Oxford Handbook of Emergency Medicine

PAEDIATRIC UPPER LIMB INJURIES: 2 725

Radius/ulna shaft fractures
Radius and ulna shaft fractures often cause significant displacement or
angulation: provide IV analgesia, immobilize in a broad arm sling, obtain
X-rays and refer for manipulation under GA. Never accept an isolated
forearm shaft fracture without X-rays demonstrating the entire radius
and ulna, otherwise a Monteggia or Galeazzi fracture-dislocation may be
missed (b Forearm fractures and related injury, p.448).

Distal radial fracture (including Salter–Harris type II injuries)
A common fracture in all ages of children (and adults) after a fall on an
outstretched hand. The fracture results in localized tenderness and
variable swelling. Check carefully for a second injury (eg involving the
thumb or scaphoid). X-rays will demonstrate the fracture and allow
assessment of the need for MUA.

Moderate displacement or slight angulation may be accepted (particularly in
younger children): if in doubt, obtain a senior opinion.

Minimally displaced or undisplaced greenstick, buckle or torus fractures
commonly occur just proximal to the distal radial epiphysis. Treat with
analgesia, elevation, a backslab forearm POP (extend this above the elbow
in children <2 years or it will fall off) and arrange review and plaster
completion at 24hr. Children who present with discrete tenderness over
the distal radial growth plate, but without a fracture apparent on X-ray
should be treated identically to those with a radiological proven fracture—
presume a growth plate injury (sometimes a subperiosteal haematoma
can be seen on ultrasound). Beware osteomyelitis (b The limping child,
p.704), which can cause tenderness over the distal radius and be mistaken
for trauma.

Removable splints For co-operative children (usually >4 years old) with
torus/buckle fractures of the distal radius, an alternative option is to use
removable splints. Parents and children report better functioning and
fewer days off school. Splints should be retained until pain wears off (usually
<3 weeks) and follow-up is not required if pain settles as expected.

Scaphoid fracture
Despite being uncommon, particularly in younger children, seek clinical
evidence of scaphoid fracture in any child with wrist/forearm injury and
obtain scaphoid views if appropriate (b p.442). Treat radiologically
evident and suspected fractures as for adults as described in b Carpal
bone fractures and dislocations, p.442.

Metacarpal and phalangeal injuries
Treat these injuries along similar lines to those described for adults
(b Hand fractures and dislocations, p.436). Remember, however, that
children may not tolerate manipulation under LA: anaesthetic help may
be required.

726 CHAPTER 15 Paediatric emergencies

Paediatric lower limb injuries

Hip fracture
Children rarely sustain neck of femur fractures similar to those seen in
adults. In the pre-adolescent child, trauma may precipitate a slipped upper
femoral epiphysis (b The painful hip, p.706). Younger children who have
been subjected to considerable violence may suffer a Salter–Harris type I
injury to the proximal femoral epiphysis—carefully exclude other injuries
and refer to the orthopaedic surgeon.

Femoral shaft fracture
May be spiral (the majority) or transverse, depending upon the mechanism
of injury. Considerable energy is required to produce a femoral fracture:
check for other injuries. Resuscitate as necessary with IV fluids and
provide nasal diamorphine (b p.281) or IV opioid analgesia (b p.280).
Perform a femoral nerve block (as described on b p.304) to provide
additional analgesia, using 0.2mL/kg of 0.5% plain bupivicaine (1mg/kg).
Allow 20min for this to work, then apply skin traction. Gallows traction
may be used on infants and children <2 years, but is best erected on the
ward. A spiral fracture in a non-ambulatory child suggests child abuse—
swelling is often not dramatic.

Knee injuries
Knee ligament injuries are rare in children compared with adults: suspect
a fracture or epiphyseal injury instead. This is a reflection of the relative
strengths of ligament and bone in the child. So, for example, an injury
which might cause anterior cruciate ligament rupture in the adult will often
produce avulsion of its tibial attachment in the child. This tibial plateau
fracture will produce a haemarthrosis and will be apparent on the lateral
X-ray. Provide analgesia and refer to the orthopaedic surgeon.

Patella fractures
Do not confuse a congenitally bipartite patella for a fracture. The small
bony fragment in a bipartite patella lies superolaterally and has rounded
edges.

Patellar sleeve fractures are not uncommon in children and adolescents.
These osteochondral fractures typically result from high impact jumping
activities or sports. Suspect clinically if there is local pain and tenderness
and an inability to actively extend the knee. Radiographs can be misleading
as only a small bony fragment is avulsed, usually from the inferior pole, but
a large part of the articular surface is removed with it, but is impossible
to see on plain X-ray. Provide analgesia and splintage and refer to the
orthopaedic team for MRI to confirm the diagnosis ± ORIF.

Patella dislocation
This is seen relatively frequently in children and is treated in a similar way
to that in adults (see b p.476). Examine the X-rays carefully as associated
osteochondral ‘chip’ fractures of the undersurface of the patella occur
relatively frequently in children.

PAEDIATRIC LOWER LIMB INJURIES 727

Tibial shaft fracture
Treat most fractures as for adults: splintage, IV analgesia, and referral for
elevation and admission. Compound fractures require IV antibiotics and
wound surgery. Displaced or angulated fractures require MUA and POP;
undisplaced fractures respond to treatment with above knee non-WB
POP and subsequent mobilization using crutches.

Toddler’s fracture
Minor trauma in 1–4-year-olds may result in characteristic spiral undis-
placed distal tibial fractures. These may not be apparent on the initial
X-rays: localized warmth and tenderness with a history of trauma may
suggest the diagnosis in the otherwise wide differential of the limping
child (b p.704). If a fracture is visible on initial X-rays treat by rest in a
POP and arrange fracture clinic follow-up. If the diagnosis is made without
a visible fracture, treat in POP and review clinically and radiologically at
10 days: further X-rays may then demonstrate a long strip of periosteal
tibial new bone formation. Continue to treat according to symptoms.

Ankle injuries
Ankle ligament injuries are less common than in adults, but are treated
similarly (as are ankle fractures—b p.486). If there is no fracture apparent
on X-ray, but there is much tenderness over the distal tibial or fibular
epiphysis, treat as a growth plate injury (undisplaced Salter–Harris type I
fracture) with BKPOP, crutches, elevation, analgesia and fracture clinic
follow-up.

Calcaneal and other foot injuries
See b Foot fractures and dislocations, p.488.

728 CHAPTER 15 Paediatric emergencies

Child abuse

The boundaries of what defines acceptable behaviour and what constitutes
child abuse are open to some debate and are certainly affected by historical
and cultural factors. For example, corporal punishment, once considered
normal and usual, is now unacceptable. The extremes of child abuse,
however, are easily defined.

Types of child abuse
• Physical abuse (NAI)—including bruises, fractures, wounds, and burns.
• Sexual abuse.
• Poisoning.
• Suffocation.
• Neglect or emotional abuse.
• Fabricated and induced illness (previously known as ‘Munchausen

syndrome by proxy’).

Prevalence
It is impossible to be sure how common child abuse is. It is generally
agreed that it is much more prevalent than was previously believed.
4% of children are brought to the attention of professional agencies for
suspected abuse. It is believed that 80.1% of UK children suffer severe
physical abuse each year and it has been estimated that 100–150 child
deaths occur each year as a result of abuse by parents or carers.

Aetiology
Child abuse affects both boys and girls. The first-born child is most
frequently affected. Infants and young children are at most risk of serious
injury or death, partly reflecting their physical vulnerability. The abuser is
often a parent or cohabitant of a parent, more commonly male and may
have suffered abuse themselves as a child. Sometimes the child may be
targeted because they are unwanted (eg ‘she should have been a boy’).
Whilst the abuser may be a young parent with unrealistic expectations and
living in difficult social circumstances (unemployment, drug abuse), often
they do not conform to this standard description. Child abuse affects all
levels of society. Clear links between domestic violence and physical abuse
of children have been identified. Children whose parents have mental
health problems may be more vulnerable to abuse and neglect.

