Rosen's Emergency Medicine: Concepts and Clinical Practice: 2-Volume Set

Cover
ROSEN’S Emergency Medicine
Concepts and Clinical Practice
Copyright
Acknowledgments
Contributors
Preface to the Tenth Edition
Preface to the Ninth Edition
How This Medical Textbook Should Be Viewed by the Practicing Clinician and Judicial System
1 - Airway
Principles
Background
Anatomy, Physiology, and Pathophysiology
Failure to Maintain or Protect the Airway
Failure of Ventilation or Oxygenation
Anticipated Clinical Course
Identification of the Difficult Airway
Difficult Direct Laryngoscopy: LEMON
. The patient first should be examined for external markers of difficult intubation, which are determined based simply on the in...
. The second step in the evaluation of the difficult airway is to assess the patient’s airway geometry to determine suitability ...
. Oral access is assessed with the Mallampati scale (Fig. 1.3). Visibility of the oral pharynx ranges from complete visualizatio...
. Upper airway (supraglottic) obstruction may make visualization of the glottis, or intubation itself, mechanically impossible. ...
. Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal DL. Neck mobi...
Difficult Bag-­Mask Ventilation: ROMAN
Difficult Extraglottic Device Placement: RODS
Difficult Cricothyrotomy: SMART
Measurement and Incidence of Intubation Difficulty
Confirmation of Endotracheal Tube Placement
Management
Decision Making
Difficult Airway
Failed Airway
Methods of Intubation
Rapid Sequence Intubation
. In the initial phase, the patient is assessed for intubation difficulty and abnormal physiology unless this has already been d...
. The goal of preoxygenation is denitrogenation of the alveoli and formation of an oxygen-­rich reservoir within the lung’s FRC....
. Airway management can be made more complex by unstable hemodynamics and impaired patient physiology. Although shock states, se...
. In this phase, a potent sedative agent is administered by rapid IV push in a dose capable of producing unconsciousness rapidly...
. The patient should be positioned for intubation as consciousness is lost. Usually, positioning involves head extension, often ...
. Approximately 45 to 60 seconds after admin­istration of the NMBA, the patient is relaxed sufficiently to permit laryngoscopy. ...
. After confirmation of tube place­ment by ETco2, obtain a chest radiograph to confirm that mainstem intubation has not occurred...
Delayed Sequence Intubation
Awake Oral Intubation
Oral Intubation Without Pharmacologic Agents
Pharmacologic Agents
Neuromuscular Blocking Agents
. Succinylcholine is a combination of two molecules of ACh. Succinylcholine is rapidly hydrolyzed by plasma pseudo­cholinesteras...
. Succinylcholine is rapidly active, typically producing intubating conditions within 45 seconds of administration by rapid IV b...
. As an ACh analogue, succinylcholine binds to ACh receptors throughout the body, not just at the motor end plate. It is difficu...
. The depolarizing action of succinylcholine results in fine chaotic contractions of the muscles throughout the body for several...
. Succinylcholine has been associated with severe fatal hyperkalemia when administered to patients with specific predisposing cl...
. Succinylcholine has rarely been reported to cause masseter spasm, primarily in children and young adults. The clinical signifi...
. Succinylcholine has been associated with malignant hyperthermia, a perplexing and exceptionally rare syndrome of rapid tempera...
. Competitive NMBAs are classified according to their chemical structure. The aminosteroid agents include pancuronium, vecuroniu...
. When a patient has a contraindication to succinylcholine, rocuronium is the paralytic agent of choice. At a dose of 1.2 mg/kg ...
. After intubation, prolonged paralysis may be desired to optimize mechanical ventilation; however, current management is based ...
Induction Agents
. Etomidate is an imidazole derivative that has been in use since 1972. Its activity profile is similar to that of thiopental, w...
. Ketamine, a phencyclidine derivative, has been widely used as a general anesthetic agent since 1970. After an IV dose of 1.5 m...
. Propofol is a highly lipophilic alkylphenol with γ-­aminobutyric acid (GABA) receptor stimulation activity. Its primary use in...
. Given the widespread acceptance and familiarity with etomidate, propofol, and ketamine, other drug classes such as barbiturate...
Special Clinical Circumstances
Status Asthmaticus
Hemodynamic Consequences of Intubation
Elevated Intracranial Pressure
Hypotension and Shock
Potential Cervical Spine Injury
Airway Devices and Techniques
Direct Laryngoscopy Versus Videolaryngoscopy
Videolaryngoscopes
Flexible Intubating Scopes
Extraglottic Devices
. LMAs collectively include a number of commercially available ovoid, silicone mask devices designed to seal above the glottis a...
. In addition to LMAs, which sit above the glottis, there are other types of EGDs that travel behind the laryngeal inlet with th...
Surgical Airway Management
Needle Cricothyrotomy with Transtracheal Jet Ventilation
Cricothyrotomy
Outcomes
References
2 - Mechanical Ventilation and Noninvasive Ventilatory Support
Foundations
Physiology of Positive-­Pressure Breathing
Positive End-­Expiratory Pressure
Noninvasive Techniques
Management
Decision Making: Noninvasive Versus Invasive Ventilation
Approach to Initial Ventilator Settings
Noninvasive Ventilation
High-­Flow Nasal Cannula
Mechanical Ventilation of the Intubated Patient
Ongoing Management
Ventilator-­Associated Pneumonia Prevention
Troubleshooting the Ventilator
Special Clinical Circumstances
Status Asthmaticus
Acute Respiratory Distress Syndrome
Outcomes
Complications
References
3 - Shock
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Specific Causes
Hemorrhagic Shock
Septic Shock
Cardiogenic Shock
Neurogenic Shock
Management
Decision Making
Quantitative Resuscitation
Pharmacology
Volume Replacement
. Standard treatment for hemorrhagic shock historically consisted of rapidly infusing several liters of isotonic crystalloid in ...
. Colloids offer the theoretical advantage of a high osmotic pressure, which should help maintain normal intravascular volume. C...
. In the setting of hemorrhage or a critically low hemoglobin level (<7 g/dL), we recommend transfusion of PRBCs (1 to 2 units i...
Vasopressors
Inotropes
Antimicrobial Therapy
Corticosteroids
Special Cases
Devices and Procedures
Ventilation
Source Control
Mechanical Circulatory Support and Percutaneous Coronary Intervention
Pericardiocentesis and Thrombectomy
Outcomes
References
4 - Brain Resuscitation
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Elevated Intracranial Pressure
Management
Decision Making
Pharmacology
Intracranial Pressure Management
Devices and Techniques
Cardiopulmonary Resuscitation
Reperfusion
. Maintaining cerebral oxygen delivery is a mainstay of therapy after ischemic brain injury. Oxygen delivery requires a sufficie...
Elevated Intracranial Pressure
. Medical treatment for elevated ICP has similarly not been proven effective in randomized controlled trials, and treatment prot...
. Surgical options for the management of refractory ICP include decompressive craniectomy and evacuation of intracranial hematom...
Maintenance of Body Temperature
Targeted Temperature Management
Outcomes
References
5 - Adult Resuscitation
Background and Importance
Anatomy, Physiology, and Pathophysiology
Management
Decision Making
Prehospital
History and Physical Examination
Resuscitation
Ventricular Fibrillation and Pulseless Ventricular Tachycardia
Pulseless Electrical Activity
Asystole
Pharmacology
Devices and Techniques
Monitoring
End-­Tidal Carbon Dioxide
Central Venous Oxygen Saturation
Echocardiography
Extracorporeal Cardiopulmonary Resuscitation
Laboratory Testing
Arterial Blood Pressure and Coronary Perfusion Pressure
Outcomes
Post–Cardiac Arrest Care
Hypothermic Targeted Temperature Management
Coronary Angiography and Primary Percutaneous Coronary Intervention
Antidysrhythmic Therapy
Oxygen Debt and Hemodynamic Management
References
6 - Pain Management
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Pain Conduction Pathways
Pain Detection
Information Transmission
. All sensory neurons are composed of a cell body located in the dorsal root ganglia. The dorsal root ganglia are connected by n...
Pain Transmission
. The dorsal horn is the gray matter of the posterior aspect of the spinal cord (Fig. 6.2). The dorsal horn acts as an integrati...
. The quantity and type of stimuli that produce pain vary among visceral structures. The myocardium, for example, is sensitive t...
. Fibers carrying pain impulses exit the dorsal horn and ascend the spinal cord to the brain. The predominant pathways for pain ...
Pain Modulation
Central Sensitization
Pain Expression
Reflex Responses to Pain
Endorphin System
Acute Versus Chronic Pain
Management
Decision Making
Pain Assessment
Oligoanalgesia
Pain Measurement
Treatment Groups
. Symptomatic treatment of pain should be initiated promptly, titrated to an acceptable level of relief, and continued while the...
. The assessment of pain in the absence of acute or obvious physical injury requires a great deal of communication skill on the ...
. Recurrent pain is a subset of chronic pain; the term describes patients who have symptoms with repeated episodes of similar pa...
. Chronic malignant pain is similar to acute pain related to ongoing nociceptive stimulation and similar to chronic pain in its ...
. Complex regional pain syndrome (CRPS) is a term that includes most sympathetically maintained neuropathic pain. CRPS type 1 (o...
Pharmacologic Therapy
Opioids
. Opioids bind to specific endorphin system receptors located throughout the nervous system. These receptors suppress pain detec...
. Some patients feign or exaggerate pain to receive opioids to abuse medications or sell them to others, an occurrence defined a...
. The goal of opioid administration is to attain effective analgesia with minimal adverse effects. The effects of opioids vary w...
Specific agents
. IV morphine is frequently used for the treatment of acute severe pain in ED patients. Morphine is the opioid analgesic agent w...
. Meperidine (Demerol), although once widely used, has several disadvantages compared with morphine and other parenteral opioids...
. Hydromorphone is a semisynthetic derivative of morphine that is a potent analgesic agent, frequently used to manage acute pain...
. Fentanyl is a synthetic opioid that is highly lipophilic; it produces analgesia within 1 to 2 minutes following IV infusion. F...
. Sufentanil is a highly lipophilic synthetic opioid. It has been noted to have fewer cardiac effects than other opioids, and no...
. Buprenorphine is a synthetic opioid with a high affinity for the opiate receptor. Buprenorphine has no current indication for ...
. Oxycodone is a strong opioid agonist that is highly bioavailable in an oral form. Oxycodone is widely sold in combination with...
. Hydrocodone is metabolized in the liver to hydromorphone and is typically given orally. Hydrocodone provides greater pain reli...
. Codeine is a weak opioid receptor agonist, usually prescribed in combination with acetaminophen, but has little, if any, role ...
. Methadone has several unique features that distinguish it from other opioids. It has no known neurotoxic or active metabolites...
. Naloxone is an opioid antagonist that reverses the effects of opioids and is used in the setting of adverse, opioid-­induced e...
. Tramadol is a synthetic oral analgesic that is a weak mu agonist, with some serotonin and norepinephrine reuptake qualities. I...
. Tapentadol is a mu opioid agonist and norepinephrine reuptake inhibitor. It is thought to control acute pain via both these pa...
. Historically, pain treatment was withheld from patients with abdominal pain to avoid confounding a diagnosis. These recommenda...
Nonopioid Analgesic Agents
. Acetaminophen is the first-­line agent for treating acute and chronic pain and is the safest pharmacologic option for pain in ...
Nonsteroidal Antiinflammatory Drugs
Drug interactions with nonsteroidal antiinflammatory drugs
. NSAIDs may impair the cardioprotective effect of aspirin, although the available evidence is unclear, and the use of daily asp...
. The antiplatelet effects of NSAIDs add to the anticoagulant properties of warfarin, compounding the risk of significant bleedi...
. Concurrent use of NSAIDs with angiotensin-­converting enzyme (ACE) inhibitors may impair renal function and impair the antihyp...
. Patients taking diuretics have a greater risk of developing renal failure due to NSAID-­mediated decreased renal blood flow. A...
. Patients on corticosteroids have an increased risk of peptic ulcer disease. NSAIDs should generally be avoided in patients con...
. NSAIDs enhance lithium reabsorption and may directly reduce lithium excretion, leading to increased lithium levels. CNS sympto...
. NSAIDs combine analgesia and antiinflammatory effects with low abuse potential and many different side effects compared to opi...
. Ketorolac was the first nonopioid analgesic agent available for parenteral use in the United States. For acute pain management...
. Ibuprofen is the most widely used agent in the NSAID class. It is available over the counter in various preparations, includin...
. Skeletal muscle relaxants have been advocated as an adjunct to analgesics in managing musculoskeletal pain with a spasm compon...
. The analgesic and anesthetic properties of nitrous oxide were discovered more than 200 years ago, and it is one of the origina...
. Ketamine is a drug that has typically been used primarily as a dissociative anesthetic for procedural sedation; it is one of t...
Local/Regional Anesthesia
. Peripheral nerves are responsible for transmitting pain information from pain receptors to the spinal cord. Each fiber consist...
. Local anesthetic agents are chemical compounds that consist of an aromatic and amine group separated by an ester (e.g., procai...
. True allergies to local anesthetics are rare. When an allergy to local anesthetics is reported, the offending substance is oft...
Local and systemic toxicity
. Local anesthetic agents, depending on the concentration, can be directly toxic to tissue. Also, there are theoretical concerns...
. Systemic toxicity of local anesthetics occurs when a sufficient quantity of the drug accumulates in the body so that sodium ch...
. Many techniques can be used to reduce the pain of anesthetic injection (Box 6.7). Distraction by manual methods such as scratc...
Topical Anesthesia
Topical anesthetics applied to intact skin
. A eutectic mixture of local anesthetics (EMLA) is a mixture of lidocaine and prilocaine in an alkaline oil mixture in which th...
. Ethyl chloride and fluoromethane sprays are occasionally used for superficial analgesia. The agents evaporate quickly and cool...
Agents applied to mucosal surfaces
. Cocaine is unique among local anesthetic agents, given that it is a potent vasoconstrictor in addition to being an anesthetic ...
. Both 2% and 4% lidocaine solutions are available in a viscous matrix for mucosal surfaces. Gel lidocaine can be used in nasal ...
. Tetracaine is a potent ester used for surface anesthesia of the cornea. Tetracaine stings when placed in the eye, but only for...
. Almost insoluble in water, benzocaine remains on mucous membranes in the mouth and is commonly used to provide superficial ana...
. The combination of lidocaine, epinephrine, and tetracaine, 5 to 10 mL, may be applied to an open wound using sterile cotton, w...
Nonpharmacologic Interventions
Transcutaneous Electrical Nerve Stimulation
Out-­of-­Hospital Analgesia
Outcomes: Treatment Endpoints
References
7 - Procedural Sedation and Analgesia
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Management
Decision Making
Patient Assessment
Preprocedural Fasting
Personnel
Devices and Techniques
Supplies and Equipment
Recovery
Post-­procedure Recovery and Discharge
Pharmacology
Routes of Administration
Opioids
Fentanyl
Morphine
Benzodiazepines
Midazolam
Ketamine
Sedative-­Hypnotics
. Etomidate is a short-­acting, sedative-­hypnotic agent structurally unrelated to the other PSA agents, with no analgesic prope...
. Propofol is another short-­acting sedative-­hypnotic that is structurally unrelated to the other PSA drugs, with no analgesic ...
. Ketamine is commonly combined with propofol (known as “ketofol”) for PSA. The two are thought to have synergistic effects that...
. Emergency department experience with agents such as alfentanil and remifentanil for PSA is limited. Alfentanil is an ultra–sho...
. Careful titration of medications to the desired level of sedation is generally the goal in PSA. At times, however, unanticipat...
. Naloxone is a competitive antagonist of opioids and has been effectively used for the reversal of opioid-­induced respiratory ...
. Flumazenil is a competitive antagonist of benzodiazepines. Although it reverses the sedation effect of benzodiazepines, it is ...
Drug Selection and Administration
References
8 - Fever in the Adult Patient
FOUNDATIONS
Epidemiology
Pathophysiology
Diagnostic Approach
Differential Considerations
Pivotal Findings
Untitled
Signs
Ancillary Testing
Diagnostic Algorithm
EMPIRICAL MANAGEMENT
DISPOSITION
9 - Weakness
Foundations
Epidemiology
Pathophysiology
Diagnostic Approach
Differential Considerations
Diagnostic Algorithm
Critical and Emergent Diagnoses
Specific Presentations of Neuromuscular Disorders
Unilateral Weakness
. Weakness involving the combination of arm, hand, or leg with ipsilateral facial involvement is generally caused by a lesion in...
. Weakness involving the combination of arm, hand, or leg with contralateral facial involvement indicates a brainstem lesion. A ...
. Weakness involving the combination of arm, hand, or leg without facial involvement is most likely to be a result of one of the...
. Isolated weakness of one extremity is usually caused by a spinal cord or peripheral nerve lesion. Examination for UMN signs in...
Bilateral Weakness
. When weakness involves the lower extremities only, the first consideration is a spinal cord lesion. If this is the case, UMN s...
. When weakness involves the upper extremities only, the lesion is localized within the central portion of the cervical spinal c...
. When weakness involves all four extremities without facial involvement, the primary concern is a cervical spinal cord injury o...
. Weakness confined to the proximal portions of the upper extremities only points to a myofiber disorder, provided that there ar...
. Weakness involving the distal portions of the extremities only is almost always caused by a peripheral neuropathy (see Box 9.2...
Facial Weakness Without Extremity Involvement
. Isolated, unilateral weakness of the upper and lower halves of the face is caused by a CN VII problem. Causes for an isolated ...
. Facial weakness not limited to CN VII will be associated with some combination of ptosis, binocular diplopia, dysarthria, or d...
Empiric Management
Disposition
References
10 - Cyanosis
Foundations
Epidemiology
Pathophysiology
Diagnostic Approach
Pivotal Findings
Presentation and Symptoms
Signs
Ancillary Testing
Imaging
Electrocardiography and Echocardiography
Diagnostic Algorithm
Critical Diagnoses
Emergent Diagnoses
Empiric Management
Methemoglobinemia and Sulfhemoglobinemia
Other Causes of Cyanosis
Patient Disposition
Discharge
References
11 - Syncope
Epidemiology
Pathophysiology
Diagnostic Approach
Differential Considerations
Pivotal Findings
Symptoms
Signs
Ancillary Testing
Electrocardiogram
Laboratory Testing
Urine Testing
Imaging
Chest Imaging
Neuroimaging
Echocardiography
Diagnostic and Management Algorithm
Risk-­Stratification
Empiric Management
References
12 - Depressed Consciousness and Coma
Epidemiology
Pathophysiology
Diagnostic Approach
Differential Considerations
Pivotal Findings
Symptoms
Signs
Ancillary Testing
Diagnostic Algorithm
Empirical Management
References
13 - Confusion
Foundations
Epidemiology
Pathophysiology
Diagnostic Approach
Differential Considerations
Pivotal Findings
Symptoms
Signs
Ancillary Testing
Diagnostic Algorithm
Empirical Management
References
14 - Seizures
Foundations
Epidemiology
Pathophysiology
Diagnostic Approach
Pivotal Findings
History Taking and Physical Exam
Ancillary Testing
Laboratory Testing
Imaging Studies
Electroencephalography
Cardiac Monitoring
Differential diagnoses
Diagnostic Algorithm
Empiric Management
Disposition
References
15 - Dizziness and Vertigo
Foundations
Epidemiology
Pathophysiology
Diagnostic Approach
Differential Considerations
Pivotal Findings
Symptoms
Physical Examination
. The vital signs, including orthostatic changes, may be the key to identifying a cardiovascular etiology or drug effect as the ...
. Carotid or vertebral artery bruits suggest atherosclerosis and risk for TIA or stroke. The vertebral artery can be auscultated...
. The presence of CN deficits suggests a space-­occupying lesion in the brainstem or cerebellopontine angle, such as an acoustic...
. Positional testing confirms the diagnosis of BPPV. The Hallpike test, also known as the Dix-­Hallpike test or the Nylen-­Baran...
. HINTS (Head Impulse test, Nystagmus, Test of Skew) is a bedside oculomotor examination test that has been proposed as a way to...
Ancillary Testing
. Acute vertigo by itself does not warrant urgent computed tomography (CT) or MRI in all patients, particularly patients in whom...
Diagnostic Algorithm
Empirical Management
Disposition
References
16 - Headache
Background and Importance
Pathophysiology
Diagnostic Approach
Differential Considerations
Pivotal Findings
Symptoms
Signs
Ancillary Testing
Diagnostic Algorithm
Empirical Management
References
17 - Diplopia
Foundations
Pathophysiology
Diagnostic Approach
Differential Considerations
Pivotal Findings
. The history begins by determining if the diplopia is monocular or binocular. Additional information helpful in formulating the...
Physical Exam
. The external eye exam includes an exam of the orbital and periorbital structures. The conjunctiva is examined for signs of inj...
. The patient should undergo a careful pupillary examination, looking for signs of asymmetry. Patients with a CN III palsy may h...
. The extraocular muscles of the eye include the lateral rectus, which is innervated by the abducens nerve (cranial nerve VI), t...
. Structures of the posterior chamber include the retina, the optic nerve, the optic disk, the central retinal artery, the retin...
. Structures of the anterior chamber include the sclera, conjunctiva, cornea, iris, lens and the aqueous humor. Examination incl...
Signs and Symptoms
. Monocular diplopia is present only if the patient complains that the diplopia persists in the affected eye with the normal eye...
Binocular diplopia
. An orbitopathy refers to any disease that affects the orbit and its contents. A structural orbitopathy can be caused by orbita...
. There are multiple causes of an isolated oculomotor nerve palsy including hypertensive or diabetic vasculopathy, a demyelinati...
. A focal brainstem lesion, seen in multiple sclerosis, may result in isolated diplopia. However, localized brainstem lesions us...
. Diplopia that is variably triggered in multiple directions, without a distinct structural or neuropathic cause, implies a neur...
Ancillary Testing
Diagnostic Algorithm
Empirical Management
Management Algorithm
References
18 - Red and Painful Eye
Epidemiology and Pathophysiology
Diagnostic Approach
Differential Considerations
Pivotal Findings
Symptoms
Signs
Visual Acuity
Visual Field Testing
External Examination
Extraocular Muscle Function
Pupillary Evaluation
Pressure Determination
Ancillary Testing
Swinging Flashlight Test
Slit-­Lamp Examination
Direct Funduscopic Examination
Topical Anesthetics
Imaging
Laboratory Testing
Diagnostic Algorithm
Critical Diagnoses
Emergent Diagnoses
Urgent Diagnoses
Empiric Management
References
19 - Sore Throat
Epidemiology
Pathophysiology
Diagnostic Approach
Differential Considerations
Pivotal Findings
Symptoms and Signs
Ancillary Testing
Imaging
Diagnostic Algorithm
Critical and Emergent Diagnoses
Empiric Management
References
20 - Hemoptysis
Epidemiology
Pathophysiology
Diagnostic Approach
Differential Considerations
Pivotal Findings
Symptoms
Signs
Ancillary Testing
Diagnostic Algorithm
Critical Diagnoses
Bronchoscopy
Empirical Management
References
21 - Dyspnea
Foundations
Epidemiology
Pathophysiology
Diagnostic Approach
Differential Diagnosis Considerations
Pivotal Findings
Symptoms
.. The description of symptoms may provide clues to a diagnosis. For example, chest tightness is fairly specific to bronchoconst...
.. Chronic or progressive dyspnea usually denotes primary cardiac, pulmonary, or, less commonly, neuromuscular disease. Many of ...
.. Orthopnea can result from left-­sided heart failure, COPD, or neuromuscular disorders.4 It can be one of the earliest symptom...
.. Anxiety or overwhelming fear, particularly if it precedes the onset of dyspnea, may point to panic attack or psychogenic dysp...
Signs
Ancillary Testing
Diagnostic Algorithm
Critical Diagnoses
Emergent Diagnoses
Empirical Management
References
22 - Chest Pain
Foundations
Epidemiology
Pathophysiology
Diagnostic Approach
Differential Considerations
Pivotal Findings
History
Physical Examination
Ultrasound
Ancillary Studies
Diagnostic Algorithm
Empirical Management
References
23 -
Abdominal Pain
DIAGNOSTIC APPROACH
Differential Considerations
Pivotal Findings
Symptoms
Signs
Ancillary Testing
Laboratory Tests
Imaging Studies
DIAGNOSTIC ALGORITHM
Critical Diagnoses
Emergent Diagnoses
EMPIRIC MANAGEMENT
REFERENCES
24 - Jaundice
Pathophysiology
Normal Bilirubin Metabolism
Abnormalities in Bilirubin Metabolism
Diagnostic Approach
Differential Considerations
Pivotal Findings
Symptoms
Signs
Laboratory Tests
Imaging
Diagnostic Algorithm
Empirical Management
References
25 - Nausea and Vomiting
Epidemiology
Pathophysiology
Diagnostic Approach
Differential Diagnosis Considerations
Pivotal Findings
Symptoms
Signs
Ancillary Studies
Diagnostic Algorithm
Empirical Management
Adults
Pediatrics
Special Situations
Opioid-­Induced Vomiting
Headache
Pregnancy
Chemotherapy
Cyclical Vomiting Syndrome and Cannabinoid Hyperemesis Syndrome
Vertigo
Gastroparesis
Disposition
References
26 - Gastrointestinal Bleeding
Foundations
Diagnostic Approach
Differential Considerations
Pivotal Findings
Symptoms
Signs
Ancillary Testing
Laboratory Testing
Electrocardiogram
Nasogastric Aspirate Testing
Imaging
Diagnostic Algorithm
Management
Empiric Treatment
Resuscitation
Blood Product Transfusion
Pharmacologic Therapy
Balloon Tamponade
Definitive Treatment
References
27 - Diarrhea
Introduction
Epidemiology
Pathophysiology
Diagnostic Approach
Differential Considerations
Pivotal Findings
Signs and Symptoms
Ancillary Testing
. Leukocytosis has been reported in C. difficile infections, although an isolated white blood cell count elevation is not sensit...
. Fecal leukocytes are not sufficiently specific or sensitive as the sole criterion to determine which patients should be treate...
. There are multiple tests available to identify the specific pathogen causing a patient’s symptoms; however, the results are ge...
. Stool cultures are generally not indicated in the ED given their low sensitivity and delayed results. Stool culture panels for...
. Testing for C. difficile should be considered if the patient is immunocompromised or reports antibiotic use during the precedi...
. This assay should be considered when there is a known outbreak or if the presentation occurs in an endemic area. It should als...
. These tests may be useful in patients with chronic diarrhea (Entamoeba histolytica and Cryptosporidium), patients with a histo...
. Giardia antigen assay and serologic testing for amebiasis should be considered in patients exposed to poor sanitation or those...
. Radiographic studies are not commonly used in the evaluation of acute diarrhea. Plain radiography is rarely indicated. If peri...
Gastrointestinal Referral
Diagnostic Algorithm
Critical Diagnoses
Emergent Diagnoses
Empiric Management
Rehydration
Antibiotics
Antimotility Agents
Probiotics
Disposition
References
28 - Constipation
Foundations
Pathophysiology
Diagnostic Approach
Differential Considerations
Pivotal Findings
Ancillary Testing
Critical Diagnoses
Emergent Diagnoses
Empirical Management
References
29 - Acute Pelvic Pain
Epidemiology
Pathophysiology
Diagnostic Approach
Differential Considerations
Pivotal Findings
Symptoms
Signs
Ancillary Testing
Laboratory Tests
Imaging
Diagnostic Algorithm
Empirical Management
References
30 - Vaginal Bleeding
Background and Importance
Pathophysiology
Nonpregnant Patients
Pregnant Patients
Diagnostic Approach
Differential Considerations
Nonpregnant Patients
Pregnant Patients
Pivotal Findings
Symptoms
Signs
Ancillary Testing
Diagnostic Algorithm
Empiric Management
Disposition
References
31 - Back Pain
Foundations
Background and Importance
Pathophysiology
Diagnostic Approach
Differential Considerations
Myelopathy
Radiculopathy
Spondylosis
Disc Herniation
Spinal Infections
Spinal Tumors
Cauda Equina Syndrome
Acute Transverse Myelitis
Mechanical Back Pain
Chronic Back Pain
Pivotal Findings
Symptoms
Signs
Ancillary Testing
Laboratory Tests
Imaging Studies
Abdominal Ultrasound
Plain Film Radiographs
Computed Tomography Scan
Magnetic Resonance Imaging
Diagnostic and Management Algorithms
Critical Diagnoses
Emergent Diagnoses
Empiric Management
Mild to Moderate Back Pain
Severe Back Pain
Chronic Back Pain
Disposition
Acknowledgments
References
32 - Multiple Trauma
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
Primary Survey
Secondary Survey
Differential Diagnoses
Diagnostic Testing
Laboratory Evaluation
Radiographic Evaluation
Management
Out-­of-­Hospital Management
Emergency Department Management
Disposition
References
33 - Head Trauma
Foundations
Background and Importance
Anatomy and Pathophysiology
Anatomy
. The scalp consists of five tissue layers (Fig. 33.1). The skull is comprised of the frontal, ethmoid, sphenoid, and occipital ...
. The brain is a semisolid structure that weighs approximately 1400 g (3 lb.) and occupies approximately 80% of the cranial vaul...
Pathophysiology
. The brain has an extremely high metabolic rate, accounting for approximately 20% of the entire oxygen consumption of the body ...
. Increased ICP is defined as a CSF pressure greater than 15 mm Hg (or 195 mm H2O) and is a frequent consequence of a severe TBI...
. Progressive hypertension associated with brady­cardia and diminished respiratory effort is a specific response to acute, poten...
Altered Levels of Consciousness
Definitions and Patterns of Injury
Traumatic Brain Injuries: Severe, Moderate, and Mild
Direct and Indirect Injuries
. Direct head trauma occurs when the head is struck, or its motion is suddenly arrested, by an object. The resulting damage to t...
. In indirect brain injury, the cranial contents are set into motion by forces other than the direct contact of the skull with a...
Neurochemical Cascade
Penetrating Head Trauma
Scalp Wounds
Skull Fractures
Linear Fractures
Depressed Fractures
Basilar Fractures
Extra-­Axial and Intra-­Axial Intracranial Injuries
Extra-­Axial Injury
. An EDH is bleeding that occurs between the inner table of the skull and dura. Most EDHs result from a direct-­impact injury th...
. An SDH is a hemorrhage that occurs between the dura and brain and is usually caused by acceleration-­deceleration injuries. SD...
. A traumatic SAH is blood within the CSF and meningeal intima and probably results from tears of small subarachnoid vessels. Tr...
. A SDHG is a collection of clear, xanthochromic blood-­tinged fluid in the dural space. The pathogenesis of an SDHG is not cert...
Intra-­Axial Injury
. Prolonged traumatic coma not caused by mass lesions or ischemic insult is thought to result from diffuse axonal injury (DAI). ...
. Contusions are bruises on the surface of the brain, usually caused by impact injury. Contusions are produced when parenchymal ...
. Intracerebral hematomas (ICHs) are formed deep within the brain tissue and are usually caused by shearing or tensile forces th...
. Primary traumatic intracerebellar hematomas are rare but can occur after a direct blow to the occipital area. Often, these pat...
Primary and Secondary Brain Injuries
Secondary Systemic Insults
. Hypotension, defined as SBP less than 90 mm Hg, has been found to have a negative impact on severe brain injury outcome. Syste...
. Hypoxia, defined as a Po2 less than 60 mm Hg, is relatively common in the brain-­injured patient. Causes include: (1) transien...
. Paco2 is one of the most potent drivers of CBF. Hypocarbia (Paco2 ≤35 mm Hg) results in vasodilation, while hypercarbia (Paco2...
. Anemia caused by blood loss can be detrimental to the head-­injured patient by reducing the oxygen-­carrying capacity of the b...
. Hyperpyrexia (core body temperature >38.5°C [101.3°F]) is also correlated with worse outcomes after TBI, and its magnitude and...
Cerebral Herniation Syndromes
Uncal Herniation
Central Transtentorial Herniation
Cerebellotonsillar Herniation
Upward Transtentorial Herniation
Clinical Features
Physical Examination
Acute Neurologic Examination
. The goals of the acute neurologic assessment of head trauma patients include detection of life-­threatening injuries and ident...
. The GCS is a 15-­point scale used to quantify the patient’s LOC and as an objective method of following the patient’s neurolog...
. An evaluation of the patient’s pupil size and responsiveness is performed early in the initial assessment of the head-­injured...
. The patient’s acute motor examination assesses for strength and symmetry. If the patient is not cooperative or is comatose, mo...
. In the acute setting, brainstem activity is assessed by the patient’s respiratory pattern, pupillary size, and eye movements. ...
Common Presentations of Specific Lesions
Epidural Hematoma
Subdural Hematoma
Traumatic Subarachnoid Hemorrhage
Subdural Hygroma
Traumatic Axonal Injury
Cerebral Contusion
Intracerebral Hematoma
Traumatic Intracerebellar Hematoma
Differential Diagnoses
Diagnostic Testing
Laboratory Tests
Neuroimaging
. Skull radiography after head trauma has long been replaced by cranial CT, which is the cornerstone of imaging for acute head t...
. Noncontrast CT of the head is the diagnostic standard for identifying intracranial injury in the ED. This scan delineates acut...
. This is often associated with missile wounds that penetrate the sinuses but can be caused by free air sucked into the penetrat...
. On CT scan, an EDH appears hyperdense, biconvex, ovoid, and lenticular. The EDH does not usually extend beyond the dural attac...
. Unlike EDHs, SDHs often extend beyond the suture lines (Fig. 33.8). An SDH may follow the contour of the tentorium and be dete...
. A noncontrast CT scan allows the diagnosis to be made, with increased density noted within the basilar cisterns. Blood can als...
. On CT, SDHGs appear crescent shaped in the extra-­axial space; the density is the same as that of CSF. Bilateral SDHGs are com...
. Diffuse TAI is the most common CT finding after severe head trauma, estimated to occur in over 50% of all comatose head injure...
. Non–contrast-­enhanced CT is the best diagnostic test to discover contusions in the early posttraumatic period. These appear h...
. An ICH may be detected on the first CT scan immediately after injury but often is not seen for several hours or days. Unlike c...
. Often, these patients have an associated skull fracture, posterior fossa EDH or SDH, or supratentorial contrecoup hematomas an...
. On CT scans, diffuse edema manifests as bilateral compression of the ventricles, loss of definition of the cortical sulci, or ...
Management
Out-­of-­Hospital Care
. The ultimate goal in the field is to prevent or minimize hypoxia. Out-­of-­hospital airway protocols balance the risks of emer...
. Avoiding and managing hypotension are critical elements of the prehospital treatment of the head-­injured patient.50 The evalu...
. Many severely head-­injured patients are initially combative or agitated. Transporting an agitated patient who is fighting aga...
Emergency Department Management
. In the ED, management of patients with severe head trauma is in accordance with ATLS (Advanced Trauma Life Support) protocols....
. Primary airway compromise in the setting of head trauma may result from craniofacial or neck trauma, bleeding, or vomiting. Se...
. While hypotension can occasionally be attributed to isolated head injury, it is almost always secondary to another systemic in...
. Osmotic therapy should be guided by findings on ICP monitoring. Prior to initiation of such monitoring, brain-­directed osmoti...
. Under normal conditions, Paco2 is the most powerful determinant of CBF and, between a range of 20 and 80 mm Hg, CBF is linearl...
. In patients with impending herniation who do not respond to first-­line therapies, cranial decompression may temporarily rever...
. Patients taking warfarin anticoagulants should have these medications reversed in the case of ongoing intracranial bleeding. V...
. Recombinant factor VIIa (rFVIIa) is a hemostatic agent that was originally developed to treat bleeding in hemophiliacs. Limite...
. Hyperpyrexia has been suggested to worsen outcomes after severe TBI. Induced therapeutic hypothermia decreases ICP and has bee...
. Though rare, acute symptomatic seizures may occur as a result of severe TBI.76 Such posttraumatic seizures (PTSs) are classifi...
. Although the practice was once widespread, there is no evidence to support the use of antibiotic prophylaxis for the preventio...
Other therapies
. Corticosteroids have no benefit for patients with head trauma, and in fact demonstrate an increase in adverse events, includin...
. Barbiturate therapy has historically been used in severely brain-­injured patients to reduce cerebral metabolic demands of the...
. Invasive ICP monitoring has been a mainstay of management for severe TBI, although its utility has recently been called into q...
. In randomized trials of patients with moderate to severe TBI, erythropoietin did not reduce severe neurologic dysfunction or i...
. Progesterone has been shown to improve neurologic outcome in early-­phase trials involving patients with TBI. In a double-­bli...
. Hyperbaric oxygen therapy following severe, acute TBI provides the injured brain with an increased partial pressure of oxygen ...
Management of Specific Injuries
. For briskly bleeding scalp wounds, rapid hemostasis is a priority. Initially, hemostasis may be achieved by the application of...
. A noncontrast head CT scan with bone windows is the imaging modality of choice for patients with suspected skull fractures or ...
. Linear skull fractures are clinically important if they cross the middle meningeal groove or major venous dural sinuses; they ...
. When a depressed fracture occurs, traumatic impact drives the bone piece below the plane of the skull. The edges of the depres...
. Basilar fractures are the result of considerable impact force and are highly associated with underlying brain injury. Emergenc...
Extra-­axial lesions
. Consensus guidelines support rapid surgical evacuation for any patient who has mass effect on a CT scan or progressive neurolo...
. SDH is often associated with significant brain injury. Further, delays in clinical signs and symptoms and the older mean age o...
. In the absence of other brain injury, tSAH generally carries a favorable prognosis. The most serious complication of tSAH is w...
. If SDHGs are asymptomatic, observation is a reasonable approach. Otherwise, they are surgically evacuated. Mortality approache...
Intra-­axial lesions
. Patients with brain contusions can often be treated conservatively, although almost half will have significant progression on ...
. Many patients with an ICH require emergent intervention or surgery to lower elevated ICP. Mortality is low in patients who are...
. Mortality from isolated traumatic intracerebellar hematoma is very high. Emergent neurosurgical consultation is indicated
Complications and Outcome
Central Nervous System Infections
. Posttraumatic meningitis can be caused by a variety of microbes, depending on the portal of bacterial entry. Patients have typ...
. Brain abscesses develop infrequently after penetrating missile injuries to the head. Abscesses can also develop after open dep...
. Cranial osteomyelitis can occur after penetrating injury to the skull. The clinical manifestations include pain, tenderness, s...
Medical Complications
. The injured brain is a source of tissue thromboplastin that activates the extrinsic clotting system. Disseminated intravascula...
. Pulmonary complications in the hours to days following TBI are common. Acute lung injury has been theorized to occur from a va...
. Cushing noted a connection between cardiac dysrhythmias and intracranial bleeding in the early 20th century, and a variety of ...
Disposition
Clinical Features
Physical Examination
Head and Neck
Mental Status and Alertness
Cranial Nerves
Cognitive Function (Attention, Memory, Concentration)
Vestibular Function (Balance, Gait, and Eye Movements)
Differential Diagnoses
Diagnostic Testing
Neuroimaging in the Emergency Department with Computed Tomography
Other Neuroimaging Modalities
. CT is the imaging modality of choice for initial screening to exclude serious traumatic intracranial lesions in MTBI. However,...
. A significant advancement in the imaging of MTBI has been the development of susceptibility-­weighted imaging (SWI). This tech...
. DTI uses MRI technology to analyze the movement of water molecules in the white matter of the brain and provides the opportuni...
