Rosen's Emergency Medicine Part 2

2047 Pages·106.124 MB·English

by  Marx J.

ROSEN’S
EMERGENCY MEDICINE
Concepts and Clinical Practice
Volume 1 8th Edition
Editor-in-Chief
John A. Marx, MD
Formerly Adjunct Professor of Emergency Medicine, University of
North Carolina at Chapel Hill, Chapel Hill, North Carolina; Chair
Emeritus, Department of Emergency Medicine, Carolinas Medical
Center, Charlotte, North Carolina
Senior Editors
Robert S. Hockberger, MD Ron M. Walls, MD
Professor of Clinical Medicine, David Geffen School of Medicine Professor and Chair, Department of Emergency Medicine,
at University of California at Los Angeles, Los Angeles, Califor- Brigham and Women’s Hospital, Harvard Medical School, Boston,
nia; Chair Emeritus, Harbor–UCLA Medical Center, Torrance, Massachusetts
California
Editors
Michelle H. Biros, MD, MS Louis J. Ling, MD
Professor, Emergency Medicine, University of Minnesota Medical Professor of Emergency Medicine and Pharmacy, University of Min-
School and Hennepin County Medical Center; Vice-Chair of Research, nesota Medical School; Medical Toxicology Consultant, Hennepin
Emergency Medicine, University of Minnesota Medical School; Regional Poison Center, Minneapolis, Minnesota; Senior Vice-
Associate Research Director, Hennepin County Medical Center, President, Hospital-Based Accreditation, Accreditation Council for
Minneapolis, Minnesota Graduate Medical Education, Chicago, Illinois
Daniel F. Danzl, MD Edward J. Newton, MD
Professor and Chair, Department of Emergency Medicine, University Professor of Emergency Medicine, Keck School of Medicine; Chair,
of Louisville School of Medicine, Louisville, Kentucky Department of Emergency Medicine, Los Angeles County and
University of Southern California Medical Center, Los Angeles,
Marianne Gausche-Hill, MD
California
Professor of Clinical Medicine, David Geffen School of Medicine at
University of California at Los Angeles; Vice Chair and Chief of the Brian J. Zink, MD
Division of Pediatric Emergency Medicine, Director of Pediatric Professor and Chair, Department of Emergency Medicine, Warren
Emergency Medicine and Emergency Medical Services Fellowships, Alpert Medical School of Brown University; Physician-in-Chief,
Department of Emergency Medicine, Harbor–University of Califor- Emergency Medicine, Rhode Island Hospital, The Miriam Hospital,
nia at Los Angeles Medical Center, Torrance, California and Hasbro Children’s Hospital, Providence, Rhode Island
Andy Jagoda, MD, FACEP
Professor and Chair, Mt. Sinai School of Medicine and Medical Direc-
tor, Mt. Sinai Medical Center, New York, New York
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
ROSEN’S EMERGENCY MEDICINE:CONCEPTS AND CLINICAL PRACTICE ISBN: 978-1-4557-0605-1
Volume 1 Part Number: 996087921
Volume 2 Part Number: 996087980
Copyright © 2014 by Saunders, an imprint of Elsevier Inc.
Copyright © 2010, 2006, 2002, 1998, 1992, 1988, 1983 by Mosby, Inc., an affiliate of Elsevier Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval
system, without permission in writing from the publisher. Details on how to seek permission, further
information about the Publisher’s permissions policies and our arrangements with organizations such as the
Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.
com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may
become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration,
and contraindications. It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Rosen’s emergency medicine : concepts and clinical practice / editor-in-chief, John A. Marx; senior editors,
Robert S. Hockberger, Ron M. Walls ; editors, Michelle H. Biros … [et al.].—8th ed.
p. ; cm.
Emergency medicine
Includes bibliographical references.