Role of the junior emergency department doctor
Managing the child and family where there is suspected child abuse is an
extremely delicate skill, requiring considerable tact and experience. The
role of the junior doctor is to consider the possibility of child abuse and
to involve a senior doctor at an early stage. Recent NICE guidance is avail-
able at http://www.nice.org.uk/nicemedia/live/12183/44872/44872.pdf

CHILD ABUSE 729

The suspicious history
Certain features should alert the doctor to the possibility of child abuse:
• Injuries inconsistent with the history given.
• Injuries inappropriate for developmental age (eg a baby aged <3 months

‘rolled off a bed’).
• Changing history of injury, or vague history, lacking vivid details.
• Delay in seeking medical attention.
• Abnormal parental attitudes (eg apparent lack of concern for child).
• Frequent ED attendances.
• Occasionally, children provide an account of abuse.

730 CHAPTER 15 Paediatric emergencies

Presentation of child abuse: 1

Physical child abuse is commonly referred to as NAI. Children may present
with a variety of injuries, which may occur singly or in combination.

Bruising

Children naturally sustain bruises during minor incidents as part of
‘growing up’. Bruising over the knees and shins is a normal finding in chil-
dren, particularly toddlers, who are also prone to sustaining injuries to
their foreheads and chins as a result of falls. Older children frequently
sustain bruises over the lateral aspect of their elbows and hips, during
normal play and sport activities. As well as considering the possibility
of NAI, remember that bruising may occur as part of an unusual patho-
logical disease process (eg Henoch–Schönlein purpura, haemophilia, ITP,
leukaemia, and other causes of thrombocytopenia). A Mongolian blue spot
is an innocuous congenital finding on the lower back of some young chil-
dren (especially non-Caucasians), which may be confused with bruising.

The following features should prompt consideration of NAI:
• Bruising in unusual sites (eg medial aspect of upper arms or thighs).
• Multiple bruising of different ages (very difficult for the non-expert to

judge) at less common sites.
• Uncommon injuries bilaterally.
• Finger ‘imprinting’ (eg grip complexes around upper limbs or slap

marks).
• Imprints or marks from other objects (eg belt, stick).
• Human bite marks (probably adult if canines >3cm apart: ensure

photographs next to a ruler are planned after admission).
• Petechiae on the face may reflect smothering and asphyxiation (it

has been previously suggested that 2–10% of SIDS may have been
smothered), but remember that petechiae also occur with forceful
coughing or vomiting.

Wounds and burns

Children commonly sustain wounds and burns unintentionally. However,
deliberately inflicted burns are found in a significant proportion of physically
abused children.

The following suggest the possibility of NAI:
• Torn frenulum of upper lip (can also reflect a ‘normal’ toddler injury).
• Perineal wounds and burns (see sexual abuse b p.732).
• Small, deep circular burns with raised edges suggest cigarette burns.
• Hand, lower limb, and buttock burns may follow forced immersion in

bath water that is too hot. These burns tend to be of the ‘stocking and
glove’ type, without higher splash burns. Parts of the buttocks may be
spared, where skin has been in contact with the bath, not the water.

PRESENTATION OF CHILD ABUSE: 1 731

Head injuries
Most head injuries result from unintentional incidents (‘accidents’). In
infants, they often result from the parent or carer dropping the child. The
fractures caused by this tend to be single, linear, and involve the parietal
bone.

Consider NAI if the following occur:
• Retinal haemorrhages (characteristic, but not diagnostic of shaking—

they may also rarely be seen in CO poisoning, for example). In the
context of NAI, retinal haemorrhages are often associated with subdural
haematomas.
• Occipital skull fracture.
• Multiple, wide or comminuted fractures.
• Subdural haematoma in an infant or toddler.

Natural progression of bruises
Swelling and tenderness of bruising suggests relatively recent origin,
but this is not very reliable. Accurate assessment of the age of bruising
according to its colour is not possible, except that a yellow bruise is
almost certainly >18hr old. Oft-quoted natural temporal progression of
colour changes of bruising allows only a guess at the age of a bruise—
avoid being drawn on this issue, which may have considerable legal
implications. Instead, record the findings as accurately as possible: describe
the colour, size, and distribution of the bruising. Usually a child suspected
of having suffered physical abuse will also be examined by a relevant
expert, such as a paediatrician and/or police surgeon (clinical forensic
physician).

732 CHAPTER 15 Paediatric emergencies

Presentation of child abuse: 2

Fractures

Certain fractures are very common in children. Pay attention to the
history of injury and whether or not it appears to be consistent with the
fracture(s) sustained. Multiple fractures of different ages (especially if
previously undiagnosed and/or not brought to medical attention) should
arouse suspicion of NAI. To help assess the approximate age of a bony
injury, see Table 15.14.

Table 15.14 Natural progression of fractures

Presence of soft tissue swelling 0–10 days
Periosteal new bone formation 10–14 days
Loss of definition of the fracture line 14–21 days
Callus formaton 14–42 days
Remodelling
81 year

Remember that times vary according to the age of the child.

Consider NAI in the following fractures
• Multiple fractures of different ages.
• Rib and spinal fractures.
• Fractures in infants who are not independently mobile.
• Long bone fractures in children <3 years old.
• Epiphyseal separation and metaphyseal ‘chip’ fractures of the knee, wrist,

elbow, and ankle. These Salter–Harris I and II injuries are associated
with traction, rotation, and shaking.

A few rare bone diseases may mimic NAI
• Osteogenesis imperfecta (blue sclerae, dental abnormalities and brittle

bones—autosomal dominant).
• Pathological fractures (through multiple cystic bone lesions).
• Rickets (enlarged, cupped epiphyses, craniotabes, ‘bow legs’).
• Copper deficiency (eg Menkes’ kinky hair syndrome).

Neglect and emotional abuse

There will be an element of emotional abuse as part of other forms of
abuse, which may be manifest in the child in a variety of ways: behavioural
problems, sleep disturbance, soiling, nocturnal enuresis. The neglected
child may be dirty and unkempt, fail to thrive, and/or fall below the 3rd
centile for height and weight. Occasionally, nutritional deficiencies may
be extreme (eg rickets). Developmental milestones are often delayed
(and may even regress).

Note the apparent attitudes of the parents/carers towards their child
(eg critical and hostile or remote and unconcerned) and the child’s attitude
to the parents/carers (if in doubt as to whether this seems appropriate,
ask an experienced nurse).

PRESENTATION OF CHILD ABUSE: 2 733

Sexual abuse
This may affect boys or girls and takes many forms, ranging from exposure
to indecent acts through to rape. The abuser is often a male relative or
carer who is well known to the child. The child may present in a variety
of ways:
• Injury to the genitalia or anus.
• Perineal pain, discharge, or bleeding.
• Behavioural disturbance, enuresis, encopresis.
• Inappropriate sexual behaviour.
• The child may allege sexual abuse.
• Sexually transmitted disease (including anogenital warts).
• Pregnancy.

Accurately record statements made by the child ‘word for word’ using
quotation marks. Do not pursue a genital examination, but involve a
senior doctor at an early stage, who may wish to examine the genitalia
using a colposcope, in collaboration with a police surgeon (clinical forensic
physician). In the context of an allegation of recent sexual assault, the
collection of forensic samples for DNA analysis is likely to be required.

Fabricated or induced illness (previously known as Munchausen
syndrome by proxy)

A parent/carer may invent a history of illness in a child and fabricate
physical signs to substantiate it. The history often involves one or more of
the following: apnoeic episodes, fits, bowel disturbances, rashes, allergies,
or fevers. Classically, the deceiver is the mother. The child may be made
ill by administering drugs or poisons. If suspected, do not confront the
deceiver, but take blood and urine samples for a toxicology screen and
refer to the paediatric team.

Bear in mind that some parents may be naturally very anxious and may
exaggerate symptoms, rather than deliberately fabricate them.

734 CHAPTER 15 Paediatric emergencies

Management of child abuse

Role of the junior emergency department doctor
The junior ED doctor needs to be vigilant in considering abuse when
initially assessing and treating children. Any suspicion of child abuse should
prompt involvement of an expert senior doctor (paediatrician or ED
consultant). In every hospital system there will be a designated doctor
for child protection who should be available for advice. He or she will
examine the child and arrange hospital admission for further investigations
(eg skeletal survey) as necessary. Social Services and the police may need
to be involved. The child may require examination by a police surgeon
(clinical forensic physician) and samples/photographs obtained. Follow
local procedures.