. Vascular imaging such as CT angiography and MR angiography are not recommended routinely for patients with MTBI unless there i...
Ancillary Studies
. Laboratory tests are not needed for patients with isolated MTBI except for a bedside glucose level in those with a GCS score l...
. Neuropsychological testing is used to assess cognitive function after MTBI and includes in-­depth testing of memory, attention...
Disposition
Complications
Postconcussive Syndrome
Seizures
Posttraumatic Transient Cortical Blindness
Special Populations with Mild Traumatic Brain Injury
Mild Traumatic Brain Injury and Sports-­Related Concussion
Military Personnel and Blast Injury
Anticoagulated Patients
. Most clinical decision guidelines for determining need for CT scan exclude patients who are taking anticoagulants such as warf...
. The most serious site of bleeding for children and adults with inherent bleeding disorders, such as hemophilia, is the CNS. In...
Head Trauma in Older Adults
References
34 - Facial Trauma
Background and Importance
Anatomy, Physiology, and Pathophysiology
Bones
Nerve Supply
Ears
Eyes
Nose
Mouth
Temporomandibular Joint
Soft Tissue, Vasculature, and Specialized Glands
Pathophysiology
Clinical Features
History
Physical Examination
. In addition to the examination of lacerations and contusions, the face should be evaluated for symmetry. The appearance of the...
. The integrity of the mouth and nasal complex may be evaluated by listening to the patient’s speech. A muffled or hoarse voice ...
. Otoscopy is performed to evaluate the integrity of the external canal, look for hemotympanum, and assess for otorrhea. Subcuta...
. The nose is palpated for tenderness, crepitus, or abnormal movement; then each naris is held closed in turn to ensure that the...
Neurologic Examination
Soft Tissue Injuries and Lacerations
Mouth
Cheeks
Nose
Ears
Eyes
Fractures and Dislocations
Forehead
Orbit
Midface
Zygoma
Mandible
Dental and Alveolar Trauma
Temporomandibular Joint
Diagnostic Testing
Imaging
Management
Out-­of-­Hospital Care
Emergency Department Treatment
Disposition
References
35 -
Spinal Trauma
FOUNDATIONS
Background and Importance
Anatomy and Physiology
Pathophysiology
Classification of Spinal Column Injuries
. Atlanto-­occipital and atlantoaxial joint dislocation can occur with or without associated fractures of the odontoid (Fig. 35....
. Trauma to the head directed in an anteroposterior (AP) direction may result in fracture of the odontoid process above the tran...
. Rotary atlantoaxial dislocation is an unstable injury visualized best on open-­mouth odontoid radiographs (Fig. 35.15) or comp...
. Fracture of the posterior neural arch of the atlas (C1) results from compression of the posterior elements between the occiput...
. Vertical compression injuries occur in the cervical and lumbar regions, which are capable of straightening at the time of impa...
Classification of Spinal Cord Injuries
. The spinal cord may be injured by three broad categories of injury patterns. First, penetrating trauma or massive blunt trauma...
. The maximum neurologic deficit after blunt spinal cord trauma is often not seen on initial examination and may, instead, progr...
Classification of Cervical Soft Tissue Injuries
CLINICAL FEATURES
Neurologic Evaluation
Spinal Cord Lesions
Complete Spinal Cord Lesions
Incomplete Spinal Cord Lesions
DIFFERENTIAL DIAGNOSES
DIAGNOSTIC TESTING
Radiographic Evaluation
Indications
Cervical Plain Radiographs
Thoracolumbar Plain Radiographs
. The inspection of the lateral cervical spine film should be methodical and complete. It is helpful to remember the ABCs of int...
MANAGEMENT
Spinal Column Stabilization
Out-­of-­Hospital Care
Emergency Department
Airway Management
Spinal Shock
Pharmacologic Treatment for Incomplete Cord Injury
Associated Injuries
Cardiopulmonary
Gastrointestinal and Genitourinary
Skin
Definitive Treatment and Prognosis
DISPOSITION
Cervical Soft Tissue Injuries
Minor Fractures
REFERENCES
36 - Neck Trauma
Foundations
Background and Importance
Anatomy and Physiology
Pathophysiology
Vascular Injuries
Pharyngoesophageal Injuries
Laryngotracheal Injuries
Hanging
Clinical Features
Vascular Injuries
Pharyngoesophageal Injuries
Penetrating injury
Blunt Injury
Laryngotracheal Injuries
Penetrating injury
Blunt injury
Hanging
Miscellaneous
Differential Diagnoses
Diagnostic Testing
Vascular Injuries
Penetrating Injury
Blunt injury
Pharyngoesophageal Injuries
Penetrating injury
Blunt Injury
Laryngotracheal Injuries
Penetrating injury
Blunt Injury
Hanging
Management
Vascular Injuries
Penetrating injury
Blunt injury
Pharyngoesophageal Injuries
Penetrating injury
Blunt Injury
Laryngotracheal Injuries
Hanging
Miscellaneous
Disposition
Penetrating Injury
Blunt Injury
References
37 - Thoracic Trauma
Rib Fracture
Foundations
Background and Importance
Anatomy and Physiology
Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Sternal Fracture
Foundations
Background and Importance
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Nonpenetrating Ballistic Injury
Foundations
Background and Importance
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Disposition
Pulmonary Contusion and Laceration
Foundations
Background and Importance
Pathophysiology
Clinical Features
Diagnostic Testing
Laboratory
Radiology
Management
Pneumothorax
Foundations
Background and Importance
Pathophysiology
. A pneumothorax is considered simple or closed (Fig. 37.5) when there is no communication with the atmosphere or any shift of t...
. A communicating pneumothorax (Fig. 37.7) is associated with a defect in the chest wall and most commonly occurs in combat inju...
. The progressive accumulation of air under pressure within the pleural cavity, with shift of the mediastinum to the opposite he...
Clinical Features
Diagnostic Testing
Occult Pneumothorax
Management
Simple Pneumothorax
Communicating Pneumothorax
Tension Pneumothorax
Hemothorax
Foundations
Background and Importance
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Foundations
Background and Importance
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Foundations
Background and Importance
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Myocardial Concussion
Foundations
Background and Importance
Pathophysiology
Clinical Features
Diagnostic Testing
Laboratory Tests and Electrocardiogram
Management
Disposition
Myocardial Contusion
Foundations
Background and Importance
Pathophysiology
Clinical Features
Diagnostic Testing
Laboratory Tests and Electrocardiogram
. The right ventricle is far more likely to be injured than the left ventricle because of its anterior position in the thorax an...
. Creatine kinase (CK) is nonspecifically increased in trauma patients owing to associated skeletal muscle injury, and CK-­MB le...
Imaging
Management
Disposition
Myocardial Rupture
Foundations
Background and Importance
Anatomy and Physiology
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Penetrating Cardiac Trauma
Acute Pericardial Tamponade
Foundations
Background and Importance
Pathophysiology
Clinical Features
Diagnostic Testing
Radiology
. Ultrasound enables rapid, accurate, and noninvasive diagnosis of pericardial tamponade.22 This study can be performed at the b...
. The radiographic evaluation of the cardiac silhouette in acute pericardial tamponade generally is not helpful, unless a trauma...
Electrocardiography
Management
Emergency Department Thoracotomy
. Although it is tempting to perform “life-­saving” EDT on all traumatic arrest victims in the ED, there are many cases in which...
Blunt Aortic Injury
Foundation
Background and Importance
Pathophysiology
Clinical Features
Diagnostic Testing
Chest Radiography
Chest Computed Tomography Scan
Management
Stabilization and Empirical Therapy
Definitive Management
. A number of studies indicate that success and complication rates are likely better than those of traditional open surgical rep...
Esophageal Perforation
Foundations
Background and Importance
Pathophysiology
Clinical Features
Iatrogenic
Foreign Bodies
Caustic Burns
Penetrating and Blunt Trauma
Spontaneous Rupture
Diagnostic Testing
Radiology
Endoscopy
Management
References
38 - Abdominal Trauma
Foundations
Background and Importance
Penetrating Abdominal Trauma
Blunt Abdominal Trauma
Anatomy and Physiology
Pathophysiology
Penetrating Abdominal Trauma
. Stab wounds occur most commonly in the upper quadrants and are caused by a variety of sharp implements besides knives. However...
. The science of ballistics is complex, but a few basic principles are helpful in understanding the pathophysiologic processes. ...
Blunt Abdominal Trauma
. Unrestrained passengers are at an unequivocally greater risk of intra-­abdominal injury than their restrained counterparts. Th...
. Abdominal injuries may be sequelae of various medical procedures. External cardiac compressions, manual chest thrusts to clear...
Clinical Features
Specific Clinical Presentations
Penetrating Abdominal Trauma
. The number of stabs inflicted, type and size of the instrument, posture of the victim relative to the direction of assault, es...
. Clinically helpful information for gunshot wound victims includes the weapon used, its distance from the victim when shot, the...
Blunt Abdominal Trauma
Physical Examination
Penetrating Abdominal Trauma
. Serial physical examination performed by the same observer is useful in appropriately staffed and established trauma centers, ...
. As with blunt or other modes of penetrating trauma, there are limitations to physical examination of patients with abdominal g...
Blunt Abdominal Trauma
Differential Diagnoses
Diagnostic Testing
Ultrasonography
Laboratory Testing
Radiology
Plain Radiographs
Computed Tomography
Magnetic Resonance Imaging
Management
Penetrating Abdominal Trauma
Stab Wounds
. In approaching the management of stab wounds to the anterior abdomen, the clinician is faced with three fundamental tasks. The...
. Various clinical factors can be used to determine the need for emergent laparotomy (Table 38.1) based on the likelihood of ass...
. If clinical indications for laparotomy are absent, the logical next step is assessing the wound tract itself. The presence of ...
. In this algorithm, patients requiring an operation on clinical grounds have proceeded to laparotomy, and those in whom periton...
. Even a single stab wound to the low chest can violate the mediastinum, thoracic cavity, diaphragm, peritoneal cavity, and retr...
. The incidence of retroperitoneal injuries after stab wounds to the flank and back is greater than with injury to the anterior ...
Gunshot Wounds
. Abdominal gunshot wounds enter the peritoneal cavity in approximately 80% of cases, and in more than 90% of those with penetra...
. Fifty percent of patients with gunshot wounds to the low chest have intraperitoneal injuries. Clinical indications for emergen...
. CT scan is highly accurate for identification of retroperitoneal injury and is the diagnostic test of choice in a stable patie...
Blunt Abdominal Trauma
Operative Versus Nonoperative Management
Pelvic Fracture
Multiple System Injury
Bedside Procedures
Diagnostic Peritoneal Lavage
Local Wound Exploration
Resuscitative Endovascular Balloon Occlusion of the Aorta
Therapeutic Angioembolization
Disposition
Consultation
Transfer
References
39 - Genitourinary Trauma
Foundations
Background and Importance
Anatomy and Physiology
Pathophysiology
Renal Trauma
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Ureteral Trauma
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Bladder Trauma
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Urethral Trauma
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Genital Trauma
Clinical Features
Differential Diagnoses
Diagnostic Testing
Imaging
Management
Disposition
References
40 - Peripheral Vascular Trauma
Background and Importance
Anatomy and Physiology
Upper Extremity
Lower Extremity
Pathophysiology
Penetrating Trauma
Blunt Trauma
Vascular Injuries
Complete occlusive injury
. The most common vascular injury is complete transection, in which distal flow is effectively eliminated. Cleanly transected ar...
. Intraluminal thrombosis (Fig. 40.3) may occur in an injured artery acutely (within 24 hours) or may be delayed for many months...
. The precise cause and incidence of significant reversible arterial spasm after trauma are unknown. In the case of arterial tra...
Nonocclusive injuries
. An intimal flap occurs when there is a break in the vessel intima, generally from excessive stretch or concussive forces. Alth...
. A true aneurysm contains all three layers of the vessel wall (intima, media, and adventitia) and is rarely caused by trauma. A...
. An AVF is formed when both an artery and an adjacent vein are injured. Higher-­pressure arterial flow is directed into the low...
Compartment Syndrome
Clinical Features
Hard Findings of Vascular Injury
Soft Findings of Vascular Injury
Asymptomatic High-­Risk Wounds
History
Physical Examination
Differential Diagnoses
Diagnostic Testing
Plain Radiography
Pulse Oximetry and Near-­Infrared Spectroscopy
Handheld Doppler
Arterial Pressure Index and Ankle-­Brachial Index
Ultrasound
Computed Tomography and Magnetic Resonance Imaging
Arteriography
Diagnosis of Specific Vascular Injuries
Management
Major Vascular Injuries
Upper Extremity Arterial Injuries
Lower Extremity Arterial Injuries
Late Complications of Arterial Injury
Venous Injuries
Minor Vascular Injuries
Arterial Spasm
Antibiotics
Disposition
References
41 - General Principles of Orthopedic Injuries
Overall Foundations
Background and Importance
Fractures
Foundations
Anatomic Location of a Fracture: Nomenclature
Anatomic Descriptors
Descriptive Modifiers
Fracture Eponyms and Mechanistic Names
Epiphyseal Fractures
Clinical Features of Fractures
Fracture Healing
Complications of Fractures
Infection (Osteomyelitis)
Hemorrhage
Vascular Injuries
Nerve Injuries
Compartment Syndrome
. Increased pressure in a closed, non-­expandable compartment essentially represents a mismatch between the volume of that space...
. Compartment syndrome theoretically can develop in any location where neuromuscular tissue is contained within a limited or con...
. Compartment syndrome is a clinical diagnosis. In a conscious and fully oriented patient, pain that is disproportionate to the ...
. Clinical examination remains the diagnostic cornerstone of acute compartment syndrome, which can then be confirmed by the meas...
. Complete fasciotomy is the only treatment that can reliably normalize elevated compartment pressure. Surgery should be perform...
Avascular Necrosis
Fat Embolism Syndrome
Fracture Blisters
Complications of Immobilization and Hospitalization
Damage Control Orthopedic Surgery
Differential Diagnoses
Diagnostic Testing
Plain Radiography
Special Imaging Techniques
. Although conventional radiography remains the initial imaging study of choice for skeletal trauma, CT offers a more detailed a...
. MRI constitutes the most advanced noninvasive examination of orthopedic structures, delineating lesions of bone, cartilage, li...
. Point of care ultrasound can be an effective tool for the diagnosis of fractures when conventional radiography is unavailable,...
Laboratory Testing
Management
Field Care
. Suspected fractures should be splinted in the field to limit damage to muscles, nerves, vessels, and skin and to prevent a clo...
Emergency Department Care
Upper Extremity
. Sling-­and-­swathe bandages are useful in immobilizing the shoulder, humerus, and elbow. They are commonly used after reductio...
. A simple sling of the arm on the affected side is sufficient to support the clavicle, improving healing immobilization and rel...
. Well-­fitting, customized plaster splints can be fashioned easily to immobilize the elbow, forearm, wrist, and hand. The advan...
Casts
Forearm and Wrist Splints
Lower Extremity
. Immobilization of the ankle can be accomplished by numerous methods. Plaster or fiberglass splints can be used temporarily for...
Thermal Therapy
Disposition
Subluxation and Dislocations
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Soft Tissue Injuries
Sprains
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
. Plain radiography is indicated in some, but not all, cases of suspected sprain to rule out a fracture. From a medical standpoi...
. MRI is generally not indicated acutely but may be indicated in follow up when significant ligamentous injuries that may requir...
Management
Disposition
Strains
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Tendinitis and Tendinosis
Foundations
Clinical Features
Differential Diagnosis
Diagnostic testing
Disposition
Bursitis
Foundations
Clinical Features
Diagnostic Modalities
Management
Disposition
Other Soft Tissue Conditions
References
42 - Hand Injuries
Anatomy
Surface Anatomy and Skin
Skeletal Anatomy and Ligaments
Musculature and Tendons
. The intrinsic hand muscles include the muscles of the thenar and hypothenar eminences as well as the adductor pollicis, lumbri...
. The extrinsic hand muscles are those that originate proximal to the wrist and insert within the hand. Most extrinsic hand musc...
. The extensors tendons pass through the dorsum of the wrist at 6 different compartments and are innervated by the radial nerve ...
. The anterior forearm contains muscles responsible for flexion of the wrist, hand, and digits and can be divided into an anteri...
. The digital flexor sheath of the hand is a closed system of synovial membranes that is divided into membranous and retinacular...
Blood Supply
. The radial and ulnar arteries are primarily responsible for blood supply to the hand. The radial artery courses through the an...
Venous and Lymphatic System
Innervation and Sensory Systems
Regional Blocks
Digital Block
Metacarpal and Transthecal Blocks
Wrist Blocks
. The radial artery at the volar surface of the wrist is palpated. Immediately lateral (radial) to this region, after aspirating...
. The tendon of the flexor carpi radialis at the volar surface of the wrist is palpated. The needle is inserted over the median ...
. The needle should be inserted between the ulnar artery and the flexor carpi ulnaris tendon and advanced approximately 1 cm. If...
Splinting
Ring Removal
Specific Hand Injuries
Phalanx and Metacarpal Fractures
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Phalanx Fractures
Distal Phalanx Fractures
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Middle Phalanx Fractures
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Proximal Phalanx Fractures
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Metacarpal Fractures
Clinical Features
Differential Diagnosis
Diagnostic Imaging
Management
Thumb Fractures
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Joint Injuries
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Interphalangeal Joint Injuries
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Metacarpophalangeal Joint Injuries
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Carpometacarpal Joint Injuries
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Thumb Dislocations and Ligamentous Injuries
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Tendon Injuries
Extensor Tendon Injuries
Clinical Features
. This zone includes the distal phalanx and DIP joint. Terminal tendon disruption from sudden flexion of the extended DIP joint ...
. Injuries occur over the middle phalanx and are usually due to a laceration. Rarely, a mallet deformity will form from a lacera...
. Injuries in this zone involve the PIP joint and the central slip. Boutonnière injury (flexion at the PIP joint with hyperexten...
. This zone includes injuries over the proximal phalanx. Like in zone II, injuries usually occur from lacerations. The tendon is...
. Injuries at this zone involve the sagittal band at the MCP joint. The most common injury is to the radial sagittal band of the...
. Injuries at this zone occur over the metacarpals, most frequently secondary to lacerations. Complete lacerations are often mis...
. Lacerations over the carpals and extensor retinaculum account for most injuries at this zone, though injuries may also occur w...
Differential Diagnoses
Diagnostic Testing
Management
. Most mallet finger injuries are successfully treated with immobilization, though injuries accompanied by fracture dislocations...
. Incomplete lacerations can be managed with simple closure and splinting of the DIP in extension for 2 weeks. Complete lacerati...
. Central slip disruptions (boutonnière injuries) are treated by splinting the PIP joint in extension for 4 to 6 weeks followed ...
Zone IV Extensor Injuries Management
. Stable sagittal band injuries (type I) can be treated with buddy or dynamic taping for 3 to 4 weeks. Acute injuries with sublu...
. Clean, complete tendon lacerations may be repaired by an EM physician, though we recommend discussion with a hand specialist f...
. If there is no need for immediate surgical intervention (such as gross contamination), wounds should be thoroughly irrigated f...
Disposition
Flexor Tendon Injuries
Clinical Features
Differential Diagnoses
Diagnostic Studies
Management
Disposition
Trigger Finger
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Finger and Nail Bed Injuries
Nail Bed Injuries
. The nail bed is frequently injured in a manner that ranges from minimal to severe. Injury occurs after direct trauma to the fi...
. When evaluating a patient with a suspected nail bed injury, the EM clinician should also consider an underlying tuft fracture,...
. Imaging is needed to determine if there is fracture of the finger tuft. PA, lateral, and oblique radiographs will identify a f...
. For a subungual hematoma covering greater than 50% of the nail bed, the typical practice is to trephinate, or create an openin...
. The injuries resulting in subungual hematomas with non-­displaced fractures can be followed up by primary care physicians as m...
Amputations
Fingertip Amputations
. Amputations of the fingertips are common, most often occurring in children. These injuries can result in macerated tissue, but...
. When caring for a patient with a digit amputation, one should consider associated foreign bodies, proximal fractures, ligament...
. Standard 3-­view x-­rays of the affected digit should be performed
. Initial management includes assessment of the wound, control of bleeding, and thorough irrigation of the injury without furthe...
. Immediate consultation with the hand specialist is needed for all but those with zone I and other minimal injuries. In the Uni...
Degloving Injuries
Mutilating Hand Injuries
Skin and Soft Tissue Injuries
Clinical Features
Diagnostic Testing
Management
. Evaluation of a laceration over the extensor tendon includes obtaining visualization of the underlying tendon throughout its e...
Disposition
Clenched Fist Injuries
Infectious Disorders of the Hand
General Hand Infections
Paronychia
Onychomycosis
Felon
Herpetic Whitlow
. Herpetic whitlow is a cutaneous herpes simplex virus (HSV) infection seen on the fingers from contact with oral lesions via se...
. Herpetic whitlow is sometimes confused with a paronychia or felon. Special attention should be given to the presence of vesicu...
. Diagnosis is made through viral culture or PCR assay of the unroofed lesions
. No antiviral therapy is indicated in immunocompetent patients because the disease is generally self-­limited, though oral acyc...
Purulent Flexor Tenosynovitis
. The most common symptom of purulent flexor tenosynovitis is fusiform swelling of the digit, with direct tenderness over the fl...
. One should also consider trigger finger (stenosing tenosynovitis), Dupuytren contracture, tendon injury, inflammatory arthriti...
. Plain films do not appear to distinguish between tenosynovitis and other general hand infections, though they are used to asse...
. Skin contaminants of gram-­positive bacteria are typical in these infections, making early use of antibiotics appropriate. Ini...
Deep Space Infections
. Deep space infections of the volar side of the hand are found under the flexor tendons but above the interosseous muscles in t...
. Consider compartment syndrome in patients with exceptional swelling, disproportional pain, and neurovascular compromise
. Ultrasound and MRI are more sensitive than CT scan and often are needed to make the diagnosis early in the course of the disea...
. The classic infectious organisms include Staphylococcus aureus and Streptococcus spp. Because there has been an increase in gr...
Skin and Soft Tissue Disorders
Onycholysis
High-­Pressure Injury
Ganglion Cysts
Dupuytren Contracture
Acknowledgments
References
43 - Wrist and Forearm Injuries
Foundations
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
Carpal Injuries
Scaphoid Fractures
. Scaphoid fractures often occur after a fall on the outstretched hand, causing hyperextension of the wrist. These injuries are ...
. Patients typically report radial-­sided wrist pain distal to the radial styloid with decreased range of motion of the wrist an...
. Radiographic imaging remains the cornerstone for the evaluation of acute wrist trauma, but radiographic diagnosis of scaphoid ...
. To avoid complications associated with delayed diagnosis, such as occult fracture displacement and AVN, patients with suspecte...
Lunate fractures
. Fractures of the lunate are relatively uncommon. This injury tends to occur in persons with a congenitally short ulna
. Patients will experience pain over the dorsum of the wrist, exacerbated by axial loading of the long finger metacarpal. On phy...
. In the ED, wrist radiographs are utilized to assess for lunate fractures; however, fractures of the lunate may be difficult to...
. To minimize the risk of AVN, clinically suspected lunate fractures should be immobilized due to the possibility of occult luna...
Triquetral Fractures
. There are two main patterns of triquetral fractures that are observed: triquetral body and dorsal cortical chip fractures. An ...
. Patients will experience local tenderness over the dorsal wrist (in the setting of dorsal cortical chips) or volar wrist (avul...
. A fracture to the triquetral body is best seen on the AP view. Dorsal triquetral chip fractures are best seen on the standard ...
. Treatment of triquetral fractures involves immobilization in a short arm volar splint. Urgent orthopedic referral within 5 to ...
Pisiform Fractures
. The pisiform is unique because it is the only sesamoid-­like carpal bone and attaches to the FCU tendon, articulating on its d...
. Fractures of the pisiform usually occur from a fall on the outstretched hand but also may be seen after direct blows to the hy...
. Pisiform fractures are poorly seen on routine wrist radiographs and are likely underreported. A reverse (supinated) oblique an...
. Nondisplaced fractures of the pisiform generally carry a good prognosis and are treated conservatively, with immobilization in...
Hamate Fractures
. The hook or hamulus is the most common site of hamate fracture, although articular surfaces and body fractures are also seen
. Fracture of the hook usually occurs from a fall on the outstretched hand or from a direct blow to the palm. A fracture to the ...
. Hamate body and articular surface fractures are best seen on PA views of the wrist (Fig. 43.17). Standard wrist radiographs ha...
. Confirmed hook of hamate fractures should be immobilized in a volar splint that includes the fourth and fifth MCP joints in fl...
Trapezium Fractures
. There are two main types of trapezium fractures, those involving the body and trapezial ridge
. A direct blow to the adducted thumb causes fracture through the body of the trapezium, with transmittal of the force by the ba...
. Although trapezium fractures may be seen on the AP view of the wrist, they are typically better visualized on oblique views (F...
. Nondisplaced trapezium fractures are treated with immobilization in a short arm thumb spica splint, with orthopedic referral w...
Capitate Fractures
. The capitate lies in a central position in the distal carpal row and, because of this protected location, it is rarely fractur...
. The mechanism generally is a direct blow to the dorsum of the wrist. Fractures may also be seen in association with perilunate...
. Fractures usually are visible on the standard PA view of the wrist, although the lateral and oblique views may be helpful in d...
. Identified or suspected nondisplaced fractures of the capitate should be managed with immobilization in a short arm thumb spic...
Trapezoid Fractures
. Trapezoid fractures are rare, usually seen in association with other carpal injuries
. The typical mechanism of injury is a direct blow down the long axis of the index metacarpal, which may result in isolated frac...
. The fracture may be visible on routine PA views of the wrist; however, oblique views may be superior for visualization of the ...
. Confirmed or suspected nondisplaced trapezoid fractures should be immobilized with a short arm thumb spica splint with urgent ...
Carpal Instability
. The Mayfield classification of carpal instability is comprised of four distinct stages. Each stage represents a sequential int...
. Carpal ligamentous injury is caused by wrist hyperextension, ulnar deviation, and intercarpal supination. Patients with these ...
. A stage I injury, or scapholunate dissociation, results in a characteristic widening of the scapholunate joint on the PA view,...
. Carpal dislocation injuries need emergent orthopedic consultation in the ED for reduction and stabilization. ED management of ...
Radiocarpal Dislocation
. Radiocarpal dislocations and fracture dislocations are considered extremely rare and are typically associated with high-­energ...
. Patients are commonly involved in polytrauma scenarios. Dislocations may be volar or dorsal, although ulnar translation of the...
. Radiographs of the wrist are typically sufficient to identify radiocarpal dislocations
. Emergent reduction of these injuries is paramount because of the extensive soft tissue damage and commonly associated neurovas...
Distal Radius and Ulna Injuries
Colles Fracture
. A Colles fracture refers to a transverse fracture of the distal radial metaphysis, which is dorsally displaced and angulated
. Patients classically present with a “dinner fork deformity” on physical examination. The fracture usually is located within 2 ...
. The PA view may show extension of the fracture into the radioulnar or radiocarpal joints and the amount of intraarticular step...
. Most Colles fractures require ED reduction for restoration of radial length, correction of dorsal angulation (especially when ...
Smith Fracture
. Smith fracture is a transverse fracture of the metaphysis of the distal radius, with associated volar displacement and angulat...
. The typical mechanism of injury involves a direct blow to the dorsum of the wrist or a fall onto the dorsum of the hand result...
. The fracture is visible on PA and lateral radiographs of the wrist, but the lateral view best shows the degree of volar displa...
. Treatment of this fracture involves closed reduction and immobilization in a splint if the fracture is extra-­articular, as di...
Barton Fracture
. Barton fracture is an oblique intraarticular fracture of the rim of the distal radius, with displacement and dislocation of th...
Clinical features
. Volar and dorsal rim fractures are visible on PA and lateral wrist radiographs; however, the lateral view best shows the degre...
. Treatment of these unstable fractures requires emergent orthopedic consultation for reduction and fixation. Closed reduction m...
Hutchinson Fracture
. Hutchinson fracture, or chauffeur’s fracture, is an intra-­articular fracture of the radial styloid
. The mechanism of injury is usually a direct blow or fall resulting in trauma to the radial side of the wrist. The term chauffe...
. The fracture is seen best on the PA view of the wrist as a transverse fracture of the radial metaphysis, with extension throug...
. Nondisplaced fractures may be immobilized in a sugar tong splint, with the patient given urgent orthopedic referral within 2 t...
Distal Radioulnar Joint Disruption
. Acute dislocation of the DRUJ can occur as an isolated injury, which is rare, or in association with a fracture to the distal ...
. Certain characteristic findings on clinical examination may constitute the only clue to the presence of this injury. The typic...
. Diagnosis often is difficult because when the injury occurs in isolation or is not suspected, plain radiographs commonly are r...
. Treatment of DRUJ dislocations commonly requires emergent orthopedic consultation for reduction and stabilization. Closed redu...
Soft Tissue Injuries of the Wrist
Carpal Tunnel and Acute Carpal Tunnel Syndrome
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
De Quervain Disease
Foundations
Clinical Features
Diagnostic Testing
Management and Disposition
Intersection Syndrome
Foundations
Clinical Features
Diagnostic Testing
Management and Disposition
Anatomy, Physiology, and Pathophysiology
Differential Diagnoses
Diagnostic Testing: Radiology
Shaft Fractures of Radius and Ulna
Foundations
Clinical Features
Diagnostic Testing
Management and Disposition
Ulna Shaft Fractures
Foundations
Clinical Features
Diagnostic Testing
Management and Disposition
Monteggia Fracture
Foundations
Clinical Features
Diagnostic Testing
Management and Disposition
Galeazzi Fracture
Foundations
Clinical Features
Diagnostic Testing
Management and Disposition
Essex-­Lopresti Lesion
Foundations
Clinical Features
Diagnostic Testing
Management and Disposition
References
44 - Humerus and Elbow Injuries
Background and Importance
Anatomy, Physiology, and Pathophysiology
General Differential Diagnoses
General Diagnostic Testing
General Management
General Disposition
Specific Fractures
Shaft of the Humerus
. Fractures of the humeral shaft commonly result from a direct blow to the arm, severe twisting, or a fall on an outstretched ha...
. Imaging studies should routinely include the shoulder and elbow joints. The humerus is a common site for benign tumors, unicam...
. Isolated, closed fractures are treated with a high degree of success. Attempts at fracture reduction and external immobilizati...
. Splinting can be done for comfort during patient manipulation but should be limited. Cefazolin (2 g intravenously) is given, a...
.5 Radial nerve injury causes wrist drop with loss of the ability to extend the fingers and thumb.6 This nerve injury is most of...
. All patients with humeral shaft fractures should be referred to an orthopedic surgeon for further evaluation within 48 hours a...
Distal Humerus
. Distal humerus fractures that occur proximal to the epicondyles are called supracondylar fractures. This type of fracture is a...
Anchor 328
. Extension supracondylar fractures occur as a consequence of a fall on the outstretched hand when the elbow is either fully ext...
. Two diagnostic aids in evaluating for possible supracondylar fractures include using the anterior humeral line and evaluation ...
. Current treatment recommendations for supracondylar fractures from the American Academy of Orthopedic Surgeons remain based on...
Flexion type supracondylar fractures
. Flexion-­type supracondylar injuries are much less common, with a reported frequency of about 2% of all supracondylar fracture...
. Plain films may reveal a simple increase in the anterior angulation of the distal supracondylar fragment or gross displacement...
. For flexion-­type supracondylar injuries, when the posterior periosteum is torn, the anterior periosteum functions as a tensio...
Transcondylar Fractures
. Both extension and flexion types of transcondylar fractures have been described based on the position of the elbow when fractu...
. Transcondylar (or dicondylar) fractures have a fracture line, either transverse or crescent shaped, that passes through both c...
. Transcondylar (or dicondylar) fractures are difficult to treat because the small distal fragment possesses little extra-­artic...
Intercondylar Fractures
. These injuries are rare and generally are seen in adults aged 50 to 70 years. The common mechanism of injury is direct trauma ...
. Good-­quality anteroposterior and lateral radiographic views are essential in evaluating fracture displacement and comminution...
. Treatment of intercondylar fractures is challenging. The goal of treatment is to reestablish articular congruity and alignment...
Condylar Fractures
. Condylar fractures are rare in adults and typically involve the articular surface and the non-­articular portion of the distal...
. Diagnosis is usually made on standard anteroposterior and lateral views, although an oblique view also may be helpful. These f...
. For condylar fractures, treatment depends on radiographic findings, but controversy exists about the accuracy of these finding...
Capitellum and Trochlea Fractures
. Fractures of the capitellum and trochlea typically occur together, usually as a result of posterior dislocation of the elbow, ...
. For capitellum fractures, a lateral plain film usually shows the fragment lying anterior and proximal to the main portion of t...
. Treatment of capitellum and trochlea fractures begins in the ED with a posterior splint, ice packs, elevation, compression, an...
Epicondylar Fractures
. Most epicondylar fractures involve the medial epicondyle. Medial epicondyle fractures are most common in children and adolesce...
. Simple fractures of the medial epicondyle are extra-­articular injuries with limited soft tissue injury.18 They generally do n...
. For epicondylar fractures, if the fracture fragment is minimally displaced (< 5 mm), treatment with a posterior splint is appr...
Olecranon
. Fractures of the olecranon commonly occur from a direct blow as a result of a fall, a motor vehicle or motorcycle crash, or an...
. Lateral radiographic views provide the most information. In addition to the fracture, the degree of comminution, the extent of...
. In olecranon fractures, non-­displacement in the 90-­degree flexion position indicates that the triceps aponeurosis tendon is ...
Radial Head and Neck
. Radial head and neck fractures, in general, are produced by an indirect mechanism, typically a fall on an outstretched hand. T...
. Radiographic findings range from a subtle disruption of the usual gradual sweep of the radial neck and head surface to an obvi...
. Radial head and neck fractures are classified by Manson criteria. Type I nondisplaced fractures are treated symptomatically wi...
Dislocations/Subluxations
Elbow
. The elbow is inherently subject to mechanical instability because of its anatomic structure and dislocations are common. The e...
. A radiographic example of posterior elbow dislocation before reduction is provided in Fig. 44.26. The anteroposterior view is ...
. Rapid reduction of complete elbow dislocations is important to relieve pain and to prevent circulatory injury or cartilaginous...
Radial Head Subluxation
. Subluxation of the radial head (or “nursemaids’ elbow”) is a common injury, representing more than 20% of upper extremity inju...
. When the history is suggestive of radial head subluxation, radiographs are not indicated and are rarely useful. If there is sw...
. Reduction may be attempted in children with typical presentations and is safe even when the classic history is absent. Althoug...
Soft Tissue Disorders
Epicondylitis
. Epicondylitis is a term first introduced to describe an inflammatory process that involves the radiohumeral joint or lateral e...
. Radiographic findings may be normal, although with chronicity, calcifications may be present over the lateral epicondyle. Char...
. Treatment includes protection, rest, ice, compression, elevation, and analgesics. Initial therapy includes avoidance of the in...
Olecranon Bursitis
. Olecranon bursitis is commonly caused by repetitive minor trauma, such as leaning on the elbow during work activities. It also...
. The most important aspect of evaluation is the differentiation of a septic process from a benign inflammatory one, and this di...
. Aspiration is diagnostic and therapeutic because relief of pressure relieves some of the pain. In cases of purulent bursitis, ...
Biceps Tendon Rupture
. Biceps tendon rupture occurs most commonly in the proximal portion of the long head of the biceps. It is most common in middle...
. The patient’s history and physical exam is often diagnostic of such an injury, and radiographs are not revealing and usually n...
. All patients require referral to an orthopedist within 72 hours for evaluation for early anatomic repair of complete ruptures....
Acknowledgments
References
General Clinical Features
45 - Shoulder Injuries
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
History
Physical Examination
Differential Diagnoses
Diagnostic Testing
Radiology
Specific Injuries
Fractures
Clavicle
. The clavicle accounts for 3% to 5% of all fractures with a 2:1 male to female ratio. It is also the most commonly fractured bo...
. The affected extremity is held close to the body as a result of the effect of gravity and the pull of the muscles (pectoralis ...
. In patients with direct fall onto lateral shoulder the differential diagnosis includes soft tissue injury (hematoma, contusion...
. Clavicle-­specific plain radiographs may be required to confirm the presence of a fracture, although most clinically significa...
. Principles of initial management for simple fractures include pain control, immobilization primarily for comfort, and proper f...
. Most fractures of the clavicle heal uneventfully, and follow-­up can be provided by a primary care physician. A sling should b...
Scapula
. Fractures of the scapula are rare, accounting for approximately 1% of all shoulder fractures and caused by high-­energy trauma...
. In a conscious patient, the shoulder is held in a position of most comfort, usually with the arm adducted and held close to th...
. High energy trauma that can lead to a scapula fracture should also include the following on the differential diagnosis: rib fr...
Diagnostic testing
. The three-­view trauma shoulder series will reveal most scapular fractures, as will careful examination of the scapula on the ...
. Presence of a scapular fracture should prompt a thorough search for associated thoracic, intracranial, orthopedic, and neurova...
Proximal Humerus
. Fractures of the proximal humerus occur primarily in the older population, in whom structural changes (osteoporosis) weaken th...
. The affected arm is held close to the body, and movement is restricted by pain. Tenderness, hematoma, ecchymosis, deformity, o...
. The differential diagnosis of a proximal humerus fracture includes: glenohumeral dislocation, AC joint separation, rotator cuf...
. The three-­view trauma series allows for assessment of the number of fracture fragments and degree of displacement or angulati...
. Minimally displaced fractures (see Fig. 45.12) constitute up to 80% to 85% of all cases. In these instances, limited displacem...
Pediatric Proximal Humeral Fracture
. Fractures of the proximal humeral physis and metaphysis are uncommon and account for a small proportion of pediatric fractures...
. The patient typically holds the injured arm tightly against the body, using the opposite hand. The area over the proximal hume...
. The differential diagnosis for pediatric proximal humeral fractures varies based on age and acuity of the injury. Differential...
. Orthogonal radiographs help confirm the diagnosis. Comparison views may be helpful with minimally displaced fractures (Fig. 45...
. Fractures of the proximal humeral epiphysis can result in significant permanent injury and disability as the physis accounts f...
Dislocations
Sternoclavicular
. SCJ dislocations are infrequent and account for less than 1% of all dislocations.17 Significant forces are required to disrupt...
. Clinical suspicion based on mechanism and exam is the single most important factor in diagnosing these injuries. The injured e...
. The differential diagnosis for patients with traumatic SC joint pain include medial clavicle fracture, rib fracture, costochon...
. Although diagnosed clinically, sternoclavicular dislocation requires radiological confirmation. Findings on standard anteropos...
. Treatment of grade I injuries includes sling immobilization for comfort and primary care follow-­up. Immobilization generally ...
Acromioclavicular Joint
. Injuries of the ACJ occur primarily in young men as a result of MVCs, bicycle accidents, or participation in high impact conta...
. Patients should be examined while they are upright, because the supine position can mask ACJ instability, and it is helpful to...
. While a lateral blow to the shoulder can cause an AC joint dislocation, other important diagnostic considerations include dist...
Diagnostic testing
. The recommended projections include routine anteroposterior and axillary lateral view to evaluate for vertical migration of th...
. Type I and II injuries should be immobilized in a sling for comfort and to remove stress on injured ligaments. Patients with t...
