hemotympanum. Seen in a basilar skull fracture when the fracture line communicates with the auditory canal, result- ing in bleeding into the middle ear. Blood can be seen behind the tym- panic membrane. (Photo contributor: Richard A. Chole, MD, PhD.)

FIGURE 1.3 ■ Raccoon Eyes. Acute periorbital ecchymosis seen in this patient with a basilar skull fracture. These findings may also be caused by facial fractures. (Photo contributor: Shannon Koh, MD.)

FIGURE 1.4 ■ Early Raccoon Eyes. Subtle periorbital ecchymosis FIGURE 1.6 ■ CT of Basilar Skull Fracture. CT bone window dem- manifests 1 hour after a blast injury. (Photo contributor: Kevin J. onstrates a fracture of the posterior wall left sphenoid sinus (arrow) Knoop, MD, MS.) and an air-fluid level. (Photo contributor: Jared McKinney, MD.) 6 ■ BASILAR SKULL FRACTURE (CONTINUED)

FIGURE 1.7 ■ Halo Sign—Cerebrospinal Fluid Leak. Otorrhea on bed sheet demonstrating a halo sign from a patient with severe head trauma. The distinctive double-ring sign, seen here, comprises blood (inner ring) and CSF (outer ring). The reliability of this test has been questioned. (Photo contributor: Suzanne Bryce, MD.) DEPRESSED SKULL FRACTURE

Clinical Summary Management and Disposition Depressed skull fractures typically occur when a large force Explore all scalp lacerations to exclude a depressed fracture. is applied over a small area. They are classified as open if CT should be performed in all suspected depressed skull the skin above them is lacerated. Abrasions, contusions, fractures to determine the extent of underlying brain injury. and hematomas may also be present over the fracture site. Depressed skull fractures require immediate neurosurgical The patient’s mental status is dependent upon the degree of consultation. Treat open fractures with antibiotics and tetanus underlying brain injury. Direct trauma can cause abrasions, prophylaxis as indicated. The decision to observe or operate contusions, hematomas, and lacerations without an underly- immediately is made by the neurosurgeon. Children below ing depressed skull fracture. Evidence of other injuries such 2 years of age with skull fractures can develop leptomenin- as a basilar fracture, facial fractures, or cervical spinal injuries geal cysts, which are extrusion of CSF or brain through dural may also be present. defects. For this reason, children below age 2 with skull frac- tures require close follow-up or admission.

FIGURE 1.8 ■ Depressed Skull Fracture. A scalp laceration over- lying a depressed skull fracture. Scalp lacerations should undergo sterile exploration for skull fracture. (Photo contributor: David W. FIGURE 1.9 ■ Depressed Skull Fracture. CT demonstrating Munter, MD.) depressed skull fracture. (Photo contributor: David W. Munter, MD.)

7 8 ■ DEPRESSED SKULL FRACTURE (CONTINUED)

Pearls 3. Ping pong ball skull fractures can occur from a forceps delivery or from compression by mother’s sacral promon- 1. Examine all scalp injuries including lacerations for evi- tory during delivery. dence of fractures or depression. When fragments are 4. Patients with head injuries must be evaluated for cervical depressed 5 mm below the inner table, penetration of the spine injuries. dura and injury to the cortex are more likely. 2. Children with depressed skull fractures are more likely to develop epilepsy.

A B

FIGURE 1.10 ■ Ping Pong Ball Skull Fracture. (A) Akin to the greenstick fracture, a ping pong ball fracture occurs when a newborn or infant’s relatively soft skull is indented by the corner of a table or similar object without causing a frank break in the bone. (B) CT demon- strates the ping pong ball effect. (Photo contributor: Johnny Wei, BS.) NASAL INJURIES

Clinical Summary Clinically significant nasal fractures are almost always evi- dent with deformity, swelling, and ecchymosis. Fractures to adjacent bony structures, including the orbit, frontal sinus, or cribriform plate, often occur. Epistaxis may be due to a septal or turbinate laceration but can also be seen with fractures of adjacent bones, including the cribriform plate. Septal hema- toma is a rare but important complication that, if untreated, may result in necrosis of the septal cartilage and a resultant “saddle-nose” deformity. A frontonasoethmoid fracture has nasal or frontal crepitus and may have telecanthus or obstruc- tion of the nasolacrimal duct.

Management and Disposition Look for more serious injuries first. Patients with associated facial bone deformity or tenderness may require CT to rule out facial fractures. Isolated nasal fractures rarely require radiographs. Refer obvious deformities within 2 to 5 days for reduction, after the swelling has subsided. Nasal fractures with mild angulation and without displacement may be reduced in the emergency department (ED). Nasal injuries without FIGURE 1.11 ■ Nasal Fracture. Deformity is evident on examina- deformity need only conservative therapy with an analgesic tion. Note periocular ecchymosis indicating the possibility of other and possibly a nasal decongestant. Immediately drain septal facial fractures (or injuries). The decision to obtain radiographs is hematomas, with packing placed to prevent reaccumulation. based on clinical findings. A radiograph is not indicated for an isolated Uncontrolled epistaxis may require nasal packing. Vigorously simple nasal fracture. (Photo contributor: David W. Munter, MD.) irrigate and suture lacerations overlying a simple nasal frac- ture and place the patient on antibiotic coverage. Complex nasal lacerations with underlying fractures should be repaired by a facial surgeon.

Pearls 1. Control epistaxis to perform a good intranasal examination. If obvious deformity is present, including a new septal deviation or deformity, treat with ice and analgesics and provide ENT referral in 2 to 5 days for reduction. 2. Although the effectiveness of prophylactic antibiotics to pre- vent toxic shock syndrome is unproven, patients discharged with nasal packing should be placed on antistaphylococcal antibiotics and referred to ENT in 2 to 3 days. 3. Consider cribriform plate fractures in patients with clear rhinorrhea after nasal injury, with the understanding that FIGURE 1.12 ■ Septal Hematoma. A bluish, grapelike mass on the this finding may be delayed. nasal septum. If untreated, this can result in septal necrosis and a 4. Patients with facial trauma should be examined for a saddle-nose deformity. An incision, drainage, and packing are indi- septal hematoma. cated. (Photo contributor: Lawrence B. Stack, MD.) 9