The chief consideration is the treatment and protection of the child, so
do not delay treatment of painful or apparently life-threatening problems,
whilst awaiting an ‘expert’. Ensure that all documentation is legible and
meticulous. Remember that if child abuse is considered likely, siblings may
also be at risk.

UK law: The Children Act 1989
This act replaced previous statutes. Central to the Act is the concept that
the welfare of the child is paramount. In the short term, the 1989 Children
Act may be used to obtain orders to protect children. A variety of orders
may be obtained:

Police Protection Order
A police officer has legal powers to take any child into ‘police protection’
for up to 72hr if deemed necessary for his/her own protection. This order
may be used to prevent a child being taken away from the ED by a parent
or guardian against medical advice.

Emergency Protection Order
This has replaced the ‘Place of Safety Order’. A court order valid for up
to 8 days may be obtained if the child is believed to be at significant risk of
harm. Such an order would normally be requested by a social worker.

Child Assessment Order
This court order may be obtained in order to allow an assessment to be
performed of a child who appears to be at risk of injury.

Care Order
This transfers the care of a child from the parent(s) to the local authority
Social Services department. If a care order is in force, matters requiring
parental consent should be referred to the social worker (not the foster
carer).

Residence Order
This court order defines where a child should live and who has parental
responsibility.

MANAGEMENT OF CHILD ABUSE 735

Child Protection Plan (replaces the ‘Child Protection
Register’)
This register is kept by the social services. It contains a list of names of
those children considered to be at current risk of harm. ED staff should be
aware of how to access Child Protection Register information. Previous
hospital case notes are also very useful in this respect. When searching for
previous records, remember that many children may be known by several
surnames.

Child protection conferences
A conference may be called by Social Services if it is suspected that a child
has been abused. Child protection conferences should be held promptly
and aim to define a protection plan for the future protection of the child
and family. Unlike the criminal courts, where the onus is on the prosecution
to prove abuse ‘beyond reasonable doubt’, child protection conferences
will determine whether a child is deemed to be at risk of significant harm
and whether a protection plan is required. Case conferences consist of a
number of individuals, including: chairman (usually a senior member of the
Social Services department), hospital consultant, GP, social worker, police,
health visitor, teacher, education welfare officer, child abuse advisor, local
authority solicitor. Parents are always invited and older children may also
attend.

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737

Index

A newborn 642–5 angioplasty for MI 76
paediatric 652–5 anion gap 99
A2 pulley injury 440 advanced trauma life ankle
abbreviations ix–xv
abdominal aortic aneurysm, support (ATLS) 321 fractures 486
aggression 608, 610 injuries 484
ruptured 530 AIDS and HIV 242–5
abdominal injury, airway management 48 in children 727
nerve blocks 306–7
children 714 burns 390, 392, 394–5 Ottawa rules 484–5
abdominal mass, cardiac arrest 50 sprains 487
children 646, 654 ankylosing spondylitis 497
children 699 foreign body 648 anorectal problems 518
abdominal pain 504 nasopharyngeal anthrax 233, 627
anti-D immunoglobulin 582
analgesia 280 airway 325 antibiotics
in cancer 506 newborn 642 abscess 526
in children 698 spinal injury 380 bites 411, 414
in pregnancy 590 surgical 326–7 in compound fractures 422
abdominal trauma 348, 350 airway obstruction 45, and oral contraception 569
abortion 584 pneumonia 111, 687
abruptio placentae 588, 594 112, 324 prophylaxis 411
abscess 526 children 677 anticoagulants 170
anorectal 519 alcohol (ethanol) antidotes 186–7
Bartholin’s 565 absorption, metabolism, antipsychotic drugs 619
breast 599 aortic aneurysm, abdominal,
peritonsillar 554 and elimination 622
pilonidal 518 abuse 622 ruptured 530
retropharyngeal 555 intoxication 202, 623 aortic dissection 92
Acanthamoeba keratitis 539 and police 30 aortic injury 344
ACE inhibitor poisoning 199 withdrawal 624 apophysitis, traction 708
acetabular fractures 468 alcohol-related brain appendicitis 507
acetaminophen see
injury 625 children 699
paracetamol alteplase 77 epiploic 517
acetylcysteine 190–2 Amanita phalloides 212 pregnancy 591
Achilles tendon injuries 482 amaurosis fugax 540 arc (welder’s) eye 538
acid-base nomogram ambulance crew 12 arterial blood gases 98
Ambulance Incident diagram inside front cover
inside front cover arthritis 494
acidosis Officer 39 in children 705
aminophylline 106 septic 495, 705
lactic 99 aspiration, pulmonary 112,
metabolic 99 in children 679
acromio-clavicular joint amiodarone 86 338
amniotic fluid aspirin (salicylate) 274
injury 458
activated charcoal 185 embolism 594 poisoning 189
activated partial amphetamine 215, 626 asthma
amputation 422, 435
thromboplastin acute 104–7
time xviii, 167 toes 490 cardiac arrest 107
acute confusional state 134 anaesthesia children 678–81
Addisonian crisis 155 asystole 51
adenosine, supraventricular general 310, 316 atracurium 316
tachycardia 88 local 282 atrial fibrillation 89
adhesive capsulitis 461 topical 288 atrial flutter 89
adrenaline (epinephrine) see also local anaesthesia atrioventricular block 80
anaphylaxis 44 anal fissure 518 atropine 82, 654
bradycardia 82–3 analgesia 274–281 as antidote 186
cardiac arrest 53 children 275–6, 280–1, poisoning 194
children 650–2 attenders
local anaesthesia 285 632, 713 inappropriate 16
newborn 644 anaphylaxis 42, 44 regular 17
advanced life support
adult 52–3 in children 650–1
angina 67

Prinzmetal’s (variant) 69
unstable 68
angio-oedema 42

738 INDEX

Australian Mental Health Boerhaave’s syndrome 333 carbon monoxide
Triage Scale 612 Bohler’s angle 488 poisoning 208, 394–5
bombs (blast injuries) 389
Autopulse 51 bone anatomy 421 carboxyhaemoglobin 70,
avian flu 33, 252 Bordetella pertussis, whooping 208, 394–5
aviator’s astragalus 498
cough 684 cardiac arrest 46–55
B botulism 143, 237 algorithms 47, 52
boutonnière deformity 433, asthma 107
back pain 492 children 646–7, 652–5
bacterial tracheitis, 440, 498 drugs 50, 644, 654
bowel problems 511–7 hyperkalaemic 163
children 677 boxer’s fracture 498 newborn 644
bad news, breaking 24 brachial plexus blocks 298 pregnancy 596
balanitis 702 bradycardia 80 reversible causes 51
Bankart lesion 498
barbiturate poisoning 197 algorithm 83 cardiac arrhythmias 80–89
barotrauma 260–3, 551 children 656 in children 656
Bartholin’s abscess 565 brain injury, in poisoning 183
Barton’s fracture 446
basic life support 48 alcohol-related 625 cardiac markers 71
breast cardiac pacing 53, 82
newborn 642–4 cardiac tamponade 342
paediatric 646–7 abscess 527, 599 cardiogenic pulmonary
BASICS 34 swelling, babies 660
batteries, button 213 breastfeeding and oedema 100
Bazett’s formula (QTc) 65 cardiogenic shock 60, 77
Beck’s triad 342 drugs 576 cardiopulmonary
bee stings 416 breathlessness
Bell’s palsy 556 resuscitation
Bennett’s fracture 439 (dyspnoea) 96 adult 46–53
benzodiazepine poisoning 196 British Association for children 646–7, 652–5
bereavement 24 mechanical 51
berry poisoning 212 Immediate Care newborn 644
beta-blocker poisoning 198 (BASICS) 34 cardioversion,
biceps injury 452, 459 bronchiolitis 682
Bier’s block 290 bronchus, ruptured 336 synchronised 86
biliary tract problems 510 Brown-Séquard carpal tunnel syndrome 445
bilious vomiting 661 syndrome 383 casts 424
birth, emergency Brugada syndrome 65 catheterization, male 521
bruises 403 cauda equina syndrome 493
delivery 578 child abuse 728–31 CBRN incidents (chemical/
bites 414–7 bumper fractures 498
bupivacaine 283 biological/radiological/
dogs 415 burns 390–3, 396–7 nuclear) 39, 210
human 416 airway, from cocaine 555 cellulitis 234, 413, 453, 528
infection 413–5 and child abuse 397 ear canal 550
insects 416 children 715 orbital 542
reverse fight bites inhalation injury 394 cement burns 397
BURP manoeuvre 314 central cord syndrome 383
415–16, 435 bursitis 427 central retinal artery
snake bites 417 infrapatellar 479 occlusion 540
and stings 416 button batteries 213 central retinal vein
tetanus 410 occlusion 540
ticks 231, 416 C central venous access 56
bladder injury 352 cephalhaematoma 660
blast injuries 389 Caesarian section 597 cerebral haemorrhage 144
bleeding disorders 166 CAGE questionnaire 622 cerebral infarction 144
blepharitis 543 calcaneal fracture 488 cerebral venous
blindness, sudden 540 calcific tendonitis 461 thrombosis 133
blood pressure, normal, calcium antagonist cervical cancer 566, 574
cervical cord syndrome,
children 633 poisoning 198 central 383
blood transfusion 172 calculous disease 557 cervical disc herniation 463
calf cervical erosion 574
reactions 175 cervical spine control 320,
blow-out fracture 374 injuries 482 712
BMA Counselling Service squeeze test 482–3 chalazion 543
cancer and abdominal chance fracture 498
for Doctors 15 charcoal, activated 185
body packers 217 pain 506
capacity, defining 629
carbamate insecticides 206