Glenohumeral Dislocations
. The GHJ is the most commonly dislocated major joint in the body. Dislocation follows a bimodal age distribution for men, age 2...
Anterior Dislocations
. Anterior dislocations can result from indirect or direct forces. In younger persons, the injury usually is sustained during at...
. The patient presents in severe pain often supporting the dislocated shoulder with the opposite extremity. The lateral edge of ...
. Patients presenting with shoulder pain and a full anterior shoulder on examination should be evaluated for glenohumeral disloc...
Diagnostic testing
. Radiographs including anterior-posterior, trans-­scapular Y view, and axillary lateral will confirm the clinical diagnosis and...
. Reduction of the dislocation should be accomplished expeditiously, because the incidence of neurovascular complications increa...
Posterior Dislocation
. Posterior dislocations are uncommon, accounting for fewer than 5% of all glenohumeral dislocations.24,26 The glenoid fossa act...
. Early diagnosis is essential to prevent long-­term complications. The affected arm is held across the chest in adduction and i...
. Posterior glenohumeral subluxation is a much more common event than posterior glenohumeral dislocation and remains an importan...
Diagnostic testing
. True or standard anteroposterior radiographs can appear deceptively normal with posterior dislocations. Radiographic features ...
. Closed reduction may be attempted in the ED with procedural sedation. The technique incorporates internal rotation and lateral...
Inferior Glenohumeral Dislocation (Luxatio Erecta)
. Luxatio erecta is a rare type (<0.5%) of glenohumeral dislocation in which the superior aspect of the humeral head is forced b...
. Clinically, the patient has the arm locked overhead in 110 to 160 degrees of abduction. The elbow usually is flexed, and the f...
. Luxatio erectae dislocations are easily mistaken, diagnosed, and treated as subglenoid anterior dislocations, because the radi...
Diagnostic testing
. Standard radiographs show the superior articular surface inferior to the glenoid fossa (Fig. 45.28). In addition, the humeral ...
. Reduction usually can be accomplished by traction/countertraction maneuvers (Fig. 45.29) under procedural sedation. Regional a...
Scapulothoracic Dissociation
. Scapulothoracic dissociation is a rare and severe injury characterized by complete disruption of the scapulothoracic articulat...
. Because most patients present with significant concomitant trauma, the dislocation may not be initially recognized. Massive lo...
. Scapulothoracic disassociation is the result of a significant forceful movement and evaluation for concurrent neurovascular in...
. Vascular and neurologic injuries can be confirmed through emergent CT angiography and MRI.30
. Identification is a critical step in the management of this injury. Rarely occurring in isolation, these dislocations will typ...
Soft Tissue Conditions
Impingement Syndrome
. Impingement syndrome of the subacromial space occurs across a wide spectrum of the population from the young adult overhead th...
. The spectrum of illness is marked by a progression of symptoms. Initially patients report a dull ache around the deltoid area ...
. People presenting with vague shoulder pain localizing to lateral shoulder that is worse with movement may have impingement syn...
. POCUS can show thickening of the supraspinatus tendon and associated fluid in the subacromial bursa.31
. Initial treatment for impingement syndrome is conservative and consists of rest, simple analgesia using acetaminophen or analg...
Rotator Cuff Tears
. The rotator cuff acts as a dynamic stabilizer of the GHJ. Its primary function is to hold the humeral head in place throughout...
. With acute tears, patients report a sudden tearing sensation in the shoulder followed by severe pain that radiates into the la...
. Rotator cuff tears are rarely acute traumatic injuries. In the evaluation of a suspected chronic rotator cuff tear alternative...
Diagnostic testing
. Plain radiographs likely will be normal in acute or chronic tears and are not generally indicated.34 If obtained, they may sho...
. Acute tears should be immobilized in a sling for comfort and the patient referred for orthopedic follow-­up within 1 to 2 week...
Lesions of the Biceps Muscle
Bicipital Tendinitis
. Anatomically, the long head of the biceps is subject to the same stresses as those incurred by the rotator cuff within the sub...
. On examination, point tenderness can be elicited over the biceps tendon as it passes through the bicipital groove. This is bes...
. The differential diagnosis of insidious onset anterior shoulder pain includes proximal biceps tendon tear, rotator cuff tear, ...
Diagnostic testing
. Radiographs are usually normal and not indicated unless fracture or dislocation is suspected. If obtained, they may show evide...
. Emergency treatment consists of rest (sling for comfort), ice, and oral analgesia. Gentle exercises are encouraged as symptoms...
Ruptures of the Biceps Tendon
. Ruptures of the biceps tendon can be classified into proximal and distal types. Distal ruptures are rare (estimated to have an...
. The classic history of an acute rupture is that of a sudden snap or pop, followed by pain and ecchymosis along the arm. Recent...
. Alternative differential considerations for anterior shoulder pain after an acute pop include: subluxing bicep tendon, rotator...
Diagnostic testing
. Radiographic findings usually are unremarkable, and the confirmatory test of choice is MRI. POCUS can be used to identify pres...
. The injured arm should be immobilized in a sling with the elbow in 90 degrees of flexion. The patient should be referred to an...
Calcific Tendinitis
. Shoulder calcific tendinitis affects up to 10% of the population and frequently is encountered in the ED. The condition affect...
. The clinical presentation can be divided into silent, subacute, and acute phases based on the physical characteristics of the ...
. The clinical presentation of symptomatic calcific tendinopathy can be similar to that of rotator cuff tendinopathy, rotator cu...
Diagnostic testing
. Radiographs show calcific deposits in the involved tendon (Fig. 45.33). POCUS can identify and effectively localize calcific d...
. The acute phase should be treated with a sling for comfort, NSAIDs, and avoidance of offending activities. Refer patients to p...
Adhesive Capsulitis
. Adhesive capsulitis (“frozen shoulder”) is a specific diagnostic entity characterized by an idiopathic inflammatory reaction w...
. Risk factors for developing adhesive capsulitis include female sex, age between 40 and 60 years old, thyroid disease, and diab...
. Asymmetric limitations in passive and active range of motion are hallmarks of adhesive capsulitis. Other causes of limited pas...
. The diagnosis of adhesive capsulitis is typically made based on a clinical exam and history alone. Radiographs are helpful to ...
. The best form of therapy is preventive in nature. Prolonged shoulder immobilization is to be avoided, and early motion encoura...
Injection Therapy
References
46 - Pelvic Injuries
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Bony and Ligamentous Anatomy
Vascular Anatomy
Neurologic Anatomy
Pathophysiology and Key Patterns of Pelvic Fracture
Stable Injuries (Tile Type A)
. The normal pelvis is not completely rigid, due to the slight mobility at the sacroiliac joints and symphysis pubis and the inh...
. Transverse fractures of the sacrum do not compromise the pelvic ring. Transverse fractures at or below the S4 level are unlike...
. These usually occur during athletic activities and are the result of a sudden, forceful muscular contraction or excessive musc...
. Stress fractures can occur with vigorous athletic or military training or during the last trimester of pregnancy. The diagnosi...
. Pathologic fracture related to neoplasm, Paget disease, or dietary osteomalacia should be included in the differential diagnos...
Partially Stable and Unstable Injuries (Tile Types B and C)
. Severe anteroposterior compression forces cause disruption at or near the symphysis pubis. The symphysis is normally ≤0.5 cm i...
. Lateral compression of the pelvic ring results in varying degrees of internal rotation of the affected hemipelvis. Initially, ...
. Vertical shear injuries are the most unstable injuries affecting the pelvic ring and are associated with violent axial loading...
. A crucial distinction in considering sacral fractures is that transverse fractures do not involve the pelvic ring, but vertica...
Open Pelvic Fractures
Penetrating Pelvic Trauma
Associated Pelvic Injuries
Urologic Injury
Neurologic Injury
Gynecologic Injury
Associated Non-­Pelvic Injuries
Acetabular Fractures
Coccyx Fractures
Clinical Features
History
Physical Examination
Deep Venous Thrombosis
Differential Diagnosis
Diagnostic Testing
Radiology
Plain Radiography
Computed Tomography
Evaluation of Hemorrhage
Diagnostic Peritoneal Lavage
Ultrasound
Computed Tomography
Management
Resuscitation
Control of Hemorrhage
Stabilizing the Pelvis
. The most readily available means to stabilize the pelvis quickly in the ED is a sheet and towel clamps. Wrapping the pelvis ti...
. External fixation of the pelvis is performed by orthopedic surgeons to prevent movement at fracture sites and to control bleed...
Angiography and Embolization
Hemodynamically Unstable Patients With Pelvic and Intra-­Abdominal Hemorrhage
Disposition
References
47 - Femur and Hip Injuries
General Information
Foundations
Anatomy of the Hip and Femur
Skeletal Anatomy
Musculature
Arterial Supply
Venous System
Nerves
Pathophysiology and Key Patterns of Injury
Fractures and Trauma of the Femur and Hip
Osteoporosis of the Femur
. A large percentage of the American population experiences chronic pain from degenerative osteoarthritis of the hip. Disability...
Avascular Necrosis
Myositis Ossificans
Calcific Bursitis and Calcifying Peritendinitis
Neoplastic Disease in the Hip
History
Physical Examination
Differential Diagnoses
Diagnostic Testing
Radiographic Evaluation
Occult Hip Fracture
Management
Traction and Immobilization
Open Fracture Care
Compartment Syndrome
Pain Management
Systemic Analgesia
Pharmacologic Approaches
Femoral Nerve Block
Specific Fractures of the Hip and Femur
Avulsion Fractures
. The incidence of avulsion fractures is increasing as a result of the growth of competitive sports and outdoor activities, espe...
. The athlete classically experiences a sudden piercing pain at the site of injury, along with a “snapping” or “popping” sound a...
. The differential diagnoses of these avulsion fractures include muscle strain and tears, tendinopathy, and hip dislocations
. As depicted in Fig. 47.15, avulsion at the ASIS involves the separation of a thin piece of bone as the sartorius muscle sudden...
Proximal Femur Fracture
Femoral Neck Fractures
. Femoral neck fractures are classified as either nondisplaced or displaced. Between 15% and 20% of all femoral neck fractures a...
. On initial evaluation, a patient with a displaced fracture of the femoral neck lies with the limb externally rotated, abducted...
. Plain hip radiographs generally confirm the diagnosis of a femoral neck fracture
. Treatment of these displaced fractures consists of open reduction and internal fixation (ORIF), hemiarthroplasty, or total hip...
. Patients with femoral neck fractures should be admitted for operative repair
Intertrochanteric Fractures
. The fracture line of intertrochanteric fractures extends between the greater and lesser trochanters of the femur. These injuri...
. The strong action of the iliopsoas muscle causes the leg to be shortened and externally rotated
. Plain hip radiographs generally confirm the diagnosis of intertrochanteric fractures
. A substantial majority of intertrochanteric fractures require internal fixation. Such fixation brings rapid mobilization, decr...
. Patients with intertrochanteric fractures should be admitted for operative repair
Isolated Fractures of the Greater or Lesser Trochanter
. Isolated fractures of the greater or lesser trochanter are rare. They occur in women more often than in men and are the result...
. Patients present with hip pain and tenderness over their trochanter
. Plain hip radiographs generally confirm the diagnosis of these isolated fractures
. Treatment consists of pain control and early mobilization with crutches; weight bearing is allowed as tolerated
. Satisfactory outpatient management of this injury is possible because the healing process and prognosis is generally good
Subtrochanteric Fractures
. Subtrochanteric fractures occur between the lesser trochanter and the proximal 5 cm of the femoral shaft. They may accompany i...
. Plain hip radiographs confirm the diagnosis of most subtrochanteric fractures
. Definitive management of subtrochanteric fractures is complex. Maintaining limb length and controlling rotation are difficult....
. Patient with subtrochanteric fractures should be admitted for operative repair
Femoral Shaft Fractures
. Femoral shaft fractures are common injuries in young adults after high-­energy trauma. As is the case with other femoral corti...
. Patients often arrive with the injured extremity immobilized by traction devices, which should be removed while immobilization...
. Plain hip radiographs including full length views of the femur confirm most femoral shaft fractures
. Internal fixation with intramedullary rods has been demonstrated to shorten both hospitalization and total disability time aft...
. Patients with femoral shaft fractures should be admitted for operative repair
Stress Fractures
. Femoral neck stress fractures or reactions occur when normal bone is subjected repeatedly to submaximal forces. This recurring...
. The symptoms of a stress fracture of the femoral neck are often subtle and can be mistaken for a muscle strain or an overuse i...
. Radiographs are helpful if they demonstrate a fracture, but findings are often negative until 10 to 14 days after the symptoms...
. Treatment of stress fractures of the femoral neck is based on involvement of the compressive or tensile aspect. Compressive-­s...
. Urgent orthopedic consultation for decision of operative versus nonoperative treatment is recommended for these types of stres...
Dislocations and Fracture-­Dislocations of the Hip and Femur
Hip Dislocations
. Dislocations and fracture-­dislocations of the hip are true orthopedic emergencies. The hip joint possesses impressive inheren...
. The position of the injured extremity might provide valuable clues in the evaluation of a hip dislocation. A patient with a po...
. Radiologic investigation begins with an anteroposterior view of the pelvis. This view alone will identify the majority of hip ...
. Hip dislocations constitute a true orthopedic emergency, and reduction should be performed within 6 hours. The incidence of AV...
. Most patients with a native hip dislocation will require admission to the hospital and urgent orthopedic referral for serial e...
Fracture-­Dislocation of the Femoral Head
. Hip dislocations can be associated with fractures of the femoral head (Fig. 47.29A). Femoral head fracture occurs in 35% to 55...
. When a femoral head fracture and hip dislocation coexist, patients assume the position typical for the dislocation. Hip mobili...
. Radiographs should be evaluated for any femoral head fracture in patients with hip dislocations. Evidence for fracture of the ...
. In most cases, satisfactory results can be obtained with closed reduction (see Fig. 47.29B). Several experts recommend obtaini...
. Patient with fracture-­dislocation of the femoral head should be admitted for operative management
Dislocation of Hip Prosthetics
. An increasing number of patients have undergone hip arthroplasty. In addition to those procedures performed for treatment of f...
. Most patients will present with inability to bear weight with associated hip or groin pain. The affected leg with be externall...
. Radiologic investigation begins with an anteroposterior view of the pelvis. See the Hip Dislocation section in this chapter fo...
. Reduction techniques for prosthetic hip dislocations are identical to those described earlier but are not as time dependent as...
. Consultation with an orthopedic surgeon is recommended for development of a long-­term treatment plan for the patient as chron...
Soft Tissue Injuries
Muscular Injuries
. Strenuous exercise by a poorly conditioned person, sudden exertion, and direct trauma all can injure soft tissues. Cold temper...
. Partial tears are reversible injuries that are aggravated by movement or tension. Mild spasm, swelling, ecchymosis, and tender...
. Differential diagnoses of these soft tissue injuries include muscle strain, partial and complete muscle tears, ligamentous or ...
. In the ED, plain radiographs can be obtained to exclude any fractures. Bedside ultrasound is also helpful in evaluating for pa...
. Initial management of incomplete tears traditionally includes the local application of ice for the first 48 hours, followed by...
. Any patient with significant injury should be referred for physical therapy. A complete muscle tear requires follow-­up care w...
Tendon Injuries
. Clinically, tendinopathies tend to have a more insidious onset than that typical for muscle strains. These strains occur at th...
. Local pain over the tendon, exacerbated by stretching of the tendon, is a common physical examination finding. Pain may radiat...
. Differential diagnoses of these tendon injuries include avulsion fractures, partial or complete tears of the muscles or tendon...
. Ultrasound imaging may lend additional diagnostic information. MRI can provide a definitive diagnosis but is not indicated in ...
. Treatment of a tendon strain is similar to that for other soft tissue injuries. The use of crutches with weight bearing as tol...
. Most patients will require follow up with an orthopedic or sports medicine specialist within a week
Osteitis Pubis
. Osteitis pubis is characterized by pubic symphysis pain and joint disruption and is most common in distance runners and soccer...
. Clinically, patients have groin pain of insidious onset, with most reporting pain at the symphysis and adductor muscles. Pain ...
. Osteitis pubis has been associated with spontaneous cases of pubic symphysis osteomyelitis and should be considered in the dif...
. Plain radiographs show widening of the symphysis, irregular contour of the articular surfaces, or periarticular sclerosis (a d...
. Treatment is conservative since in most cases the process is self-­limited. Patients benefit from activity modification, weari...
. Owing to the length of healing associated with these injuries, follow-­up care should be arranged at the time of initial injur...
Vascular Injuries
. Hip dislocations and femoral fractures may have associated arterial injury. The vessel can be partially lacerated, dissected, ...
. Patients may have decreased pulses, poor capillary refill, cold extremities, paresthesias and increased pain
. The differential diagnoses of these vascular injuries include arterial thrombus, arterial dissection, and complete or partial ...
. Ultrasound or CT angiogram are indicated for evaluating the vasculature
. Orthopedic or vascular surgery consultation is recommended if any partial or complete vascular tear is found. Fracture reducti...
. Most patients with these vascular injuries will require admission for their femoral fracture repair
Neurologic Injuries
. Peripheral nerve injuries can be caused by trauma, external compression, infection, and degenerative disease. In trauma, nerve...
. Patients present with sensory loss or motor weakness. Mild cases may present with paresthesias
. No specific testing in the emergency department is indicated other than a focused physical examination, though MRI may be able...
. Treatment of neurovascular compromise from a hip dislocation or a displaced femoral fracture consists of immediate reduction t...
. Most traumatic nerve injuries will be observed in the hospital or require urgent orthopedic consultation. Neurapraxia from com...
References
48 - Knee and Lower Leg Injuries
Knee Injuries—Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Femur
The Tibia
Cruciate Ligaments (ACL and PCL)
Collateral Ligaments (MCL and LCL)
Knee Compartments
Fabella
Popliteal Fossa
Popliteal Artery
Tibial Nerve
Extensor Mechanism
Meniscus
The Iliotibial band
The Popliteus
Bursae
Knee Injuries—Clinical Features
Physical Examination
Knee Injuries—Differential Diagnoses
Dislocation
Effusion
Anterior Knee Pain
Medial and Lateral Pain
Posterior Knee Pain
Knee Injuries—EXAMINATION MANEUVERS
Anterior Drawer/Lachman Test
Posterior Drawer Test
Posterior Sag Sign Test
Collateral Ligament Stress Test
Assessing for Meniscal Tears
McMurray Test
Apley Test
Knee Injuries—Diagnostic Testing
Radiologic Evaluation
Vascular Imaging
Arthroscopy
Joint Injection
Arthrocentesis
Specific Knee Injuries
Knee Dislocations—Foundations
Knee Dislocations—Clinical Features
Knee Dislocations—Diagnostic Testing
Knee Dislocations—Management and Disposition
Distal Femur Fractures—Foundations
Distal Femur Fractures—Clinical Features
Distal Femur Fracture—Diagnostic Testing
Distal Femur Fractures—Management and Disposition
Tibial Plateau Fractures—Foundations
Tibial Plateau Fractures—Clinical Features
Tibial Plateau Fractures—Diagnostic Testing
Tibial Plateau Fractures—Management and Disposition
Tibial Spine Fractures—Clinical Features
Tibial Spine Fractures—Diagnostic Testing
Tibial Spine Fractures—Management and Disposition
Osteochondritis Dissecans—Foundations
Osteochondritis Dissecans—Clinical Features
Osteochondritis Dissecans—Diagnostic Testing
Patellar Fractures—Foundations
Patellar Fractures—Clinical Features
Patellar Fractures—Diagnostic Testing
Patellar Fractures—Management and Disposition
Patellar Dislocation—Foundations
Patellar Dislocation—Clinical Features
Patellar Dislocation—Diagnostic Testing
Patellar Dislocation—Management and Disposition
Cruciate and Collateral Ligament Injuries—Foundations
Meniscal Injuries—Foundations
Meniscal Injuries—Clinical Features
Meniscal Injuries—Diagnostic Testing
Meniscal Injuries—Management and Disposition
Overuse Syndromes
Patellofemoral Pain Syndrome—Foundations
Patellofemoral Pain Syndrome—Clinical Features
Patellofemoral Pain Syndrome—Diagnostic Testing
Iliotibial Band Syndrome—Foundations
Iliotibial Band Syndrome—Clinical Features
Iliotibial Band Syndrome—Diagnostic Testing
Iliotibial Band Syndrome—Management and Disposition
Patellar Tendinopathy—Foundations
Patellar Tendinopathy—Clinical Features
Patellar Tendinopathy—Diagnostic Testing
Patellar Tendinopathy—Management and Disposition
Plica Syndrome—Foundations
Plica Syndrome—Clinical Presentation
Plica Syndrome—Diagnostic Testing
Plica Syndrome—Management and Disposition
Popliteus Tendinopathy—Foundations
Popliteus Tendinopathy—Clinical Presentation
Popliteus Tendinopathy—Diagnostic Testing
Popliteus Tendinopathy—Management and Disposition
Bursitis—Foundations
Bursitis—Clinical Features
Bursitis—Diagnostic Testing
Bursitis—Management and Disposition
ARTHRITIS
Osteoarthritis—Foundations
Osteoarthritis—Clinical Features
Osteoarthritis—Diagnostic Testing
Osteoarthritis—Management and Disposition
Septic Arthritis—Foundations
Septic Arthritis—Clinical Features
Septic Arthritis—Diagnostic Testing
Septic Arthritis—Management and Disposition
BAKER CYST
Baker Cyst—Foundations
Baker Cyst—Clinical Features
Baker Cyst—Diagnostic Testing
Baker Cyst—Management and Disposition
Leg
Foundations
Anatomy, Physiology, Pathophysiology
Tibia and Fibula
Vascular Supply
Fascial Compartments
Leg Injuries Differential Diagnoses
Specific Leg Injuries
Proximal Extra-­articular Tibial Fractures
Subcondylar Tibial Fractures—Foundations
Subcondylar Tibial Fractures—Clinical Features
Subcondylar Tibial Fractures—Diagnostic Testing
Subcondylar Tibial Fractures—Management and Disposition
Tibial Tubercle Fractures—Foundations
Tibial Tubercle Fractures—Clinical Features
Tibial Tubercle Fractures—Diagnostic Testing
Tibial Tubercle Fractures—Management and Disposition
Tibial Shaft Fractures—Foundations
Tibial Shaft Fractures—Clinical Features
Tibial Shaft Fractures—Diagnostic Testing
Tibial Shaft Fractures—Management and Disposition
Proximal Fibula Fractures—Foundations
Proximal Fibula Fractures—Clinical Features
Proximal Fibula Fractures—Diagnostic Testing
Proximal Fibula Fractures—Management and Disposition
Proximal Tibiofibular Joint Dislocations—Foundations
Proximal Tibiofibular Joint Dislocations—Clinical Features
Proximal Tibiofibular Joint Dislocations—Diagnostic Testing
Proximal Tibiofibular Joint Dislocations—Management and Disposition
Stress Fractures—Foundations
Stress Fractures—Clinical Features
Stress Fractures—Diagnostic Testing
Stress Fractures—Management and Disposition
Medial Tibial Stress Syndrome—Foundations
Medial Tibial Stress Syndrome—Clinical Features
Medial Tibial Stress Syndrome—Diagnostic Testing
Medial Tibial Stress Syndrome—Disposition and Management
Compartment Syndrome
Soft Tissue Injuries Involving the Lower Leg
. The gastrocnemius is composed of two distinct muscle bellies, the medial and lateral heads. The medial head is usually slightl...
. Patients with gastrocnemius injury typically present to the ED with point tenderness and swelling in the calf. If the gastrocn...
. Venous duplex should be performed to rule out DVT and may help to differentiate between these conditions. Soft tissue defects ...
. A small partial rupture of the medial head of the gastrocnemius can be treated with rest and non–weight bearing for several da...
. Foreign bodies such as plant matter (e.g., thorns), glass, and metallic objects are commonly encountered in the leg. Missed re...
References
49 - Ankle and Foot Injuries
Background and Importance
Anatomy
Physiology and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Radiology
Other Imaging Techniques
Ankle Fractures and Dislocations
General Considerations
Unimalleolar Fractures
Lateral Malleolar Fractures
Medial Malleolar Fractures
Posterior Malleolar Fractures
Bimalleolar Fractures
Trimalleolar Fractures
Open Fractures
Pilon Fractures
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Dislocations
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Ligamentous Injuries
Foundations
Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Tendon Injuries
Differential Diagnoses
Achilles Tendon Rupture
. Achilles tendon rupture is most common in middle-­aged men, and its causes are multifactorial. This condition is easily misdia...
. Achilles tendon rupture results from direct trauma or indirectly transmitted forces, including sudden unexpected dorsiflexion,...
. The diagnosis of Achilles tendon rupture is primarily clinical. Patients usually describe a sudden onset of pain at the back o...
. A lack of consensus exists between operative and nonoperative management in the treatment of Achilles tendon rupture.14 Surgic...
Peroneal Tendon Dislocation or Rupture
. The peroneal muscles are the primary evertors and pronators of the foot and also participate in plantar flexion. The peroneus ...
. Plain radiographs of the ankle may show the peroneal “fleck” sign, which can be confused for a simple avulsion fracture off th...
. Peroneal tendon rupture, subluxation or dislocation should be clinically (see Table 49.2) or radiologically assessed and the p...
Tibialis Posterior Tendon Rupture
. The tibialis posterior is primarily responsible for plantar flexion and inversion along the subtalar joint. Its tendon uses th...
. The diagnosis is generally made on a clinical basis. Plain radiographic films can exclude other bony pathology. Ultrasound can...
. Urgent outpatient orthopedic consultation within a week is indicated for tibialis posterior tendon ruptures because surgical r...
Other Tendon Injuries
Foot
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Specific Pathologic Conditions
Hindfoot Injuries
Differential Diagnoses
Talar Fractures
. The talus is a complex structure with articular cartilage covering 60% of its surface. It has no muscular attachments and is h...
. Talar fractures range from obvious fractures to subtle injuries requiring special imaging for diagnosis. There is generally a ...
. Talar neck fractures account for 50% of all talus fractures. With the exception of dorsal avulsion fractures, talar neck fract...
. Talar head fractures make up 10% of all talar fractures. Their mechanism is an axial compressive force applied on a plantar-­f...
. Major talar body fractures are uncommon and usually result from falls with axial compression of the talus, between the tibial ...
. When talar fractures are clinically suspected, initial imaging should include standard foot and ankle radiographs. This series...
. Talar neck fractures have a significant risk of long-­term morbidity and require precise reduction. Type 1 fractures, which ar...
. With the exception of minor dorsal avulsion fractures, all talar fractures should be managed by orthopedics. In the case of ma...
Osteochondral Lesions
. Osteochondral lesions of the talar dome warrant special mention. These talar body injuries are defects of the articular cartil...
. An osteochondral lesion should be considered in any patient with an acute ligamentous ankle injury with a joint effusion. Most...
. Differential diagnoses of osteochondral lesions include those items outlined in Box 49.2
. Plain radiography can identify significant osteochondral defects, although CT is useful in identifying occult osteochondral le...
. When an acute osteochondral lesion is confirmed or suspected, patients are best managed with outpatient orthopedic or sports m...
Subtalar Dislocations
. Subtalar dislocation, also called peritalar dislocation, is the simultaneous disruption of the talocalcaneal and talonavicular...
. Obvious deformity is typically present, often with skin tension on the side opposite the direction of dislocation. Neurovascul...
. Although standard foot radiographic views are diagnostic, properly positioning the patient for them may be difficult. The sing...
. Subtalar dislocations require emergent reduction. Most closed subtalar dislocations can be treated with closed reduction with ...
. Emergent orthopedic consultation is indicated for subtalar dislocations
Pantalar Dislocation
Calcaneal Fractures
. The calcaneus is the largest and most commonly fractured tarsal bone. It articulates superiorly with the talus (forming the su...
. These are more serious and more common, accounting for up to 75% of calcaneal fractures. Classification systems used to descri...
. These include fractures of the anterior process, sustentaculum tali, lateral and medial calcaneal processes, peroneal tubercle...
. Physical examination reveals pain, swelling, and tenderness over the heel. Weightbearing on the hindfoot is usually impossible...
. Please refer to Table 49.3 for differential diagnoses of extraarticular calcaneal fractures
. In the case of a suspected calcaneus fracture, initial radiographic imaging should include a foot series with the addition of ...
. Emergency evaluation includes careful assessment for associated injuries, particularly vertebral fractures. Adequate pain cont...
. All patients with intraarticular calcaneal fractures, or fractures that compromise overlying skin or soft tissue, warrant orth...
Midtarsal Joint Injuries
. The midtarsal joint (Chopart joint) is comprised of the talonavicular and calcaneocuboid joints. Injury in this area is uncomm...
. Refer to Table 49.3 for a list of differential diagnoses of midtarsal joint injuries
. Although standard radiographs are often abnormal, the diagnosis frequently is overlooked or delayed, with symptoms ascribed to...
. Nondisplaced injuries may heal with casting, but operative fixation is often required. Orthopedic consultation in the outpatie...
Nontraumatic Hindfoot Pain
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Midfoot Injuries
Differential Diagnoses
Navicular Fractures
. The navicular forms the supporting structure for the medial arch of the foot and bears most of the load within the tarsal comp...
. Navicular fractures are classified as dorsal avulsion fractures, tuberosity fractures, and body fractures. Fractures of the bo...
. Navicular fractures cause localized tenderness over the dorsal and medial aspects of the midfoot. The navicular tuberosity is ...
. See Table 49.3. The os tibiale externum is an accessory bone present in approximately 10% of the population and it is not unco...
. Although standard foot radiographs usually identify navicular fractures, advanced imaging with CT may be necessary. This is pa...
. Nondisplaced dorsal avulsion fractures can be treated symptomatically. Displaced dorsal avulsion fractures, or those involving...
. The majority of navicular fractures are suitable for outpatient orthopedic referral. Nondisplaced dorsal avulsion fractures in...
Cuboid Fractures
Cuneiform Fractures
Dislocations of the Navicular, Cuboid, and Cuneiforms
Lisfranc (Tarsometatarsal) Fractures and Dislocations
. Lisfranc injuries refer to any fracture, dislocation, or ligamentous injury at the tarsometatarsal joint (Lisfranc joint). In ...
. Lisfranc injuries carry a significant risk of long-­term disability resulting from arthritis, instability, foot deformity, and...
. The diagnosis of Lisfranc injury can be a challenge, particularly in the case of low-­energy, isolated ligamentous injuries. C...
. See Table 49.3 for differential diagnoses of Lisfranc (tarsometatarsal) fractures and dislocations
. Standard radiographic views of the foot are the initial investigation of choice for suspected Lisfranc injuries. However, plai...
. High-­energy Lisfranc injuries or ligamentous injuries with displacement, either on standard radiographs or stress imaging, ar...
. All proven or suspected Lisfranc injuries should be managed with orthopedic consultation. Delayed treatment or misdiagnosis ca...
Nontraumatic Midfoot Pain
Forefoot Injuries
Differential Diagnoses
Diagnostic Testing
Metatarsal Fractures
. Metatarsal fractures are common and account for one-­third of foot fractures. Management depends both on the specific location...
. The first metatarsal is the largest and strongest of the metatarsal bones and is rarely fractured. Injury to the first metatar...
. Middle metatarsal fractures often result from crush injuries but can occur from indirect trauma such as in twisting injuries. ...
. Patients will present with pain, tenderness, and swelling in the midfoot and usually inability to bear weight
. See Table 49.3 for a list of differential diagnoses of metatarsal fractures
. Plain radiographs are generally adequate for diagnosis of acute fractures. CT imaging may better delineate the diagnosis, part...
. The middle metatarsals are inherently stable with extensive soft tissue support from adjacent metatarsals. Nondisplaced fractu...
. The fifth metatarsal is the most commonly fractured metatarsal. Fractures of the fifth metatarsal are divided anatomically int...
. Fractures of the shaft of the 5th metatarsal are often referred to as “dancers’ fractures.” These injuries result from an inve...
. Fractures in zone 1 of the fifth metatarsal base occur from avulsion of the tuberosity by the lateral band of the plantar apon...
. See Box 49.2 and Table 49.3 for a list of differential diagnoses of fifth metatarsal fractures
. Plain radiographs are generally adequate for diagnosis of acute fractures of the fifth metatarsal
. Historically, tuberosity fractures involving more than 30% of the articular surface or with more than 2 mm of displacement wer...
Phalangeal Fractures
. Phalangeal fractures are the most common forefoot fracture. The proximal phalanges are more commonly fractured than middle or ...
. Although phalangeal fractures generally are considered minor injuries, they can lead to disabling sequelae. Patients present w...
. See Table 49.3 listing differential diagnoses for phalangeal fractures
. As with metatarsal fractures, carefully assessed standard radiographic views are sufficient to demonstrate phalangeal fracture...
. Most phalangeal fractures are easily managed and heal well. Large (greater than 50% of the nail bed) and symptomatic subungual...
. In general, primary care follow-­up is appropriate for phalangeal fractures. If displacement persists or causes cosmetic or fu...
Sesamoid Fractures
Metatarsophalangeal Dislocations
. MTP joint dislocations can occur in any joint and in any direction. First MTP joint dislocations require large forces and usua...
. First MTP joint dislocations usually are obvious because the toe is angled upward, with dorsal and proximal displacement of th...
. See Table 49.3 describing differential diagnoses of metatarsophalangeal dislocations
. Dislocations of the MTP joint are well-­visualized on standard radiographic views of the foot. Radiographs should be scrutiniz...
. Most MTP joint dislocations, particularly of the lesser toes, are easily reduced with longitudinal traction. Analgesia or loca...
. Most MTP joint dislocations can be managed without orthopedic consultation. If crepitus or obvious instability is present, or ...
Interphalangeal Joint Dislocations
Nontraumatic Forefoot Pain
. The forefoot is the site for a myriad of painful problems. Bunions, painful bursae, blisters, corns, calluses, hammertoes, and...
. Refer to Table 49.3 for differential diagnoses of nontraumatic forefoot pain
. Although the vast majority of nontraumatic forefoot pain is diagnosed clinically, plain radiography may be useful to rule out ...
. Most diagnoses of nontraumatic forefoot pain may be managed on a nonurgent basis by a podiatrist or primary care physician. Mo...
Special Considerations
Complex Regional Pain Syndrome
Stress Fractures
Foundations and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Tendon Injuries
Compartment Syndrome of the Foot and Ankle
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing: Special Procedures
Management and Disposition
References
50 - Wound Management Principles
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
History
Physical Examination
Differential Diagnoses
Diagnostic Testing
Management
Anesthesia
Anesthetic Agents
Allergy
Skin Preparation
Wound Preparation
Debridement
Wound Cleansing
Irrigation
Wound Closure
Decision-­Making
Wound Tension
Suture Technique
. Wound closure with simple interrupted sutures is the most common method of laceration repair in the ED and the majority of wou...
. The needle is placed to one side of the laceration margin and enters the skin at approximately 90 degrees. To pass the needle ...
. Placing cutaneous sutures in wounds under tension can lead to ischemia of the wound margin and an unsightly scar. Proper place...
.. Placement of buried sutures differs from traditional suturing because of the need to bury the knot deep to the skin. Failure ...
. In contrast to small lacerations elsewhere on the body, most scalp lacerations require repair because of the propensity to ble...
. Anesthesia with epinephrine is recommended to help control bleeding. Hair removal is necessary only if the hair makes closure ...
. Most commonly seen in elders and the chronically ill, skin tears can be a treatment dilemma for emergency clinicians. These te...
. Vertical mattress sutures improve wound edge eversion. They are also used to close gaping wounds and deep lacerations that may...
. A vertical mattress suture technique is a combination of deep and superficial components. The needle is introduced at a 90-­de...
. Horizontal mattress sutures are useful to help disperse excess skin tension and to evert wound edges. The scalp, which has min...
. The initial step is to pass the needle as for a simple interrupted stitch (Fig. 50.4). On exiting the skin, however, the needl...
. Redundant tissue may be left on one side of the repair as the closure nears completion, especially with curvilinear laceration...
. The laceration repair begins in a traditional manner and continues to approximately the final 1 cm of the wound (Fig. 50.5). A...
. Jagged and triangular wounds create corners that can be difficult to repair. The clinician must avoid placing the suture direc...
. The needle is introduced percutaneously through the non-­flap side of the wound a few millimeters from the corner of the wound...
. The V-­Y closure is indicated for the repair of V-­shaped wounds with tissue loss or with nonviable margins that must be trimm...
. Nonviable tissue is trimmed with fine iris scissors (Fig. 50.7). The long V-­shaped portion of the wound is sutured with simpl...
Materials
. The ideal suture is inert to metabolism, resistant to infection and inflammatory reactions, has great tensile strength, does n...
. Surgical needles are available in a variety of sizes and shapes with myriad other characteristics. Cutting needles may be reve...
. Tape closure may be superior to closure with sutures and staples if applied in the appropriate circumstances. In general, the ...
. Staples offer several advantages over sutures. Monofilament stainless steel staples offer less risk of infection than even the...
. European and Canadian physicians have used tissue adhesives (butyl-­2-­cyanoacrylates) for many years. In 1998, octyl-­2-­cyan...
Antibiotic Prophylaxis
. Antibiotic prophylaxis with an antibiotic covering skin flora (e.g., cefazolin IV, cephalexin PO) is recommended for patients ...
. Wounds that involve joints or open fractures require prophylactic antibiotics. Prospective randomized controlled studies have ...
. Antibiotics are indicated for through-­and-­through intraoral lacerations, cat bites, some dog bites, some human bites, and so...
. Antibiotic prophylaxis is required for patients with cat bites, especially bites to the hand. These bites tend to be deep punc...
. Antibiotic prophylaxis for dog bites is more controversial. The infection rate has been reported as 6% to 16% for patients not...
. In addition to the previous bite wound recommendations, antibiotic prophylaxis of injuries to the metacarpophalangeal joints i...
. Lacerations of the oral mucosa involve bacteria-­rich oral secretions and may become infected slightly more often (6% to 12%) ...
. Puncture wounds of the foot are seen frequently in the ED. These wounds are often caused by common carpentry nails, although o...
Drains, Dressings, and Immobilization
. Drains have no role in ED wound care. In general, drains are placed when a collection of fluid exists or may develop. The pres...
. Various dressing materials are available. The microenvironment created by a dressing affects the biology of healing. The optim...
. Wounds in proximity to joints must be immobilized as part of routine care. Splinting the injured body part places the injury a...
Disposition
Wound Care Instructions
Tetanus Immunization
References
51 - Foreign Bodies
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Specific Disorders
Eye
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Ear
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Nose
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Airway
Foundations
. Children and the elderly are at high risk for foreign body aspiration. Most airway foreign body patients are younger than 9 ye...
. Foreign bodies can be located as proximally as the oropharynx, with retained objects having been found in the palatal and phar...
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Gastrointestinal Tract
Foundations
Pharynx and Esophagus
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Stomach and Bowel
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Rectum
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Genitourinary Tract
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Soft Tissues
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
References
52 - Mammalian Bites
Foundations
Background and Importance
Dog Bites
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
Capnocytophaga canimorsus
Diagnostic Testing
Differential Diagnoses
Management
. The value of prophylactic antibiotics given for mammalian bites is secondary to the value of vigilant cleaning, debridement, a...
Disposition
Cat Bites
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
Pasteurella multocida
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Other Mammals
Monkeys
Foundations
. Monkey bites are rare in the United States, occurring primarily in laboratory workers involved in biomedical research. Monkey ...