ISBN 978-1-4557-0605-1 (hardcover : alk. paper)
I. Marx, John A. II. Rosen, Peter, 1935- Emergency medicine. III. Title: Emergency medicine.
[DNLM: 1. Emergencies. 2. Emergency Medicine. WB 105]
RC86.7
616.02′5—dc23
2013015607
Senior Content Strategist: Stefanie Jewell-Thomas
Senior Content Development Specialist: Deidre Simpson
Publishing Services Manager: Patricia Tannian
Senior Project Manager: Claire Kramer
Designer: Steven Stave
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
We, the authors and editors, dedicate this edition of Rosen’s Emergency Medicine: Concepts and
Clinical Practice to our late, beloved colleague, John Andrew Marx, who died suddenly and unex-
pectedly in his sleep on July 1, 2012. The loss of John, as mentor, friend, colleague, and leader,
has left an enormous void in our lives and in the lives of countless others in our field who were
inspired or counseled by his incisive intellect and sedulous devotion to scientific rigor. This book
was born in 1983, when Peter Rosen’s dream of a compendium of the biology of emergency
medicine, written by those who study, teach, and practice it, was realized with the publication of
the first edition. For three subsequent editions, Peter guided, cajoled, and willed the book to
completion, all the while grooming John as his obvious and worthy successor. John became editor
in chief for the fifth edition and remained so through this eighth edition, on which, in charac-
teristic fashion, he had discharged his duties fully and flawlessly, prior to his untimely death. As
editors, we are proud to have shared this vision, Peter’s vision, which became John’s vision, with
one of the most influential and inspiring physicians of our time. Although he did not live to hold
a bound copy in his hands, John guided every aspect of this book from beginning to end, and
we know that he was particularly proud that, with this edition, he had served as editor in chief
for as many iterations of the book as had Peter and that he felt a sense of completeness and of
the inevitability of a timeless legacy on reaching that milestone. Although John achieved profes-
sional success beyond description and received virtually every conceivable honor and recognition,
including the highest awards from each of our three major societies, he remained a humble,
devoted emergency physician, deeply rooted in his love for his patients and for his colleagues
and trainees. He was endlessly proud of his children, Shelby and Connor, whom he loved without
bound, and who were his favorite topic of conversation. He was inspired, supported, and nur-
tured by his wife, Karin, with whom he was deeply in love, and from whom he received the gifts
of extraordinary happiness and peace. We both are humbled and honored to be able to set these
final few words to paper and to gently convey this great work to posterity on behalf of our dear
friend and beloved editor, John Andrew Marx.
Ron M. Walls
Robert S. Hockberger
2012
Acknowledgments
To John, for his friendship, leadership, and unwavering commit- 10—girls do grow quicker than books. Emergency medicine has
ment to our specialty; to Ron, for his friendship, vision, and ability sure come a long way. Thanks Peter; we all owe you one.
to make hard work fun; to our editors, for their dedication, DFD
insights, and ability to get it all done “on time and under budget”;
to Stefanie and Dee, for their vigilance and support; to Peter, for I dedicate this book to Dr. John Marx, one of our nation’s brightest
the leadership, mentorship, and opportunities he provided us all; leaders in emergency medicine, a respected colleague and friend,
and to Patty, the love of my life. and to my family for their love and support.
RSH MGH
With affection, admiration, and gratitude to Barb, and to our To Silvana, my wife and closest colleague, who gives me inspiration
children, Andrew, Blake, and Alexa, whom together we recognize and keeps me focused on the important things in life. To John, a
as the most meaningful and priceless gifts we have been privileged great mentor and friend who will be missed beyond words.
to receive. With humble thanks to Peter Rosen, whose selfless com- ASJ
mitment to our specialty and to us, as individuals, helped define
an entirely new direction in modern medicine. To my hero, John To the emergency medicine faculty and residents at Hennepin
Marx, whose incandescent brilliance changed the trajectory of my County Medical Center and all that we have learned together. To
career, and to Bob Hockberger, for his consummate professional- John Marx, a specially gifted teacher and leader, who had a mis-
ism and skill. To our authors and editors, who are the real artists chievous streak but who could get it done. I am grateful to all the
of this creation, and, finally, to my extraordinary faculty and resi- authors who have generously shared their time, energy, and
dents at Brigham and Women’s Hospital, whose intellectual curi- wisdom and to my fellow editors for their commitment to this
osity and boundless intelligence inspire me to be better. terrific book. Special thanks to Eric, who should read this book,
RMW and to Ali, Amanda, and Beth, for their patience, understanding,
and love.