INDEX 739

CHEMDATA 36 collateral ligament injuries D
chemical burns 397 knee 475, 478
thumb 438, 440 dacrocystitis 543
of eyes 538 dantrolene 183, 214, 265
chemical incidents 36, Colles fracture 444, 499 dashboard dislocation 499
colovaginal fistulae 566 De Quervain’s
37, 210 coma 136, 138
decontamination 211 tenosynovitis 447
roadside 36 alcohol overdose 623 death 24–27
chest compression 49 Glasgow Coma decompression illness 260
children 646 decontamination
newborn 644 Scale 360–1
chest drain insertion 115, children 717 chemical 211
hypoglycaemia 151 radiation incidents 211, 268
336–7 compartment deep venous
chest injury 328–344 syndrome 398
compound fractures 422 thrombosis 118
analgesia 279 compulsory in IV drug users 627
children 714 hospitalisation 628 in pregnancy 593
penetrating 340, 342 concussion 368 defibrillation 50
chest pain 66 confusional state 134 children 652–3
assessment units 71 conjunctival FB 538 defibrillator, implantable 82
atypical 67 conjunctivitis 543 dehydration 152, 227, 681
differential diagnosis 66 neonatal 660 deliberate self-harm 612
pericarditis 78 consent 28 delirium 134, 603
sickle cell disease 176 contact lens problems 539 delirium tremens 624
chickenpox 240 contraceptive problems 568 delivery, emergency 578
child abuse 728–35 convulsions 148–9 delusion 603
fractures 732 children 688 dementia 135
child protection poisoning 183 dengue fever 248
plan 735 COPD 108 dental anaesthesia 302
Children Act (1989) 734 coping as a junior dental anatomy 558
chlorine poisoning 209 doctor 14 dental emergencies 558
choking 45, 648 corneal trauma 538 see also teeth
cholangitis, ascending 510 coronary syndromes, dento-alveolar
cholecystitis 510 acute 68
cholesteatoma 551 Coroner 26, 31 fractures 372
Christmas disease 169 corpus luteum cyst 572, 587 depression 616
chronic obstructive cortical blindness 717 dermatitis
cot death 658
pulmonary disease 108 counselling service 15 herpetiformis 672
chronic renal failure 160 court, going to 31 dermatomes 386–7
ciguatera fish poisoning 229 cranial arteritis 132, 541 detention, compulsory 628
clavicle fracture 458 cricoid pressure 312–5 diabetes mellitus 152
cricothyroidotomy 326–7
children 722 Crohn’s disease 517 hypoglycaemia 150
clay-shoveller’s croup 676 pregnancy 593
cruciate ligaments 474, 478 diabetic ketoacidosis 152
fracture 499 crush syndrome 398 children 691
clomethiazole crushed fingers 435 diagnostic peritoneal
crying babies 661
poisoning 196 CS gas 209 lavage 347
Clothier report 620 CT scan dialysis problems 160–1
clozapine 619 coma 138 diamorphine 276
CN gas 209 headache 127–8
co-codamol 274 head injury 362 nasal 281
co-dydramol 274 stroke 145 diaphragm, ruptured 333
coagulation cascade 169 trauma 322, 348 diarrhoea 226
coagulation disorders 166 ureteric colic 525 diazepam
cocaine 215, 626 CURB-65 score 111
Cushing response 354 overdose 196
pharyngeal burns 555 cut down, venous 639 status epilepticus 149
coccyx fractures 469 cyanide poisoning 207, 395
cochlear implants 549 cystic fibrosis 685 children 690
codeine 276 cystitis 158 diclofenac 275
cognitive assessment 607 digital nerve block 294–5
cold injury 257 digital nerve injury 432, 434
colitis digoxin poisoning 199
diphtheria 676
ischaemic 515 discharge from ED 2, 8
ulcerative 517
collapse 140 against advice 29
elderly patient 20

740 INDEX

disclosure in public tachyarrythmias 87–9 external jugular vein 57
interest 30 tricyclic antidepressant eye 533

dislike of a patient 18 poisoning 194–5 burns 538
dislocations 423 eclampsia 592 examination 534
ecstasy 214, 626 foreign bodies 537
ankle 486 injury 536
children 718 liquid 215 problems and HIV 244
elbow 449, 451 ectopic pregnancy 586 eye signs
finger 436 eczema 662 head injury 360
hip 468 edrophonium test 142 in poisoning 182
knee 477 elbow eyebrow wounds 464
patella 476 eyelid wounds 464
fat-pad sign 450 eyelids, superglued 538
children 726 injuries 450
shoulder 454–7 F
thumb 438 children 724
toes 490 problems, soft fabricated illness 620, 733
wrist 442, 448 facial burns 394–6
disseminated intravascular tissue 452–3 facial fractures 370–7
pulled 724 facial injury 370, 464
coagulation 169, 592 elderly patient, facial nerve palsy 556
diverticular disease 516 facial wounds 464
diving emergencies 260–3 discharge 20 factitious disorder 621
documentation see notes electrical injuries 266
dog bites 415 emesis, induced 185 in health care
dressings 412 EMLA cream 288 workers 620
emotional abuse 732
burns 396 endocarditis 740 fainting 140
Dressler’s syndrome 79 endometriosis 572 FAST scan (focused
driving 30, 535 enflurane 317
drowning 258 enteric fever 248 assessment with
Entonox® 278–9 sonography for
children 715 environmental trauma) 346
drug abuse fatal accident inquiry 31
emergencies 253 febrile child 663
complications 627 epicondylitis 452 febrile convulsions 688
illicit drugs 214 epididymitis 522 feeding difficulties,
withdrawal 627 epididymo-orchitis 701 babies 661
drugs epiglottitis 677 femoral neck, fracture 470
anaesthetic 316 epilepsy 148, 688 femoral nerve block 304–5
doses in children 633, 644 femoral shaft
interactions with see also seizures fracture 472
epinephrine see adrenaline children 726
OCP 569 epiphyseal injury femoral vein
newborn doses 644, 655 children 639
psychiatric, complications children 718 venous access
Salter-Harris
of 619 56–7
see also poisoning classification 719 fentanyl 276, 281
dry socket pain 561 epiphysis, slipped upper fetal injury 594
Dupuytren’s fracture 499 fibula, fractures 480
dyspnoea 96 femoral 706 field block 289
dystonic reaction 619 epiploic appendagitis 517 fight bites, reverse 415–6
episcleritis 543 finger pad amputations 435
E episiotomy 580 fingers
epistaxis 552
ear ergotamine 130 crushed fingers 435
examination 548, 674 erysipelas 528 digital nerve block 294–5
nerve blocks 300–1 erythema dislocations 436
problems 546–551 fractures 456–7, 725
wounds 464 chronicum migrans 673 fishhooks, removal of 406
marginatum 672 fish bones in pharynx 547
earache 550 multiforme 672 fish poisoning 229
Ebola fever 250 nodosum 672 fish spine stings 416
ECG 64 toxicum, infants 662 fits see convulsions; seizures
ESR xviii flail segment 332
bradyarrhythmias 81 Essex Lopresti fracture 499 fleas 230
diagram inside back cover ethanol see alcohol flexor tendon injury 432–4
hyperkalaemia 162 ethyl chloride 288
hypothermia 255 ethylene glycol
myocardial infarction
poisoning 203
72–5 etomidate 316
pericarditis 78 extensor tendon