. Monkey bites may present with superficial bruising, puncture marks, or small, grouped lacerations. Superficial and deep soft t...
. B virus disease in humans has an incubation period as short as 2 days but more commonly 2 to 5 weeks. The disease often starts...
. The bacteria isolated from infected monkey bites is similar to that from infected human bites, with a predominance of Staphylo...
. While under studied, monkey bites may also have a risk profile for bacterial infection similar to human bites and should recei...
. The majority of monkey bites can be safely discharged home from the emergency department (ED) following local wound care, appr...
Rodents
Foundations
. As with monkey bites, laboratory workers are frequent rodent bite victims because these animals are commonly used in biomedica...
. Infection and systemic illness, “rat bite fever,” is caused by bacteria from Streptobacillus moniliformis or Spirillum minus, ...
. Disease transmission may occur by bite, scratch, handling a rat, or by ingestion of contaminated food or water. The incubation...
Differential diagnoses
. Rodent bites are at low risk for local wound infection and require only appropriate wound care without antibiotic prophylaxis....
. The vast majority of rodent bites can be safely discharged home from the ED with wound care instructions and outpatient follow...
Uncommon Animal Bites
Ferrets
Domestic Herbivores
Sheep, Cattle, and Pigs
Horses
Camels
Wild Animals
Bears
Wild Cats
Coyotes and Wolves
Management
Human Bites
Foundations
. Human bites tend to occur during summer months, typically on weekends, and most often involve acts of aggression. Sporting eve...
. Human bites can be divided into two categories: occlusive bites and clenched-­fist injuries (CFIs). Occlusive bites are those ...
. Fight bites (clenched-­fist injury). Acute CFIs typically present as an innocuous appearing 3-­ to 8-­mm laceration over the d...
. Human occlusive bites generally cause less tearing and crush injury than dog bites, and do not penetrate soft tissues as readi...
. Human bites have resulted in transmission of tetanus, syphilis, actinomycosis, and herpes. Herpetic whitlow, an infection of t...
. Due to their high incidence of deep structure injury and the possibility of retained tooth fragments, we advise obtaining radi...
. Treatment should focus on the mechanism of the bite (occlusive or CFI), the health of the bite victim including medical histor...
Prophylactic Antibiotics
Disposition
References
53 - Venomous Animal Injuries
Foundations
Venom Delivery
Venomous Reptiles
Snakes
Classification and Characteristics
Anatomy and Identification
Other Reptiles
Pathophysiology and Toxins
Venom Delivery
Clinical Features
Crotalids (Pit Vipers)
Coral Snakes
Infection
Differential Diagnoses
Diagnostic Testing
Management
Out-­of-­Hospital Care
Emergency Department Care
Patient History
Patient Examination
Initial Medical Care
Pit Viper Envenomation Classification
Antivenom
Dosage and Precautions
Coral and Exotic Snakes
Wound Care
Serum Sickness
Heloderma Envenomation
Disposition
Venomous Arthropods
Foundations
Hymenoptera
Spiders and Scorpions
Black Widow Spider
Brown Recluse Spider
Scorpions
Clinical Features
Hymenoptera
Africanized Bees
Fire Ants
Black Widow Spider
Brown Recluse Spider
Scorpions
Differential Diagnoses
Hymenoptera
Black Widow Spider
Brown Recluse Spider
Scorpions
Diagnostic Testing
Hymenoptera
Black Widow Spider
Brown Recluse Spider
Scorpions
Management
Prehospital Care
Hymenoptera
Black Widow Spider
Brown Recluse Spider
Scorpions
Emergency Department Care
Hymenoptera
Black Widow Spider
Latrodectus Antivenom
Brown Recluse Spider
Scorpions
Disposition
Hymenoptera
Black Widow Spider
Brown Recluse Spider
Scorpions
Other Arthropods
Venomous Marine Animals
Foundations
Pathophysiology and Venom Delivery
Bites
Nematocyst
Toxicity
Clinical Features
Stings
Sea Urchins
Cone Shells
Stingrays
Bony Fishes
Differential Diagnoses
Diagnostic Testing
Management
Bites
Nematocysts
Stings
Disposition
References
54 - Thermal Injuries
Background and Importance
Anatomy, Physiology, and Pathophysiology
Pathophysiology of Burns
Cutaneous Injury
Clinical Features
Classification and Diagnosis of Burns
Depth
Size
Inhalation Injury
Differential Diagnoses
Diagnostic Testing
Management
Initial First Aid
Airway Management
Breathing Management
Circulation Management and Fluid Resuscitation
Escharotomy
Local Wound Therapies
Pain Management
Disposition
References
55 - Chemical Injuries
General Approach to a Hazmat Event
Foundations
Background and Importance
Community Preparedness and HazMat Response
Contingency Plan
Anatomy, Physiology, and Pathophysiology
Clinical Features and Differential Diagnoses
Diagnostic Testing
Management
Disposition
Ocular Injuries
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Specific Toxins
Hydrofluoric Acid
Foundations
. Hydrofluoric acid is an acidic aqueous solution made from fluorine. It has a variety of industrial indications, including glas...
. Absorption of hydrofluoric acid can occur upon exposure to the lung, skin, and eyes. In a 20-­year review of all hydrofluoric ...
Clinical Features
Inhalational Exposure
Gastrointestinal Exposure
Ocular Exposure
Dermal Exposure
Differential Diagnoses
Diagnostic Testing
Management
Infiltration Therapy
. Infiltrative therapy is necessary for treatment of deep, painful hydrofluoric acid burns. Calcium gluconate is the agent of ch...
. Patients with pain refractory to local or subcutaneous calcium administration may benefit from regional anesthesia, either int...
Respiratory Exposures
Ocular Exposures
Systemic Toxicity
Disposition
Formic Acid
Foundations
. Formic acid is a caustic organic acid used in rubber, paper, tanning, agricultural, and electroplating industries. It has also...
. Formic acid causes cutaneous injury by inducing a coagulative necrosis
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Anhydrous Ammonia
Foundation
. Anhydrous ammonia is a colorless, pungent gas used extensively as a fertilizer in agriculture. It can also be used to manufact...
. Anhydrous ammonia is generally stored at an extremely low temperature (−33°C). Consequently, exposure to liquid at this temper...
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Cement
Phenol and Derivatives
Foundations
. Phenols are used industrially as starting materials for many organic polymers and plastics. They are widely used in the agricu...
. Phenol (carbolic acid) is an aromatic acidic alcohol with a characteristic odor. The concentration of phenol is inversely rela...
. When the skin comes in contact with a phenol, treatment should be instituted immediately. The exposed area should be irrigated...
Differential Diagnoses
Diagnostic Testing
Management
Treatment of Systemic Toxicity
Disposition
Phosphorus
Foundations
. Phosphorus is a nonmetallic element that exists in three forms: elemental, white (yellow), and red. White phosphorus (also kno...
. The autoignition temperature (the temperature at which spontaneous combustion can occur) is 30°C (86°F). When white phosphorus...
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Nitrates and Nitrites
Foundations
. Both nitrates (NO3−) and nitrites (NO2−) are abundant in rural and industrial settings. Both sodium nitrate and sodium nitrite...
. Reduced hemoglobin contains four heme groups, each with a ferrous (Fe2+) ion. Methemoglobinemia results when the ferrous ion b...
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Hydrocarbons
Foundations
. Hydrocarbons are a heterogeneous group of organic compounds that are derived from carbon and hydrogen molecules. They are foun...
. The toxicity from hydrocarbons can affect many different organs, but the lungs are the most commonly affected. The toxicity of...
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Tar
Foundations
. There are two types of hot tar: coal tar pitches and petroleum-­derived asphalts. Both products are heated to maintain a liqui...
Clinical Features
Management
Disposition
Elemental Metals
Chromium
Miscellaneous
Chlorine, Chloramine, Phosgene, Nitrogen Oxide and Phosphide
. Chlorine and phosgene gases were used in World War I as part of chemical warfare. Today, exposure to chlorine exposures can re...
. Chlorine is a heavy greenish-­yellow gas or liquid with a characteristic odor. The combination of bleach (sodium hypochlorite)...
. Mild exposure to chlorine or chloramine may simply cause mucosal membrane irritation, whereas more severe exposure will induce...
. The first step in treating an exposure to chlorine, chloramine, or phosgene gas is removal of the individual from the environm...
. Phosgene, phosphene, NO2, nickel carbonyl, diborane, as well as zinc-­based smoke bombs can cause delayed-­onset pulmonary ede...
Chemical Terrorism
Response During a Chemical Attack
Chemical Agents
Nerve Agents
Foundations
. The nerve agents are classified as either “G” agents or “V” agents and most recently include the Russian-­based novice or “Nov...
. The nerve agents function by affecting acetylcholine (ACh). Acetylcholine receptors are found on the postsynaptic membranes of...
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Vesicants
Foundations
. At temperatures below 14°C, mustard exists in the solid form. Once in the liquid or gaseous form, mustard gas can be recognize...
. Mustard gas can enter the body after inhalational, dermal, or oral exposures. After entering the body, it functions as an alky...
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Cyanide
Foundations
. Cyanide salts and hydrocyanic acid are commonly used for metal cleaning, precious metal extraction, photographic processes, el...
. Cyanide is a cellular toxin. It binds to both Fe3+ and cobalt. By binding and inactivating the enzyme cytochrome oxidase, whic...
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
References
56 - Oral Medicine
Introduction
Disorders of the Tooth
Foundations
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
Disorders of the Gingiva and Periodontium
Foundations
Anatomy, Physiology, and Pathophysiology
. Periodontitis is inflammation of the supporting structures of the teeth (gingiva, alveolar bone, cementum, and periodontal lig...
. The gingiva and surrounding tissue can also become inflamed leading to a condition known as pericoronitis. As teeth start to e...
. Gingival hyperplasia is an overgrowth of the gum tissue surrounding the teeth. It can occur secondary to poor oral hygiene, de...
Clinical Features
Differential Diagnoses
Diagnostic Testing
Gingivitis and Periodontitis
Pericoronitis
Management
Gingivitis and Periodontitis
Pericoronitis
Disposition
Gingivitis and Periodontitis
Pericoronitis
Disorders Involing Dental Procedures
Foundations
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Odontogenic and Deep Neck Infections
Foundations
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Dentoalveolar Trauma
Foundations
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
Dental Fractures
Tooth Avulsion
Luxation and Alveolar Fractures
Soft Tissue Injuries
Disposition
Foundations
Anatomy, Physiology, and Pathophysiology
. The cause of TMD is debated, but jaw clenching and grinding associated with stress is thought to contribute. Tooth malocclusio...
. TMJ dislocation occurs when the condyle travels anteriorly along the eminence and becomes locked in the anterosuperior aspect ...
Clinical Features
Temporomandibular Joint Disorder
Temporomandibular Joint Dislocation
Differential Diagnoses
Diagnostic Testing
Management
Temporomandibular Joint Disorder
Temporomandibular Joint Dislocation
Disposition
References
57 - Ophthalmology
Overview
Traumatic Conditions
Foundations
Periorbital Contusions and Eyelid Lacerations
Clinical Features and Differential Diagnoses
Diagnostic Testing
Management and Disposition
Conjunctival and Scleral Injuries: Subconjunctival Hemorrhage, Conjunctival Laceration, and Scleral Laceration
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
Corneal Injuries: Corneal Abrasions, Foreign Bodies, and Lacerations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
. There is no evidence that the treatment of corneal abrasions with topical antibiotics, as often recommended, has any beneficia...
. Foreign bodies of the cornea and conjunctiva, especially those containing iron (given the risk of rust deposition over time), ...
. Large but partial corneal lacerations should be evaluated by ophthalmology for potential closure in the operating room versus ...
Anterior Segment Injuries: Traumatic Hyphema, Iritis, Cyclodialysis, and Lens Dislocation
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
. With isolated traumatic iritis, the primary goals of treatment are minimizing scarring, decreasing inflammation, and pain reli...
. Lens subluxations or dislocations can be vision-­threatening emergencies and should be evaluated by an ophthalmologist in the ...
Posterior Segment/Ocular Injuries: Commotio Retinae, Retinal Detachment, Intraocular Foreign Body, and Perforated Globe
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
. A traumatic retinal detachment, if detected and treated early before the macula is involved, carries a good prognosis. Approxi...
. For patients with a possible globe perforation (open globe) with or without an intraocular foreign body, examine the eye with ...
Retrobulbar and Peribulbar Injuries: Orbital Wall Fracture, Retrobulbar Hemorrhage, and Optic Nerve Injury
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
. Prophylactic antibiotics are commonly administered for orbital wall fractures that extend into an adjacent sinus, although the...
. The loss of vision associated with a retrobulbar hematoma is thought to be irreversible within 60 to 100 minutes after the ons...
. Once the determination of the type and degree of optic neuropathy is determined, treatment options can be considered. There is...
Chemical Exposures and Glues
Clinical Features and Differential Diagnoses
Diagnostic Testing
Management and Disposition
Inflammatory Conditions
Foundations
The Conjunctiva and Cornea: Keratitis, Pterygium, and Pinguecula
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
. Superficial punctate keratitis and UV keratitis are treated the same as corneal abrasions because all entail injury to the cor...
. Treatment of pterygium and pinguecula are similar, and it includes UV protection, lubrication, and treatment of acute inflamma...
Disposition
The Globe: Uveitis, Scleritis, and Episcleritis
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
The Orbit: Orbital Pseudotumor, Orbital Apex Syndrome, and Thyroid Orbitopathy
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Infectious Conditions
Foundations
The Conjunctiva: Allergic, Viral and Bacterial Conjunctivitis, and Ophthalmia Neonatorum
Clinical Features and Differential Diagnoses
Diagnostic Testing
Management and Disposition
. Allergic conjunctivitis and viral conjunctivitis are usually self-­limited and can be treated with supportive measures such as...
. Although bacterial conjunctivitis is typically self-­limited, most resolving in 1 to 2 weeks without treatment, topical antibi...
. Hospitalization of neonates with blood and cerebrospinal fluid (CSF) examination may be indicated for ophthalmia neonatorum. N...
The Cornea: Corneal Ulcers, Herpes Simplex Keratitis, and Herpes Zoster Keratitis
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
. Topical anti-­microbial therapy for corneal ulcers and infiltrates is appropriate initial therapy, although systemic antibioti...
. Herpes simplex keratitis is the most common cause for corneal transplants in the United States. Emergent ophthalmologic consul...
. Herpes zoster ophthalmicus accounts for approximately 10% to 20% of all zoster cases and necessitates emergent ophthalmologic ...
Disposition
The Eyelids and Periorbital Area: Hordeolum, Chalazion, Dacryocystitis, Blepharitis, and Cellulitis
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
. Hordeola and chalazia are typically self-­limited and can resolve on their own when the glands become unobstructed. Conservati...
. The most common causative organisms in dacryocystitis are S. aureus, S. pneumoniae, H. influenzae, Serratia marcescens, and Ps...
. The initial treatment of blepharitis is conservative, designed to remove residual oils and scurf, and entails warm massage wit...
. If pre-­septal cellulitis in a patient with no other underlying medical conditions is diagnosed with certainty, the patient ca...
Disposition
The Globe: Endophthalmitis
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Acute Angle-­Closure Glaucoma
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Primary Disorders of Vision
Foundations
Blurred Vision: Optic Neuritis, Toxic and Metabolic Disturbances, and Papilledema
Clinical Features
Differential Diagnoses
Diagnostic Testing
. With optic neuritis, visual acuity will usually be abnormal, and the patient may have variable visual field defects with centr...
. These processes are bilateral, progressive, and symmetrical and may manifest with a significant drop in visual acuity along wi...
. Early or mild papilledema may be difficult to detect with the direct ophthalmoscope. When clinical suspicion is high, consulta...
Management
Disposition
Floaters, Flashes, and Field Deficits: Vitreous and Retinal Disorders
Clinical Features
Differential Diagnoses
Diagnostic Testing
. With a vitreous hemorrhage, direct ophthalmoscopy reveals a reddish haze in mild cases and a black reflex in severe cases. Det...
. With a retinal detachment, visual acuity can range from minimally changed to severely decreased. Visual field deficits relate ...
. A chiasmic or cortical cause of a visual field disturbance can usually be made by confrontation visual field testing. The clas...
Management
Disposition
Sudden Monocular Vision Loss: Retinal Artery and Vein Occlusion, and Ischemic Optic Neuropathy
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
. Like acute ischemic stroke, CRAO is a time-­sensitive process. Animal models suggest that the retina will likely make a full r...
. An ultimate visual acuity better than 20/200 is seen in over 80% of patients with a non-­ischemic CRVO but in less than 10% of...
. Temporal arteritis with evolving vision loss or amaurosis fugax from A-­AION represents a distinct clinical emergency. Untreat...
Disposition
Functional Vision Loss
Diplopia
Anisocoria
Foundations
Clinical Features
Adie’s and Argyll Robertson Pupils
Pharmacologic Mydriasis and Miosis
Third-­Nerve Palsy
Horner Syndrome
Physiologic and Headache-­Associated Anisocoria
Diagnostic Testing, Management, and Disposition
Nystagmus
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
References
58 - Otolaryngology
Otitis Media
Foundations
Background and Importance
Anatomy and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Otitis Externa
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Necrotizing (Malignant) External Otitis
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
Mastoiditis
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
Sudden Hearing Loss
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
Epistaxis
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Sialolithiasis
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
Neck Masses
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
Disclaimer
References
59 - Asthma
Foundations
Background and Importance
Anatomy and Physiology
Pathophysiology
Clinical Features
Signs and Symptoms
Risk Factors
Specific Contexts
Cough Variant
Cigarette Smokers
Athletes
Perimenstrual Asthma
Elderly
Obesity
Aspirin-­Exacerbated Respiratory Disease
Differential Diagnoses
Diagnostic Testing
Peak Expiratory Flow
Pulse Oximetry
Capnography
Blood Gas
Other Blood Testing
Radiology
Point of Care Ultrasound
Electrocardiogram
Management
Oxygen Administration
Adrenergic Medications
Inhaled Beta2 Agonists
Long-­Acting Beta-­2 Agonists
Intravenous Beta2 Agonists
Subcutaneous Beta2 Agents
Epinephrine
Corticosteroids
Systemic Corticosteroids
Inhaled Corticosteroids
Corticosteroids and Discharged Patients
Anticholinergic Medications
Magnesium
Methylxanthines
Leukotriene Modifiers
Antibiotics
Sedatives
Ketamine
Heliox
High-Flow Nasal Canula
Noninvasive Ventilation
Mechanical Ventilation
Extracorporeal Membrane Oxygenation
Other and Future Therapies
Special Situations
Pregnancy
Near Fatal Asthma
Clinical Approach to Acute Severe Asthma
Disposition
References
60 - Chronic Obstructive Pulmonary Disease
Foundations
Background
Anatomy/Physiology/Pathophysiology
Clinical Features
Acute Exacerbations
Respiratory Failure
Differential Diagnosis for the Emergency Presentation
Diagnostic Testing
Chest Radiography
Pulse Oximetry
Blood Gas Analysis
Electrocardiogram
Laboratory Tests
Management
Short-­Acting Beta Agonists
Glucocorticoids
Antibiotics
Adjunctive Treatments
Respiratory Support
Oxygenation
Non-­Invasive Ventilation
High-­Flow Nasal Cannula
Invasive Ventilation
Disposition
References
61 - Upper Respiratory Tract Infections
Pharyngitis
Foundations
Clinical Features
Differential Diagnosis for Emergency Presentation
Diagnostic Testing
Management
Disposition
Laryngitis
Foundations
Clinical Features
Differential Diagnosis for Emergency Presentation
Diagnostic Testing
Management
Disposition
Epiglottitis
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Foundations
Clinical Features
Differential Diagnosis for Emergency Presentation
Diagnostic Testing
Management
Disposition
Ludwig Angina
Foundations
Clinical Features
Differential Diagnosis for Emergency Presentation
Diagnostic Testing
Management
Disposition
Retropharyngeal Abscess
Foundations
Clinical Features
Differential Diagnosis for Emergency Presentation
Diagnostic Testing
Management
Disposition
Parapharyngeal Abscess
Foundations
Clinical Features
Differential Diagnosis for Emergency Presentation
Diagnostic Testing
Management
Disposition
Rhinosinusitis
Foundations
Clinical Features
Differential Diagnosis for Emergency Presentation
Diagnostic Testing
Management
Disposition
References
62 - Pneumonia
Background and Importance
Anatomy and Physiology
Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
References
63 - Pleural Disease
Spontaneous Pneumothorax
Foundations
Background and Importance
Anatomy and Physiology
Clinical Features
Differential Diagnosis
Diagnostic Testing
Point of Care Ultrasound
Management
Primary Spontaneous Pneumothorax
Secondary Spontaneous Pneumothorax
Tension Pneumothorax
Disposition
Pleural Effusion
Foundations
Background and Importance
Anatomy and Physiology
Pathophysiology
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
References
64 - Acute Coronary Syndromes
Epidemiology
Stable Angina
Unstable Angina
Acute Myocardial Infarction
Pathophysiology
Clinical Features
Prehospital Evaluation
Emergency Department Evaluation
History
. A description of typical symptoms may not be present in ACS. This nontraditional presentation may be a result of atypical feat...
Physical Examination of the ACS Patient
Early Complications of Acute Myocardial Infarction
Differential Diagnoses
Diagnostic Testing
Electrocardiography
Electrocardiographic Abnormalities in Acute Coronary Syndromes
Anatomic Location of Acute Myocardial Infarction
Electrocardiographic Differential Diagnosis of ST Segment Elevation
Non–ST Segment Elevation Myocardial Infarction
Electrocardiographic Adjuncts in the Diagnosis of Acute Coronary Syndrome
Limitations of Electrocardiography in Acute Coronary Syndrome
Chest Radiography
Serum Markers
Troponin Testing
Other Serum Markers
Exercise Stress Testing
Echocardiography
Myocardial Scintigraphy (Nuclear Imaging)
Coronary Computed Tomography Angiography
Risk Stratification Instruments
Management
Pharmacologic Intervention
Oxygen
Nitroglycerin
Morphine and Other Opioid Analgesic Agents
Beta-­Adrenergic Blockers
Angiotensin-­Converting Enzyme Inhibitors
HMG–Coenzyme A Reductase Inhibitors
Calcium Channel Blockers
Antiplatelet Therapy
. Aspirin, the prototypical antiplatelet agent, is the most cost-­effective treatment in ACS care. It irreversibly acetylates pl...
. The P2Y12 inhibitors include the thienopyridines ticlopidine, clopidogrel, and prasugrel, as well as ticagrelor and cangrelor....
. Glycoprotein IIb/IIIa receptor inhibitors (GPIs) are potent antiplatelet agents; they include abciximab, eptifibatide, and tir...
Antithrombins
. The term heparin refers not to a single structure but to a family of mucopolysaccharide chains of varying lengths and composit...
. The direct thrombin inhibitor bivalirudin is a potent antithrombin anticoagulant providing significant theoretical advantages ...
Reperfusion Therapies
Fibrinolytic Therapy
. Options for fibrinolytic therapy include streptokinase (the original fibrinolytic agent) and three types of plasminogen activa...
. In the absence of contraindications, fibrinolytic therapy should be considered in patients with STEMI and the onset of ischemi...
. Combined with the patient’s history and physical examination, the 12-­lead ECG is the key determinant of eligibility for fibri...
. Past trials do not provide evidence to support withholding fibrinolytic therapy or choosing one particular agent over another ...
. The generally accepted therapeutic time window for administration of a fibrinolytic agent after the onset of STEMI is 12 hours...
. Patients with a history of chronic hypertension should not be excluded from fibrinolytic therapy if their blood pressure is ad...
. Active diabetic hemorrhagic retinopathy is a strong relative contraindication to fibrinolytic therapy because of the potential...
. CPR is not a contraindication to fibrinolytic therapy unless CPR is prolonged—more than about 10 minutes—or extensive chest tr...
. A history of a previous stroke or TIA is a major risk factor for hemorrhagic stroke after treatment with fibrinolytic therapy....
. In the setting of STEMI, a previous MI should not preclude consideration for treatment with fibrinolytic agents. Without treat...
. Recent surgery or trauma is considered a relative contraindication to fibrinolytic therapy. The term recent has been subject t...
. There is minimal clinical experience with fibrinolysis in premenopausal women. Any excessive vaginal bleeding that may occur a...
. Although fibrinolysis has widespread availability and a proven ability to improve coronary flow, limit infarct size, and impro...
. Historically, rescue PCI was considered advantageous in patients whose infarct-­related arteries failed to reperfuse after fib...
. Facilitated percutaneous coronary intervention refers to combination therapy involving fibrinolysis coupled with emergent PCI....
. As noted, the two primary choices for reperfusion therapy in the STEMI patient include fibrinolysis and PCI. Important issues ...
. Patients with STEMI complicated by cardiogenic shock, occurring in up to 10% of cases, demand special consideration because of...
Resuscitated Cardiac Arrest with Suspected ACS
Disposition
Transfer of a Patient with Acute Coronary Syndrome
Missed Diagnosis of Acute Coronary Syndrome
References
65 - Dysrhythmias
Foundations
Cardiac Cellular Electrophysiology
Anatomy and Conduction
Mechanisms of Dysrhythmia Formation
Classification of Antidysrhythmic Drugs
Class IA Agents
Procainamide
Class IB Agents
Lidocaine
Class IC Agents
Flecainide
Propafenone
Class II Agents
Esmolol
Metoprolol
Class III Agents
Amiodarone
Ibutilide
Sotalol
Dofetilide
Dronedarone
Class IV Agents
Diltiazem
Verapamil
Miscellaneous Agents
Adenosine
Digoxin
Magnesium
Isoproterenol
Clinical Features
Initial Assessment of Stable Patients
Differential Diagnosis
Management
Sinus Bradycardia and Sinoatrial and Atrioventricular Block
Sinus Bradycardia
Sinus Dysrhythmia
Sinus Arrest and Sinoatrial Exit Block
Sick Sinus Syndrome
Atrioventricular Block
First-­Degree Atrioventricular Block
Second-­Degree Atrioventricular Block
. Type I second-­degree AV block, also called Wenckebach or Mobitz I AV block, is associated with progressive impairment of cond...
. Type II second-­degree AV block, or Mobitz II block, is a conduction block just below the level of the AV node. On the surface...
Third-­Degree Atrioventricular Block
Extrasystoles
Premature Atrial Contractions
Premature Ventricular Contractions
Narrow-­Complex Tachycardia
Sinus Tachycardia
Atrial Tachycardia
Atrial Fibrillation
Atrial Flutter
Atrioventricular Nodal Reentrant Tachycardia
Junctional Tachycardia
Preexcitation and Accessory Pathway Syndromes
Wide-­Complex Tachycardia
Ventricular Tachycardia
Torsades de Pointes
Brugada Syndrome
Disposition
References
66 - Implantable Cardiac Devices
Clinical Features
Pacemaker Terminology
Pacemaker Components
History
Physical Examination
12-­Lead Electrocardiogram
Differential Diagnosis
Complications of Implantation
Infection
Venous Thrombosis and Stenosis
Complications of Existing Pacemakers
The “Pacemaker Syndrome”
Complications Unique to Biventricular Pacing
Pacemaker Malfunction
Failure to Capture
Inappropriate Sensing
Inappropriate Pacemaker Rate
Diagnostic Testing
Chest Radiograph
12-­Lead Electrocardiogram
Pacemaker Interrogation
Magnetic Resonance Imaging in Patients with a Pacemaker
Management
Resuscitation
Disposition
Clinical Features
Terminology and Components
Differential Diagnosis
Complications of Implantation
Malfunction
Diagnostic Testing
Management
ICD Defibrillation
Resuscitation
Disposition
Mechanical Circulatory Support Devices
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
References
67 - Heart Failure
Foundations
Background and Importance
Epidemiology
Congestion and Preload
Afterload
Disorganized Contraction
Myocardial Infarction Versus Injury
Cardiorenal Syndrome
Other Factors
Clinical Features
History and Physical Exam
Precipitants
Differential Diagnosis
Diagnostic Testing
Electrocardiogram
Chest Radiography
Laboratory Testing
Lung Ultrasound
Echocardiography
Management
Initial Evaluation
Blood Pressure Considerations
Vascular Phenotype
Cardiac Phenotype
Disposition
References
68 - Pericardial and Myocardial Disease
Dilated Cardiomyopathy
Foundations
Clinical Features
Diagnostic Testing
Differential Diagnosis
Management and Disposition
Disposition
Hypertrophic Cardiomyopathy
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Restrictive Cardiomyopathy
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Peripartum Cardiomyopathy
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Takotsubo Syndrome
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Arrhythmogenic Right Ventricular Cardiomyopathy
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Channelopathies
Myocarditis
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Chagas Disease
Cocaine Cardiotoxicity
Sudden Death
Pericardial Disease
Pericarditis
Foundations
Clinical Findings
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Uremic Pericardial Disease
Post–Myocardial Infarction Pericarditis
Postinjury Pericarditis
Neoplastic Pericardial Disease
Radiation-­Induced Pericarditis
Miscellaneous Causes of Pericarditis
Pericardial Effusion
Purulent Pericarditis
Constrictive Pericarditis
Cardiac Tamponade
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Pneumopericardium
References
69 - Infective Endocarditis and Valvular Heart Disease
Infective Endocarditis
Foundations
Background and Importance
Pathophysiology and Microbiology
Clinical Features and Differential Diagnosis
Diagnostic Testing
Management
Disposition
Prophylaxis
Rheumatic Fever
Foundations
Background and Importance
Pathophysiology
Clinical Features and Differential Diagnosis
Diagnostic Testing
Management and Disposition
Valvular Heart Disease
Foundations
Anatomy and Physiology
Mitral Stenosis
Pathophysiology
Clinical Features
Management
Mitral Regurgitation
Pathophysiology
Clinical Features
Acute Mitral Regurgitation
Chronic Mitral Regurgitation
Management
Mitral Valve Prolapse
Pathophysiology
Clinical Features
Management
Aortic Stenosis
Pathophysiology
Clinical Features
Management
Aortic Regurgitation
Pathophysiology
Clinical Features
Acute Aortic Regurgitation
Chronic Aortic Regurgitation
Management
Complications of Prosthetic Valves
Structural Failure
Valve Thrombosis
Systemic Embolization
Hemolysis
Endocarditis
Disposition
References
70 - Hypertension
Background and Importance
Importance
Definition of Hypertension and Relevant Terminology
Physiology of Hypertension
Neurohormonal Dysregulation
Vascular Modulation
Sodium Intake
Psychosocial Stress
Obesity
Pathophysiology of Target-­Organ Damage
Clinical Features
Hypertensive Emergency
Hypertensive Encephalopathy
Other Hypertension-­Related Emergencies
Acute Target Organ Damage in the Context of Systemic Illness
Absence of Target Organ Dysfunction
Differential Diagnoses
Diagnostic Testing
Management
Acute Blood Pressure Control
Antihypertensive Therapy
Blood Pressure Goals
Acute Coronary Syndrome and Acute Heart Failure
Aortic Dissection
Acute Ischemic Stroke
Spontaneous Intracranial Hemorrhage
Hypertensive Encephalopathy
Acute Kidney Injury
Preeclampsia and Eclampsia
Sympathetic Crises
Chronic Antihypertensive Therapy
Disposition
References
71 - Aortic Dissection
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
References
72 - Abdominal Aortic Aneurysm
Epidemiology
Pathophysiology
Natural History
Clinical Features
Unruptured Aneurysms
Ruptured Aneurysms
Pain-­Hypotension-­Mass Triad
Aortoenteric Fistula
Arteriovenous (Aortocaval) Fistula
Differential Diagnoses
Diagnostic Testing
Abdominal Radiography
Ultrasonography
Computed Tomography
Other Diagnostic Modalities
Management
Ruptured Aneurysms
Fluid Resuscitation
Diagnostic Confirmation
Surgery and Mortality
Intact Asymptomatic Aneurysms
Traditional Repair
Endovascular Repair
Survival
Late Complications of Repair
Graft Infection
Aortoenteric Fistula
Pseudoaneurysm (Anastomotic Aneurysm)
Complications of Endovascular Aneurysm Repair
Disposition
References
73 - Peripheral Arteriovascular Disease
Foundations
Background
Arterial Anatomy
Pathophysiology
Atherosclerosis
Arterial Embolism
.. Most arterial emboli (85%) originate from thrombus formation in the heart. Left ventricular thrombus formation resulting from...
.. Atheroembolism refers to microemboli consisting of cholesterol, calcium, and platelet aggregates dislodged from proximal comp...
Arterial Thrombosis
Aneurysms
Inflammation
Trauma
Vasospasm
Arteriovenous Fistulae
Clinical Features
History
Physical Examination
Inflammation
Vasospasm
Differential Diagnosis
Diagnostic Testing
Noninvasive Assessment
Contrast Arteriography
Management
Noninvasive Therapy
Acute Anticoagulation with Heparin
Fibrinolytic Therapy
Invasive Therapy
Fogarty Catheter Thrombectomy
Peripheral Percutaneous Transluminal Angioplasty
Grafting
Hyperbaric Therapy
Disposition
Specific Arteriovascular Diseases
Diseases of Chronic Arterial Insufficiency
Arteriosclerosis Obliterans
Clinical Features
.. Acute arterial occlusion from embolism, thrombosis, or trauma is ruled out primarily by history. Chronic arterial insufficien...
.. Atheromatous emboli from proximal ulcerated plaques or aneurysms cause small scattered ischemic lesions in the toes, feet, or...
.. Exercise-­induced claudication should be distinguished from nocturnal muscle cramps frequently seen in older patients. Aortoi...
.. The first step is to identify patients whose symptoms are the sole result of arteriosclerosis obliterans without coexistent t...
Buerger Disease (Thromboangiitis Obliterans)
. First described by Buerger in 1908, thromboangiitis obliterans is an idiopathic inflammatory occlusive disease primarily invol...
. Clinical criteria for Buerger disease include (1) a history of smoking, (2) onset before the age of 50, (3) infrapopliteal art...
. Arteriosclerosis obliterans is most likely in patients older than 50 years old who have signs of peripheral ischemia. In young...
. Adherence to diagnostic clinical criteria should suffice for ED diagnosis of Buerger disease. Noninvasive vascular laboratory ...
. Permanent complete abstinence from tobacco is the only effective treatment for Buerger disease. If a patient does not complete...
Diseases of Acute Arterial Occlusion
Arterial Embolism
Clinical Features
. Patients with acute arterial occlusion usually exhibit some variant of the five Ps: pain, pallor, pulselessness, paresthesias,...
. The physical examination can help differentiate arterial embolism from in situ thrombosis. Sudden loss of a pulse is the hallm...
. Phlegmasia cerulea dolens is a massive iliofemoral deep venous thrombosis. The initial symptom is the acute onset of a swollen...
. Acute arterial embolism is a surgical emergency. The likelihood of limb salvage decreases after 4 to 6 hours. On the basis of ...
Atheroembolism (Blue Toe Syndrome)
. The typical presentation of atheroembolism is the sudden onset of a small, cyanotic, and tender area on the foot, typically th...
. A variety of conditions can mimic blue toe syndrome. Acrocyanosis is painless, has a symmetrical distribution, and is located ...
. Treatment is directed toward identifying and removing the proximal source of atheroembolism. CT angiography is the diagnostic ...
Arterial Thrombosis
Physical Exam
. Heparinization (80 units/kg bolus, followed by a maintenance infusion of 18 units/kg/hr) should be started when the diagnosis ...
Peripheral Arterial Aneurysms
Lower Extremity
Upper Extremity
Viscera
. Splenic artery aneurysms account for 60% of all visceral arterial aneurysms. They are the only aneurysms that are more common ...
. Hepatic artery aneurysms represent 20% of visceral artery aneurysms. The lesions are caused by atherosclerosis, infection (mos...
. Superior mesenteric artery aneurysms are the third most common visceral aneurysms. Nearly 60% are infected aneurysms caused by...
Traumatic Aneurysms
Infected Aneurysms
. The term mycotic aneurysm is a source of confusion because there is no association with fungal disease. Although used to descr...
. Currently, the most common cause of an infected aneurysm is sepsis with hematogenous spread of bacteria, such as Salmonella, S...
. The incidence of infection in patients with preexisting atherosclerotic aneurysms is estimated at 3% to 4%, and patients with ...
. Post-­traumatic infected pseudoaneurysms result from invasive hemodynamic monitoring, angiography, and intravenous drug use. T...
Vasospastic Disorders
Thoracic Outlet Syndrome
Clinical Features
. The most reliable test in screening for thoracic outlet syndrome is the elevated arm stress test (EAST).44 With the patient si...
. Cervical spine radiographs with oblique views and chest radiographs identify skeletal abnormalities (first rib, cervical rib, ...
Differential Diagnosis
Management
. The correct diagnosis of thoracic outlet syndrome can be achieved in more than 90% of patients with a careful history, physica...
Peripheral Arteriovenous Fistulae
Physical Exam
Differential Diagnosis
Management
Vascular Abnormality Caused by Drug Abuse
Principles
Clinical Features
Management
References
74 - Pulmonary Embolism and Deep Vein Thrombosis
Foundations
Background and Importance
Anatomy, Pathology, and Pathophysiology of VTE
Deep Vein Thrombosis
Clinical Features
Differential Diagnosis
Diagnostic Testing
Pretest Probability Estimation
Laboratory Evaluation
Radiographic Evaluation
Management
Assessing Bleeding Risk
Superficial Vein Thrombophlebitis
Isolated Calf Vein Thrombosis
Phlegmasia Cerulean and Alba Dolens
Upper Extremity Venous Thromboses
Complications
Disposition
Pulmonary Embolism
Clinical Features
Symptoms
Vital Signs
Physical Examination
Differential Diagnosis
Diagnostic Testing
Bedside Assessment
Pretest Probability Assessment
Pulmonary Embolism Rule-­Out Criteria
D-­Dimer Testing
Computed Tomography Pulmonary Angiography
Ventilation/Perfusion Scan
Pregnant Women
Clinical Course
Management
Airway, Oxygenation, and Ventilation
Hemodynamic Resuscitation
Pulmonary Vasodilators
Standard Anticoagulation
. All anticoagulants commonly used in the ED, including the DOACs, now have effective reversal agents. The anticoagulant effect ...
Thrombolytic (Fibrinolytic) Therapy
Catheter-­Directed Interventions
Surgical Embolectomy
Inferior Vena Cava Filters
Pulmonary Embolism Response Teams (PERT)
Mortality and Morbidity
Disposition
References
75 - Esophagus, Stomach, and Duodenum
Dysphagia
Foundations
Anatomy and Pathophysiology
Oropharyngeal Dysphagia
. Neuromuscular disease causes approximately 80% of cases of oropharyngeal dysphagia, with most remaining causes being localized...
. Congenital anomalies of the aortic arch may cause dysphagia in children and adults. In children, respiratory symptoms are usua...
Esophageal Dysphagia
. Esophageal dysphagia is caused by mechanical lesions or a motility disorder. Mechanical lesions may be intrinsic or extrinsic ...
. Patients with esophageal dysphagia who have no readily identifiable mechanical cause may have a motor disorder. Intrinsic moto...
