Evaluación del paciente que consulta por odinofagia en la unidad de emergencia / Evaluation of the patient that consults for odynophagia in the emergency unit

El dolor de garganta es el tercer motivo de consulta a los médicos de atención primaria. Si bien a menudo es ocasionada por infecciones de la vía aérea superior de origen viral autolimitadas, la odinofagia puede ser la forma de presentación de una variedad de otras enfermedades potencialmente graves, tales como la epiglotitis y absceso retrofaríngeo. Este artículo se centra en el diagnóstico diferencial de la odinofagia y se realizan recomendaciones para la evaluación de este síntoma en la unidad de emergencia a propósito de un caso de epiglotitis aguda. La epiglotitis es una afección inflamatoria de la vía aérea superior que puede ocasionar obstrucción aguda y muerte por asfixia en el adulto. Las manifestaciones clínicas que permiten sospechar el diagnóstico son el inicio agudo de fiebre, odinofagia, estridor, disfagia, disnea y sialorrea. El médico de atención primaria debe diferenciar este cuadro clínico de las infecciones respiratorias virales más comunes. Para establecer el diagnóstico son útiles la radiografía lateral de cuello y laringoscopia directa. La vía aérea superior del paciente debe ser controlada durante la evaluación para evitar episodios de obstrucción aguda. El manejo óptimo requiere el trabajo en equipo entre el personal de la unidad de emergencia y profesionales expertos en intubación, así como la consulta oportuna con el otorrinolaringólogo. La laringoscopia y la intubación siempre deben ser realizadas por el personal más capacitado, porque los intentos reiterados o frustros de intubación pueden aumentar la inflamación supraglótica y favorecer la obstrucción de la vía aérea. El reconocimiento de esta entidad clínica en pacientes adultos que consultan por odinofagia y la vigilancia estrecha de la vía aérea superior son las claves para la pesquisa y manejo óptimo de esta condición potencialmente mortal.

Sore throat is the third most common reason for visits to primary care practitioners. While often associated with pharyngitis, a complaint of sore throat may also herald a variety of other underlying disorders, both common and uncommon. These disorders range from local to systemic diseases, and include infectious as well as non-infectious etiologies. This article focuses on the differential diagnosis of sore throat and reviews useful approaches to the evaluation of this prevalent symptom a propos a case of acute epiglottitis. Epiglottitis can be a rapidly fatal condition in adults. Important clues that should raise clinical suspicion include the tripod sign, fever, stridor, sore throat, odynophagia, shortness of breath, and drooling. These features must be differentiated from those associated with common viral infections. The most helpful diagnostic studies are radiography of the neck and direct laryngoscopy. The patient’s airway should be monitored during evaluation to avoid obstruction. Successful management requires teamwork between the emergency physician and personnel skilled in intubation as well as timely consultation with an otolaryngologist. Laryngoscopy and intubation always should be performed by the most skilled personnel because repeated attempts may increase periepiglottal swelling and the risk of airway obstruction. Awareness of the possibility of epiglottitis in adults and close monitoring of the airway are the keys to management of this potentially life-threatening condition. Key words: sore throat, odynophagia, acute epiglottitis, intubation, tracheostomy, ICU.

Estudio de sobrevida de los pacientes adultos mayores en unidades de cuidado intensivo: ¿deben ingresar? / Survival of elderly patients in intensive care units: should they be admitted?

We retrospectively analyzed the mortality of 443 patients older than 65 years old, admitted to an intensive care unit between 1993 and 1994. The mortality was compared with that of 334 younger patients admitted in the same period. Severity of disease was determined using admission APACHE II score. Older patients had a higher admission APACHE score than younger subjects (18.4+- and 14.5+-8.7 respectively, p 0.01). Mortality during the intensive care unit stay was similar in older and younger patients (18.5 and 14.4 per cent, respectively). Hospital mortality was also similar (22.4 and 25.9 per cent respectively). Older patients had a higher frequency of chronic diseases and degree of functional impairment. Mortality rates for different diseases were also similar in older and younger patients. Older age was not associated with a higher mortality during intensive care unit stay. Prognosis is determined by the admission severity score and the number of concomitant chronic diseases

Estudio clínico epidemiológico de los pacientes ingresados a UCI según grupo etáreo / Clinical epidemiological study of patients admitted at ICU according to age

The charts of all patients admitted to an intensive care unit of a University Hospital, during 1 year, were reviewed. The diagnosis that caused the admission was considered the main disease. Severity at the moment of admission was assesses using the Apache asore. A total of 777 patients were admitted during the study period. Twenty had to be excluded due to lack of reliable data. Four hundred thirty two (57 percent) were over 65 years old. Cardiovascular diseases were the main cause of admission in young and old patients. Mortality was 14,8 percent of patients over 65 years old and 18.7 percent in younger patients. Main causes of death were cardiac arrest, cardiogenic shock, sepsis and cerebrovascular disease. No differences in causes of death were observed between young and old patients. Patients older than 65 years old admitted to intensive care units are very similar to the younger counterparts in their prognosis and causes of admission

Síndrome neuroléptico maligno: aproximación médico-psiquiátrica / Malignant neuroleptic syndrome: a clinical-psychiatric approach

We report the case of a 42 years old male, with a bipolar disorder and receiving lithium therapy, valproic acid and clonazepam. Due to an exacerbation of his underlying disease, he was admitted to a psychiatric clinic and received 50 mg of intramuscular chlorpromazine in 2 ocasions. Afterwards, the patient had an alteration of conciousness, fever reaching 39ºC and generalized muscular rigidity. Laboratory work-up showed a normal brain CT scan, a diffuse slowness in the EEG and a creatinphosphokinase that reached values of 3.040 U/l. He was transferred to an intensive care unit and treated with sodium dantrolene and bromocriptine, obtaining a good clinical response