injury 432, 434

INDEX 741

flumazenil 196, 309 glue sniffing 626 handover of patients 9
follow-up arrangements 5 golfer’s elbow 452 hangman’s fracture 499
food poisoning 226–9 gonorrhoea 238 Hawkin’s impingement
foot gout, acute 496
gout bursitis 453 test 460
dislocations 488 GPs, liaising with 5, 10 Hazchem board 36, 37
fractures 488 Graves’ disease 156 head injury 354–368
soft tissue problems 491 gravidity 576
forearm injuries 448, 725 grease gun injuries 435 analgesia 279
forehead, nerve blocks 300 groin lumps 700 and child abuse 731
foreign bodies GTN intravenous children 714, 716
ear 546 examination 360
eye 537–8 infusion 68 Glasgow Coma
foot 491 Guillain-Barré
ingested 213, 547 Scale 360–1
inhaled 112, 547, 648, 677 syndrome 142 history 358
nose 213, 546 gunshot injuries 30, 388 imaging 362–3
rectal 519 gynaecological management 364
under fingernail 435 minor 366
vaginal 567 problems 564–575 monitoring 356–7
wounds 405 risks of haematoma 363
foreskin problems 523, 702 H triage 356
fractures headache 126–133
and child abuse 732 haemarthrosis, knee 478 analgesic 133
eponymous 498–502 haematemesis 122 cluster 132
see also specific fractures haematoma sudden severe 128
fragmentation injuries 389 tension 132
frontal sinus, fractures 374 block 289 hearing 548
frostbite 257 extradural 365 heart block 80–81
fundoscopy 535 intracranial 365 heart rates
funny turns 689 risks, after head injury 363 inside back cover
furunculosis of ear 550 soft tissue 426 normal, children 633
subdural 365 heat illness 264
G subungual 435 heat stroke 265
haematuria, children 695 helicopters 36
Galeazzi fracture 448, 499 haemodialysis problems Henoch-Schönlein
gallstones 510
161 purpura 664
in pregnancy 591 haemolytic uraemic hepatitis 220, 239, 415
gamekeeper’s thumb 438, hernia 161, 512, 698, 700–1
syndrome 694 heroin 188, 217, 233,
440, 499 haemophilia 166, 168
gammahydroxybutyrate Haemophilus influenzae 636 276, 627
haemoptysis 94 herpes simplex 240, 565
(GHB, GBH) 215 haemorrhage herpes zoster 240
Garden classification 471 Hib vaccine 636
gas gangrene 237 antepartum 588 high pressure injection
gastric lavage 184 and anticoagulants 170
gastroenteritis 226, 228 cerebral 144 injuries 435
gastrointestinal bleeding lower GI 124 Hill-Sachs lesion 500
post-partum 598 hip
lower 124 subarachnoid 128
upper 122 tooth extraction 561 dislocations 468
General Medical Council 30 upper GI 122 fractures 468, 470
generalized weakness 142 vitreous 541
genital injury 570, 733 haemorrhoids 518 in children 726
genital ulcers/sores 238 haemostasis 167 hip pain in children 706
german measles 223 haemothorax 335 HIV 242–5
gestational trophoblastic hallucinations 603 horse rider’s knee 500
haloperidol 611 hospitalization,
disease 588 halothane 317
GHB 215 hamate fracture 443 compulsory 628
giant cell arteritis 132, 541 hand Hume fractures 449, 500
glandular fever (infectious anatomy 430 humerus
arthritis 496
mononucleosis) 241 crushed fingers 435 fractures 459
Glasgow Coma Scale 360–1 infections 413, 441 children 722
injuries 430, 432
children 717 wounds 413, 434 Hunt and Hess scale,
glaucoma 542 hand hygiene 32 subarachnoid
glue (for wounds) 406 haemorrhage 129

Hutchinson fracture 500
hydatid of Morgagni, torsion

of 701

742 INDEX

hydrocarbons 112, 205 immobilization, intra-hospital transfers 22
hydrocoele 700 spinal 380–1 intracranial haematoma 365
hydrofluoric acid intracranial pressure 354–5
immunization 636 Intralipid in
burns 397 immunoglobulin,
hyperbaric poisoning 187, 284
anti-D 582, 595 LA toxicity 284
chambers 261 impetigo 235, 662 intraocular pressure 535
oxygen 208, 395 impingement syndromes intraosseous infusion 640–1
hyperglycaemic crises 152 intrauterine contraceptive
hyperkalaemia 162 in shoulder 460
renal failure 160, 694 impingement test 460 device 569
hypernatraemia 154 inappropriate attenders 16 intravenous fluids
hyperosmolar incubation periods of
children 640
hyperglycaemic state 152 infectious diseases 220 trauma 340
hypertension 90 induced illness 620, 733 intubation 312–5
infantile spasm 688 difficult 314
malignant 133 infection failed intubation drill 315
in pregnancy 91, 592 intussusception 699
in renal failure 160, 694 bites 413–15 ipratropium bromide, in
hyperthermia 183, 264 cellulitis 528
hypertrophic control and prevention 32 asthma 679, 680
dental 561 iritis, acute 542
cardiomyopathy 141 pelvic 566, 573 iron poisoning 201
ECG 141 wounds 235, 413 irradiated patient 268–9
hyperventilation 97 see also abscess irritable bowel
hypoglycaemia 150–1 infections
alcohol-induced 623 staphylococcal 235 syndrome 517
coma 136, 138 streptococcal 234, 528 irritable hip, children 706
newborn 644 infectious diseases 33, 219 ischaemic colitis 515
sulphonylurea childhood 222 ischaemic limb 531
duration of infectivity 220 isoflurane 317
poisoning 197 imported 246 ISS (injury severity
hypokalaemia 164 incubation periods 220
hyponatraemia 154 notifiable 221 score) 323
hypotension tropical diseases 246 IUCD 569
infectious IVU in renal trauma 351
poisoning 183
see shock 60–1 mononucleosis 241 J
hypothermia 254–6 infestations 230
bleeding disorders 166 influenza jaundice
blood transfusion 174 hepatitis 239
and drowning 258 pandemic 33, 252 neonatal 660
ECG 255 infraorbital nerve block 302 obstructive 510
in poisoning 183 infrapatellar bursitis 479
rewarming methods 256 inguinal swellings jaw thrust manoeuvre 325
hypovolaemic shock 60 Jefferson fracture 500
aortic aneurysm 530 children 700 jellyfish stings 416
burns 390 inhalation injury 394 Johansson-Larsen’s
GI bleed 122, 124
pregnancy 582–9 children 715 disease 708
transfusion 172 inhalational joint aspiration 494
trauma 320 Jones fracture 489, 500
anaesthetics 317 jugular vein 56–8
I injury prevention 711
injury severity children 639
ice 428 junior doctor, coping as 14
ice skater’s fracture 500 score (ISS) 323
idiopathic thrombocytopenic inquest 31 K
INR xviii, 167, 170
purpura 664 insect bites 416 Kawasaki disease 672
iliac fossa mass 507 insecticide poisoning 206 Kemler plate 36
imaging insulin overdose 151 Kernig’s sign 127
insulin therapy in ketamine 278, 316
children 720
head injury 362–3 poisoning 187 children 715
spine and spinal intercostal (chest) drain ketoacidosis

cord 384, 482 insertion 115, 336–7 alcoholic 624
see also CT; X-ray intercostal nerve block 303 children 691
immersion foot 257 internal jugular vein 57–8 diabetic 152
interview, psychiatric 604 ketorolac 275
intestinal obstruction 512,