Clinical Features
Esophageal Dysphagia
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Foreign Bodies
Foundations
Background
Anatomy and Physiology
Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Overview
Upper Esophagus
Lower Esophagus
Stomach
Disposition
Esophageal Perforation
Foundations
Background
Anatomy and Physiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Esophagitis
Foundations
Gastroesophageal Reflux Disease
Eosinophilic Esophagitis
Infectious Esophagitis
Pill Esophagitis
Radiation-­Induced Esophagitis
Clinical Features
Gastroesophageal Reflux Disease
Eosinophilic Esophagitis
Infectious Esophagitis
Pill Esophagitis
Differential Diagnoses
Diagnostic Testing
Management
Gastric Reflux
Eosinophilic Esophagitis
Infectious Esophagitis
Pill Esophagitis
Disposition
Gastritis and Peptic Ulcer Disease
Foundations
Background
Pathophysiology
Clinical Features
Complications
Differential Diagnoses
Diagnostic Testing
Management
Antacids
Histamine Blockers
Proton Pump Inhibitors
Prostaglandins
Other Agents
Disposition
Gastric Volvulus
Foundations
Clinical Features
Complications
Differential Diagnoses
Diagnostic Testing
Management
Disposition
References
76 - Liver and Biliary Tract Disorders
Hepatic Disorders
Hepatitis
Viral Hepatitis
Foundations
. Hepatitis A virus (HAV), is an RNA enteroviral picornavirus. It is spread by the fecal-­oral route directly or through fecally...
. Hepatitis B virus (HBV) is a virion that envelopes DNA polymerase, hepatitis B surface antigen (HBsAg), and hepatitis B core a...
Hepatitis C and E
. Hepatitis delta virus (HDV) is a defective RNA virus that can infect only patients who are actively producing HBsAg (HBV disea...
. Hepatitis E, which is associated with fecal-­oral transmission, is encountered most often in Asia, Africa, or Russia. Hepatiti...
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
. Effective preexposure and postexposure prophylaxis for HAV and HBV are available. For HBV exposure in an unimmunized patient, ...
Disposition
Alcoholic Hepatitis
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Autoimmune Hepatitis
Foundations
Diagnosis
Management
Disposition
Cirrhosis
Foundations
Clinical Features
Diagnostic Testing
Management
Ascites
Gastrointestinal Bleeding
Hepatorenal Syndrome
Hepatic Encephalopathy
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Spontaneous Bacterial Peritonitis
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Hepatic Abscesses
Pyogenic Abscess
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Amebic Abscess
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Liver Disease of Pregnancy
Benign Cholestasis
Acute Fatty Liver
Budd-­Chiari Syndrome
Liver Transplantation
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Special Considerations
Disposition
Cholecystitis
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Special Considerations
. Acute cholecystitis absent of stones is more common in older adults and is often found in patients who are recovering from non...
. This is an uncommon variant of cholecystitis, occurring in approximately 1% of cases. It is characterized by the presence of g...
Disposition
Cholangitis
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Sclerosing Cholangitis
Aids Cholangiopathy
References
77 - Pancreas
Pancreatitis
Anatomy, Physiology, and Pathophysiology
Acute Pancreatitis
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
. Laboratory diagnosis of pancreatitis is made primarily by serum lipase and amylase levels. Lipase is an enzyme produced predom...
. Abdominal imaging by computed tomography (CT) or magnetic resonance imaging (MRI) is not routinely recommended in the diagnosi...
. Predicting the disease course in acute pancreatitis is challenging but important given the range in severity from mild cases t...
Management
Disposition
Chronic Pancreatitis
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Pancreatic Cancer
Foundations
Clinical Features
References
78 - Small Intestine
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Pathophysiology
Clinical Features
History
Physical Examination
Differential Diagnosis
Diagnostic Testing
Laboratory
Imaging
Management
Disposition
Acute Mesenteric Ischemia
Foundations
Background and Importance
Anatomy and Physiology
Pathophysiology
Mesenteric Arterial Embolism
Mesenteric Arterial Thrombosis
Nonocclusive Mesenteric Ischemia
Mesenteric Venous Thrombosis
Unusual Causes of Mesenteric Ischemia
Clinical Features
. The history at presentation of mesenteric ischemia is largely dependent on the nature of the underlying cause. The traditional...
. The pain in acute mesenteric ischemia is typically described as being out of proportion to the physical examination findings. ...
Differential Diagnosis
Diagnostic Testing
Laboratory Tests
Imaging
Management
Complications
Disposition
References
79 - Acute Appendicitis
Principles
Background
Anatomy and Physiology
Pathophysiology
Clinical Features
History
Physical Examination
Differential Diagnosis
Diagnostic Testing
General Principles
Laboratory Testing
White Blood Cell Count
C-­Reactive Protein
Urinalysis
Other Laboratory Tests
Combined Laboratory Tests
Clinical Decision Instruments
Imaging
General Principles
Plain Radiographs
Graded Compression Ultrasound
Computed Tomography
Magnetic Resonance Imaging
Summary of Imaging Methods
. Graded compression US may be considered first. In nonpregnant females, a pelvic US may also be considered to assess for pelvic...
. US should be the initial study of choice, followed by MRI of the abdomen without gadolinium in cases of nondiagnostic or negat...
Management
Supportive Care
Antibiotic Therapy
Definitive Treatment
Uncomplicated Appendicitis
Complicated Appendicitis
Disposition
References
80 - Gastroenteritis
Foundations
Background and Importance
Clinical Features
Patient History
Physical Examination
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Bacterial Gastroenteritis
Invasive Bacteria
Campylobacter Enteritis
Epidemiology
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Salmonellosis
Epidemiology
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Shigellosis
Epidemiology
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Yersinia enterocolitica Gastroenteritis
Epidemiology
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Vibrio parahaemolyticus Gastroenteritis
Epidemiology
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Shiga Toxin–Producing Escherichia coli
Epidemiology
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Noninvasive Toxin-­Forming Bacteria
Staphylococcus spp
Epidemiology
Pathophysiology
Clinical Features
Management
Clostridium perfringens
Epidemiology
Pathophysiology
Clinical Features
Management
Bacillus cereus
Epidemiology
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Cholera and Noncholera Vibrio Species
Epidemiology
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Enterotoxigenic Escherichia coli
Epidemiology
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Clostridium difficile Colitis
Epidemiology
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Viral Gastroenteritis
Norovirus
Epidemiology
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Rotavirus
Epidemiology
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Parasites
Giardia
Epidemiology
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Amebiasis
Epidemiology
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Food Poisoning
Foundations
Clinical Features
Diagnostic Testing
Management
Scombroid Fish Poisoning
Epidemiology
Pathophysiology
Clinical Features
Management
Ciguatera Fish Poisoning
Epidemiology
Pathophysiology
Clinical Features
Management
Specific Groups With Gastroenteritis
Traveler’s Diarrhea
Epidemiology
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Epidemiology and Pathophysiology
Clinical Features
Diagnostic Testing
Management
References
81 - Large Intestine
Irritable Bowel Syndrome
Foundations
Background
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Diverticular Disease
Foundations
Background
Anatomy, Physiology, and Pathophysiology
Clinical Features
Diverticulosis
Diverticulitis
Differential Diagnoses
Diagnostic Testing
Management
Diverticulosis
Uncomplicated Diverticulitis
Complicated Diverticulitis
Disposition
Large Bowel Obstruction
Foundations
Background
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Laboratory Tests
Imaging Studies
. Both supine and upright plain films are advised for the workup of LBO and ACPO (Fig. 81.4). A distended colon (>6 cm diameter)...
. CT is a valuable tool for determining the cause of the obstruction, especially if it is a diverticular abscess or intussuscept...
. Water-­soluble contrast enemas are no longer advised, given that CTs are now more accurate in making the diagnosis of LBO. Col...
Management
Disposition
Volvulus
Foundations
Background
Anatomy, Physiology, and Pathophysiology
. Residents of long-­term care facilities and patients with neurologic or psychiatric disease are predisposed to sigmoid volvulu...
. The mobility of the colonic segment involving the cecum is likely a result of a congenital incomplete fusion of the cecal mese...
Clinical Features
Sigmoid Volvulus
Cecal Volvulus
Differential Diagnoses
Diagnostic Testing
Sigmoid Volvulus
Cecal Volvulus
Management
Sigmoid Volvulus
Cecal Volvulus
Disposition
Intussusception
Foundation
Background
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Ultrasound Examination
Plain Radiography
Computed Tomography
Colonoscopy
Management
Disposition
Inflammatory Bowel Disease
Foundations
Background
Anatomy, Physiology, and Pathophysiology
Crohn Disease
Ulcerative Colitis
Clinical Features
Toxic Megacolon
Extraintestinal Manifestations
Differential Diagnoses
Diagnosis
Management
Crohn Disease
. Since CD can affect any area of the GI tract, location of disease and severity of symptoms are important factors in treatment ...
. For moderate to severe CD that is responsive to systemic steroids, early introduction to an immunomodulator, such as thiopurin...
. Severe to fulminant disease requires aggressive therapy, gastroenterology consultation, and often hospitalization. For patient...
Ulcerative Colitis
. For mild to moderate UC, aminosalicylates (5-­ASA) including mesalazine and sulfasalazine are mainstays of treatment.18 Combin...
. Vedolizumab was approved to treat moderate to severe UC resistant to immunomodulators, steroids, or anti-­TNF therapy. While s...
Managing Special Populations With Irritable Bowel Syndrome
Toxic Megacolon
Disposition
Colonic Ischemia
Foundations
Background
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Laboratory Tests
Imaging Studies
. Plain radiographs often show only nonspecific dilated bowel. Findings specific for CI occur in approximately 20% of patients. ...
. Although CT does not allow the definitive diagnosis of CI, it is useful to support the clinical suspicion, assess the extent o...
. Emergent colonoscopy should be performed after the colon is prepped with an enema. It is the most useful within 48 hours of sy...
. Angiography is usually not helpful in the diagnosis or management of CI. In most cases, the blood flow defect is at the microv...
Management
Disposition
Stercoral Colitis
Foundations
Background
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnosis
Management
Disposition
Radiation Proctocolitis
Foundations
Background
Anatomy, Physiology, and Pathophysiology
. Intestinal epithelium normally sloughs off and is replaced at a rapid rate. After the initiation of radiation therapy, growth ...
. The pathologic mechanism in chronic RP is entirely different and results from a progressive endarteritis, with abnormal tissue...
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Acute Radiation Proctocolitis
Chronic Radiation Proctocolitis
Disposition
Neutropenic Enterocolitis
Foundations
Background
Anatomy, Pathology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Laboratory Tests
Radiologic Tests
Management
Disposition
References
82 - Anorectum
Clinical Features
Specific Anorectal Problems
Hemorrhoids
Foundations
Clinical Features
Management
Anal Fissures
Foundations
Clinical Features
Management
Abscesses and Fistulae
Foundations
Management
. Perirectal and perianal abscesses account for about half of anorectal abscesses. They produce painful swelling at the anal ver...
. Ischiorectal abscesses account for one-­fifth to one-­quarter of anorectal abscesses. They form outside the sphincter muscles ...
. One-­fourth of abscesses form in the intersphincteric space, located deep to the external sphincter and inferior to the levato...
. Supralevator abscesses, which cause less than 5% of anorectal abscesses, present as perianal and buttock pain associated with ...
. Postanal abscesses are uncommon and occur posterior to the rectum, deep to the external sphincter and inferior to the levator ...
. A large, communicating, horseshoe-­shaped abscess may form in the ischiorectal, intersphincteric, or supralevator spaces. The ...
. A delay in the management of an anorectal abscess may lead to the destruction of surrounding tissue, especially in diabetic or...
. A fistula is a connection between two epithelium-­lined surfaces and commonly develops in patients with abscesses. Other cause...
Pilonidal Disease
Foundations
Management
Hidradenitis Suppurativa
Foundations
Clinical Findings
Differential Diagnosis
Management
Proctalgia
Levator Ani Syndrome
Proctalgia Fugax
Fecal Incontinence
Foundations
Clinical Features
Management
Pruritis Ani
Foundations
Diagnostic Testing
Management
Sexually Transmitted Disease and Proctitis
Foundations
. The gram-­negative diplococcus Neisseria gonorrhoeae causes gonorrhea. Proctitis (inflammation of the rectum) results from ana...
. Infection with Chlamydia trachomatis, an intracellular organism that is endemic to the tropics, is a common STD in the United ...
. Herpes proctitis is caused by herpes simplex virus type 1 (HSV-­1) and HSV-­2. Symptoms appear 1 to 3 weeks after exposure. Th...
. Syphilis is caused by Treponema pallidum, a motile spirochete. During anal intercourse, the organism enters the rectal mucosa ...
. Chancroid is caused by the gram-­negative bacillus Haemophilus ducreyi, and begins as an inflammatory pustule or macule that r...
. Condyloma acuminatum (genital warts), the most commonly encountered anorectal STD, is caused by the human papillomavirus. The ...
. There is significant comorbidity between patients who are HIV seropositive and other STDs. Anorectal complaints in HIV-­positi...
Management
Radiation Proctitis
Rectal Prolapse
Rectal Foreign Bodies
Foundations
Clinical Features
Diagnostic Testing
Management
References
83 - Renal Failure
Renal Failure
Acute Kidney Injury
Foundations
Clinical Features
Differential Diagnosis
Prerenal Azotemia
Postrenal (Obstructive) Acute Kidney Injury
Intrinsic Acute Kidney Injury
. This may represent a primary renal process or may be the manifestation of any of a wide range of other disease entities (see B...
. Acute interstitial nephritis (AIN) is usually precipitated by drug exposure or by infection. Drug-­induced AIN is poorly under...
. This can be classified according to the size of the vessel that is affected. Disorders such as renal arterial thrombosis or em...
. ATN refers to a generally reversible deterioration of kidney function associated with a variety of renal insults. Oliguria may...
Diagnostic Testing
Urine Volume
Urinalysis
. The dipstick detects free hemoglobin from lysed RBCs (or myoglobin) and the hemoglobin inside RBCs but is more sensitive to fr...
. The dipstick test for protein, which uses the color change of tetrabromophenol blue, can detect protein at concentrations of 1...
Serum and Urine Chemical Analysis
. The normal range for the serum creatinine level extends from 0.5 mg/dL in thin people to 1.5 mg/dL in muscular persons. Spurio...
. Normally, urine sodium concentration parallels sodium intake. A low urine sodium concentration thus indicates not only intact ...
Renal Imaging
. Noncontrast CT may be useful in evaluating some azotemic patients. Hydronephrosis can be recognized without the use of contras...
. Ultrasonography is a safe and reasonably reliable method for excluding obstruction as a cause of AKI. The normal kidney shows ...
Diagnosis
Management
Hyperkalemia and Other Metabolic Derangements
. The most common metabolic cause of death in patients with AKI results from an inability to excrete endogenous and exogenous po...
. Hypocalcemia is a common feature of AKI that can develop rapidly after its onset. Vitamin D–dependent intestinal absorption of...
. Hyperphosphatemia resulting from decreased renal elimination of phosphate is another common feature. The serum phosphorus leve...
. This may complicate AKI when patients are given magnesium-­containing antacids or laxatives. Thus, these products, as well as ...
. These can be expected to occur in most patients with AKI. Some nonoliguric patients excrete enough salt and water to produce i...
Disposition
Chronic Kidney Disease
Foundations
Pathophysiology
Clinical Features
Cardiovascular System
Pulmonary Effects
Neurologic Features
Gastrointestinal System
Dermatologic Features
Musculoskeletal System
Immunologic Considerations
Hematologic Effects
Differential Diagnosis
Diagnostic Testing
Management
Hyperkalemia
Pulmonary Edema
Infection
Dialysis
. This requires special access to the patient’s circulation, generally through a surgically created arteriovenous fistula or an ...
. In peritoneal dialysis, the patient’s peritoneum functions as the dialysis membrane. Dialysate is infused through a surgically...
. The decision to initiate chronic dialysis in the patient with CKD generally is made by the patient’s nephrologist in the setti...
Complications of Dialysis
Hemodialysis
Vascular Access–Related Complications
Non–Vascular Access–Related Complications of Dialysis
. Hypotension that occurs after dialysis is usually the result of an acute reduction in circulating intravascular volume and fai...
. Shortness of breath in dialysis patients generally is caused by volume overload. In the patient who becomes short of breath wh...
. Cardiovascular disease is a leading cause of death in patients with CKD, and most episodes of chest pain occurring during dial...
. Neurologic symptoms during or immediately after hemodialysis may be caused by disequilibrium syndrome, a constellation of symp...
Peritoneal Dialysis
References
84 - Sexually Transmitted Infections
Disorders Characterized by Genital Ulcers
Herpes
Background and Importance
Clinical Features
Diagnostic Testing
Management
Disposition
Syphilis
Background and Importance
Clinical Features
Diagnostic Testing
Management
Disposition
Chancroid
Background and Importance
Clinical Features
Diagnostic Testing
Management
Foundations
Gonorrhea
Background and Importance
Clinical Features
Diagnostic Testing
Treatment
Disposition
Chlamydia
Background and Importance
Clinical Features
Diagnostic Testing
Management
Disposition
Nongonococcal Urethritis
Trichomoniasis
Background and Importance
Clinical Features
Diagnostic Testing
Management
Disposition
Pelvic Inflammatory Disease
Background and Importance
Clinical Features
Diagnostic Testing
Management
Disposition
Bacterial Vaginosis
Background and Importance
Clinical Features and Diagnostic Testing
Management
Vulvovaginal Candidiasis
Background and Importance
Clinical Features and Diagnostic Testing
Management
Epithelial Cell Infections
Condyloma Acuminata (Genital Warts)
Background and Importance
Clinical Findings
Diagnostic Testing
Management
Molluscum Contagiosum
Ectoparasites
Pediculosis Pubis
Scabies
References
85 - Urologic Disorders
Background
Anatomy and Physiology
Pathophysiology
Clinical Features
Differential Diagnosis
Diagnostic Testing
Urinalysis and Urine Culture
Imaging
Management
Simple Urinary Tract Infection
Complex Urinary Tract Infection
Disposition
Pregnancy
Indwelling and Temporary Urinary Catheters
Prostatitis
Background
Clinical Features
Diagnostic Testing
Management
Renal Calculi
Background
Pathophysiology
Clinical Features
Differential Diagnosis
Diagnostic Testing
Urinalysis and Culture
Other Laboratory Tests
Imaging
Radiography of the Kidney, Ureter, and Bladder
Intravenous Pyelography
Computed Tomography
Ultrasonography
Management
Disposition
Indications for Admission
Outpatient Management
Bladder (Vesical) Calculus
Background
Clinical Features
Diagnostic Testing
Management
Acute Scrotal Pain
Background
Specific Disorders
Testicular Torsion
Background
Clinical Features
Differential Diagnosis
Diagnostic Testing
Urinalysis
Imaging
Management
Disposition
Torsion of Appendages of the Testis
Background
Clinical Features
Diagnostic Testing
Management and Disposition
Epididymitis
Background
Clinical Features
Diagnostic Testing
Management
Disposition
Orchitis
Background
Clinical Features
Diagnostic Testing
Management
Testicular Tumors
Background
Clinical Features
Diagnostic Testing
Management and Disposition
Testicular Trauma
Acute Urinary Retention
Background
Physiology and Pathophysiology
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Hematuria
Background
Clinical Features
Diagnostic Testing
Management and Disposition
References
86 - Gynecologic Disorders
Gynecologic Disorders
Adnexal Torsion
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Laboratory Tests
Imaging Tests
. Ultrasound examination is the optimal initial imaging test in the evaluation of patients with pelvic pain highly suggestive of...
. When alternative abdominal pathologies are strong considerations in the differential diagnosis of a patient’s acute pelvic pai...
. MRI may also demonstrate findings consistent with torsion. It is particularly helpful when the diagnosis is unclear, such as i...
. Given the frequency of equivocal findings on imaging studies, the lack of reliable clinical decision tools, the absence of a p...
Management and Disposition
Ovarian Cysts and Masses
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Laboratory Tests
Imaging Tests
. Ultrasonography is used to diagnose and characterize all ovarian pathologic processes and lesions, including cysts and masses....
. When the differential diagnosis of unilateral pelvic pain is broad, particularly in the patient with symptoms or physical find...
. MRI provides better soft tissue contrast than CT and has been shown in multiple studies to differentiate benign from malignant...
Management and Disposition
Foundations
Clinical Features
History
Physical Examination
Differential Diagnoses
Diagnostic Strategies
Laboratory Tests
Imaging Tests
Management
Disposition
Emergency Contraception
References
87 - Stroke
Foundations
Background and Importance
Ischemic Stroke
Transient Ischemic Attack
Hemorrhagic Stroke
Anatomy, Physiology, and Pathophysiology
Clinical Features
Ischemic Stroke
Chemoreceptor Trigger Zone for Emesis
Hemorrhagic Stroke
Differential Diagnoses
Ischemic Stroke
Hemorrhagic Stroke
Diagnostic Testing
Ischemic Stroke
Transient Ischemic Attack
Hemorrhagic Stroke
Management
Ischemic Stroke
Blood Pressure Management
Temperature
Blood Glucose
Reperfusion Therapy
Thrombolytic Therapy
Agent and Dosage
Time Window
Thrombolysis for Mild Disabling Versus Nondisabling Acute Ischemic Stroke
Thrombolysis in Patients on Anticoagulants Before the Stroke
Symptomatic Intracerebral Hemorrhage Following Thrombolysis
Cerebral Microbleeds
Mechanical Thrombectomy
Timing
Mechanical Thrombectomy and Thrombolysis
Monitoring
Blood Pressure Management
Reversal of Anticoagulation
Hemostatic Agents
Seizures
Prognosis
Increased Intracranial Pressure
Neurosurgical Intervention
Transient Ischemic Attack
Disposition
References
88 - Seizure
Background and Classification
Anatomy, Physiology, and Pathophysiology
Clinical Features
Clinical History
Physical Examination
Differential Diagnosis
Diagnostic Testing
Laboratory Studies
Radiology
Special Procedures and Tests
Management
Stabilization and Empirical Therapy
Definitive Management
Special Cases
Alcohol-­Related Seizures
Seizures Related to Other Toxins
Post-­Traumatic Seizures
Seizures in Pregnancy
First-­Time Seizures
Breakthrough Seizures
Post-­Anoxic Seizures
Nonconvulsive Status Epilepticus
Inflammation-­Related Seizures
Disposition
References
89 - Headache Disorders
Migraine Headache
Principles
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Cluster Headache
Principles
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Tension-­Type Headache
Principles
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Secondary Headache Disorders
Subarachnoid Hemorrhage
Principles
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Intracranial Neoplasm
Principles
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Giant Cell Arteritis
Principles
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Carotid and Vertebral Artery Dissection
Principles
Clinical Features
. The classic presentation of symptoms for carotid artery dissection includes (1) unilateral headache or neck pain, sometimes ra...
. Vertebral artery dissections are less common than carotid dissections. The classic presentation is that of a relatively young ...
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Cerebral Venous Thrombosis
Principles
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Idiopathic Intracranial Hypertension
Principles
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Post–Dural Puncture Headache and Other Low CSF Pressure Headaches
Principles
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Post-­Traumatic Headache
Principles
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Hypertensive Headache
Principles
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Reversible Cerebral Vasoconstriction Syndrome
Principles
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
References
90 - Delirium and Dementia
Delirium
Background
Pathophysiology
Clinical Features
Differential Diagnosis
Diagnostic Studies
Management
Disposition
Dementia
Principles
Background
Pathophysiology
Clinical Features
Differential Diagnosis
Senescent Forgetfulness
Delirium
Depression
Diagnostic Testing
Cognitive Evaluation
Laboratory Tests and Imaging Studies
Management
Disposition
References
91 - Brain and Cranial Nerve Disorders
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Cerebral Venous Thrombosis
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Cranial Nerve Disorders
Trigeminal Neuralgia (Cranial Nerve V)
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Facial Nerve Paralysis (Cranial Nerve VII)
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Vestibular Schwannoma (Cranial Nerve VIII)
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Diabetic Cranial Mononeuropathy
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
References
92 - Spinal Cord Disorders
Foundations
Anatomy
Classification of Spinal Cord Syndromes
Complete (Transverse) Spinal Cord Syndrome
Incomplete (Partial) Spinal Cord Lesions
. Central cord syndrome is the most common of the partial cord syndromes. Because of the anatomic organization of the spinal cor...
. Brown-­Séquard syndrome is the result of an anatomic or functional hemisection of the spinal cord. Usually associated with pen...
. Anterior cord syndrome is characterized by loss of motor function, pinprick, and light touch below the level of the lesion wit...
Conus Medullaris and Cauda Equina Syndromes
Clinical Features
History
Physical Examination
Motor Function
Sensory Function
Reflexes
Differential Diagnoses
Diagnostic Testing
Management
Specific Disease Processes
Intrinsic Cord Lesions
Multiple Sclerosis
Transverse Myelitis
. Acute transverse myelitis (TM) refers to acute or subacute spinal cord dysfunction characterized by paraplegia, a transverse l...
. In addition to motor, sensory, and urinary disturbances, patients with acute transverse myelitis may complain of back pain as ...
. Considerations in the differential diagnosis for transverse myelitis include MS, SEA, spinal epidural hematoma (SEH), primary ...
. MRI with gadolinium enhancement is the diagnostic modality of choice for suspected transverse myelitis (Fig. 92.4). In cases o...
. Treatment is tailored to the suspected underlying etiology. There are no good studies supporting a role for steroids. The exce...
Spinal Subarachnoid Hemorrhage
. Intraspinal hemorrhage is rare and may occur in the same anatomic locations as intracranial hemorrhages; epidural, subdural, s...
. Patients with SSAH present with excruciating back pain of a sudden and severe nature at the level of the hemorrhage. This pain...
. Considerations in the differential diagnosis include disc herniation, tumor, ischemia from aortic dissection, and anterior spi...
. Because bone artifact may obscure the presence of blood in the spine, the diagnostic study of choice in patients with suspecte...
. The treatment of spinal subarachnoid hemorrhage depends on the etiology of the hemorrhage. Neurosurgical referral is obtained ...
Syringomyelia
. Syringomyelia is the presence of a cavitary lesion within the tissue of the spinal cord. The word syrinx is derived from the G...
. Headache and neck pain are the most common presenting complaints of patients with syringomyelia, followed by sensory disturban...
. Considerations in the differential diagnosis for syrinx include intrinsic spinal tumor, demyelination, and trauma resulting in...
. Syringomyelia is best seen on MRI (Fig. 92.5). No other modality currently in widespread use is equivalent in diagnostic abili...
. When the diagnosis of syringomyelia is considered, emergent imaging in the ED may not be necessary if follow-­up evaluation ca...
Human Immunodeficiency Virus Myelopathy
Spinal Cord Infarction
Surfer’s Myelopathy
Extrinsic Cord Lesions
Spinal Epidural Hematoma
. Spinal epidural hematoma (SEH) is a relatively rare condition where blood accumulates in the epidural space and can cause comp...
. Patients usually present with sudden, severe, constant back pain. The pain is frequently radicular and may occur after a strai...
. Considerations in the differential diagnosis include SEA, epidural neoplasm, acute disc herniation, and SSAH. SEH has even bee...
. MRI with and without IV contrast is the diagnostic study of choice. CT myelography will frequently pick up the hematoma or sho...
. In patients with SEH, recovery without surgery is rare. Neurosurgical consultation for emergent decompressive laminectomy is i...
Spinal Epidural Abscess
. Spinal epidural abscess (SEA) is an infectious process usually confined to the adipose tissue of the dorsal epidural space whe...
. The clinical presentation of SEA begins with back pain localized to the level of the affected spine, often associated with ten...
. SEA is frequently misdiagnosed on initial presentation, especially in a patient who is neurologically intact. In someone with ...
. MRI with IV contrast is the imaging modality of choice and should be performed emergently if the diagnosis of SEA is considere...
. Urgent surgical consultation for possible decompress­ion is required for SEA. Antibiotics effective against the most common pa...
Discitis
. Discitis is an uncommon primary infection of the vertebral disc, specifically the nucleus pulposus, with secondary involvement...
. Clinical presentation can be quite variable. In general, patients present with moderate to severe pain localized to the level ...
. Considerations in the differential diagnosis of discitis include vertebral osteomyelitis, spinal epidural abscess, neoplasm, a...
. MRI with IV contrast is the radiographic study of choice for suspected discitis, because it not only enables diagnosis but als...
. With timely diagnosis and treatment, outcome is usually very good and medical treatment with IV antibiotics that cover Staphyl...
Neoplasm
. Spinal cord tumors are classified according to their relationship to the dura and spinal cord (extradural, intradural extramed...
. In nearly all patients with spinal neoplasm, the initial complaint is pain, either in the back at the level of the tumor or in...
. Considerations in the differential diagnosis of spinal neoplasm include any of the compressive lesions (e.g., hematoma, infect...
. Patients presenting with new back pain (<6 weeks) and no risk factors or neurologic deficits on examination generally do not r...
. Acute compressive myelopathy from neoplasm constitutes an oncologic emergency. Immediate treatment is required to preserve fun...
Autonomic Dysreflexia
Foundations
Clinical Features
Management
Spasticity
Infection
References
93 - Peripheral Nerve Disorders
Principles
Differential Diagnosis
Diagnostic Testing
Specific Types of Neuropathies
Type 1: Demyelinating Polyneuropathy (Guillain-­Barré Syndrome)
Principles
Clinical Features
Diagnostic Testing
Management
Disposition
Type 2: Distal Symmetrical Polyneuropathy
Principles
Clinical Findings
Differential Diagnosis
Diagnostic Testing
Management
Type 4: Isolated Mononeuropathies
Radial Mononeuropathy
. The radial nerve arises from the C5 to T1 roots. After exiting the brachial plexus, it passes behind the proximal humerus in t...
. Because innervation of the wrist and finger extensors occurs distal to this area of the humeral shaft, findings are characteri...
. There exists no diagnostic test per se for this disease entity beyond the physical examination. EMG testing is employed to aid...
. While patients are waiting for spontaneous recovery to occur, the hand should be maintained in about 60 degrees of dorsiflexio...
Ulnar Mononeuropathy
. The ulnar nerve includes C7 to T1 roots and passes through the brachial plexus to descend medially, without branching, to the ...
. There exists no true diagnostic entity for this disease process beyond the physical examination
. Most ulnar mononeuropathies will spontaneously resolve. The evidence and options for nonoperative management are limited, but ...
Median Mononeuropathy
. The median nerve arises from the C5 to T1 spinal nerve roots and exits the brachial plexus through the lower trunk (Fig. 93.6)...
. Although the patient may complain of bilateral symptoms, a careful history usually reveals that symptoms in one hand preceded ...
. The Tinel sign (percussion of the median nerve at the wrist) and Phalen sign (maximal palmar flexion at the wrist) are provoca...
. There are a variety of nonsurgical treatments, with splinting and steroid injections being the most common. A neutral wrist sp...
Sciatic Mononeuropathy
. The sciatic nerve includes L4 to S3 spinal nerve roots that pass through the lumbosacral plexus and divides into two terminal ...
. Ambulation is extremely difficult because of inability to flex the knee and a flail foot (i.e., neither flexion nor extension ...
. This condition is mainly diagnosed by physical findings. If used, electrophysiologic studies show evidence of involvement of g...
. Treatment of footdrop requires a posterior splint to maintain the ankle at 90 degrees until a brace can be obtained (see the C...
Lateral Femoral Cutaneous Mononeuropathy
. Lateral femoral cutaneous mononeuropathy (meralgia paresthetica) is a common syndrome believed to be caused by injury to this ...
. Numbness and dysesthesia over the skin of the upper lateral thigh is typically found on physical examination
. There is no diagnostic test for this disease process beyond the physical examination
. Resolution usually occurs spontaneously. In select patients, such as obese patients with BMI of 30 or greater, recommendations...
Common Peroneal Mononeuropathy
. The common peroneal nerve is a continuation of one trunk of the sciatic nerve. It is most vulnerable to injury where it winds ...
. The most striking feature of a complete common peroneal mononeuropathy is footdrop caused by weakness of foot dorsiflexion. At...
. Most patients with peroneal palsy recover. Those who do not should be studied electrophysiologically to ensure that the point ...
. Treatment of common peroneal palsy requires a posterior splint to maintain the ankle at 90 degrees until the nerve regenerates...
Type 5: Mononeuropathy Multiplex
Principles
Clinical Findings
. The PNS manifestations of Lyme disease are divided into early and late. The early PNS syndromes commonly include facial nerve ...
Diagnostic Testing
Management
Type 6: Amyotrophic Lateral Sclerosis
Principles
Clinical Findings
Diagnostic Testing
Management
Type 7: Sensory Neuronopathy (Ganglionopathy)
Principles
Clinical Findings
Diagnostic Testing
Management
References
94 - Neuromuscular Disorders
Clinical Features
History
Physical Examination
Differential Diagnosis
Myelopathies
Motor Neuron Disease
Neuropathies
Diseases of the Neuromuscular Junction
Myopathies
Diagnostic Testing
Disorders of the Neuromuscular Junction
Myasthenia Gravis
Principles
. Myasthenic crisis is defined as respiratory failure requiring mechanical ventilation. It occurs in 15% to 20% of patients with...
. Lambert-­Eaton myasthenic syndrome is a rare disorder. Almost 50% of cases are associated with small cell carcinoma of the lun...
Diagnostic Testing
Management
Disposition
Botulism
Principles
Clinical Features
Diagnostic Testing
Management
Disposition
Tick Paralysis
Principles
Clinical Features
Management
Disposition
Disorders of the Muscles
Inflammatory Disorders
Principles
Clinical Features
Diagnostic Testing
Management
Disposition
Metabolic Disorders
Periodic Paralysis
. Periodic paralysis of the hypokalemic and hyperkalemic forms is a rare hereditary disorder of ion channels resulting in interm...
. Patients may suffer either isolated or recurrent episodes of flaccid paralysis. The lower limbs are involved more often than t...
. The ECG may demonstrate signs of hyperkalemia or hypokalemia. ECG findings of hyperkalemia include peaked T waves, prolongatio...
. Many cases resolve spontaneously with supportive care alone. The mainstay of management is the treatment of the underlying ele...
. In the past, most cases of periodic paralysis required an inpatient stay, but most patients can be managed in less than 24 hou...
References
95 - Central Nervous System Infections
Foundations
Background and Pathophysiology
Bacterial Meningitis
Viral Meningitis
Viral Encephalitis
Tuberculous Meningitis
Fungal Meningitis
Central Nervous System Abscess
Clinical Features
Meningitis
Encephalitis
Central Nervous System Abscess
CSF Shunt Infection
Differential Diagnoses
Diagnostic Testing
Blood Testing
Neuroimaging
Lumbar Puncture
Opening Pressure
Cerebrospinal Spinal Fluid Analysis
Cerebrospinal Spinal Fluid Cell Count
Gram Stain
Xanthochromia
Glucose
Protein
Other Stains
Lactic Acid
Antigen Detection
Bacterial Cultures
Additional Investigations
Management
Bacterial Meningitis
Tuberculous Meningitis
Fungal Meningitis
Viral Meningitis
Viral Encephalitis
Central Nervous System Abscess
CSF Shunt Infection
Chemoprophylaxis
Immunoprophylaxis
Disposition
References
96 - Thought Disorders
Background and Importance
Pathophysiology
Clinical Features
Differential Diagnoses
Medical Disorders
Psychiatric Disorders
Diagnostic Testing
Management
Disposition
References
97 - Mood Disorders
Foundations
Background and Importance
Epidemiology
Neuroanatomy
Pathophysiology
Neurophysiology
Endocrine System
Genetics
Psychosocial Factors
Clinical Features
Major Depressive Disorder
Mood Disturbances
Disturbances in Psychomotor Activity
Vegetative Disturbances
Thought Process and Content
Masked Depression
Special Considerations
. Criteria for depression in children and adolescents are the same as for depression in adults. Depression in these age groups c...
. A newly described phenomenon for children who may have been previously diagnosed with depression or bipolar disorder is disrup...
. Depression is more common in elders because of more frequent occurrences of loss, comorbid health issues, and loss of autonomy...
Other Depressive Disorders
Peripartum Depression
Persistent Depressive Disorder
Premenstrual Dysphoric Disorder
Seasonal Affective Disorder
Bipolar Disorders
Manic Episode
Cyclothymic Disorder
Mood Disorders Caused by a General Medical Condition
Differential Diagnoses
Medical Disorders, Medications, and Substance Abuse or Withdrawal
Grief and Bereavement
Adjustment Disorders
Borderline Personality Disorder
Dementia
Diagnostic Testing
Management
Disposition
References
98 - Anxiety Disorders
Background and Importance
Epidemiology
Pathophysiology
Clinical Features
Panic Disorder
Generalized Anxiety Disorder
Post-­Traumatic Stress Disorder
Specific Phobias
Obsessive-­Compulsive Disorder
Hyperventilation Syndrome
Somatic Symptoms and Related Disorders
Differential Diagnosis
Cardiac Diseases
Endocrine Diseases
Respiratory Diseases
Neurologic Disorders
Drug Intoxication and Withdrawal States
Diagnostic Testing
Management
Pharmacologic Treatment
Nonpharmacologic Therapy
Disposition
References
99 - Somatic Symptoms and Related Disorders
Foundations
Clinical Features
Somatic Symptom Disorder
Illness Anxiety Disorder
Conversion Disorder
Factitious Disorder
Psychological Factors Affecting Medical Illness
Differential Diagnoses
Diagnostic Testing
Management
Disposition
References
100 - Factitious Disorders and Malingering
Clinical Features
Factitious Disorders
Factitious Disorders Imposed on Self
. Individuals may intentionally produce or feign psychological (often psychotic) symptoms suggestive of a mental disorder. Stimu...
. The intentional production of physical symptoms may take the form of fabricating symptoms without signs (e.g., feigning abdomi...
. The uncommon patient with true Munchausen syndrome has a prolonged pattern of “medical imposture,” usually years in duration. ...
Factitious Disorder Imposed on Another
. Ninety-­eight percent of perpetrators are biological mothers who come from all socioeconomic groups.7,17,18 Many have a backgr...
. Victims of FDIA are equally male and female children. The proper diagnosis for the victims of FDIA is the coding for confirmed...
Differential Diagnoses
Diagnostic Testing
Factitious Disorder
Malingering
Management
Factitious Disorders
Malingering
Disposition
References
101 - Suicidal Behavior
Foundations
Background and Importance
Epidemiology
Risk Factors
Precipitating Factors
At Risk Populations
Mental Illness
Alcohol and Substance Abuse Disorders
Chronic Illness
Pathophysiology
Methods of Suicide
Clinical Features
Initial Recognition and Screening
History and Physical Examination
Differential Diagnoses
Normal Colloquialisms and Expressions of Suffering
Malingering
Non-­Suicidal Self-­Injury
Unintentional Injury or Ingestion
Substance Intoxication, Abuse, or Misuse
Suicidal Obsessions or Preoccupations
Diagnostic Testing
Management
Overview
Suicide Precautions
Pharmacologic Treatment
Risk Assessment
Documentation
Disposition
Psychiatric Hospitalization
Discharge
Brief Patient Education
Joint Safety Planning
Lethal Means Restriction Counseling
Referral for Outpatient Care
Caring Contacts
Additional Ethical Considerations
Do-­Not-­Resuscitate Orders
Physician-­Assisted Dying
References
102 - Arthritis
General Approach to Arthritis
Foundations
Background
Pathophysiology
Clinical Features and Differential Diagnosis
History
Physical Examination
. The initial examination should focus on the affected joint or joints and should also assess for systemic or distant findings w...
. The examination of the painful joint is performed in a systematic manner following the general principle of inspection, palpat...
. Begin the examination by watching the patient move in the exam room. Gait can provide important clues to discomfort and disabi...
