PEM Pearls: Red Flags for Child Abuse – Case 2
Fractures are a common sign of abuse. It is impossible to tell from an x-ray alone whether or not a fracture is due to abuse. Fractures of the extremities are the most common skeletal injury in children who have been abused and approximately 80% of fractures due to abuse occur in children under 18 months old.1 In non-mobile children, rib fractures, long bone fractures, and metaphyseal fractures have a high correlation with child abuse. An understanding of the motor development of young children can aid physicians in the identifying fractures due to abuse.
Emergency medicine (EM) is on the frontlines of climate change, which the Lancet Commission declared “the biggest global health threat of the 21st century” with “potentially catastrophic risk to human health.”
Ethanol withdrawal is a complex disease state. Two of the main players are GABA (an inhibitory neurotransmitter) and glutamate (an excitatory transmitter that can act on NMDA receptors). Simplistically, chronic ethanol use leads to a down-regulation of GABA receptors and an up-regulation in glutaminergic receptors, such as NMDA. When ethanol is abruptly discontinued, we are left with a largely excitatory state with less ability for GABA-mediated inhibition and more capacity for NMDA/glutamate-mediated excitation. While much of the treatment of severe ethanol withdrawal is focused on GABA, there are agents, such as phenobarbital and propofol, that can suppress the glutaminergic response. Ketamine seems like it should confer benefit, as well, due to its NMDA antagonist properties. Until recently there was only one clinical study using ketamine for severe ethanol withdrawal.
The Toxicologist Mindset series features real-life cases from the San Francisco Division of the California Poison Control System.