591
in pregnancy 591

INDEX 743

knee locked knee 479 menstrual cycle and
children 726 long bone anatomy 421 pain 572
injuries 474–8 lorazepam 611
problems 479 low back pain 492 Mental Capacity Act 29,
lower GI tract bleeding 124 615, 629
Kocher’s method, shoulder LSD 215
dislocation 454 Lucas CPR device 51 mental health, triage 612
lumbar puncture, mental health
Kohler’s disease 708
Korsakoff’s psychosis 625 children 670 legislation 615, 628–9
lunate dislocation 442 mental nerve block 302
L Lund and Browder charts mental state

labour 578 (for burns) 391 examination 606
lactic acidosis 99 luxatio erecta 457, 500 mephedrone 215, 626
Langer’s lines 464–5 Lyme disease 231 mesenteric ischaemia 514
laryngospasm 315 metabolic acidosis 99
laryngotracheobronchitis 676 M metabolic diseases 661
Lassa fever 250 metacarpal fractures 436–7
Le Fort fractures 372–3, 500 magnesium
learning difficulties 21 arrhythmias 53, 85, 87 children 725
legal aspects 28–31 children 654, 656 metacarpophalangeal
Legg-Calvé-Perthes’ asthma 106
children 679, 680 joint 438
disease 706–7 deficiency 164 metatarsal fractures 489
leptospirosis 239 eclampsia 149, 592 methanol poisoning 202
leukaemia, acute 664 normal range xvii methedrone 215
levonorgestrel 568 methicillin resistant Staph.
lice 230 Maisonneuve injury 480, 501
lidocaine 283 major incidents 38 aureus 235
lidocaine gel 288 methionine 191–2
life support, advanced 52–3 chemical 36, 37, 210 midazolam
radiation 268
newborn 642–5 malar fractures 374 sedation 308
paediatric 652–5 malaria 247 status epilepticus 149,
trauma (ATLS) 321 Malgaigne’s fracture 501
life support, basic 46–9 malingering 620 655, 688, 690
newborn 643 mallet finger 433, 436, migraine 130
paediatric 646–7 Milch method, shoulder
lightning 266 440, 501
lignocaine see lidocaine mandibular injuries 376–7 dislocation 455
limb injuries mania 617 milestones, paediatric 637
acute ischaemia 531 mannitol 129, 365, 542 milia 662
paediatric 720 MAOIs 619 Mini-Mental State
salvage 422 Marburg fever 250
limping child 704 march fracture 501 Examination 607
lip wounds 464 mastitis 599 miscarriage (abortion) 584
lipid emulsion in mastoiditis 550 mittelschmerz 572
maxillofacial injuries 370 Mobile Medical Team 39
poisoning 187, 284 measles 222 monilial infection 662
LA toxicity 284 meconium aspiration 645 monoamine oxidase
Lisfranc fracture 500 median nerve block 296–7
lithium 617 median nerve inhibitors 619
complications of 619 Monteggia fracture 449, 501
lithium injury 432, 442 mood, affect 616
medical defence “morning after pill” 568
poisoning 197, 619 morphine 276
liver transplantation, organisation 29
Medical Incident Officer 39 children 280
paracetamol medically unexplained overdose 188
poisoning 191 smooth muscle spasm 277
local anaesthesia 272, 282 symptoms 621 trauma 279
children 287 medicolegal aspects 28, 30 Morton’s metatarsalgia 491
consent 286 melaena 124 mouth to mouth
contraindications 282 meningitis 224–5, 666–9
indications 282 ventilation 48, 646
infiltration 289 fungal 225 MRSA 235
toxicity 284 tuberculous 225 MSU 158
see also nerve blocks viral 225 multiple sclerosis 142
locked finger 441 meningococcal mumps 222

infection 224, 664, 666–9 orchitis 222, 701
menorrhagia 574 Munchausen’s

syndrome 620
by proxy 733
muscle injuries 426
muscle relaxants 316
mushroom poisoning 212

744 INDEX

myasthenia gravis 142 newborn resuscitation 642 osteochondritis 708–9
myocardial infarction 68–77 NHS Direct 11 osteochondritis
NHS24, 11
ECG changes 72–5 nimodipine 129 dissecans 452, 479,
localization 74 nitrous oxide 278, 317 491, 709
NSTEMI 68 non-accidental osteomyelitis 705
STEMI 70, 76–7 finger infection 441
myoclonic fit 688 injury 728–33 sickle cell disease 176
myositis ossificans 427 non-cardiogenic pulmonary tuberculosis 232
otitis externa 550
N oedema 102 otitis media 550
non-shockable rhythms 51 Ottawa ankle rules 484–5
N-acetylcysteine 190 non-steroidal anti- Ottawa knee rules 475
nailbed lacerations 435 ovarian problems 572
naloxone 188 inflammatory oxygen therapy 95
nappy rash 662 drugs 275 hyperbaric oxygen 208,
narrow complex normal values
blood tests xvii–xviii 261, 395
tachycardia 88 physiological, children 633
nasal bleeding 552 pregnancy 577 P
nasal diamorphine 281 note keeping 4–5, 28
nasal foreign bodies 546 notifiable infectious P wave 64
nasal fracture 553 diseases 221 pacemakers 82
nasoethmoidal fracture 372 NSAIDs 275 pacing (in ALS) 53
nasopharyngeal airway 325 nursemaid’s elbow 501 paediatric emergencies 630
near drowning 258 nutcracker fracture 501 paediatric fractures 718
neck nystagmus 548 paediatric milestones 637
paediatric resuscitation
cervical spine O
injury 380–5 chart 655
obsession 603 pain relief 272
pain 463 obstetrics and palivizumab,
penetrating injury 378
soft tissue injury 462 gynaecology 563 RSV disease 683
wounds 378 obstructive jaundice 510 pancreatitis 508
necrotizing fasciitis 234 OCP 4, 569
needle cricothyroidotomy O’Donahue’s triad 501 in pregnancy 591
oesophageal intubation 314 paracetamol 274
326–7 oesophageal obstruction
needlestick injury 418 poisoning 190–3
Neer’s impingement (food bolus) 547 paraffin poisoning 205
oesophageal rupture 333 paralysis, periodic 143
test 460 olecranon bursitis 453 paranasal sinusitis 555
neglect 732 olecranon fracture 450 paraphimosis 523, 702
nephroblastoma 699 ophthalmology 533 paraquat poisoning 204
nephrotic syndrome 694 opioids 276 paratyphoid 248
nerve blocks 292 parity 576
poisoning 188 paronychia 441
ankle 306–7 sedation 308 parotid gland injury 464
digital 294–5 optic neuritis 142, 541 parotitis 557
ear 300–1 oral contraceptive pill 4 Parvolex (acetylcysteine)
femoral 304–5 drug interactions 569
forehead 300–1 oral rehydration 190
infraorbital 302 patella fracture 476, 726
intercostal 303 therapy 228 patellar tendon rupture 478
median 296–7 oral wounds 464 pathological fractures 420
mental 302 orbital blow-out patients
radial 297–9
supraorbital 300–1 fractures 374 discharge from ED 2, 8
sural 306–7 orchitis 522, 701 discharge of elderly
tibial 306–7
ulnar 296–7 mumps 222 patient 20
nerve injuries, hand 432, 434 organ donation 27 dislike of specific 18
neuroblastoma 699 organophosphate inappropriate
neuroleptic malignant
poisoning 206 attenders 16
syndrome 265 oropharyngeal airway 325 regular attenders 17
neurological examination ‘special’ patient groups 19
children 654 transfer of patient 22
coma 138 Osgood-Schlatter’s with a label 17
head injury 360 with learning
spinal injury 382 disease 708
osmolal gap 99 difficulties 21
ossification centres 721 PEA 51
osteoarthritis 495