. When palpating, begin with an assessment of joint warmth. Large joints, such as the knee, should feel cool to the touch or sim...
. Both active and passive ROM should be assessed and compared with the unaffected extremity whenever possible. Active ROM refers...
. Strength and sensation should be assessed in the affected joint, as well as the joints directly above and below the painful ar...
Diagnostic Testing
Radiographic Tests
. Plain radiographs or X-rays (XR) are useful in determining possible etiologies of acute arthritis. Although they are more help...
. Bedside ultrasound may be used to complement the physical examination in cases of acute joint pain. The simple evaluation for ...
. Advanced imaging modalities may add to the evaluation by showing the presence or absence of osteomyelitis, joint effusions, ab...
Laboratory Testing
Arthrocentesis and Synovial Fluid Analysis
. Joint fluid aspiration with synovial fluid analysis is the most important modality used to diagnose the cause of an acutely pa...
. Indications for urgent arthrocentesis include (1) to obtain joint fluid for analysis for possible infection or crystals, (2) t...
. Patients should be counseled about the potential risks of the procedure, the most serious of which include inoculation of infe...
. Analysis of the joint fluid obtained via arthrocentesis is a critical step in determining the cause of acute arthritis. Examin...
. Visual inspection of the fluid upon aspiration can aid in diagnosis, although no findings are diagnostic without microscopic f...
. The synovial WBC count is helpful in distinguishing different causes of arthritis. Although the number of WBCs is generally us...
. Much like synovial WBC count and pleocytosis, increasing lactate and CRP levels in the synovial fluid correlate with an increa...
. Analysis under light microscopy to evaluate for monosodium urate or calcium pyrophosphate is used to diagnose gout or pseudogo...
. A positive Gram stain is diagnostic of septic arthritis though is only found in 30% to 50% of confirmed infections. A negative...
Management
Disposition
Acute Monoarticular Joint Pain
Nongonococcal Bacterial Septic Arthritis
Foundations
Clinical Features and Differential Diagnosis
. Laboratory testing, including a serum WBC, ESR, and CRP, is commonly performed although often is of limited utility. Elevated ...
Management
Chronic Monoarticular Arthritis
Osteoarthritis
Foundations
Clinical Features
Diagnostic Testing
Management
Acute Polyarticular Joint Pain
Gonococcal Arthritis
Foundations
Clinical Features
Management
Gout
Foundations
Clinical Features
Diagnostic Testing
Management
Pseudogout
Foundations
Clinical Features
Diagnostic Testing
Management
Lyme Disease
Foundations
Clinical Features
Diagnostic Testing
Management
Acute Rheumatic Fever
Foundations
Clinical Features
Diagnostic Testing
Management
Chronic Polyarthritis
Rheumatoid Arthritis
Foundations
Clinical Features
Diagnostic Testing
Management
Seronegative Spondyloarthropathies
Foundations
Ankylosing Spondylitis
. Patients with AS are more likely to be male and younger (younger than 40 years of age) and often report chronic back pain with...
. Acute therapies are directed at managing pain and reducing inflammation. Therefore analgesics and antiinflammatory medications...
Reactive Arthritis (Formerly Termed Reiter Syndrome)
. Reactive arthritis, formerly termed Reiter syndrome, generally occurs in patients 20 to 40 years of age following infection wi...
. In reactive arthritis, synovial fluid demonstrates an inflammatory pattern. The joint fluid is sterile, although antigen testi...
. Patients with reactive arthritis respond well to antiinflammatory treatment with NSAIDs. Antibiotics may be appropriate in pat...
Psoriatic Arthritis
Enteropathic Arthritis
References
103 - Tendinopathy and Bursitis
Foundations
Background and Importance
Clinical Features
General Tendinopathy
Specific Tendinopathies
. Tendinopathies of the shoulder joint include impingement syndrome (which includes subacromial bursitis or rotator cuff tendino...
. The shoulder joint is predisposed to soft tissue injury because of its extensive range of motion and unique anatomic structure...
. The tendon of the long head of the biceps, given its passage between the supraspinatus and subscapularis tendons in the anteri...
. Calcific tendinopathy is an acutely or chronically painful condition associated with the deposition of calcium crystals in or ...
. Increasingly, athletes of all ages and skill levels are participating in sports involving overhead arm motions. Consequently, ...
. Lateral epicondylitis (“tennis elbow”) is a painful elbow condition that occurs at the insertion of the common extensor tendon...
. Less common than its lateral counterpart, medial epicondylitis (“pitcher’s elbow” or “golfer’s elbow”) can result from microtr...
Wrist
. The wrist and hand include several tendons that pass through thick, fibrous retinacular tunnels. These help to prevent subluxa...
Knee
. Patellar tendinopathy (“jumper’s knee”) commonly occurs in sports featuring a prominent jumping component, although it can als...
Ankle
. Achilles tendinopathy is a common overuse syndrome that historically was thought to affect male athletes more frequently than ...
. Although rupture of the Achilles tendon most often occurs when it is preceded by tendon damage, it is possible for untrained a...
Differential Diagnoses
Diagnostic Testing
Management
General Tendinopathy
Specific Tendinopathies
. The treatment of rotator cuff tendinopathies and impingement syndrome follows the treatment of tendinopathy in general. Emphas...
. The initial treatment of calcific tendinopathy is mainly conservative and consists of analgesia and brief immobilization (e.g....
. In up to 95% of patients, epicondylitis will improve with time and conservative therapy. Initial efforts include making the pa...
. The initial treatment of de Quervain’s tenosynovitis consists of immobilization with a thumb spica splint, antiinflammatory me...
. In addition to routine conservative treatment, patients with Achilles tendinopathy should be referred for orthopedic evaluatio...
Disposition
Bursitis
Foundations
Clinical Features
Olecranon and Prepatellar Bursitis
Subacromial Bursitis
Trochanteric Bursitis
Ischiogluteal Bursitis
Iliopsoas Bursitis
Pes Anserine Bursitis
Differential Diagnoses
Diagnostic Testing
Management
Septic Bursitis
Nonseptic Bursitis
Disposition
References
104 - Musculoskeletal Back Pain
Foundations
Background
Epidemiology
Anatomy and Physiology
Pathophysiology
Nonspecific or Uncomplicated Back Pain
Nerve Root Syndromes
Skeletal Causes of Back Pain
Clinical Features
History
Physical Examination
Differential Diagnoses
Diagnostic Testing
Laboratory Testing
Imaging Studies
Point-­of-­Care Ultrasound
Plain Radiographs
Computed Tomography
Magnetic Resonance Imaging
Computed Tomography Myelogram
Management
Nonspecific or Uncomplicated Back Pain
Disc Herniation and Nerve Root Pain
Epidural Abscess and Spinal Osteomyelitis
Epidural Hematoma
Cauda Equina Syndrome
Malignancy
Fracture
Disposition
References
105 - Systemic Lupus Erythematosus and the Vasculitides
Foundations
Background and Importance
Etiology and Pathophysiology
Clinical Features
Overview
Specific Symptoms
Fever
Cardiopulmonary Presentations
. As with other systemic inflammatory conditions, there is a significantly increased risk of coronary artery disease (CAD) in pa...
. Pericarditis and effusions of the pericardium occur commonly in patients with SLE and are among the classification criteria fo...
. SLE is associated with a type of noninfectious endocarditis known as Libman-­Sacks endocarditis (Fig. 105.2). Mitral valve dis...
. Due to disease-­associated hypercoa­gulability, deep venous thrombosis (DVT) and pulmonary embolism (PE) are more frequent in ...
. Pleuritis is the most common respiratory condition occurring in SLE. Characterized by pleuritic chest pain with or without a p...
. Diseases of the lung parenchyma associated with SLE include infectious pneumonia, acute and chronic pneumonitis, interstitial ...
. Shrinking lung syndrome is a rare condition associated with SLE that is characterized by symptoms of shortness of breath and p...
Renal Disease
Gastrointestinal Presentations
Dermatologic Presentations
Musculoskeletal Presentations
Hematologic Disease
Complications Due To Medications
Differential Diagnosis
Diagnostic Testing
Laboratory Tests
Initial Diagnosis
Disease Activity
Evaluation for Infection
Imaging Studies
Management
Emergent Stabilization
General Systemic Disease Activity
Patients Diagnosed With Systemic Lupus Erythematosus
Patients Not Diagnosed With Systemic Lupus Erythematosus
Specific Presentations
Infection
Musculoskeletal Pain
Cutaneous Manifestations
Special Considerations
Antiphospholipid Syndrome
Foundations
Clinical Features
Diagnostic Testing
Management
Drug-­Induced Lupus
Disposition
Vasculitis
Foundations
Large-­Vessel Vasculitis
Giant Cell Arteritis
Background
Clinical Features
Diagnostic Testing
Management
Takayasu Arteritis
Background
Clinical Features
Diagnostic Testing
Management
Small And Medium Vessel Vasculitis
Differential Diagnosis
Specific Disorders
ANCA-­Associated Vasculitis
. GPA is a granulomatous vasculitis affecting small-­ and medium-­sized vessels. It affects individuals in their fifth and sixth...
. MPA is a non-­granulomatous vasculitis affecting small-­ and medium-­sized vessels. MPA most commonly affects patients in thei...
. EGPA is an eosinophilic vasculitis of small and medium vessels.18 Mean age of the diagnosis is in the fourth and fifth decade ...
Anti-­Glomerular Basement Membrane Disease (Goodpasture Disease)
Immune Complex Mediated Vasculitis
. IgAV, formerly known as Henoch-­Schonlein purpura, is a small- and medium-vessel vasculitis that is characterized by IgA depos...
. Cryoglobulinemic vasculitis is characterized by a primarily small-­vessel vasculitis in association with cryoglobulins in the ...
Polyarteritis Nodosa
Other Vasculitides
. Behçet disease (BD) is a vasculitis that affects all blood vessel sizes and is characterized by the presence of recurrent oral...
. Cutaneous small-­vessel vasculitis (CSVV) is the most common single-­organ vasculitis.24 It has been previously known as hyper...
References
106 - Allergy, Anaphylaxis, and Angioedema
Allergy
Background and Terminology
Pathophysiology
Classification of Reactions
Anaphylaxis
Epidemiology and Risk Factors
Common Triggers for Anaphylaxis
Foods
Drugs
Insect Stings
Natural Rubber Latex
Radiocontrast Media
Exercise-­Induced Anaphylaxis
Idiopathic Anaphylaxis
Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Overview
Positioning
Epinephrine
Airway
Volume Expansion
Antihistamines
Glucocorticoids
Patients Receiving Beta-­Blockade
Disposition
Urticaria and Angioedema
Diagnostic Testing
Management
Angioedema With Urticaria
Angioedema Without Urticaria
Special Considerations
Disposition
References
107 - Dermatologic Presentations
Overview
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features and Differential Diagnoses
Diagnostic Testing
Management
Disposition
Infectious Disorders
Bacterial Infections
Impetigo
Folliculitis
Cellulitis
Abscess
Methicillin-­Resistant Staphylococcus aureus (MRSA)
Erythema Migrans
Necrotizing Fasciitis
Meningococcal Infection
Scarlet Fever
Syphilis
Disseminated Gonococcal Infection
Staphylococcal Scalded Skin Syndrome
Toxic Shock Syndrome
Rocky Mountain Spotted Fever
Viral Infections
Herpes Simplex Virus
Varicella-­Zoster Virus
. Varicella, or chickenpox, is an infection caused by the varicella-­zoster virus. After an incubation period of 14 to 21 days, ...
. Herpes zoster, or “shingles,” is an infection caused by the varicella-­zoster virus. It occurs in individuals who have previou...
Viral Exanthems
. Roseola infantum, otherwise known as exanthem subitum or sixth disease, is a benign illness caused by human herpesvirus 6 and ...
. Measles, or rubeola, is a highly contagious viral illness spread by contact with infectious droplets, with an incubation perio...
. Rubella, or German measles, is a viral illness characterized by fever, skin eruption, and generalized lymphadenopathy. It is s...
. Erythema infectiosum, or “fifth disease,” is caused by parvovirus B19 infection and typically affects pediatric patients. It i...
Fungal Infections
Tinea Corporis
Tinea Capitis
Kerion
Tinea Pedis
Tinea Versicolor
Tinea Unguium (Onychomycosis)
Candidiasis
. Oral candidiasis (“thrush”) is the most common clinical expressions of Candida infection. It is common in newborns with one-­t...
. Cutaneous candidiasis affects intertriginous areas, including the interdigital web spaces, groin, axilla, and intergluteal or ...
. Vaginal candidiasis accounts for 20% to 25% of vaginitis. It has been estimated that 75% of women will experience vaginal cand...
. Sporotrichosis, caused by a variety of Sporothrix species, is a fungal infection that may be transmitted by contact with soil,...
Infestations
Scabies
Pediculosis
Bed Bugs
Allergic Reactions
Contact Dermatitis
Urticaria
Poison Ivy
Drug Reactions
Toxic Epidermal Necrolysis
Inflammatory Conditions
Atopic Dermatitis
Pityriasis Rosea
Kawasaki Disease
Erythema Multiforme
Erythema Nodosum
Lichen Planus
Autoimmune Disorders
Bullous Pemphigoid
Pemphigus Vulgaris
Cutaneous Malignancies
References
108 - Blood and Blood Components
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Blood Banking
Blood Typing
. An individual blood type and screen test includes ABO grouping, Rh typing, and antibody screen for unexpected, non-­ABO/Rh ant...
. When a unit of blood is ordered for transfusion, a crossmatch follows the initial type and screen. In an ideal situation, bloo...
. Although patients with type O blood are considered to be universal donors of packed red cells (PRBCs), whole blood from type O...
Management
Decision Making
Pharmacology
Devices and Techniques
Whole Blood
Packed Red Blood Cells
Special Preparations of PRBCs
. PRBCs can be washed to remove residual plasma and any remaining leukocytes, platelets, microaggregates, plasma proteins, and f...
. A typical unit of whole blood or packed red cells can contain from 1 to 3 billion white blood cells (WBC), which can cause a v...
. Blood products can be irradiated to reduce the risk for TA-­GvHD in susceptible patients, which occurs in about 1 per 1 millio...
. Because CMV is endemic worldwide and seropositivity rates in the United States are reported at 30% to 97%, most donated blood ...
Fresh Frozen Plasma
Platelets
Cryoprecipitate
Prothrombin Complex Concentrate
Outcomes
Safety and Effectiveness
Massive Transfusion Protocols
Acute Transfusion Reactions
. The most common manifestation of a minor allergic transfusion reaction is urticaria. In some cases, however, wheezing and angi...
. The reported incidence of transfusion-­associated anaphylaxis is 1 in 20,000 to 50,000 transfusions, with most cases being idi...
. A febrile, nonhemolytic transfusion reaction (FNHTR) is defined as a temperature elevation of 1°C (1.8°F) or higher that occur...
. Intravascular hemolytic transfusion reaction is the most serious transfusion reaction. It generally results from ABO incompati...
. TRALI refers to noncardiogenic pulmonary edema occurring during or shortly after the transfusion of virtually any blood produc...
. Transfusion associated circulatory overload (TACO) is volume overload after transfusion that is proportional to the volume tra...
Infectious Complications of Transfusions
Delayed Transfusion Reactions
. A delayed hemolytic transfusion reaction (DHTR) typically occurs 3 to 10 days following transfusion with blood that initially ...
. This rare but typically fatal complication results when transfused lymphocytes proliferate and attack a recipient who is incap...
. Rarely, profound thrombocytopenia can develop 1 to 3 weeks after a transfusion associated with an antibody response to a plate...
References
109 - Anemia and Polycythemia
Anemia
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Foundations
Iron Deficiency Anemia
Foundations
Clinical Features
Diagnostic Testing
Management
Thalassemia
Foundations
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Sideroblastic Anemia
Foundations
Clinical Features
Differential Diagnoses
Management
Anemia of Chronic Disease
. Anemia of chronic disease (ACD) is secondary to reduced erythropoiesis and reduced RBC survival time in the peripheral circula...
Clinical Features
Diagnostic Testing
Management
Macrocytic and Megaloblastic Anemias
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Normochromic and Normocytic Anemias
Foundations
Clinical Features
Diagnostic Testing
Management
Increased Red Blood Cell Destruction
Foundations
Pathophysiology
Clinical Features
Differential Diagnoses
. Of the membrane-­sustaining energy production of the erythrocyte, 85% to 90% is through the anaerobic glycolytic pathway. At l...
Intrinsic Membrane Abnormality
Intrinsic Hemoglobin Abnormality
Extrinsic Alloantibodies
Extrinsic Autoantibodies
Extrinsic Mechanical Causes
Environmental Causes
Abnormal Sequestration
Diagnostic Testing
. In patients with newly diagnosed reticulocytopenia or severe hemolytic anemia, the emergency clinician may need to institute r...
Sickle Cell Disease
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Polycythemia
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
References
110 - White Blood Cell Disorders
Foundations
Background and Importance
Anatomy and Physiology
Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Specific Disorders
Chronic Myeloid Leukemia
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Lymphocytic Leukocytosis
Foundations
Clinical Features
Diagnostic Testing
Management
Leukopenia
Foundations
. Signs and symptoms of neutropenia are nonspecific and may include fatigue, sweats, or weight loss. Due to the body’s inability...
. Neutropenic fever, defined as a single oral temperature greater than or equal to 101°F (38.3°C) in a neutropenic patient, or g...
Disposition
References
111 - Disorders of Hemostasis
Foundations
Anatomy and Physiology
Pathophysiology
Clinical Features
Differential Diagnosis
Diagnostic Testing
Complete Blood Count and Blood Smear
Platelet Count
Bleeding Time and Platelet Function Assay
Prothrombin Time
Partial Thromboplastin Time
Anti-­Xa Assay
Fibrinogen
Thrombin Time
Clot Solubility
Factor Level Assays
Management
Thrombocytopenia
Immune Thrombocytopenia
Drug-­Induced Thrombocytopenia
. Heparin-­induced throm­bocytopenia (HIT) is a serious immune-­mediated process associated with unfractionated heparin (UFH) an...
Post-­Transfusion Purpura
Thrombotic Microangiopathy
. TTP is most often acquired and results from autoantibodies to ADAMTS13, an endothelial protein that cleaves large vWF multimer...
Dilutional Thrombocytopenia
Hereditary Thrombocytopenia and Thrombocytopathy
. Knowledge of abnormal platelet function as a clinical disorder has grown rapidly in recent years, with identified disorders of...
. Bernard-­Soulier Syndrome (BSS) results from an abnormality in the platelet gpIb complex, which allows platelet adhesion to vW...
. Glanzmann thrombasthenia (GT) is a rare autosomal-­recessive disorder that results from a defect in the integrin complex glyco...
. Secretory defects comprise two pathologic groups: defective platelet granule formation or defective secretory machinery. These...
Thrombocytosis
Coagulation Disorders
Hemophilia A
Hemophilia B (Christmas Disease)
von Willebrand Disease
Miscellaneous Coagulation Disorders
Medication-­Induced Anticoagulation
Disseminated Intravascular Coagulation
Disposition
References
112 - Oncologic Emergencies
Foundations
Febrile Neutropenia
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
REFERENCES
113 - Acid-­Base Disorders
Clinical Features
Diagnostic Testing
Basic Metabolic Panel Interpretation
Five-­Step Acid-­Base Approach to the BMP
. Check for Abnormal Values. Evaluate the BMP for any abnormalities. A low HCO3 concentration (for example, <22 mmol/L) identifi...
BMP Step 2. Check the Anion Gap. The anion gap (AG) is calculated with the formula: AG = [Na+] − ([Cl−] + []). The anion gap is ...
. If a Metabolic Acidosis is Present, Apply the Rule of 15. The rule of 15 is used to evaluate for concomitant respiratory acid-...
. If a Wide Anion Gap Metabolic Acidosis Is Present (Anion Gap ≥15), Check the Delta Gap. Calculation of the delta gap is used t...
. If a Wide Anion Gap Metabolic Acidosis Is Present (Anion Gap ≥15), But the Cause Is Not Evident, Check the Osmolar Gap. The os...
Blood Gas Interpretation
Three-­Step Acid-­Base Approach to the ABG
. Determine if the Patient Is Acidemic or Alkalemic. Evaluate the pH. A pH less than 7.35 indicates acidemia; pH greater than 7....
. Determine if a Predominant Respiratory or Metabolic Acid-­Base Disturbance Is Present. Evaluate Paco2 and place it into contex...
. If a Predominant Respiratory Acid-­Base Disturbance Is Present, Determine If There Is a Concurrent Metabolic Disturbance. Comp...
Differential Diagnosis of Acid-­Base Disorders
Metabolic Acidosis
. An elevated anion gap using the threshold of 15 mmol/L, regardless of the value of the pH or [HCO3−], indicates that a wide an...
. The mnemonic HARDUP (see Box 113.3) can be used to recall the causes of a normal anion gap metabolic acidosis, which is also c...
Metabolic Alkalosis
. When the circulating volume is decreased, the renin-­angiotensin-­aldosterone system is activated, and the kidneys reabsorb fi...
. Causes of metabolic alkalosis that cannot be corrected with infusion of sodium chloride containing fluids are called chloride-...
Respiratory Acidosis
Respiratory Alkalosis
Management
Intravenous Fluids
Sodium Bicarbonate Therapy
Disposition
References
Acid-­Base Disorder Sample Calculations
Rule of 15 Example 1
Rule of 15 Example 2
Rule of 15 Example 3
Rule of 15 Example 4
Delta Gap Example 1
Delta Gap Example 2
114 - Electrolyte Disorders
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Hypokalemia
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Hypernatremia
Foundations
Clinical Features
Diagnostic Testing
Management
Disposition
Hyponatremia
Foundations
Pseudohyponatremia
Hypovolemic Hyponatremia
Hypervolemic Hyponatremia
Euvolemic Hyponatremia
Clinical Features
Diagnostic Testing
Management
Hypovolemic Hyponatremia
Hypervolemic Hyponatremia
Euvolemic Hyponatremia
Disposition
Hypercalcemia
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Hypocalcemia
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Hypermagnesemia
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Hypomagnesemia
Foundations
Clinical Features
Differential Diagnosis
Patients Maintained on Diuretics
Malnourished and Alcoholic Patients
Patients With Hypokalemia
Patients With Acute Coronary Artery Disease and Ventricular Arrhythmias
Patients Receiving Specific Medications
Diagnostic Testing
Management
Disposition
Hyperphosphatemia
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Hypophosphatemia
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
References
115 - Diabetes Mellitus and Disorders of Glucose Homeostasis
Diabetes Mellitus Foundations
Background and Importance
Epidemiology
Anatomy, Physiology, and Pathophysiology
. Because plasma glucose is the predominant metabolic fuel used by the central nervous system (CNS), maintenance of the plasma g...
. Insulin receptors on the beta cells of the pancreas sense elevations in the blood glucose concentration and trigger insulin re...
. Maintenance of the normal plasma glucose concentration requires precise matching of glucose use with endogenous glucose produc...
. Type 1 diabetes results from a chronic autoimmune process that usually exists in a preclinical state for years. The classic ma...
Types of Diabetes
. Type 1 diabetes is characterized by an abrupt failure of insulin production with a tendency to ketosis, even in the basal stat...
. Patients with type 2 diabetes may remain asymptomatic for long periods and show low, normal, or elevated levels of insulin. Ke...
. Gestational diabetes mellitus is characterized by an abnormal OGTT result that occurs during pregnancy and reverts to normal d...
. Myriad causes of diabetes have been identified, including chronic pancreatitis, cystic fibrosis, genetic defects in the beta c...
. Impaired glucose tolerance (IGT) has been replaced by the term prediabetes to identify individuals at high risk for the develo...
Diabetes Mellitus Clinical Features
Type 1
Type 2
Diabetes Mellitus Differential Diagnosis
Diabetes Mellitus Diagnostic Testing
Serum Glucose Level
Glycosylated Hemoglobin
Urine Glucose Level
Urine Ketone Level
Dipstick Blood Glucose Level
Diabetes Mellitus Management
Management of Hyperglycemia
Management of Diabetes Mellitus
. Goals of diabetic management include lowering the hemoglobin A1c to less than 7% and maintenance of the fasting blood sugar le...
. The ADA and European Association for the Study of Diabetes have recommended lifestyle changes, including weight control, at th...
. Developed in the 1940s, sulfonylureas have historically been a mainstay of oral diabetes treatment. These drugs increase insul...
. Thiazolidinediones reduce insulin resistance and are especially useful in patients who require large amounts of insulin and st...
. The α-­glucosidase inhibitors delay intestinal monosaccharide absorption and prevent complex carbohydrate breakdown; these age...
. The nonsulfonylurea secretagogues, the meglitinides, are similar to the sulfonylureas in action and mechanism. They bind to ad...
. Glucagon-­like peptide (GLP-­1) analogs and agonists stimulate the release of insulin from pancreatic cells. Exenatide (Byetta...
. Dipeptidyl peptidase-­4 (DPP-­4) inhibitors include sitagliptin (Januvia), saxagliptin (Onglyza), and linagliptin (Tradjenta)....
. Pramlintide, administered three times daily before meals, is an amylinomimetic agent, or amylin analog, and decreases gastric ...
. Dapagliflozin (Farxiga), canagliflozin (Invokana), and empagliflozin (Jardiance) are sodium-­glucose cotransporter 2 (SGLT2) i...
. Certain principles apply to all insulins, such as their ability to enhance gluconeogenesis and lipogenesis and suppress glycog...
. Solid organ pancreas transplantation has become more common; several centers have performed combined pancreas and kidney trans...
. Changes in the therapy of diabetes have recently included greater use of human insulin, which has prevented some of the advers...
Late Complications of Diabetes
Vascular Complications
Diabetic Nephropathy
Retinopathy
Neuropathy
The Diabetic Foot
Infections
Cutaneous Manifestations
Skin Conditions
. This is characterized by a velvety, brown-­black thickening of the keratin layer, most often in the flexor surfaces. It is the...
. This begins as erythematous papular or nodular lesions, usually in the pretibial area but in other areas as well. The early le...
. These lesions are evidence of the hyperlipidemia associated with diabetes, similar to the xanthoma found in nondiabetic hyperl...
. This is a rare occurrence. Bullae are usually filled with a clear fluid and are most often found on the extremities, especiall...
. Also known as skin spots, this is the most common skin finding in diabetes. It arises as discrete, depressed, and brownish les...
. Resistant, aggressive impetigo or intertrigo may suggest diabetes
Diabetes Disposition
Diabetic Ketoacidosis
Foundations
Pathophysiology
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Intravenous Fluids
Potassium
Insulin
Magnesium
Sodium Bicarbonate
Complications
Diabetic Ketoacidosis Disposition
Hyperglycemic Hyperosmolar State
Foundations
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Intravenous Fluids
Electrolytes
Insulin
Other Considerations
Acute Complications
Hyperglycemic Hyperosmolar State Disposition
Diabetes in Pregnancy
Hypoglycemia
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
References
116 - Rhabdomyolysis
Background and Importance
Anatomy, Physiology, and Pathophysiology
Complications
Early Complications
. Most skeletal muscles are encased in compartments formed by bones, fascia, and other structures. The massive influx of calcium...
. Potassium released from damaged muscle may lead to hyperkalemia. Over 98% of the body’s potassium is found in the intracellula...
. In rhabdomyolysis, fluid moves from intravascular compartments into damaged muscle. In cases of massive muscle crush or electr...
. Reversible elevations in aspartate transaminase (AST) levels may occur with rhabdomyolysis, possibly caused by myocyte release...
Late Complications
. Experimental evidence suggests that myoglobinuric acute renal failure is caused by myoglobin cast formation in the distal conv...
. Extensive muscle damage may result in the release of prothrombotic substances, mainly thromboplastin, which activate the coagu...
Differential Diagnosis
Diagnostic Testing
Serum Creatine Kinase
Serum and Urine Myoglobin
Urine Dipstick and Urinalysis
Other Laboratory Findings
Prognostic Tests in Rhabdomyolysis
Management
Fluid Replacement
Mannitol and Other Diuretics
Experimental Therapies
Renal Replacement Therapy
Disposition
Prognosis
References
117 - Thyroid and Adrenal Disorders
Hyperthyroidism
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
History and Physical Examination
Thyroid Storm
Differential Diagnoses
Diagnostic Testing
Management
Supportive Treatment
Symptomatic Treatment
Thyroid-­Directed Treatment
. Thionamides inhibit oxidation and organic binding of iodine to thyroglobulin, thereby blocking the synthesis of thyroid hormon...
. Inorganic iodine blocks the release of stored thyroid hormone. Because an iodine load can increase the synthesis of thyroid ho...
. Corticosteroids are capable of inhibiting the peripheral conversion of T4 to T3 and blocking the release of hormone from the t...
Miscellaneous Therapies
Identification and Treatment of the Precipitating Event
Disposition
Hypothyroidism
Foundations
Background and Importance
Pathophysiology
Clinical Features
History and Physical Examination
Myxedema Coma
Differential Diagnoses
Diagnostic Testing
Management
Hypothyroidism
Myxedema Coma
Disposition
Adrenal Excess States
Foundations
Background and Importance
Cushing Syndrome
Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Hyperaldosteronism
Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Pheochromocytoma and Paraganglioma
Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Adrenal Insufficiency
Foundations
Background and Importance
Anatomy and Physiology
Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
References
118 -
Bacteria
DIPHTHERIA
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
PERTUSSIS
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Acute Treatment
Vaccination
TETANUS
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
Generalized Tetanus
Localized Tetanus
Cephalic Tetanus
Neonatal Tetanus
Complications
Differential Diagnoses
Diagnostic Testing
Management
Supportive Care
. Passive immunization with human tetanus immune globulin (HTIG) and active immunization with Td should be initiated as soon as ...
. Toxin production is eliminated by treatment of the C. tetani infection. Wound débridement and antibiotic administration can ca...
Vaccination
BOTULISM
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
PNEUMOCOCCEMIA
Foundations
Background
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Acute Treatment
Vaccination
Disposition
MENINGOCOCCEMIA
Foundations
Background
Anatomy, Physiology, and Pathophysiology
Clinical Features
Occult Bacteremia
Meningococcal Meningitis
Meningococcal Septicemia
Fever and a Nonblanching Rash
Chronic Meningococcemia
Complications
Differential Diagnoses
Diagnostic Testing
Management
Acute Treatment
Antibiotic Prophylaxis and Vaccination
Disposition
TOXIC SHOCK SYNDROME
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
REFERENCES
119 - Viruses
Foundations
Mumps
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management and Disposition
Measles (Rubeola)
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Rubella (German Measles)
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management and Disposition
Viral Infections with Vesicular Rash
Herpes Simplex
Clinical Features
. The first episode of HSV-­1 infections usually occurs early in life and manifests as a gingivostomatitis and pharyngitis. Symp...
. This infection is characterized by painful vesicles and ulcers on the external genitalia. The first infection is usually the m...
. HSV-­1 is a common cause of infectious encephalitis; it causes necrotizing hemorrhagic encephalitis, typically involving the t...
. Herpes can cause a variety of cutaneous manifestations. They typically present with the classic painful grouped vesicles on an...
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Varicella-­Zoster Virus
Clinical Features
. Chicken pox is a febrile illness characterized by malaise and rash. The rash begins first on the scalp and face and then sprea...
. Herpes zoster typically causes a vesicular rash with an erythematous base that occurs unilaterally in a single dermatome (Fig....
Differential Diagnosis
Diagnostic Testing
Management
. The management is mainly supportive care with antipyretics and antihistamines to decrease the pruritus caused by the skin lesi...
. The goals of treatment for zoster are to treat the viral infection and control the pain that occurs with the rash. Uncomplicat...
Disposition
Epstein-­Barr Virus
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Cytomegalovirus
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Enteroviruses
Clinical Features
. The poliovirus causes a nonspecific febrile illness with malaise, myalgias, headache, and sore throat. The most feared present...
. Most enterovirus infections are subclinical, but they can also cause a variety of symptoms and syndromes. Enteroviruses accoun...
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Influenza
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
. Oseltamivir, zanamivir, and peramivir are the currently available neuraminidase inhibitors. They work by inhibiting the releas...
. Amantadine and rimantadine are the currently available adamantane antivirals. They prevent or greatly reduce the uncoating of ...
. Baloxavir is a novel antiviral that gained US Food and Drug Administration (FDA) approval to treat influenza A and B in patien...
Disposition
Coronavirus
Rhinovirus
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management and Disposition
Adenovirus
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management and Disposition
Parainfluenza
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Respiratory Syncytial Virus
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Viruses Associated with Diarrheal Illness
Norovirus and Rotavirus
Clinical Features
. The disease causes a severe gastroenteritis, with vomiting, diarrhea, and abdominal cramping. In infants and children, vomitin...
. The illness manifests as sudden onset of nausea, vomiting, and profuse watery diarrhea, with fever, headache, and myalgias. Th...
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Rabies
Epidemiology
Pathophysiology
Clinical Features
. Encephalitic rabies progresses rapidly over days, and the presenting signs and symptoms are supplanted rapidly by diffuse neur...
. Paralytic rabies accounts for approximately 20% of human rabies infections. The presenting symptoms are similar to encephaliti...
Differential Diagnoses
Diagnostic Evaluation and Testing
Management
. Pasteur described the first rabies vaccine in 1885.51,52 Nerve tissue–derived vaccines similar to Pasteur’s were used worldwid...
. An animal bite or potential rabies exposure is a medical urgency, not an emergency. In the emergency department, PEP is either...
. All mammal bites require meticulous wound care, and if rabies prophylaxis is considered the initial wound care is critical. Ra...
. PEP is almost 100% effective when administered according to CDC or WHO guidelines. Treatment failures usually occur when local...
Management
Disposition
Arboviruses
Clinical Features
. The majority of people who become infected with WNV are asymptomatic. The most common presentation of symptomatic WNV is West ...
. EEE virus is the most dangerous of the viruses that cause equine encephalitides. It occurs along the Gulf and Atlantic coast w...
. Louis Encephalitis Virus. The majority of infections are asymptomatic, but as patients get older the rate of symptomatic infec...
. The infection usually presents as fever with neurologic complaints including headache, confusion, weakness, paralysis, letharg...
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Other Arboviral Infections
Dengue Virus
. Dengue can cause a wide spectrum of disease. Many infected individuals with dengue are asymptomatic. Dengue fever is a self-­l...
. Other diagnoses to consider in suspected dengue patients include Zika, malaria, chikungunya, rickettsial infections, leptospir...
. The diagnosis can be made via serologic testing with IgM assay, antigen testing of the viral antigen nonstructural protein 1 (...
. There are no specific antiviral agents that treat dengue. The treatment is mainly supportive. Dengue fever is usually a self-­...
. Depending on the severity of illness, patients with dengue fever can be treated as outpatients, but some may require admission...
. Zika virus is an arbovirus in the Flaviviridae family that is transmitted to humans via the Aedes species mosquitos. Although ...
. The majority of patients infected with Zika virus are asymptomatic. For those who do develop symptoms, the clinical manifestat...
. Other diseases with fever, rash, myalgias, and travel history should be considered, including dengue, chikungunya, malaria, ri...
. The diagnosis of Zika virus infection can be made with RT-­PCR or serology. In nonpregnant symptomatic patients with symptoms ...
. Similar to other flavivirus infections, treatment largely consists of symptom management and supportive care. Antipyretics, an...
. Chikungunya is an arbovirus in the Alphaviridae family that was originally endemic to West Africa. Since early this millennium...
. Chikungunya causes a self-­limiting disease very similar to dengue. Fever, myalgias, and polyarthralgias are the hallmark of t...
. Other febrile illnesses with rash, myalgias, and arthralgias should be considered, including dengue, Zika, malaria, African ti...
. The diagnosis can be confirmed via enzyme-­linked immunosorbent assay (ELISA) testing for antibodies, RT-­PCR for detecting vi...
. Treatment is mainly supportive. Antipyretics, antiinflammatory agents, and analgesics play an important role in symptom contro...
Viral Hemorrhagic Fevers
Yellow Fever Virus
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Ebola
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Marburg
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
Lassa Fever
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Disposition
References
120 - Coronaviruses
Transmission
Clinical Features
Coronavirus Disease 2019
Multisystem Inflammatory Syndrome in Children
Differential Diagnoses
Diagnostic Testing
Coronavirus Disease 2019
Multisystem Inflammatory Syndrome in Children
Management
Coronavirus Disease 2019
Oxygenation and Ventilation
Intubation and Mechanical Ventilation
Therapeutics
. Remdesivir, an adenosine nucleotide analog active against a wide variety of RNA viruses including SARS-­CoV-­2, shows some pro...
. Convalescent serum has been used for over a century for viral infections and even bacterial infections. Studies are underway f...
. Cytokine storm may trigger severe COVID-­19 morbidity. Monoclonal antibodies targeting IL-­6 and other components of the infla...
. Patients with COVID-­19 are at risk for thrombotic complications, and those exhibiting evidence of thrombotic complications sh...
Prevention and Vaccination
Multisystem Inflammatory Syndrome in Children
Middle East Respiratory Syndrome
Disposition
References
121 - HIV
Background and Importance
Pathophysiology
Clinical Features
Acute HIV Infection
Chronic HIV Infection
AIDS
Clinical Manifestations by Organ System
Cardiac Manifestations
Pulmonary Manifestations
Oropharyngeal and Gastrointestinal Manifestations
Central Nervous System Manifestations
Renal Manifestations
Rheumatologic and Orthopedic Manifestations
Hematologic Manifestations
Cutaneous Manifestations
Differential Diagnoses
Initial Evaluation
Diagnostic Testing
HIV Testing
Management
Preexposure Prophylaxis
Postexposure Prophylaxis
ART Initiation and Linkage to Care
Disposition
References
122 - Parasites
Foundations
Malaria
Background and Importance
Pathophysiology
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Babesiosis
Background and Importance
Clinical Features
Diagnostic Testing
Management
Schistosomiasis and Katayama Fever
Background and Importance
Diagnostic Testing
Management
Cysticercosis
Background and Importance
Clinical Features
Diagnostic Testing
Management
African Trypanosomiasis
Background and Importance
Clinical Features
Diagnostic Testing
Management
Toxoplasmosis
Background and Importance
Clinical Features
Diagnostic Testing
Management
Eosinophilic Meningitis
Parasites Associated with Fever
Leishmaniasis
Amebic Abscess
Strongyloides
Whipworm And Hookworm
Tapeworm
Elephantiasis
Cutaneous Leishmaniasis
Cutaneous Larva Migrans
Swimmer’s Itch (Cercarial Dermatitis)
Strongyloides
Dracunculus medinensis
Onchocerciasis
Loiasis
Toxocara canis (Dog Roundworm)
Chagas Disease
Diarrhea
Cryptosporidium and Cyclospora
Entamoeba histolytica
Balantidium coli
Giardia lamblia
Echinococcosis
Enterobius vermicularis
Specific Parasitic Coinfections
References
123 - Tickborne Illnesses
Overview
Identification of Ticks
Physiology of Tick Feeding
Lyme Disease
Clinical Features
Early Lyme Disease
Acute Disseminated Infection
. A relatively symptom-­free interval usually occurs between early and disseminated infection; however, neurologic signs and sym...
. Cardiac involvement in Lyme disease is uncommon, with an estimated incidence in untreated patients ranging from 4% to 10%. Car...
. Although it is generally considered a sign of late Lyme disease, acute arthritis may begin during the acute disseminated stage...
. Ocular involvement also may be seen in early disseminated disease; manifestations include conjunctivitis, keratitis, choroidit...