To my family, friends, students, and teachers, who have constantly LJL
provided encouragement and support. To the leadership of our
specialty, especially John Marx, for the hard work and devotion Thank you to my colleagues, mentors, and friends and particularly
that have advanced the care of emergency patients everywhere. thanks to John Marx, who has been all of these for the past 20
MHB years. His gentle guidance and quick wit will be sorely missed.
EJN
When Peter invited me on board in 1995 for edition four, it felt
exhilarating, kind of like being called by Osler (in baritone). I To my mother, Audrey Zink, for instilling in me a love of academ-
reread his preface to the first edition, which was dedicated to all ics and for working so hard to advance her children, against many
of our founding colleagues in emergency medicine “who have odds. To John Marx, whose legacy includes this tome and a genera-
accepted its responsibilities, challenges, and excitements.” Joanna tion of grateful emergency physicians.
observes that our daughters, now just married, were 12 and BJZ
vii
FOUNDING EDITOR
Peter Rosen
PAST EDITORS
Frank J. Baker II (Editions 1 and 2)
G. Richard Braen (Editions 1, 2, and 3)
Robert H. Dailey (Editions 1, 2, and 3)
Jerris R. Hedges (Edition 3)
Richard C. Levy (Editions 1, 2, and 3)
Vincent Markovchick (Edition 4)
Mark Smith (Edition 3)
Glenn C. Hamilton (Editions 5 and 6)
James G. Adams (Editions 5, 6, and 7)
William G. Barsan (Editions 5, 6, and 7)
EMERITUS EDITORS
Peter Rosen
Roger M. Barkin
Preface to the Eighth
Edition
With heavy hearts, we commend to you the eighth edition of this to our editors, whose names you see on the cover and title page.
comprehensive resource for the biology and practice of the spe- We bid a fond farewell, with endless gratitude, to Jim Adams and
cialty of emergency medicine. We are fortunate to have had the Bill Barsan, editors of extraordinary talent who departed after the
benefit of working with not one, but two iconic editors in chief. seventh edition, finally succumbing to the overwhelming demands
This edition marks the final stage in the evolution of John Marx’s for their time and talents. We were fortunate to recruit Brian Zink
vision of a highly authoritative and pithy, timely and timeless, and Andy Jagoda to our cause, and it was clear within weeks that
clinical reference for all students, devotees, and practitioners of we had made the right choice, with each taking the reins as if
this most honorable of the medical specialties. This edition builds seasoned by multiple prior editions. Our other editors, veterans
on the great success of the seventh edition, with further refinement all, embraced their new colleagues, and we had an extraordinary
of our chapter formatting, prose, and citations. We worked dili- unity of purpose as we moved relentlessly toward our shared
gently to balance appropriate citation support for the material vision. We are grateful also to our skilled, patient, and brilliant
presented against the prospect of a bewildering sea of references, publishing team at Elsevier: Judy Fletcher, our global content
seeking always to reduce redundancy, while providing timely and development director; Stefanie Jewell-Thomas, our senior content
authoritative background. strategist; and Deidre (Dee) Simpson, our senior content develop-
Recommendations are based on the best evidence available and, ment specialist. Their expertise, creativity, and dedication contrib-
in the absence of clear scientific support for a single course of ute much to the book, allowing us to develop and share its rich
action, on the collective experience and judgment of our authors content. We are grateful, also, to Dr. Barry Brenner and Dr. Michael
and editors. This edition is more richly illustrated than any before Richardson, each of whom meticulously read the entire seventh
it, both to enhance readability and to improve our effectiveness in edition, providing literally dozens of suggestions for improve-
conveying key information in the best possible format. Emergency ment, which we have incorporated into edition eight. On behalf
medicine is increasingly a procedure-based specialty, but we con- of John, we thank Tricia Wyatt, his dedicated, long-serving assis-
tinue to leave the detailed description of procedures to other tant, whose heart we know aches as do our own. We also thank
works, focusing instead on the substantial basis of knowledge, Diane Pugh and Janice Bingham (RMW) and Maria Figueroa
experience, and reasoning that is necessary to achieve the highest (RSH), for without their extraordinary organizational talent and
possible levels of clinical performance. We have updated and attention to detail, we would most certainly be lost. Finally, we
enriched the Continuing Medical Education questions that relate have to thank, one final time, our beloved John, with the sadness
to each chapter, to assist the reader both in learning and in meeting that this is our final project together, but with the joy of having
regulatory requirements. We have provided, and will continue shared so much, for so long.