INDEX 745

peak expiratory flow tension 328–9 psychiatric drugs,
rates 105 traumatic 334 complications of 619
poisoning 179
children 678 chemical incidents 38, 211 psychiatric interview 604
Pelligrini-Stieda’s deliberate 180, 753 psychiatry 601
diagnosis 182 psychogenic coma 138
disease 501 fish 229 psychosis 603
pelvic fractures 466–7 food 226–8 pulmonary aspiration 112,
pelvic infection 598 general principles 180
pelvic inflammatory in children 181, 696–7 338
reducing pulmonary contusion 332,
disease 573
pelvic injury, children 714 absorption 184–5 338
penile problems 523, 702 supportive care 183 pulmonary embolus 120
peptic ulcer disease 511 poisons information 180–1
police requests for blood in pregnancy 593
pregnancy 591 pulmonary oedema
pericardial effusion 78–9 alcohol 30
pericardiocentesis 79, 343 police statements 31 cardiogenic 100–1
pericarditis 78 poliomyelitis 249 non-cardiogenic 102
perineal tear, imminent 580 polyhydramnios 590 pulp infections 441
periodic paralysis 143 polymyositis 142 pulse oximetry 95, 96
peritoneal dialysis 161 porphyria 165 CO poisoning 208
peritoneal lavage 347 post-coital pulseless electrical
peritonitis 161, 504, 507,
contraception 568 activity (PEA) 51, 107
516 post-concussion puncture wounds 419
peritonsillar abscess 554 purpuric rash 664
peroneal nerve block 306–7 symptoms 368 pyelonephritis 158, 159
peroneal nerve injury 487 post-partum problems 598
peroneal tendon post-resuscitation care 54 children 692–3
Pott’s fracture 502 pregnancy 591
subluxation 487 PR interval 64 pyloric stenosis 698
perseveration 603 pre-eclampsia 590, 592 pyogenic tenosynovitis 441
personal protective pregnancy 563, 576–599 pyrexia of unknown

equipment 32, 34 abdominal pain 590 origin 246
Perthes disease 706–7 bleeding in 582–3, 588
pertussis, whooping cardiac arrest 596 Q
ectopic 586
cough 684 electric shock 266 Q waves 65, 72
pethidine 276 hypertension 91, 592 QRS amplitude 65
petit mal 688 psychiatric problems 599 QRS width 64
petrol poisoning 205 thrombosis 593 QT interval 65
phalangeal fractures 436 trauma 594 quadriceps rupture 478
pharyngeal burns pregnancy tests 582 quinsy 554
prepatellar bursitis 479
(cocaine) 555 pretibial lacerations 481 R
phenol burns 397 priapism 523
phenothiazine prilocaine 283 rabies 249, 415
Prinzmetal’s angina 69 radial fractures 444–6,
poisoning 196 Procurator Fiscal 10, 26, 31
phimosis 702 propofol 308, 316 448–9, 724–5
physiological values in prostatitis 523 radial head fracture 450,
prostheses, hip 468
children 633 prosthetic joint infection 495 724
physiotherapy 428 prosthetic valve failure 101 radial head subluxation
Pilon fractures 501 protective equipment 32, 34
pilonidal abscess 518 prothrombin time (pulled elbow) 724
Pipkin fracture 501 radial nerve block 297–9
placenta praevia 588 (INR) xviii, 167, 170 radial nerve injury 432, 453
placental abruption 588, 594 proxymetacaine 283 radial styloid fracture 446
plant poisoning 212 pruritus ani 518 radial tenosynovitis 447
plantar fasciitis 491 pruritus vulvae 565 radiation incidents 268
plaster of Paris 424–5 pseudo-gout 496
platelet disorders 168 psychiatric assessment 604 decontamination 211, 269
pleural effusion 103 radiological requests 6
Pneumocystis after deliberate self radius, fractures 444–6,
harm 612–4
infection 110, 244 448–9
pneumonia 110 history 605 children 724–5
Ramsay Hunt
children 686
differential diagnosis 111 syndrome 556
pneumothorax rape 570
spontaneous 114–6 rapid sequence induction

(intubation, RSI) 312–5

746 INDEX

rashes 664, 666, 672 rifampicin 190, 225, 569 self-labelled patients 17
records see note keeping ring avulsions 435 sepsis 59
recuronium 316 Rinne’s test 548
red cell transfusion 173 Road Traffic Act 30 in babies 660
red dot system 6 roadside procedures 36 septic arthritis 495
red eye 542 Rockall score 123 septic shock 59–61
referral 8, 28 Rolando fracture 502 septicaemia,
Romano–Ward
inappropriate 16 meningococcal 666–9
patient with a label 17 syndrome 65 sero-negative spondylo-
regular attenders 17 Rosier score, stroke 145
Reiter’s disease 238, 497 rotator cuff tears 459 arthropathies 497
rejection, transplant 161 rotator cuff tendonitis 461 serotonin syndrome 216
relatives Rovsing’s sign 507 severe acute
bereaved 24–5 RSV 682–3
in cardiac arrest 46 rubella 223 respiratory syndrome
in major incidents 39 runner’s fracture 502 (SARS) 33, 251
renal failure 160, 694 Sever’s disease 708
renal trauma 351 S sevoflurane 317
rescue breaths 48 sexual abuse 733
children 646 sacrum fracture 469 sexual assault 570
resin casts 424 Sad Persons Scale 614 sexually transmitted
respiratory depression safety, personal 609 diseases 238
coma 137 salaam attack 688 Sgarbossa criteria,
opioids 188, 276 salbutamol ACS in LBBB 72
respiratory failure, sharps, safe handling
anaphylaxis 43, 651 disposal 32
type I II 98 asthma 106, 679–681 shellfish poisoning 229
respiratory rate COPD 109 shifts 15
hyperkalaemia 162, 694 shin splints 483
coma 137 inhalation injury 395 shingles 240
normal, children 633 poisoning 200 shock 60
respiratory syncytial salicylate poisoning 189 anaphylactic 42–4
salivary gland problems 557 cardiogenic 60, 77
virus 682–3 Salter-Harris classification, hypovolaemic 60, 172–4
resuscitation in poisoning 183
epiphyseal injury 718–9 neurogenic 382
burns 392 saphenous nerve septic 59
cardiac arrest 46–53 shockable rhythm 52, 652–3
block 306–7 shoulder
pregnancy 596 SARS 33, 251 dislocation 454–7
children 634–5, 646–7, scabies 231 injuries 458–9
scalded skin children 722
652–5 pain diagnosis 461
formulae 655 syndrome 235, 662 soft tissue problems 460–1
discontinuing 51, 655 scaphoid fracture 442 shoulder dystocia 580
mechanical 51 sick sinus syndrome 80
newborn 642–5 children 725 sickle cell disease 176–7
paediatric trauma 712 scapula fracture 458 Sinding Larsen’s disease 708
post-resuscitation care 54 scarlet fever 234 sinusitis 555
trauma 320–1 Scheuermann’s disease 708 SIRS (systemic inflammatory
unconscious patient 136 schizophrenia 618 response syndrome) 59
resuscitation chart skin lesions
paediatrics 655 thought blocking 603 causes 673
reteplase 77 SCIWORA 714 children 672
retinal artery occlusion 540 scrotal injuries 352 popping (drugs) 627
retinal detachment 541 scrotal swellings, problems, infants 662
retinal vein occlusion 540 skin tissue glue 406
retropharyngeal children 700 skull fracture 355, 361–4
abscess 555 seborrhoeic dermatitis 662 basal fracture 361, 364
return visits 28 sedation, of violent child abuse 731
reverse fight bites 415–16, compound (open) 364
435 patient 611 depressed 362, 364
Revised Trauma Score 323 sedation for slit lamp examination 535
rewarming methods 256 Smith’s fracture 446, 502
rhabdomyolysis 214–6, procedures 308 snake bites 417
265, 398 children 309 Snellen chart 534
rheumatic fever 497 seizures 148–9, 688
rheumatoid arthritis 496 Seldinger technique 44,
rib fracture 330–2
56, 115
self-harm