Late Lyme Disease
Differential Diagnoses
Diagnostic Testing
Management
Early Disease
Early Disseminated Infection
. For patients with relatively mild symptoms (e.g., solitary facial nerve palsy with normal findings on CSF examination), doxycy...
. Patients with mild cardiac conduction system involvement, such as a first-­degree AV block with a PR interval less than 0.30 s...
Late Infection
. In established Lyme arthritis, the response to antibiotic therapy may be delayed for several weeks or months. An oral regimen ...
. Patients with late neurologic disease affecting the central or peripheral nervous system should be treated with ceftriaxone (2...
Lyme Disease and Pregnancy
Vaccination
Prophylaxis and Asymptomatic Tick Bites
Southern Tick-­Associated Rash Illness
Relapsing Fever
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Tularemia
Clinical Features
Presentations
. This accounts for approximately 80% of cases. Typically, a skin lesion on an extremity at the site of primary inoculation begi...
. This is the second most common form. It is characterized by the development of lymphadenopathy (usually cervical) without an a...
. This is seen in less than 2% of cases. It is characterized by unilateral conjunctivitis, with regional adenopathy involving pr...
. This is manifested as severe exudative pharyngitis, with associated cervical lymphadenitis. It has been known to cause acute g...
. This is a systemic form of the disease in which no obvious entry site can be found; it occurs in approximately 10% of cases. O...
. This has symptoms similar to those of other bacterial pneumonias—fever and chills, cough (usually nonproductive), substernal b...
Other Considerations
Diagnostic Testing
Management
Rocky Mountain Spotted Fever
Pathophysiology
Clinical Features
Cutaneous Manifestations
Cardiopulmonary Manifestations
Neurologic Manifestations
Differential Diagnoses
Diagnostic Testing
Skin Biopsy
Serologic Studies
Isolation of Organism
Management
Supportive Care
Antibiotics
Corticosteroids
Q Fever
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Ehrlichioses
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Babesiosis
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Colorado Tick Fever
Pathophysiology
Clinical Features
Diagnostic Testing
Management
Other Tickborne Viruses
Tick Paralysis
Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
References
124 - Tuberculosis
Foundations
Background and Importance
Pathophysiology
Transmission
Pathogenesis
Stage 1
Stage 2
Stage 3
Stage 4
Clinical Features
Risk Factors
Physical Examination
Complications of Pulmonic Tuberculosis
Hemoptysis
Pneumothorax
Pleural Effusion
Empyema
Airway Tuberculosis
Superinfection with Fungi
Primary Tuberculous Pericarditis
Differential Diagnoses
Pulmonary Tuberculosis
Bacterial Pneumonia
Fungal and Nontuberculous Mycobacterial Infections
Pneumonias in Patients with HIV Infection
Cavitary Lesions
Mediastinal Lymphadenopathy
Extrapulmonary Tuberculosis
Lymphadenitis
Bone and Joint Infection
Renal Disease
Genital Disease
Multisystem Disease
Central Nervous System Disease
Gastrointestinal Disease
Diagnostic Testing
Laboratory Tests
White Cell Stimulation Tests
Serology
Diagnostic Imaging
Primary Tuberculosis
Postprimary Tuberculosis
Microbiologic Testing
Sputum Studies
. Direct microscopic examination of a stained sputum specimen for AFB (i.e., an AFB smear) is the most rapid laboratory test wid...
. Nucleic acid amplification (NAA) tests are performed on sputum and take only 24 to 48 hours to yield results. Their overall po...
. Sputum culture is more sensitive than microscopy for the detection of MTB and is still considered the gold standard diagnostic...
Tuberculin Skin Test
Management
Initial Management in the Emergency Department
Hemoptysis
Fever or Wasting
History of Tuberculosis, Therapy Discontinued
Antituberculosis Medications
First-­Line Agents
Second-­Line Agents
Corticosteroids
Initial Therapy
Drug-­Resistant Tuberculosis
Multidrug-­Resistant Tuberculosis
Extensively Drug-­Resistant Tuberculosis
Vaccines for Mycobacterium tuberculosis
Disposition
Prevention of Transmission in the Emergency Department
Early Identification
Isolation and Environmental Control
Personal Respiratory Protection
Preventive Therapy After Inadvertent Exposure
References
125 - Bone and Joint Infections
Background and Importance
Anatomy, Physiology, and Pathophysiology
Causes and Microbiology
Osteomyelitis
Clinical Features
History and Physical Examination
Complications
Clinical Subsets of Osteomyelitis
. Osteomyelitis in children tends to be acute, usually arising from hematogenous seeding of bone, and can often be treated with ...
. Vertebral osteomyelitis usually affects older adults and is increasing in frequency as the population ages and has more chroni...
. Posttraumatic osteomyelitis is a form of osteomyelitis that results from open fractures, burns, bites, puncture wounds, and su...
. Diabetic foot infections lead to osteomyelitis 20% of the time, while diabetic ulcers have underlying osteomyelitis 15% of the...
. Patients with sickle cell disease (SCD) are at increased risk for hematogenous infection, including osteomyelitis, often due t...
. Most chronic bone infections occur as a complication of posttraumatic infection, surgical procedures, or diabetic foot infecti...
Differential Diagnoses
Diagnostic Testing
Laboratory Tests
Diagnostic Imaging
. Conventional radiography is the initial modality of choice to evaluate osseous changes and, in most cases, will be the only im...
. Radionuclide skeletal scintigraphy (bone scanning) is more sensitive than plain radiography for the early diagnosis of osteomy...
. Even though MRI is the best imaging modality to diagnose osteomyelitis because it can identify early changes in the bone, when...
. The use of bone scans and CT for the evaluation of osseous anatomy has been decreasing as the availability and image quality o...
Microbiologic Diagnosis
Management
Disposition
Septic Arthritis
Foundations
Clinical Features
History and Physical Examination
Complications
Clinical Subsets of Septic Arthritis
. The human mouth is a polymicrobial environment comprised of aerobic organisms, such as Staphylococcus, oral gram-­negative rod...
. Septic arthritis is more common in children than in adults, and the incidence of septic arthritis is twice that of osteomyelit...
. In the United States, N. gonorrhoeae is the most common cause of septic arthritis in sexually active patients. A person with g...
. Lyme disease, the most common tickborne disease in the United States, is caused by infection with a spirochete, Borrelia burgd...
. Infections occurring after joint replacement are a challenging and dangerous complication of arthroplasty, with rates reported...
. Patients with underlying joint disease, especially rheumatoid arthritis or a crystal arthropathy, are at increased risk for se...
. Septic arthritis can be particularly difficult to diagnose and treat if it occurs in fibrocartilaginous joints, such as the st...
Differential Diagnoses
Diagnostic Testing
Serum and Urine Tests
Joint Fluid Analysis
Imaging
Management
Disposition
References
126 - Skin and Soft Tissue Infections
Foundations
Background and Importance
Anatomy and Physiology
Pathophysiology
Clinical Features
Overview
Cellulitis
Clinical Features
Diabetic Foot Infections
Bite Wounds
Water-Borne Infections
Differential Diagnosis
Diagnostic Testing
Wound Cultures
Blood Cultures
Radiographic Studies
Surface Thermal Imaging
Management
Disposition
Abscess
Clinical Features
Differential Diagnosis and Diagnostic Testing
Management
Disposition
Impetigo
Clinical Features and Management
Folliculitis
Clinical Features and Management
Acne Vulgaris and Hidradenitis Suppurativa (ACNE INVERSA)
Clinical Features and Management
Necrotizing Skin and Soft Tissue Infections
Clinical Features
Differential Diagnosis and Diagnostic Testing
Management and Disposition
Toxic Shock Syndromes
Clinical Features
Streptococcal Toxic Shock Syndrome
Staphylococcal Toxic Shock Syndrome
Staphylococcal Scalded Skin Syndrome
Differential Diagnosis and Diagnostic Testing
Management
Disposition
Other Infections With Skin Manifestations
References
127 - Sepsis Syndrome
Foundations
Background
Pathophysiology
Mediators of Sepsis
Organ System Dysfunction
. Patients with sepsis may display neurologic impairment manifested by altered mental status and lethargy, commonly referred to ...
. Cardiovascular dysfunction is common with sepsis. The cardiovascular dysfunction and failure arise from direct myocardial depr...
. Involvement of the lung is often seen in the inflammatory response to infection. These effects are apparent, irrespective of t...
. Splanchnic blood flow is dependent on mean arterial pressure because there is relatively little autoregulation. Therefore, hem...
. An absolute or relative adrenal insufficiency is common in sepsis. Depending on the balance of circulating cytokines, augmenta...
. Sepsis causes abnormalities in many parts of the coagulation system. Endotoxin, TNF-­α, and IL-­1 are the key mediators. Patho...
Genetic Factors
Clinical Features
Symptoms and Signs
Diagnostic Considerations
Differential Diagnoses
Diagnostic Testing
Laboratory Testing
. The white blood cell count can be an indicator of inflammation and activation of the inflammatory cascade. Leukocytosis is ass...
. Electrolyte abnormalities should be identified and corrected. A low bicarbonate level suggests acidosis and inadequate perfusi...
. Urinalysis is another essential laboratory test, especially in older patients with higher risk of urinary tract infection who ...
. Proper blood, urine, sputum, cerebrospinal fluid, and other tissue culture samples are important in guiding therapy. Although ...
Special Procedures
Radiology
Management
Respiratory Support
Cardiovascular Support
Fluid Resuscitation
Vasoactive Drug Therapy
. Norepinephrine is predominantly α-­agonist with some β1-­agonism with minimal β2 activity and primarily functions to increase ...
. Dopamine is the immediate precursor of norepinephrine and epinephrine. It is primarily an α-­, β1-­, and dopaminergic agonist....
. Vasopressin is a naturally occurring peptide that is synthesized as a large prohormone in the hypothalamus. In states of septi...
. Epinephrine is a potent mixed α-­ and β-­agonist. Epinephrine infusion is also associated with increased oxygen consumption, i...
. Phenylephrine is a selective α1-­agonist, increasing systemic vascular resistance without significant changes in cardiac outpu...
. Dobutamine is a mixed α-­ and β-­agonist. In dosage ranges from 2 to 28 μg/kg/min, the cardiac index is increased at the expen...
Bicarbonate
Antibiotics
Steroid Therapy
Disposition
References
128 -
Hypothermia, Frostbite, and Nonfreezing Cold Injuries
ACCIDENTAL HYPOTHERMIA
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Temperature Regulation
Cardiovascular System
Central Nervous System
Renal System
Respiratory System
Predisposing Factors
. Decreased thermogenesis may be due to endocrine dysfunction, such as hypopituitarism, hypoadrenalism, or myxedema. Myxedema co...
. Patients with erythrodermas, such as psoriasis, exfoliative dermatitis, ichthyosis, eczema, and burns, can have increased peri...
. Thermoregulation can be impaired centrally, peripherally, or metabolically. Skull fractures, particularly basilar fractures, a...
Trauma
Clinical Features
Differential Diagnoses
Diagnostic Testing
. Blood gas analyzers warm blood to 37°C (98.6°F), increasing the partial pressure of dissolved gases. This results in arterial ...
. The hematocrit can be deceptively high due to decreased plasma volume. The hematocrit increases 2% for every 1°C (1.8°F) fall ...
. A physiologic hypercoagulable state can occur with hypothermia and can be associated with a disseminated intravascular coagula...
Imaging
Management
General Measures
Volume Resuscitation
Advanced Life Support
Pharmacologic Treatment
. The effects of hypothermia on the autonomic nervous system are variable. In primates, sympathetic response increases rapidly t...
. Hypothermia compromises host defenses and predisposes to infection. In hypothermia, the usual signs of infection, including fe...
. Cold abolishes adrenal responsiveness to adrenocorticotropic hormone (ACTH). A false diagnosis of decreased adrenal reserve is...
Rewarming
. Spontaneous passive external rewarming is noninvasive. It is the treatment of choice for patients with mild hypothermia when a...
. Active rewarming is the direct transfer of exogenous heat to the patient. It can be accomplished by external or internal techn...
. Early concern with AER was sparked after a 1961 study, in which 20 of 23 patients died. Retrospective analysis of clinical ser...
. Many methods achieve active rewarming of the core. These techniques minimize the risk of rewarming collapse in patients with c...
. Airway rewarming with heated humidified oxygen is a simple and inexpensive method that can be used as an adjunct to other form...
. Peritoneal dialysis delivers dialysate at 40°C to 45°C (104°F to 113°F). Heat is conducted directly to intraperitoneal structu...
. Heat transfer from irrigation fluids is usually limited due to the minimal surface area available for heat exchange. Gastric o...
. Another active core rewarming option uses endovascular warming devices that are intended for therapeutic cooling and subsequen...
. Truncal diathermy involves the conversion of energy waves into heat. Large amounts of heat can be delivered to deep tissues wi...
. The four common extracorporeal techniques to rewarm blood are venovenous rewarming, hemodialysis, continuous arteriovenous (AV...
Disposition
FROSTBITE
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Prehospital
Emergency Department
. Stabilize hypothermia and other life-­threatening conditions before warming frostbitten extremities.15 Do not delay treatment ...
Thawing by Immersion in Warm Water
. We elevate injured extremities to minimize edema formation, apply sterile dressings loosely, and handle frostbitten areas gent...
Disposition
NONFREEZING COLD INJURIES
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
Immersion Injury
Pernio
Differential Diagnoses
Diagnostic Testing
Management
Immersion Injury
Pernio
Disposition
REFERENCES
129 -
Heat Illness
Heat Regulation
. Temperature-­sensitive structures are located peripherally in the skin and centrally in the body. However, skin temperature ch...
. The central nervous system (CNS) interprets information received from the thermosensors to instruct thermoregulatory effectors...
. Sweating and peripheral vasodilation are the major mechanisms whereby heat loss can be accelerated. In a warm environment, eva...
Acclimatization
Predisposing Factors
Fever Versus Hyperthermia
MINOR HEAT ILLNESSES
Miliaria Rubra
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
Heat Cramps
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
Heat Edema
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
Heat Syncope
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
MAJOR HEAT ILLNESSES
Heat Exhaustion
Foundations
. Heat exhaustion (heat prostration) is a clinical syndrome characterized by volume depletion that occurs under conditions of he...
. Water depletion heat exhaustion results from inadequate fluid replacement by individuals working in a hot environment and inca...
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Heatstroke
Foundations
. In the previously discussed forms of heat illness, although the body temperature rises, homeostatic thermoregulatory mechanism...
. As heatstroke develops, energy will be insufficient to sustain thermoregulatory mechanisms, resulting in dramatic increases in...
Clinical Features
. The two forms of heatstroke, classic (epidemic) heatstroke (CHS) and exertional heatstroke (EHS), may have significantly diffe...
Differential Diagnoses
. These can masquerade as heatstroke. In patients with heatstroke, the spinal fluid should be clear, with occasional lymphocytic...
. In patients with thyroid storm, the clinical symptoms resemble those of heatstroke. It should be suspected if the thyroid glan...
. This is an important consideration, particularly anticholinergic poisoning. Differentiation may be difficult because heatstrok...
. Symptoms of hyponatremia, especially exercised associated hyponatremia, can be mistaken for heat exhaustion or heat stroke. Al...
. This disorder is induced by antipsychotic medications and is characterized by muscle rigidity, severe dyskinesia or akinesia, ...
. This can also mimic heatstroke because of the elevated body temperature tremors, clonus, and CNS alterations that occur. Serot...
Diagnostic Testing
Management
. Immediate cooling is the cornerstone of treatment. If heatstroke cannot be excluded, begin cooling immediately. In EHS, it is ...
. Mortality correlates with the elevated temperature duration and number of dysfunctional organ systems, with an increased risk ...
Disposition
REFERENCES
130 - Electrical and Lightning Injuries
Background and Importance
Anatomy, Physiology, and Pathophysiology
Electrical Injury
. Joule’s law, which describes the amount of thermal energy applied to tissues from electricity, is described by the formula
. Electrical sources create current that flows in one direction (direct current, DC) or alternates direction cyclically at varyi...
. Resistance is the degree to which a substance resists the flow of current; when resistance goes down, current increases. Resis...
. The pathway followed by electrical current determines morbidity and mortality. The entrance and exit sites of the electrical c...
. The degree of tissue damage is directly proportional to the duration of exposure for all voltage levels. Exposure times greate...
Lightning Injury
Conducted Energy Weapons
Clinical Features
Electrical Injury
Lightning Injury
Skin
. Most electrical injuries result in skin burns, which fall into one or more of four patterns (as described in Box 130.4). The r...
. Roughly 90% of lightning strike victims suffer skin burns, but less than 5% are deep burns. Although the voltages involved in ...
Cardiovascular
. Cardiac or respiratory arrest is the most common cause of death immediately following electrical injury. High-­voltage exposur...
. The most severe effects of lightning strike are cardiac and respiratory arrest. The massive surge is analogous to defibrillati...
Head and Neck
. Ocular involvement is common following exposure to electrical current, with cataracts being the most frequent manifestation. O...
. The most common ocular event after lightning strike is the development of cataracts, occurring immediately or in a delayed fas...
Extremities
. Neurovascular bundles have low resistance and are particularly prone to damage from electrical current. Muscle necrosis occurs...
Nervous System
. Electrical injury damages the central and peripheral nervous systems. The most common immediate central symptoms are altered m...
. A wide variety of very serious neurologic effects follow lightning strike. Apnea, due to effects on the medullary respiratory ...
Other Viscera
. Extensive muscle damage may result in significant myoglobinuria, subsequent renal failure, and life-­threatening hyperkalemia....
. The lungs, gastrointestinal tract, and other internal organs may suffer injury from blunt trauma or a blast effect. Strikes to...
. Patients who present after receiving a CEW barb discharge may have local injury to the skin and nearby superficial structures,...
Differential Diagnoses
Electrical Injury
Lightning Injury
Diagnostic Testing
Electrical Injury
Lightning Injury
Conducted Electrical Weapon
Management
Electrical Injury
Lightning Injury
Conducted Electrical Weapon
Disposition
Electrical Injury
Lightning Injury
Conducted Electrical Weapon
References
131 - Scuba Diving and Dysbarism
Foundations
Background and Importance
Physiology and Pathophysiology
Clinical Features
Disorders Related to Descent/Barotrauma
Middle Ear Barotrauma
External Ear Barotrauma
Inner Ear Barotrauma
Reverse Middle Ear Squeeze
Barosinusitis
Alternobaric Vertigo
Facial Barotrauma or Mask Squeeze
Disorders Arising at Depth
Nitrogen Narcosis
Oxygen Toxicity
Contaminated Air
Disorders Arising on Ascent
Alternobaric Vertigo
Barodontalgia
Gastrointestinal Barotrauma
Pulmonary Barotrauma
Decompression Sickness
Arterial Gas Embolism
Pulmonary Edema
Differential Diagnoses
Diagnostic Testing
Management
Diving Disorders Requiring Recompression Therapy
Diving Disorders Not Requiring Recompression Therapy
External Ear Barotrauma
Middle Ear Barotrauma
Internal Ear Barotrauma
Barosinusitis
Facial Barotrauma
Nitrogen Narcosis
Pulmonary Barotrauma
Alternobaric Vertigo
Disposition
References
132 - High-­Altitude Medicine
Background and Importance
Epidemiology
Definitions
Environmental Considerations
Anatomy, Physiology, and Pathophysiology
Acclimatization
Physiologic Response to Hypobaric Hypoxia
Acute Mountain Sickness
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Oxygen Therapy
Analgesics and Antiemetics
Acetazolamide
Dexamethasone
Disposition
Prevention
High-­Altitude Pulmonary Edema
Clinical Features
Differential Diagnoses
Diagnostic Testing
Ultrasonography
Chest Radiographs
Electrocardiogram and Echocardiogram
Management
Descent
Oxygen Therapy
Nifedipine
Other Medications
Disposition
Prevention
High-­Altitude Cerebral Edema
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Special Considerations
High-­Altitude Retinal Hemorrhage
Carbon Monoxide Poisoning
Respiratory Illnesses
Cardiovascular
Hypertension
Seizures
Sickle Cell Disease
Pregnancy
Radial Keratotomy
References
133 - Drowning
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
History and Physical Examination
Prognostic Factors
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Preventive Efforts and Discharge Education
References
134 - Radiation Injuries
Background and Importance
Radiation Measurements
Radiation Protection
Radiation Sources
Anatomy, Physiology, and Pathophysiology
Routes of Exposure
Clinical Features
Acute Radiation Syndrome
Local Radiation Injury
Differential Diagnoses
Diagnostic Testing
Management
Prehospital Care
Emergency Department
Preparation
External Contamination
Internal Contamination
Acute Radiation Syndrome
. Colony-­stimulating factors (cytokines) that induce bone marrow hematopoietic cells to proliferate may have substantial benefi...
. Treatment for the gastrointestinal sub-­syndrome is largely supportive with antiemetics (preferably serotonin receptor antagon...
. Patients who develop signs and symptoms consistent with this sub-­syndrome within the first 24 hours should be provided pallia...
Local Radiation Injury
Psychological Consequences
Disposition
Additional Resources
References
135 - Care of the Poisoned Patient
Clinical Features
Toxicologic History and Physical
Toxidromes
Sympathomimetic
Anticholinergic
Cholinergic
Sedative/Hypnotic
Opioid
Serotonin Syndrome
Neuroleptic Malignant Syndrome
Differential Diagnoses
Diagnostic Testing
Management
Decontamination
Syrup Of Ipecac
Gastric Lavage
Single-­Dose Activated Charcoal
Whole Bowel Irrigation
Enhanced Elimination
Multiple-­Dose Activated Charcoal
Serum Alkalinization
Intravenous Fat Emulsion (Intralipid)
Focused Therapy
Toxicology Consultation
Disposition
References
136 - Toxic Alcohols
Foundations
Principles of Toxicology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Ethylene Glycol
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Isopropyl Alcohol
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Other Alcohols of Clinical Significance
References
137 - Alcohol-­Related Disease
Clinical Features
Alcohol Withdrawal Syndrome
Alcohol-­Related Seizures
Alcohol Withdrawal Seizures
Alcoholic Hallucinosis
Cardiovascular Effects
Pulmonary Effects
Gastrointestinal and Hepatic Effects
Esophagus and Stomach
Gastrointestinal Bleeding
Liver Damage
Alcoholic Hepatitis
Cirrhosis
Pancreatitis and Malabsorption
Neurologic Effects
. A symmetric sensorimotor polyneuropathy is common with chronic alcohol abuse, usually in the lower extremities. It is thought ...
. There are high rates of dementia reported in patients with AUD, and up to 25% when all types of severe cognitive impairment ar...
Alcoholic Cerebellar Degeneration
Infectious Disease
Endocrine Effects
Metabolic Effects
Carbohydrates
Lipids
Electrolytes
Alcoholic Ketoacidosis
Hematologic Effects
Anemia
Leukocyte Abnormalities
Platelet Disorders
Hemostasis
Oncologic Effects
Hypothermia
Psychiatric Effects
Toxicologic Effects
Disulfiram and Similar Reactions
Other Considerations—Patient Groups Affected
. Excessive high school and college drinking continues to be prevalent and problematic. Approximately 1.2 million youths aged 12...
. Alcohol use is a growing public health concern for elderly adults. Elderly patients, meaning patients ages 65 years and older,...
. There is no known safe level of alcohol consumption during pregnancy. Alcohol is a known teratogen that can impact fetal growt...
Trauma
Differential Diagnosis
Diagnostic Testing
Laboratory Tests
Alcohol Screening Questionnaires
Management
Alcohol Withdrawal Syndrome
Pharmacologic Treatment
. Benzodiazepines have anticonvulsant activity, dose-dependent respiratory and cardiovascular depressive effects, and and be giv...
. Haloperidol, a dopamine antagonist, can be considered in patients with major alcohol withdrawal or delirium tremens and acute ...
. Patients being treated for major alcohol withdrawal may be given thiamine (100 mg IV) and magnesium (2 g IV). Although magnesi...
Neurologic Examination
New-­Onset Seizures
Prior History of Seizures During Withdrawal
Abnormal Neurologic Examination
. Partial seizures account for up to 50% of alcohol-­related seizures. Conversely, approximately 20% of patients with partial al...
. A patient currently taking antiepileptic drugs for an antecedent seizure disorder who presents with a seizure while intoxicate...
Disposition
Acute Intoxication
Alcohol Withdrawal
Seizures
Psychiatric and Social Problems
References
138 - Acetaminophen
Clinical Features
Differential Diagnoses
Diagnostic Testing
Risk Assessment With Acute Acetaminophen Ingestion
Risk Assessment With Chronic Ingestion
Risk Assessment in Pregnant Women
Management
Stabilization and Supportive Care
Decontamination
Enhanced Elimination
Antidote Therapy
N-Acetylcysteine
Use in Pregnancy
Duration of Therapy
Disposition
Need for Transplantation
References
139 - Aspirin and Nonsteroidal Agents
Principles of Toxicity
Overview
Epidemiology
Salicylate-Containing Products
Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Stabilization and Supportive Care
Decontamination
Enhanced Elimination
Antidote Therapy
Disposition
Nonsteroidal Agents
Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Stabilization and Supportive Care
Decontamination
Enhanced Elimination
Antidote Therapy
Disposition
References
140 - Anticholinergics
Principles of Toxicology
Overview
Clinical Features
Differential Diagnoses
Diagnostic Testing
Laboratory
Electrocardiogram
Management
Stabilization
Decontamination
Pharmacologic Intervention and Antidote Treatment
Disposition
Observation at Home
Emergency Department Observation
Hospital Admission
ICU Admission
Consultations
References
141 - Antidepressants
Principles Of Toxicity
Monoamine Oxidase Inhibitors
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Tricyclic Antidepressants
Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Selective Serotonin Reuptake Inhibitors
Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Serotonin Modulators And Stimulators
Miscellaneous Antidepressants
Bupropion
Trazodone
Nefazodone
Serotonin Syndrome
Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Discontinuation Syndromes
References
142 - Cardiovascular Drugs
Foundations
Clinical Features
Pediatric Considerations
Differential Diagnoses
Diagnostic Testing
Management
Fab Fragments (DigiFab)
Electrolyte Correction
Atropine
Pacing and Cardioversion
Phenytoin and Lidocaine
Extracorporeal Membrane Oxygenation
Disposition
Foundations
Principles of Toxicity
Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Hypotension, Bradycardia, and Atrioventricular Block
Calcium
Glucagon
High-­Dose Insulin
Sodium Bicarbonate
Vasopressors and Other Inotropes
Intravenous Fat Emulsion (Intralipid)
Ventricular Dysrhythmias
Extracorporeal Elimination and Circulatory Assistance
Pediatric Considerations
Sequential Approach to Beta-­Blocker Poisoning
Disposition
Foundations
Principles of Toxicity
Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Hypotension and Bradycardia
Pediatric Considerations
Disposition
Clonidine and Other Central Alpha-­2 Agonists
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Foundations
Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
References
143 - Caustics
Foundations
Principles of Toxicity
Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Special Cases
Povidone-­Iodine
Phenol and Formaldehyde
Hydrogen Peroxide
Button Batteries
References
144 - Cocaine and Other Sympathomimetics
Foundations
Cocaine
Epidemiology
Formulation
Pathophysiology
Amphetamine and Its Derivatives
Epidemiology
Methamphetamine
Pathophysiology
Ephedrine and Ephedra
Caffeine
Novel Psychoactive Substances
Ecstasy
Bath Salts
Kratom
Clinical Features
Hyperthermia
Hypertensive Emergencies
Cardiac Dysrhythmias
Cocaine Use Disorder, Stimulant Use Disorder
Cardiomyopathy
Washout
Nontoxicologic sequelae
Differential Diagnoses
Diagnostic Testing
Management
Pharmacologic Sedation for Agitation
Hyperthermia
Acute Hypertensive Emergencies
Dysrhythmias
Hyponatremia
Cocaine-­Related Chest Pain
Special Topics
Body Packers
Body Stuffers
Disposition
References
145 - THC and Hallucinogens
Principles of Toxicity
Lysergamides
Tryptamines
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Dissociative Agents
Principles of Toxicity
Phencyclidine
Ketamine
Methoxetamine
Dextromethorphan
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Cannabis and Synthetic Cannabinoids
Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
Other Agents
Mescaline
Nutmeg
Salvia
Kratom
Ibogaine
Isoxazole Mushrooms
References
146 - Iron and Heavy Metals
Iron
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Stabilization and Supportive Care
Decontamination
Enhanced Elimination
Antidotal Therapy
Disposition
Lead
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Stabilization and Supportive Care
Decontamination
Antidotal Therapy
. Treatment for lead toxicity rarely is commenced in the ED, but the decision to admit for chelation or source control may be in...
. The treatment of adults with chronic poisoning is based primarily on symptoms and threshold BLLs established by workplace regu...
Disposition
Arsenic
Foundations
Clinical Features
Acute Arsenic Toxicity
Chronic Arsenic Toxicity
Arsine Gas
Differential Diagnoses
Diagnostic Testing
Management
Stabilization and Supportive Care
Decontamination and Enhanced Elimination
Antidotal Therapy
. With a confirmed history of exposure in a symptomatic patient, chelation should start as early as possible without waiting for...
. Treatment of chronic arsenic toxicity should begin in a symptomatic patient after confirmation of elevated urinary arsenic lev...
Disposition
Mercury
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Stabilization and Supportive Care
Decontamination
Enhanced Elimination
Antidotal Therapy
Disposition
References
147 - Hydrocarbons
Overview
Pathophysiology
Pulmonary Pathophysiology
Central Nervous System Pathophysiology
Cardiac Pathophysiology
Other Organ Systems
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
References
148 - Inhaled Toxins
Simple Asphyxiants
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Pulmonary Irritants
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Smoke Inhalation
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Cyanide and Hydrogen Sulfide
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Hydrogen Cyanide
Hydrogen Sulfide
Disposition
Carbon Monoxide
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
References
149 - Lithium
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Stabilization and Supportive Care
Decontamination
Enhanced Elimination
Disposition
References
150 - Antipsychotics
Background
Pathophysiology
Toxicity
Clinical Features
Acute Overdose
Acute Extrapyramidal Syndromes
Tardive Syndromes
Neuroleptic Malignant Syndrome
Cardiovascular Toxicity
Agranulocytosis
Seizures
Differential Diagnoses
Diagnostic Testing
Management
General
Anticholinergic Toxidrome
Seizures
Acute Extrapyramidal Syndromes
Cardiotoxicity
Neuroleptic Malignant Syndrome
Disposition
References
151 - Opioids
Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Stabilization and Supportive Care
Decontamination
Enhanced Elimination
Antidote Therapy
Disposition
Withdrawal
References
152 - Pesticides
Organophosphate Insecticides
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Decontamination
Stabilization and Supportive Care
Enhanced Elimination
Antidote Therapy
Disposition
Carbamate Insecticides
Chlorinated Hydrocarbons Insecticides
Foundations
Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Decontamination
Stabilization and Supportive Care
Enhanced Elimination
Antidote Therapy
Disposition
Substituted Phenols
Foundations
Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Decontamination
Stabilization and Supportive Care
Enhanced Elimination
Antidote Therapy
Disposition
Chlorophenoxy Herbicides
Foundations and Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Decontamination
Stabilization and Supportive Care
Enhanced Elimination
Antidote Therapy
Disposition
Bipyridyl Herbicides
Foundations and Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Decontamination
Stabilization and Supportive Care
Enhanced Elimination
Antidote Therapy
Disposition
Pyrethrin and Pyrethroid Insecticides
Foundations and Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Decontamination
Stabilization and Supportive Care
Enhanced Elimination
Antidote Therapy
Disposition
Glyphosate
Foundations and Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Decontamination
Stabilization and Supportive Care
Enhanced Elimination
Antidote Therapy
Disposition
DEET
Foundations and Principles of Toxicology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Decontamination
Stabilization and Supportive Care
Enhanced Elimination
Antidote Therapy
Disposition
Rodenticides
Foundations
Principles of Toxicology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Decontamination
Stabilization and Supportive Care
Enhanced Elimination
Antidote Therapy
Disposition
References
153 - Plants, Herbal Medications, and Mushrooms
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Plant Categories
Anticholinergics
Foundations
. Datura stramonium (Jimson weed, angel’s trumpet) (Fig. 153.1) and Atropa belladonna (deadly nightshade) are the most frequentl...
. Ingestion can cause the antimuscarinic syndrome of agitation, diminished gastrointestinal (GI) motility, dry skin, flushing, h...
. The differential diagnosis of antimuscarinic toxicity includes toxicity from pharmaceutical agents such as diphenhydramine, be...
. Symptomatic patients with altered mental status or abnormal vital signs should have a screening ECG to assess corrected QT (QT...
. Management should be focused on supportive care, including active cooling for hyperthermia and benzodiazepines for agitation. ...
. Mildly symptomatic patients can be observed in the ED for 6 to 8 hours and discharged from the ED. Severely poisoned patients ...
Antimitotic Toxins
Foundations
. Colchicum autumnale is also known as autumn crocus, meadow saffron, or wild saffron, and contains the toxic alkaloid colchicin...
. The clinical course of colchicine poisoning is typically divided into three phases of illness.7 The first phase is marked by G...
. Patients presenting in the first phase of illness may be misdiagnosed as having gastroenteritis or food poisoning. In the seco...
. Laboratory data should include a complete blood count to assess for pancytopenia. Additional labs include serum electrolytes, ...
. There is no specific therapy for colchicine poisoning, and management consists primarily of supportive care. There is no comme...
. Patients presenting with GI symptoms but normal laboratory testing may be discharged home after 6 to 8 hours of hydration and ...
Cardiac Glycosides
Foundations
. Cardiac glycosides bind to cell transmem­brane Na+-­K+-­ATPases, which, in turn leads to a rise in intracellular Ca2+ concentr...
. Similar to digoxin poisoning, patients with exposure to cardiac glycosides can present with GI symptoms, generalized weakness,...
. The differential diagnoses of cardiac glycoside plant poisoning is broad and includes pharmaceutical toxicity with digoxin, ca...
. Patients should have an ECG performed, and serum electrolytes should be evaluated with attention to potassium because cardiac ...
. The cornerstone of therapy is digoxin-­specific antibody fragments (Fab) and should be administered in any patient displaying ...
. Symptomatic patients with bradycardia, hypotension, altered mental status, or hyperkalemia are admitted to a monitored setting...
Other Cardiotoxic Plants
Cicutoxin
Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Other Toxic Plants
Nicotinic toxin
Raphides
Toxalbumins
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Mushroom Categories
Hepatotoxic Mushrooms
Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Gyromitrin-­containing Mushrooms
Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Other Mushroom Classes
Cholinergic Agonists
Disulfiram Reaction-­Inducing Mushrooms
Hallucinogenic Mushrooms
Gastrointestinal Irritants
Renal Insufficiency
Rhabdomyolysis-­Inducing Mushrooms
Herbal Medications
Principles of Toxicity
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
References
154 - Sedative-­Hypnotics
Foundations
Benzodiazepines
Clinical Features
Pharmacokinetics
Differential Diagnoses
Diagnostic Testing
Management
Stabilization and Supportive Care
Antidote Therapy
Disposition
Benzodiazepine Withdrawal Syndrome
Barbiturates
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Supportive Care and Stabilization
Gastrointestinal Decontamination
Enhanced Elimination
Disposition
Individual Medications
Zolpidem, Zaleplon, and Zopiclone
Eszopiclone
Buspirone
Flunitrazepam
Chloral Hydrate
Clinical Features
Differential Diagnoses
Management
Disposition
Over-­The-­Counter Sleep Aids
Gamma-­Hydroxybutyrate
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Withdrawal
References
155 - Care of the Pediatric Patient
Foundations
Pathophysiology
Temperature Regulation
Airway
Cardiovascular System
Musculoskeletal System
Immunologic System
Pharmacologic Considerations
Developmental Considerations
Young Infants
Infants (<12 Months)
Toddlers (1-­ to 2-­Year-­Olds)
Preschoolers (3-­ to 5-­Year-­Olds)
School-­Age Children
Adolescents
Evaluation
Triage
History
Pediatric Assessment Triangle
Appearance
Work of Breathing
Circulation to the Skin
Length-­Based Resuscitation Tape
Physical Examination
Specific Disorders
Common Neonatal Complaints
Neonatal Intensive Care Unit Graduate
Children With Special Health Care Needs
Child Abuse
Other Considerations
Consent for Emergency Care
Pediatric-­Ready Emergency Department
Pediatric-­Friendly Emergency Department
References
156 - Pediatric Airway Management
Background and Importance
Anatomy
156
Physiology
Equipment
Management
Decision Making
Rapid Sequence Intubation
Pretreatment
Sedatives
Neuromuscular Blocking Agents
Devices and Techniques
Basic Airway Management
Advanced Airway Management
Preparation
Preoxygenation
Positioning
Placement of Tube
Post-Intubation Management
Video Laryngoscopy
Airway Rescue Devices for Children
Pediatric Surgical Airway Techniques
Outcomes
References
157 -
Pediatric Sedation and Analgesia
SEDATION
Foundations
Definitions1,2
Specific Issues
Preparation
Preprocedural Fasting
Supplemental Oxygen and Capnography During Procedural Sedation and Analgesia
Specific Medications
. Propofol has several advantages for PSA; it has a rapid onset in 30-­60 seconds, is short acting, and has antiemetic propertie...
. Ketamine, a dissociative anesthetic, has sedative, amnestic, and analgesic properties. Ketamine maintains cardiovascular and r...
. Multiple studies have dispelled the myth that ketamine increases intracranial pressure (ICP). Ketamine may even have beneficia...
. Emergence reaction or recovery agitation refers to agitation (which may include floating sensation, vivid pleasant dreams, nig...
. Ketamine stimulates tracheobronchial and salivary secretions. However, studies have shown that the co-­administration of antic...
. Vomiting with ketamine sedation in children is common.10 Vomiting usually develops during recovery, when patients are alert an...
. The combination of ketamine with propofol has the potential to provide benefits of both sedatives. The combination allows for ...
. Dexmedetomidine is an effective sedative, anxiolytic and analgesic that does not cause respiratory depression.13A loading dose...
Nitrous Oxide
Post-­Sedation Monitoring
Outcomes
PAIN MANAGEMENT
Foundations
Specific Issues
Pain Assessment
Nonpharmacologic Techniques
Pharmacologic Techniques
. Used in conjunction with other methods for decreasing pain, topical anesthetics may decrease the need for systemic analgesics ...
Local Anesthetics
. A nerve block is regional anesthesia attained by the injection of a local anesthetic agent near a nerve, nerves, or nerve plex...
. Nonopioid systemic analgesics (Table 157.5) include acetaminophen (paracetamol), which has analgesic and antipyretic effects b...
. Opioids, previously termed narcotics, produce analgesia by binding to opioid receptors in the brain, brainstem, spinal cord, a...
. In 2017, the Department of Health and Human Services declared a public health emergency due to the opioid crisis. Although the...
. Low dose ketamine has been successfully used in adults and pediatric patients for the treatment of acute pain.27 Doses for the...
. Naloxone is used for the reversal of opioids effects on the mu receptors (e.g., sedation and respiratory depression). Although...
Outcomes
REFERENCES
158 - Pediatric Resuscitation
Foundations
Pathophysiology
Clinical Features
Recognizing Imminent Arrest
Management
Compressions-­Airway-­Breathing
. High quality compressions improve outcomes but are rarely performed. When administered appropriately, compressions generate on...
. Although life-­threatening airway emergencies in children are rare, most critical illness in children stems from respiratory e...