to provide online updates, between editions, recognizing that
new information flows without regard to publishing schedules, Ron M. Walls, MD
continuously complementing the comprehensive base we have Robert S. Hockberger, MD
provided. 2012
A book, in the beginning, middle, and end, is about the people
who make it happen. We are deeply indebted to our authors and
xi
How This Medical Textbook Should Be Viewed by
the Practicing Clinician and the Judicial System
The editors and authors of this textbook strongly believe that the complex practice of
medicine, the vagaries of human diseases, the unpredictability of pathologic conditions, and
the functions, dysfunctions, and responses of the human body cannot be defined, explained, or
rigidly categorized by any written document. Therefore, it is neither the purpose nor intent of
our textbook to serve as an authoritative source on any medical condition, treatment plan, or
clinical intervention, nor should our textbook be used to rigorously define a standard of care that
should be practiced by all clinicians.
Our written word provides the physician with a literature-referenced database, and a
reasonable clinical guide that is combined with practical suggestions from individual
experienced practitioners. We offer a general reference source and clinical roadmap on a
variety of conditions and procedures that may confront clinicians who are experienced in
emergency medicine practice. This text cannot replace physician judgment; cannot describe
every possible aberration, nuance, clinical scenario, or presentation; and cannot define rigid
standards for clinical actions or procedures. Every medical encounter must be individualized,
and every patient must be approached on a case-by-case basis. No complex medical interaction
can possibly be reduced to the written word. The treatments, procedures, and medical
conditions described in this textbook do not constitute the total expertise or knowledge base
expected to be possessed by all clinicians. Finally, many of the described complications and
adverse outcomes associated with implementing or withholding complex medical and surgical
interventions may occur, even when every aspect of the intervention has been standard or
performed correctly.
The editors and authors of Rosen’s Emergency Medicine:
Concepts and Clinical Practice, 8th Edition
From Roberts JR, Marx JA: Position Statement: Use of Medical Textbooks in Malpractice Claims, Emerg Med News, Vol.
XXXI, 2:3, February 2009.
Section One
HEAD AND NECK DISORDERS
CHAPTER 70
Oral Medicine
James T. Amsterdam
normally visible and anchors the tooth is called the root. The root
PERSPECTIVE AND PRINCIPLES
is covered with cementum, which is much softer than enamel and
OF DISEASE
not designed for exposure in the oral cavity (Fig. 70-2).