deliberate 612, 614
risk of 607

INDEX 747

snowblindness 538 stillbirth 576 talar injuries 488
sodium bicarbonate Stimson’s technique 455 team leader 46
stings, bites 416 tear gas 209
cardiac arrest stool culture 226 teeth
children 654 straddle fracture 502
newborn 644 strains 426 eruption 559
streptococcal extraction,
hyperkalaemia 162, 694
tricyclic antidepressant infections 234, 528 haemorrhage 561
streptokinase 77 fractures 560
poisoning 194–5 stress fractures, MTs 489 toothache 280, 561
sodium derangements stridor 676 see also dental
stroke 144
154 emergencies
soft tissue injuries 426 Rosier score 145 telemedicine 11
solvent abuse 626 stye 543 telephone advice 11
somatoform pain subacromial bursitis 461 temperature, core,
subarachnoid
disorder 621 measurement of 254,
sonography, trauma haemorrhage 128 264
subclavian vein 56 temporal arteritis 132, 541
scan 346 temporal lobe epilepsy 688
space-occupying venous access 57–8 tendon injury
subconjunctival Achilles 482
lesions 133 finger 432–4, 440
sphincter of Oddi, haemorrhage 543 hand 447
substance misuse 626 in wounds 404
spasm 277 subtarsal examination 535 patella 478
spinal cord injury 380–5 subtrochanteric quadriceps 478
tendonitis 427
airway management fractures 472 tenecteplase 77
380 subungual haematoma 435 tennis elbow 452
sudden infant death tenosynovitis 427, 441
children 714 terrorism, poisoning 181
circulation 382 syndrome 658 testis problems 522
examination 382 suicide, risk of 614 children 700
imaging 384–5, 462 sulphonylurea torsion 522, 701
incomplete injury trauma 352
poisoning 197 undescended 700
patterns 383 sumatriptan 130 tetanus 236
muscle power superglued eyelids 538 prophylaxis 410
supracondylar fracture 451, tetracaine 283, 288, 535
grading 383 TFCC injury 447
neurological 742 theophylline poisoning 200
supraorbital nerve thiopentone 316
examination 382 Thomas splint 473
without radiographic block 300–1 thoracolumbar spine 384
supratrochlear nerve 300–1 throat 554, 674–7
abnormality supraventricular tachycardia examination,
(SCIWORA) 383, 714
spinal (SVT) 86–8 children 674–5
immobilization 380–1 children 656 foreign bodies 547
spine sural nerve block 306–7 infection 554, 676–7
control 320 surgery 503 sore 554
injury 380–5 surgical airway 326–7 thrombocytopenic purpura,
children 714 sutures 407–9
Xrays 384–5, 462 suxamethonium 316 idiopathic 664
sprains 426 swine flu 33, 252 thromboembolic disease, in
ankle 487 symbols ix
neck 462 synchronized pregnancy 593, 599
wrist 447 thrombolysis
ST segment 65, 70–5 cardioversion 86
staff 2 syncope 140 myocardial
care after death of infarction 76–7
patient 27 funny turns in,
debriefing after major children 689 pulmonary embolus 121
incident 39 stroke 145
interaction 15 synovitis, transient 706 thrombophlebitis,
sudden infant death systemic inflammatory
syndrome 659 superficial 119, 529
staphylococcal response syndrome 59 thrombosis, deep vein 118
infections 235, 662
staples 407 T pregnancy 593
status epilepticus 148–9 thrush 566, 662
children 690 T waves 65, 72
Steristrips 406, 481 tachyarrythmias 86–9
sternum fracture 331 tachycardia

algorithm 84–5

748 INDEX

thumb, collateral ligament tricyclic antidepressant vaginal infection 566
injuries 438, 440 poisoning 194–5 Valsalva manoeuvre 88
varicella zoster 240
thyrotoxic crisis 156 trigeminal neuralgia 132 varices 123
TIA 146–7 trigger finger/thumb 441 varicose veins 529
tibia TRISS methodology 323 vecuronium 316
tropical diseases 246 venereal proctitis 519
fractures 477, 480 troponins 71 venous access
children 727 trouble
central 56
tibial nerve block 306–7 aggressive patient 608 children 638
ticks, bites 231, 416 avoidance of 28, 608 choice of vein 56
TICTAC 180 violence/violent cut down 639
Tillaux fracture 502 intraosseous 640–1
TIMI risk score 69 patients 608–611 umbilical vein 645
toddler’s fracture 502, 727 tuberculosis 232, 685 venous thrombosis 118
Todd’s paresis 144, 148 tuberculous meningitis 225 cerebral 133
toe fractures 490 tympanic membrane in pregnancy 593
toe injuries 490 venous ulcers 529
toenails, ingrowing 491 rupture 551 ventilation
tongue wounds 464 typhoid 248 in asthma 107, 679
tonsillitis 554 in children 654
torsades de pointes 87 U in COPD 108
torticollis 463 hyperventilation 97
TOXBASE 181 ulcerative colitis 517 mouth to mouth 48, 646
toxic shock syndrome 235, ulcerative keratitis 543 in newborn 642
ulna, fractures 448, 725 non-invasive 109
567 ulnar nerve block 296–7 ventricular activation
tracheal intubation 312–5 ulnar nerve injury 432, 453
ultrasound time 72
children 654 ventricular shunts 133
newborn 644 diagnosis of DVT 119, 593 ventricular
trauma 325 for nerve blocks 292
tracheal tube size for in pregnancy 576, 584, tachycardia 86–7
children 652, 656
children 654–5 587, 589 vertigo 549
tracheitis, bacterial 677 in trauma (FAST) 346, violence/violent
traction apophysitis 708
tranquillization, 595 patients 608–11
for venous access 56, 639 intoxication 623
emergency 611 umbilical cord sepsis 660 viral arthritis 496
transcutaneous pacing 82 umbilical vein viral haemorrhagic
transfer of patient 22
transfusion cannulation 645 fevers 250
unconscious patient 136 visual acuity 534
blood 172 upper gastrointestinal tract visual loss, sudden 540
massive 174 vitreous haemorrhage 541
transfusion reactions 175 bleeding 122 volar plate injury 440
transient ischaemic upper respiratory tract volvulus 516, 698
vomiting, bilious vomiting in
attacks 146 infections, children 676
transplant patients 161 ureteric colic 524 babies 661
transplantation of urethral carbuncle 565 von Willebrand’s
urethral injuries 352
liver, paracetamol urethritis 238, 497 disease 166, 168
poisoning 191 urinary retention 520 vulval ulcers 565
transport emergency card urinary tract infections vulvovaginal problems 565
(TREM) 36
transvenous pacing 82 (UTIs) 158, 591 W
trauma children 692
injury prevention 711 urine microscopy 158, 693 wasp stings 416
injury severity score urticaria, neonatal 662 weakness, generalised 142
USS see ultrasound Weber’s test 548
(ISS) 323 uterine bleeding 574 weight estimation,
in pregnancy 594 uterine problems 572
major 319–99 uterine rupture 594 children 633
paediatric 710 uterine size, pregnancy 577 Weil’s disease 239
paediatric uveitis 542 Wells criteria 119–20
Wernicke’s
resucitation 712 V
Revised Trauma encephalopathy 625
vaccines, immunization 636 whole-bowel irrigation 185
Score 323 vaginal bleeding 574
trench foot 257
triage 7 in pregnancy 582–3, 588

mental health 612

whooping cough 684 exploration 404 INDEX 749
Wilm’s tumour 699 foreign bodies in 405
Wolff-Parkinson-White of hand 434 X
infection 413, 415
syndrome 89 in children 715 X-rays
worms 230 lip 464 children 720
wounds 401–19 of neck 378 in pregnancy 576
oral 464 reporting system 6
of abdomen 350 puncture 419 requests 6
antibiotics 411, 422 tendon injury 434
bites/stings 414 of tongue 464 Z
of chest 340–3 X-rays 404
child abuse 730 wrist zip entrapment of
classification 403 anatomy 430 foreskin 702
cleaning 406 dislocations 442–3
closure 406 fractures 442–6 zygomatic (malar)
delayed primary nerve blocks 296–9 fractures 374

closure 412
ear 464