Anatomy The normal primary, or deciduous, dentition consists of 10
mandibular and 10 maxillary teeth. The primary dentition is
The stomatognathic system comprises the musculoskeletal unit of important for mastication, cosmesis, and growth and develop-
the mandible, maxilla, and muscles of mastication; the dental unit ment and functions as a physiologic space maintainer. Starting at
(teeth); the attachment apparatus that anchors teeth; and other the midline and moving posteriorly in any quadrant, the normal
soft tissues of the oral cavity. dentition consists of a central incisor, lateral incisor, canine, and
two primary molars. The lower central incisor is the first tooth to
erupt, at approximately 6 months of age; all primary teeth should
Musculoskeletal Unit
be present by 3 years of age. If not, further investigation for devel-
The mandible is formed by two rami that divide into a horizontal opmental or endocrine abnormalities is warranted. The perma-
and an ascending portion. The horizontal portion forms the body nent dentition begins to erupt at approximately 5 to 6 years of age
of the mandible. The ascending ramus divides into the coronoid with the appearance of the first molar. Normally, the permanent
process anteriorly and the condylar process posteriorly. The tem- dentition consists of 32 teeth: the central incisor, lateral incisor,
poromandibular articulation is unique because it consists of a canine, two premolars, and three molars. The third molars are the
bilateral joint, or diarthrosis, between the mandibular fossa and last to erupt, appearing at approximately 16 to 18 years of age, and
articular eminence of the mandible’s temporal bone and condyle are commonly called “wisdom teeth.” The primary molars are
(Fig. 70-1). An intervening layer of fibrous connective tissue sepa- replaced by the permanent premolars. There are many numbering
rates the articulating surfaces. A fibrous capsule also surrounds the systems for teeth, but none are universal. Perhaps the most
temporomandibular joint (TMJ) and is reinforced by capsular common system for the permanent dentition consists of number-
ligaments that help limit mandibular range of motion. Function- ing the teeth from 1 to 32, starting with the upper right third
ally, when the mandible opens, the condyles move inferiorly and molar (1) and moving to the upper left third molar (16), to the
anteriorly down the eminence; during closure, the mandible moves lower left third molar (17), and to the lower right third molar (32).
posteriorly along the eminence and superiorly into the fossa. The starting point for this numbering system can be recalled by
The muscles of mastication are divided into the mandibular the mnemonic “upright.” Because there may be congenital absence
elevators (the supramandibular group) and depressors (the infra- of teeth or additional, supernumerary teeth, it is perhaps best for
mandibular group). The elevators, or masseteric sling, consist of practitioners to describe anatomically which tooth is involved—
the masseters, medial pterygoids, and temporalis. The posterosu- for example, the upper left second premolar or the lower right
perior movement of the condyle during mandibular closure is the second molar (Fig. 70-3).
result of bilateral, simultaneous movement of this group. The Specific terminology is used to describe aspects of dentition.
muscles involved in the opening or depression of the mandible The labial or buccal surface faces outside the oral cavity; the oral,
include the lateral pterygoid, digastric, geniohyoid, and mylohy- palatal, or lingual surface faces the tongue; the medial surface is
oid. Bilateral activity of these muscles results in opening; unilateral toward the midline; and the distal surface is toward the ramus of
contraction causes the mandible to deviate to the opposite side. the mandible. The interproximal surface refers to the contacting
At rest the mandible assumes a position in which the mandibular area of adjacent teeth, and the occlusal surface refers to the biting
and maxillary teeth are separated by a few millimeters of space. area. Finally, apical is in the direction of the root, whereas coronal
During functional activity, mandibular closure occurs as the is toward the crown of the tooth.
action of the elevators predominates.
Periodontium
Teeth
The periodontium consists of the gingival unit and the attachment
The pulp is the tooth’s center and serves as its neurovascular apparatus. The gingiva is covered with keratinized, stratified, squa-
supply. The primary purpose of the pulp is to provide sensation mous epithelium and invests the tooth and alveolar bone. Apical
and to produce dentin, a microtubular structure that hydrates and to the gingiva is the alveolar mucosa, which is covered by nonke-
cushions the tooth during mastication. The part of the tooth nor- ratinized epithelium and is more subject to trauma. In healthy
mally visible in the oral cavity is the coronal portion covered with individuals the gingiva is attached firmly to the tooth by connec-
enamel, the hardest substance in the body. The part that is not tive tissue fibers inserting into the cementum, extending coronally
895
896 PART III ◆ Medicine and Surgery / Section One • Head and Neck Disorders
from the alveolar bone to the cementoenamel junction. A 2- to inferior border of the internal pterygoid muscles at the mandible’s
3-mm cuff of tissue, the gingival sulcus, is bordered by the enamel ascending ramus. This split forms the masticator space. This space
surface of the tooth, the gingival epithelium, and the junctional communicates superiorly above the level of the zygomatic arch
epithelium at its base (see Fig. 70-2). In a disease state, such as in with the superficial and deep temporal pouches.
the presence of the loss of alveolar bone, this cuff increases in Other spaces of importance in the neck to which dental infec-
depth and is called a “pocket.” tion may spread include the lateral pharyngeal or parapharyngeal
The attachment apparatus refers to the cementum on the tooth, space, which is lateral to the pharynx and medial to the masticator
the periodontal ligament, and the alveolar bone. The periodontal space; the retropharyngeal space, which is between the deep cervi-
ligament is a fibrous structure that surrounds the root of the tooth. cal and prevertebral fascia; and the prevertebral space, which is
It is the key structure that anchors the tooth because it serves as a posterior to the retropharyngeal space. The pharyngomaxillary
double periosteum that lays down cementum on the tooth on one space extends from the base of the skull to the hyoid bone and
side and alveolar bone on its other side. is especially important because it communicates with all deep
spaces. The mandible itself is divided further by the mylohyoid
muscle, which separates the superior sublingual and inferior sub-
Fascial Planes of the Head and Neck
maxillary spaces.
The fascial planes of the head and neck are defined as potential
spaces filled with loose areolar tissue that separates the layers of
Pathophysiology
fascia of the head and neck. The deep cervical fascia is most
important in a discussion of the extension of oral infection to the Nontraumatic Dental Emergencies
head and neck (Fig. 70-4). The deep cervical fascia consists of the
superficial and investing layer, the pretracheal layer, the preverte- Two pathophysiologic processes affect the dental health of most
bral layer, and the carotid sheath. The superficial and investing of the population: (1) dental caries and (2) periodontal disease.
layer surrounds the entire neck; it splits as it attaches to the Variables related to both disease states include the oral environ-
ment, consisting of the teeth and attachment apparatus; the pres-
ence of local factors such as bacterial plaque, oral microflora, and
substrate; and host states, including immunocompromising dis-
eases and nutritional status. Factors such as water fluoridation,
3
fluoride supplements, and plaque control techniques (e.g., floss-
2 ing, brushing, orthodontic and dental surgical procedures) have
significantly decreased the prevalence of dental caries and peri-
4 odontal disease. However, the emergency department (ED) is the
frequent source of care for dental emergencies, with toothache
1 related to dental caries being the most common complaint.
This occurs because of both lack of after-hours access for dental
5 complaints and socioeconomic factors (self-pay and Medicaid).
A recent study from Kansas City shows an increased volume from
2001 to 2006 from 13.1% up to 19%.1
Figure 70-1. Temporomandibular joint structures in sagittal section: 
Dental caries is a multifactorial disease involving a susceptible
1, condyle; 2, disk; 3, mandibular (temporal) fossa; 4, eminence; 
host, cariogenic oral flora, and a substrate. Caries results from the
5, lateral pterygoid. (Redrawn and adapted from Weisgold AS, et al: 
Dental medicine. In Kaye D, Rose LF [eds]: Fundamentals of Internal  decalcification of enamel by the production of acids from bacteria.
Medicine, St Louis, Mosby; 1983.) In the presence of saliva and a carbohydrate, cariogenic oral flora
Enamel
Crown Dentin
Pulp cavity
Gingival sulcus
Gingiva
Periodontal
ligament
Attachment
Alveolar bone
Root apparatus
Cementum
Root canal
Figure 70-2. The dental anatomic unit and attachment apparatus.