Compression-­Only Cardiopulmonary Resuscitation
. Although ventricular fibrillation and pulseless ventricular tachycardia are rarely the presenting rhythm in children, they ari...
Pharmacology
. The particular site of vascular access is less important than its timely acquisition. Peripheral venous and intraosseous drug ...
. There are no universal criteria to guide the termination of a pediatric resuscitation. Emergency clinicians are less comfortab...
E-­CPR
Post-­Arrest Care
Blood Pressure
Ventilation and Oxygenation
Targeted Temperature Management
Glucose
Arrhythmia and Seizures
Family Presence
Septic Shock in the Pediatric Patient
Foundations
Background
Pathophysiology
Clinical Features
Management
Monitoring Response to Therapy
Brief Resolved Unexplained Events
Background
Clinical Features
Management
Disposition
References
159 - Neonatal Resuscitation
Foundations
Transition From Fetal to Extrauterine Life
Specific Issues
Indications for Resuscitation
Hypoxia
Hypothermia
Hypoglycemia
Hypovolemia
Prematurity
Meconium-Stained Amniotic Fluid
Maternal Factors
Infection
Medications
Withholding and Discontinuing Resuscitation
Special Anatomic Anomalies
Diaphragmatic Hernia
Myelomeningocele and Omphalocele
Choanal Atresia
Pierre Robin Sequence
Congenital Cardiac Disease
Newborn Resuscitation Algorithm
Preparation
Dry, Warm, Stimulate, Position, Suction, and Assess Need for Further Intervention
Ventilation, Oxygen, Intubation
Chest Compressions
Vascular Access
Medications
. Epinephrine is indicated for asystole and persistent bradycardia (<60 beats/min) despite effective ventilation with 100% oxyge...
. When indicated, volume expansion is accomplished with packed red blood cells (Rh-negative type O blood), normal saline, or Lac...
. Antibiotics are not indicated in the initial resuscitation phase but may be required once the neonate has been stabilized. Whe...
. Concomitant hypoglycemia should be considered and promptly treated in a neonate requiring ongoing resuscitation. Hypoglycemia ...
. Dopamine is indicated only when signs of shock (e.g., poor peripheral perfusion, weak pulses) are still present, despite adequ...
Therapeutic Hypothermia
Disposition
Outcomes
Safety
Effectiveness
Complications
References
160 - Pediatric Trauma
Foundations
Anatomy and Physiology
Clinical Features
Initial Assessment and Primary Survey
A—Airway and Cervical Spine Stabilization
B—Breathing and Ventilation
C—Circulation and Hemorrhage Control
D—Disability Assessment
E—Exposure and Environment
F—Family
Secondary Survey
Physical Examination
Pain Assessment
Diagnostic Testing
Laboratory Testing
Radiologic Imaging
Disposition
Specific Injuries
Head Injury
Clinical Features
. A concussion is a functional brain injury seen after a blow to the head or body, a fall, or another injury that “shakes” the b...
. Bleeding from scalp wounds is often profuse and can lead to hemodynamic compromise in infants and small children if not quickl...
. In children, skull fractures occur in many different configurations. Simple linear non-­depressed fractures rarely require the...
. Cerebral contusions are often the result of coup and countercoup forces and manifest as multiple microhemorrhages. Patients of...
. Epidural hematomas are typically caused by bleeding from the meningeal vessels and are often associated with overlying skull f...
. Subdural hematomas are often secondary to the rupture of bridging veins. Subdural hematomas most commonly occur in patients yo...
Diagnostic Testing
. Clinicians have historically used skull radiographs as a screen for skull fractures in young patients with scalp hematomas. Du...
. Cranial CT provides substantial information but should be balanced with the risk of radiation. Substantial research has now id...
Management and Disposition
. Historically, children with skull fractures are routinely admitted to the hospital. However, alert children with linear, non-­...
. Prehospital BVM is recommended over ETI for support of ventilation and oxygenation. In the ED, ETI is performed in those with ...
Vertebral and Spinal Cord Injury
Foundations
Clinical Features
Diagnostic Testing
Management
Cardiothoracic Injury
Foundations
Diagnostic Testing
. Traumatic pneumothoraces are less common in children and often associated with a hemothorax. Patients present with symptoms of...
. Significant bleeding may occur as a result of injury to intercostal vessels, the internal mammary vessels, or lung parenchyma....
. Both penetrating and blunt thoracic trauma may cause pulmonary contusions, the most common thoracic injury in children. The co...
. Traumatic diaphragmatic hernias are exceedingly rare. Mechanisms causing these injuries usually involve a sudden increase in i...
. Although cardiac injuries following trauma are rare, cardiac contusion is the most common injury of the heart but is frequentl...
Abdominal and Pelvic Injury
Foundations
Clinical Features
Diagnostic Testing and Management
. The spleen is the most commonly injured abdominal organ. Findings include left upper quadrant abdominal pain that may radiate ...
. The liver is the second most commonly injured abdominal organ. Abdominal tenderness especially in the right upper quadrant sug...
. Due to unique anatomic differences, the pediatric kidney is more susceptible to injury: potential remnant fetal lobules; incre...
. Approximately 15% of children with intra-­abdominal injuries will have gastrointestinal injuries. These injuries range from si...
. Fortunately, pancreatic injury is rare, occurring in 5% of children with intra-­abdominal injuries, but less than 1% of childr...
. Penetrating wounds to the abdomen usually require rapid evaluation by a surgeon and consideration for operative intervention. ...
. Straddle injuries occur when the child falls, striking their genitals and perineum on a hard object, most commonly bicycles an...
. While pelvic fractures are less common in children than adults, pelvic avulsion fractures are significantly more common in chi...
Musculoskeletal Injuries
References
161 - Pediatric Fever
Background
Anatomy, Physiology, and Pathophysiology
Clinical Features
Diagnostic Testing
White Blood Cell Count
Inflammatory Markers
Blood Culture
Urinalysis and Urine Culture
Lumbar Puncture
Stool Studies
Chest Radiography
Rapid Viral Antigen Testing
Management
Approach to the Febrile Infant and Child
Infants 0 to 28 Days Old
Infants 29 to 90 Days Old
Infants 3 to 36 Months Old
Children 3 Years Old to Adulthood
Specific Disorders
Febrile Seizures
Fever and Petechiae
Toxic Shock Syndrome
Fever in Children With an Underlying Chronic Medical Illness
Oncology Patients
Patients With the Acquired Immunodeficiency Syndrome
Sickle Cell Disease
Congenital Heart Disease
Ventriculoperitoneal Shunts
References
162 - Pediatric Upper Airway Obstruction and Infections
Foundations
Clinical Features
Diagnostic Testing and Management
Specific Disorders
Supraglottic Airway Diseases
Congenital Lesions
. All infants are obligate nose breathers; they breathe nasally when the mouth is closed to allow breathing while feeding. In ch...
. Macroglossia, an abnormally large tongue that protrudes posteriorly into the hypopharynx, is associated with conditions such a...
. With micrognathia, an abnormally small mandible posteriorly displaces the normal-­sized tongue (e.g., Pierre Robin and Treache...
Pharyngitis
Peritonsillar Abscess
Mononucleosis
Retropharyngeal Abscess
. Retropharyngeal infections typically progress from cellulitis to organized phlegmon to mature abscess. Presenting symptoms may...
. Careful evaluation of airway patency takes precedence in the management of a child with a presumed RPA. Examination of the pha...
. The size of the abscess, degree of airway obstruction, and overall toxicity of the patient dictate management. The need for in...
Ludwig’s Angina
Epiglottitis
. Epiglottitis is an invasive bacterial disease that causes inflammation and edema of the epiglottis, aryepiglottic folds, aryte...
. Epiglottitis is classically acute in onset. It is marked by high fever, intense sore throat, toxicity, and rapid progression. ...
. When epiglottitis is strongly suspected, a lateral neck radiograph can be helpful to confirm the diagnosis and should be evalu...
. For the younger child, the importance of securing the airway takes precedence over diagnostic evaluation. A stable patient who...
Trauma and Burns
Allergic Reactions
Diseases of the Larynx
. Laryngomalacia is the most common cause of chronic stridor in infants and accounts for 60% to 75% of congenital laryngeal anom...
Acquired lesions
. Laryngeal papillomas are the most common benign laryngeal neoplasm in children and the second most common cause of hoarseness....
. The subglottic trachea is the origin of the high-­pitched inspiratory sound commonly associated with upper airway obstruction....
Viral Croup
. Croup (laryngotracheobronchitis) is the most common infectious cause of upper airway distress and obstruction in childhood. It...
. Croup is diagnosed clinically. A 1-­ to 3-­day prodrome of mild fever and URI symptoms is followed by a fairly abrupt onset of...
. Glucocorticoids reduce symptoms, decrease the need for aerosolized epinephrine, and result in fewer readmissions to the ED and...
Spasmodic or Atypical Croup
Diseases of the Trachea
Congenital lesions
. Tracheomalacia results from abnormally soft, undeveloped supporting cartilage of the tracheal rings. Primary or congenital tra...
. Tracheal stenosis is a congenital anomaly that results from complete tracheal rings. Infants have persistent stridor and respi...
. Tracheal compression may also occur externally from vascular anomalies or mediastinal lesions (Fig. 162.11). A vascular ring i...
. Infants with vascular rings typically present with persistent, unexplained respiratory and feeding problems. A chest radiograp...
Bacterial tracheitis
. Bacterial tracheitis, also referred to as bacterial laryngotracheobronchitis, pseudomembranous croup, is a serious cause of st...
. The classic presentation of bacterial tracheitis is a toxic child with high fevers and rapidly worsening stridor that fails to...
. The evaluation of a toxic-­appearing child with bacterial tracheitis should be conducted expeditiously. Laboratory tests are n...
. Severe distress may rarely require immediate intubation and suctioning in the ED, although airway management in the operating ...
Foreign Bodies
. Asphyxia from airway obstruction by an airway or esophageal foreign body is a common cause of death in children. Round foods (...
. An upper airway foreign body can cause partial or complete obstruction. Clinical signs of complete obstruction include poor ai...
. In a child with an aspirated foreign body in the upper airway, there is often no time, nor is it prudent, to perform diagnosti...
. An acute obstructing upper airway foreign body requires emergent intervention with basic life support maneuvers. Choking infan...
. Surgical cricothyrotomy is not generally recommended for infants and young children younger than 8 to 10 years. The anatomy ch...
References
163 - Pediatric Lower Airway Obstruction
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
History
Physical Examination
Differential Diagnoses
Diagnostic Testing
Management
Mild Exacerbation
Moderate Exacerbation
Severe Exacerbation
Foundations
Anatomy, Physiology, and Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Prophylaxis
Disposition
References
164 - Pediatric Lung Disease
Pneumonia
Foundations
Clinical Features
Differential Diagnoses
Bacterial Pneumonia
Viral Pneumonia
Mycoplasma Pneumonia
Chlamydia Pneumonia
Aspiration Pneumonia
Pneumonia in the Immunocompromised Patient
Diagnostic Testing
. A chest radiograph is unnecessary in children without comorbid conditions who have no fever, tachypnea, or focal findings on a...
. Recent studies have examined the utility of lung ultrasound for the diagnosis of pneumonia in children.18 Most studies use hig...
. Children with pneumonia are at risk for hypoxemia and should undergo pulse oximetry to determine oxygen saturation; arterial o...
Management
. An infant younger than 2 months with pneumonia should usually be admitted to the hospital and monitored with continuous pulse ...
. Blood and urine cultures should be obtained for infants 2 to 3 months of age. The decision to perform a lumbar puncture depend...
. In an older child, pneumonia should be categorized into likely bacterial, viral, or mycoplasmal. The emergency clinician shoul...
. Well-­appearing children who can maintain hydration and are not in respiratory distress should be considered for outpatient ma...
Pertussis
Cystic Fibrosis
Bronchopulmonary Dysplasia
References
165 - Pediatric Cardiac Disorders
Fetal and Neonatal Circulation
Pathophysiology of Cardiovascular Compensatory Responses
Clinical Features
Pathophysiology of Cyanosis
Clinical Features of Cyanosis
History
Chest Pain
Physical Examination
General Appearance and Pulses
Vital Signs and Blood Pressures
Cardiac Auscultation
Diagnostic Testing
Hyperoxia Test
Laboratory Analysis
Chest Radiography
Electrocardiography
Biochemical Markers
Specific Disorders
Congenital Heart Disease
Foundations
Clinical Features
Differential Diagnosis
Diagnostic Testing
Management
Acyanotic Congenital Heart Defect
Foundations
Specific Disorders
. VSD is the most common congenital cardiac defect and accounts for 20% to 25% of all cases of CHD. Spontaneous closure occurs i...
. Symptoms from a VSD are dependent on its size, and the degree of pulmonary vascular resistance present. Most VSDs are clinical...
. The chest radiograph in children with small VSDs may be entirely normal. Cardiomegaly with increased pulmonary vascular markin...
. All VSDs, regardless of the size of the defect, are at risk for bacterial endocarditis because of the high velocity of turbule...
. ASDs account for 5% to 10% of all cases of CHD. The majority of infants and children with ASDs remain clinically asymptomatic ...
. Large ASDs or those associated with comorbid conditions, such as bronchopulmonary dysplasia, can be manifested with symptoms o...
. The chest radiographs of children with ASDs will reveal varying degrees of cardiomegaly, right atrial and right ventricular en...
. Traditionally, ASDs required open heart surgery to place a patch over the septal defect. Newer therapies include septal occlus...
Eisenmenger Syndrome
. Eisenmenger syndrome can occur in any large left-­to-­right shunt defect. Left uncorrected, irreversible changes in the pulmon...
Coarctation of the Aorta
. Nearly 50% of patients with coarctation of the aorta also have an associated bicuspid aortic valve. The area of coarctation ca...
. The severity of symptoms and age at time of presentation are dependent on the location of the coarctation, the degree of narro...
. The chest radiograph will most often reveal a normal cardiac silhouette and normal pulmonary vascular markings, but notching a...
. Definitive surgical repair of coarctation of the aorta involves angiography or stenting of the narrow aortic lumen; resection ...
Cyanotic Congenital Heart Diseases
. Cyanotic CHDs are a result of either decreased pulmonary blood flow to the lungs or right-­to-­left shunting of desaturated bl...
Tetralogy of Fallot
. Tetralogy of Fallot is the most common cause of cyanotic CHD beyond infancy. It arises from a single embryologic defect in whi...
. The degree of cyanosis and the age at presentation are directly dependent on the degree of right ventricular outflow tract obs...
. The chest radiograph of a patient with cyanotic Tetralogy of Fallot (see Fig. 165.4) shows decreased pulmonary vascular markin...
. The overall treatment goals for tet spells are to increase the SVR, to abolish the hyperpnea, and to correct the metabolic aci...
Postoperative Complications of Congenital Heart Defects
Respiratory Syncytial Virus Infections in Infants and Children With Congenital Heart Defects
Congestive Heart Failure
Foundations
Clinical Features
Diagnostic Testing
Management
Pediatric Dysrhythmias
Foundations
Clinical Features
Management
Bradydysrhythmias
. Bradycardia is defined as a heart rate that is slower than the lower limit of normal for a child’s age. Clinically significant...
Tachydysrhythmias
. Supraventricular tachycardia is the most common symptomatic dysrhythmia in infants and children. No cardiac abnormalities are ...
. Supraventricular tachy­cardia is most likely with heart rates above 180 in young children and 220 in infants, without beat-­to...
. The emergency clinician should quickly initiate synchronized cardioversion (0.5 to 1 J/kg) for children in supraventricular ta...
. Both atrial flutter and atrial fibrillation are rare in children and are usually associated with underlying heart conditions (...
. The majority of children with ventricular tachycardia have an underlying condition, such as post–cardiac surgery status, myoca...
Special Resuscitation Situations in Children
Bacterial Endocarditis
Foundations
Clinical Features
Diagnostic Studies
Management
Pericarditis
Foundations
Clinical Features
Diagnostic Studies
Management
Myocarditis
Foundations
Clinical Features
Diagnostic Testing
Management
Kawasaki Disease
Foundations
Clinical Features
. The classic presentation of Kawasaki disease is a clinical diagnosis of four or more of the five criteria in a child who is fe...
Differential Diagnoses
Management
Acute Rheumatic Fever
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Cardiac Causes of Sudden Death in Young Athletes
Specific Disorders
. Although there are a variety of congenital coronary artery anomalies, the most common potentially lethal lesion is the anomalo...
. Clinical manifestations of the disease include tall and slender habitus, striae atrophicae, disproportionately long extremitie...
. Obstructive hypertrophic cardio­myopathy involves a thickened muscular intraventricular septum that bulges into the left ventr...
. Some individuals with hypertrophic cardio­myopathy have experienced previous “warning” episodes of chest pain, dyspnea, syncop...
. The electrocardiographic findings in hyper­trophic cardiomyopathy show left ventricular hypertrophy and left atrial enlargemen...
. No pharmacologic therapy has been proven to prevent sudden death. Beta-­blockers exert negative inotropic effects, attenuate a...
. Both the Jervell–Lange-­Nielsen (congenital deafness) and the Romano-­Ward syndromes are inherited disorders characterized by ...
. Symptoms in the young athlete that are suggestive of QT prolongation include exercise-­induced palpitations, chest pain, synco...
. Treatment of a prolonged QT interval depends on the cause. Underlying metabolic disorders should be corrected, and medications...
. Commotio cordis occurs after a high-­impact trauma to the chest, as in a high-­speed motor vehicle collision or a baseball to ...
References
166 - Pediatric Gastrointestinal Disorders
Foundations
Specific Disorders
Neonatal Jaundice
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Hypertrophic Pyloric Stenosis
Foundations
Clinical Features
Diagnostic Testing
. Vomiting in infants is common, and the differential diagnosis is broad. Usually, infants present early in the disease progress...
Management
Disposition
Malrotation with Midgut Volvulus
Foundations
Clinical Features
Diagnostic Testing
Differential Diagnoses
Management
Disposition
Necrotizing Enterocolitis
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Gastroesophageal Reflux
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Intussusception
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Hirschsprung Disease
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Meckel Diverticulum
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Henoch-­Schönlein Purpura
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Inflammatory Bowel Disease
Foundations
Clinical Features
Diagnostic Testing
Differential Diagnoses
Management
Disposition
Gastrointestinal Foreign Bodies
Foundations
Clinical Features
Diagnostic Testing
Differential Diagnoses
Management
Disposition
Appendicitis
Foundations
Clinical Features
Diagnostic Testing
Differential Diagnoses
Management
Disposition
Pancreatitis
Foundations
Clinical Features
Diagnostic Testing
Differential Diagnoses
Management
Disposition
Biliary Tract Disease
Foundations
Clinical Features
Diagnostic Testing
Differential Diagnoses
Management
Disposition
References
167 - Pediatric Infectious Diarrheal Disease and Dehydration
Foundations
Background and Importance
Anatomy, Physiology, and Pathophysiology
Clinical Features
Specific Etiologies
. In the United States and Europe, the majority of cases of diarrhea are caused by viral pathogens, with incidence peaking in th...
. The common bacterial organisms causing acute diarrhea in U.S. children along with their presentations and associated character...
. Protozoa can also cause diarrhea in children but are responsible for less than 1% of all cases of acute infectious diarrhea in...
Complications
Diagnostic Strategies
Differential Diagnoses
Management
Disposition
Dehydration
Foundations
Anatomy and Physiology
Pathophysiology
Clinical Features
Diagnostic Strategies
Differential Diagnoses
Management
Oral Rehydration Therapy
Intravenous Therapy
. Rapid reexpansion of the intravascular space is the goal of immediate resuscitation and can be achieved with an isotonic cryst...
. Appropriate fluid therapy for the patient should be determined after initial resuscitation. Some patients may tolerate ORT; ot...
. IV rehydration can lead to hyponatremia in children. This rare complication can lead to significant neurologic morbidity, incl...
Disposition
References
168 - Pediatric Genitourinary and Renal Tract Disorders
Specific Disorders
Priapism
Foundations
Clinical Features
Differential Diagnoses
Management
Disposition
Phimosis
Foundations
Diagnostic Testing
Management
Disposition
Paraphimosis
Foundations
Clinical Features
Diagnostic Testing
Management
Disposition
Balanoposthitis
Foundations
Clinical Features and Diagnostic Testing
Management
Disposition
Complications of Circumcisions
Foundations
Management
Penile Entrapment and Tourniquet Injuries
Foundations
Clinical Features and Diagnostic Testing
Management
Disposition
Epididymitis and Orchitis
Foundations
Clinical Features
Diagnostic Testing
Management
Disposition
Testicular Torsion
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Varicocele and Hydrocele
Foundations
Clinical Features
Diagnostic Testing
Management and Disposition
Acute Idiopathic Scrotal Edema
Foundations
Clinical Features and Diagnostic Testing
Management
Inguinal Hernia
Foundations
Clinical Features
Differential Diagnoses
Management and Disposition
Testicular Carcinoma/Tumors
Foundations
Clinical Features
Diagnostic Testing and Management
Urinary Tract Infections
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing and Management
Hematuria
Foundations
Nephrolithiasis
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Renal Tumors
Foundations
Clinical Features
Diagnostic Testing
Management and Disposition
Proteinuria
Foundations
Clinical Features
Diagnostic Testing and Management
Disposition
Poststreptococcal Glomerulonephritis (PSGN)
Foundations
Clinical Features
Diagnostic Testing
Management
Nephrotic Syndrome
Foundations
Clinical Features
Diagnostic Testing
Differential Diagnoses
Management
Disposition
Acute Kidney Injury
Foundations
Clinical Features and Differential Diagnoses
Diagnostic Testing
Management
Disposition
Hypertension
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
Henoch-­Schönlein Purpura
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Hemolytic Uremic Syndrome
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
References
169 - Pediatric Neurologic Disorders
Seizures
Foundations
Clinical Features
Generalized Seizures
Focal Onset
Differential Diagnoses
Management
Status Epilepticus
Febrile Seizures
Afebrile Seizures
Neonatal Seizures
Disposition
Anticonvulsant Therapy at Discharge
Altered Mental Status
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Headaches
Foundations
Clinical Features
Differential Diagnoses
Acute Headache
Chronic Progressive Headache
Migraine Headache
Chronic Nonprogressive Headache
Cluster Headache
Diagnostic Testing
Management
Disposition
Pediatric Ataxia
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Disposition
Pediatric Vertigo
Foundations
Clinical Features
Diagnostic Testing
Differential Diagnoses
Management
Disposition
Motor Dysfunction
Stroke
Foundations
Clinical Features
Diagnostic Testing
Management
Disorders of the Spinal Cord
Foundations
Clinical Features
Diagnostic Testing
Management and Disposition
Guillain-­Barré Syndrome
Foundations
Clinical Features
Diagnostic Testing
Management and Disposition
Infant Botulism
Foundations
Clinical Features
Diagnostic Testing
Management and Disposition
Myasthenia Gravis
Foundations
Clinical Features
Diagnostic Testing
Management and Disposition
References
170 - Pediatric Musculoskeletal Disorders
Anatomy and Physiology
Fracture Patterns
Specific Disorders
Clavicle Fracture
Supracondylar Fractures of the Humerus
Monteggia and Galeazzi Fracture-­Dislocations
Nursemaid’s Elbow
Toddler’s Fracture
Nonaccidental Trauma
Developmental Dysplasia of the Hip
Foundations
Clinical Features
Diagnostic Testing
Management
Pediatric Hip Pain
Transient Synovitis
Acute Septic Arthritis
Legg-­Calvé-­Perthes Disease
Slipped Capital Femoral Epiphysis
Lyme Arthritis
Apophyseal Injuries
Osgood-­Schlatter Syndrome
Sever Disease
Little League Elbow
Apophysitis and Avulsion Fractures of the Hip
Gymnast Wrist
References
171 - Pediatric Drug Therapy
Absorption
Distribution
Metabolism
Elimination
Other Considerations
Drug Therapy in the Neonate
Use of Antipyretics in Children
Over-­the-­Counter Cough and Cold Medications
Opioid Analgesics
Medication Safety and Adverse Drug Events
References
172 - Child Abuse
Physical Abuse
Foundations
Role of the Emergency Clinician
Clinical Features
Social and Demographic Risk Factors
History
Physical Examination
Sentinel Injuries
Universal Screening
Differential Diagnoses
Diagnostic Testing
Skeletal Survey
Retinal Examination
Abdominal Injury Testing
Toxicology Testing
Management
Household Contacts
Timing
Mandated Reporting
Disposition
Sexual Abuse
Foundations
Trafficking
Clinical Features
History
Physical Examination
Differential Diagnoses
Diagnostic Testing
Management
Disposition
References
173 - Complications of Pregnancy
Problems in Early Pregnancy
Pathophysiology
Terminology
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
. After assessment of hemodynamic status and management of blood loss, a patient with a threatened miscarriage requires very lit...
. Treatment of the patient with incomplete miscarriage includes expectant management, medical management, or surgical evacuation...
. Management of patients with presumed completed miscarriage is more complicated. If the patient brings passed tissue with her, ...
Foundations
Pathophysiology
Clinical Features
Differential Diagnoses
Diagnostic Testing
. Ultrasonography is the primary method used to locate early gestation, establish gestational age, and assess fetal viability. T...
. Quantitative hCG levels serve two primary functions—serial levels can be used in the stable patient who can be observed as an ...
. Dilation and evacuation can be used in patients without a viable IUP or ectopic pregnancy on ultrasonography to differentiate ...
Management and Disposition
. Approximately 20% of women with ectopic pregnancies manifest signs and symptoms warranting immediate intervention. This includ...
. In stable patients with first-­trimester bleeding, the goal is to exclude ectopic pregnancy in a timely manner. In the patient...
Molar Pregnancy
Foundations
Clinical Findings
Diagnostic Tests
Management
Complications of Late Pregnancy
Vaginal Bleeding in Later Pregnancy
Foundations
Abruptio Placentae
. Abruptio placentae is a separation of the placenta from the uterine wall and complicates roughly 1% of pregnancies. Small subc...
. Vaginal bleeding occurs in 70% of patients with abruptio placentae. Blood is characteristically dark and the amount is often i...
. The main alternative diagnosis in the woman with late-­pregnancy bleeding is placenta previa, which is usually associated with...
Placenta Previa
. Placenta previa, or implantation of the placenta over the cervical os, is the other major cause of bleeding episodes during th...
. Painless, fresh vaginal bleeding is the most common symptom of placenta previa. In approximately 20% of cases, some degree of ...
. Ultrasonography is the diagnostic procedure of choice for localization of the placenta and diagnosis of placenta previa. Accur...
. Patients who experience vaginal bleeding during late pregnancy require immediate obstetric consultation and arrangements for s...
Foundations
Pathophysiology
Clinical Features
. The patient with gestational hypertension has mild systolic or diastolic blood pressure elevation, no proteinuria, and no evid...
Complications
Differential Diagnoses
Diagnostic Testing
Management
. The management of patients with mild preeclampsia includes documentation of blood pressure, reflexes, weight, and blood testin...
. Hospitalization is recommended for patients with sustained hypertension above 140/90 mm Hg and signs of severe preeclampsia. B...
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management
Abdominal Pain
Appendicitis
. Appendicitis is the most common surgical emergency in pregnant patients. The incidence of appendicitis in pregnant patients is...
. The gastrointestinal symptoms of appendicitis, such as anorexia, nausea, and vomiting, mimic those of pregnancy, particularly ...
. Pyelonephritis, cholecystitis, nephrolithiasis, and pregnancy-­related diseases such as ectopic pregnancy, round ligament pain...
. Leukocytosis is common in pregnant patients with appendicitis, although it is rarely high enough to distinguish it from the ph...
. The pregnant patient with suspected appendicitis should be hospitalized after consultation with a surgeon and obstetrician. Ul...
Gallbladder Disease
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Management and Disposition
Liver Disorders
Foundations
Hepatitis
Acute Fatty Liver
. Acute fatty liver of pregnancy is a disorder of the third trimester that can result in hepatic failure, complicated labor, and...
. Nausea and vomiting associated with malaise or jaundice during the third trimester should trigger consideration of a diagnosis...
. Liver tenderness and coagulopathy usually suggest preeclampsia during the third trimester. Jaundice and increases in the ALT l...
. Typically, leukocytosis is present, the platelet count and fibrinogen level are low, prothrombin and partial thromboplastin ti...
. The patient with acute fatty liver of pregnancy may require acute stabilization for seizures or coma. Hypoglycemia may occur, ...
Intrahepatic Cholestasis
. Intrahepatic cholestasis of pregnancy, also termed idiopathic jaundice of pregnancy, icterus gravidarum, or pruritus gravidaru...
. Generalized pruritus and mild jaundice are the hallmarks of intrahepatic cholestasis of pregnancy. However, only 20% of patien...
. Exclusion of more serious entities, such as viral hepatitis, acute fatty liver, drug-­induced cholestasis, and complicated cho...
Normal Pregnancy
Hyperemesis Gravidarum
. Hyperemesis gravidarum occurs in approximately 1% of pregnant patients and is defined by nausea and vomiting that cause starva...
. Laboratory studies should assess volume status and reversible electrolyte abnormalities. A urinalysis screens for the presence...
. Initial management of hyperemesis involves rehydration with IV fluids (2 L of Ringer lactate [LR] at a rate of 500 ml/h), anti...
Foundations
Clinical Features
Diagnostic Testing
. Because of its widespread availability and avoidance of radiation, Doppler ultrasonography is the first-­line test for the dia...
. Currently, studies do not support the use of D-­dimer tests in pregnancy to exclude the diagnosis of PE because this test may ...
Management and Disposition
Urinary Tract Infection
. Asymptomatic bacteriuria in pregnancy predisposes the patient to the development of symptomatic lower and upper tract genitour...
. The pregnant patient who presents with lower urinary tract symptoms (e.g., dysuria, frequency, urgency) or upper tract symptom...
. Vaginitis, herpes genitalis, chlamydial infection of the urethra, and ovarian torsion can masquerade as urinary tract symptoms...
. Patients with asymptomatic bacteriuria or lower urinary tract signs and symptoms should be treated with 7 to 10 days of an ant...
Vaginitis
. Bacterial vaginosis (formerly known as Gardnerella vaginitis or Haemophilus vaginalis vaginitis) is an overgrowth of multiple ...
. The incidence of vulvovaginal candidiasis is increased during pregnancy by high levels of estrogen and other steroids. There i...
. Trichomoniasis is a sexually transmitted vaginitis caused by a protozoan parasite, Trichomonas vaginalis. Of patients who have...
Sexually Transmitted Disease
. Chlamydia trachomatis infection is the most common sexually transmitted disease in the United States and worldwide. Its preval...
. Gonococcal infection of the cervix occurs in 1% of pregnant women.30 Symptoms are similar to those in nonpregnant women. Salpi...
. Herpes simplex virus (HSV) infections pose a risk in pregnancy to the mother and newborn. Women who have genital herpes during...
Upper Genital Tract Infection
. PID is very rare in pregnancy and does not occur after the first trimester. The differential diagnosis includes ectopic pregna...
. Chorioamnionitis is the infection or inflammation of the placenta and fetal membranes. After 16 weeks of pregnancy, the chorio...
Endocrine Disorders
Thyroid Disorders
. Thyroid disorders are common in women of childbearing age. During pregnancy, however, this is associated with a range of adver...
. The diagnosis of thyroid dysfunction during pregnancy is difficult because pregnancy itself can mimic the findings in mild to ...
. Thyroid dysfunction should be considered in the patient with nonspecific symptoms, including fatigue, anxiety, depression, and...
. Normal values of thyroid hormones vary based on stage of pregnancy. The diagnosis of hyperthyroidism is confirmed by a low (<0...
. Generally, no treatment is required for hCG-­mediated hyperthyroidism. Treatment of pregnant women with overt hyperthyroidism ...
Disorders of the Hypothalamic-­Pituitary Axis
. The pituitary gland is normally enlarged in pregnancy due to estrogen stimulation. Disorders of the hypothalamic-­pituitary ax...
. Disorders of the hypothalamic-­pituitary axis usually present as an insidious set of chronic symptoms, many of which can mimic...
. Diagnostic considerations vary according to the patient’s presentation. Growth hormone levels are elevated in patients with ac...
. Stabilization consists of treatment of serious manifestations, such as hyperkalemia, tachycardia, and hypotension. Outpatient ...
Acknowledgment
References
174 - Medical Emergencies During Pregnancy
Foundations
Asthma
Cardiovascular Disorders
Foundations
Hypertension
Chronic Hypertension
Hypertensive Emergencies
Cardiac Disorders
Acute Coronary Syndromes
Valvular Heart Disease and Pulmonary Hypertension
. Valvular heart disease, including both native and mechanical valves, can lead to acute heart failure during pregnancy and is a...
. Pregnancy is poorly tolerated by patients with pulmonary hypertension because the pulmonary circulation cannot cope with the i...
. Mitral stenosis is the most commonly encountered valvular lesion in pregnancy but is typically well tolerated except in modera...
. Mitral valve prolapse is the most common cause of mitral regurgitation in developed countries, whereas rheumatic heart disease...
. Symptomatic aortic stenosis during pregnancy usually occurs in the setting of a congenital bicuspid valve and patients with se...
. Pregnant women with mechanical heart valves are classified as high risk with a World Health Organization (WHO) risk classifica...
Hematologic Disorders
Anemia
Dilutional Anemia
Iron Deficiency Anemia
Folate Deficiency
Sickle Cell Anemia
Neurologic Disorders
Epilepsy
Multiple Sclerosis
Spinal Cord Injury
Myasthenia Gravis
Renal Disorders
Metabolic and Endocrine Disorders
Diabetes
General Management
Hyperglycemic
Hypoglycemia
Fetal Effects
Obesity
Thyroid Disorders
Hyperthyroidism
Hypothyroidism
Adrenal Insufficiency
Electrolyte Abnormalities
Systemic Infections
Human Immunodeficiency Virus Infection
Tuberculosis
Syphilis
Viral Hepatitis
Hepatitis B
Hepatitis C
Inflammatory Disorders
Systemic Lupus Erythematosus
Psychiatric Disorders
Schizophrenia, Bipolar Disorder, and Depression
Eating Disorders
Substance Dependence/Use Disorder
Alcohol
Smoking
Cannabis
Cocaine and Methamphetamines
Opioids
References
175 - Drug Therapy in Pregnancy
Foundations
Classification of Teratogenic Risk
Drug Transfer Across the Placenta
Drug Transfer During Lactation
Drug Therapy During Pregnancy
Pharmacologic Therapy
Analgesic Agents
Acetaminophen
Nonsteroidal Antiinflammatory Drugs
Aspirin
Opiate Analgesics
Rapid Sequence Intubation Agents
Anticoagulants
Thrombolytic Agents
Antidotes
N-­Acetylcysteine
Deferoxamine
Digoxin Immune Fragment
Dimercaprol
Flumazenil
Fomepizole
Hydroxycobalamin
Methylene Blue
Naloxone
Physostigmine
Pralidoxime
Pyridoxine
Dimercaptosuccinic Acid (Succimer)
Antiinfective Agents
Antibiotics
Aminoglycosides
Cephalosporins
Chloramphenicol
Clindamycin
Fluoroquinolones
Linezolid
Macrolides
Metronidazole
Nitrofurantoin
Penicillins
Sulfonamides
Tetracyclines
Vancomycin
Antifungals
Antituberculous Agents
Antiviral Agents
Antiherpetic Drugs
Antiinfluenza Drugs
Anti-­HIV Drugs
Cardiovascular Agents
Antidysrhythmics
. Adenosine has been used safely throughout pregnancy and is the drug of choice for termination of maternal supraventricular tac...
. Amiodarone contains large amounts of iodine and is associated with congenital goiter and transient neonatal hyperthyroidism an...
. Digoxin and quinidine are considered safe for use during pregnancy and lactation. Neither has been linked to congenital defect...
. Lidocaine rapidly crosses the placenta and becomes ion-­trapped in the fetus. There is no evidence of a link between the use o...
. Procainamide has been safely used in the treatment of stable, wide-­complex tachydysrhythmias during pregnancy. It is not asso...
. Flecainide has been used safely to terminate maternal and fetal tachycardia, but it is associated with fetal hyperbilirubinemi...
. There are only a few case reports of the successful and safe use of ibutilide during the latter part of pregnancy in humans. I...
. Sotalol has been used in pregnant women to treat atrial arrhythmias successfully and safely, as well as hypertension. It has a...
Antihypertensives
. Angiotensin-­converting enzyme (ACE) inhibitors are contraindicated for use during pregnancy. Furthermore, ACE inhibitors are ...
. Angiotensin II receptor antagonists should be avoided during pregnancy because their use has been reported to result in fetal ...
. Beta blockers are a first-­line treatment of hypertension in pregnancy.15 They have not been associated with fetal malformatio...
. Calcium channel blockers are effective treatments for hypertension and the termination of supraventricular rhythm disturbances...
Diuretics
. Nitroglycerin has not been shown to cause fetal harm in animal studies. Limited reports in humans have not shown any major eff...
. Clonidine has been safely used throughout pregnancy, but experience during the first trimester remains limited. It does not ap...
. Hydralazine use is associated with higher rates of maternal hypotension, placental abruption, and neonatal distress compared w...
. Methyldopa has been safely used throughout pregnancy, and most reviews have not linked it to any teratogenic effects on the of...
Vasopressors
Endocrine Agents
Diabetes Medications
Thyroid Medications
Gastrointestinal Agents
Antacids
. None of the H2 receptor antagonists has been linked to congenital malformation, and they all appear to be safe for the nursing...
. Studies on proton pump inhibitor (PPI) use in pregnancy are limited but several studies and a meta-­analysis have found no ass...
Antiemetic Medications
. Pyridoxine is used alone, or in combination with doxylamine, an antihistamine, for the treatment of nausea and vomiting of pre...
. Phenothiazines, such as metoclopramide, proch­lorperazine, and promethazine, are dopamine antagonists commonly used in the tre...
. Dolasetron, granisetron, and ondansetron have not been consistently linked to any fetal malformations, although experience wit...
Neurologic Agents
Anticonvulsants
Antipsychotics
Migraine Medications
Ergot Alkaloids
Triptans
Respiratory Agents
Antihistamines
Asthma Medications
Corticosteroids
Decongestants
References
176 - Labor and Delivery
Foundations
Limitations of the Emergency Department
Epidemiology of Emergency Delivery
Patient Transfer Considerations
Normal Delivery
Initial Presentation
Distinguishing False From True Labor
Bloody Show
Stages of Labor
First Stage of Labor
Second Stage of Labor
. During labor and delivery, the identification of fetal distress and appropriate intervention can reduce fetal morbidity and mo...
. Electronic fetal monitoring uses tracings of the fetal heart rate and uterine activity. Documentation of organized cyclic uter...
. This is the average fetal heart rate during a 10-­minute period (in the absence of a uterine contraction) and is the most impo...
. This can be instantaneous (beat to beat) or long term (intervals ≥ 1 minute). Both types of variability are indicators of feta...
. Decelerations in fetal heart rate are more complicated and should be interpreted according to the clinical scenario. There are...
. Finally, the emergency clinician should be aware of the significance of sinusoidal tracings. Tracings of this type have low ba...
. In the third trimester or during labor, ultra­sonography can provide crucial information pertaining to impending delivery, suc...
. As stage 2 of labor progresses, preparation for delivery should be under way. A radiant warmer should be available and heated....
. With a controlled delivery, routine performance of an episiotomy is not recommended. It should be performed only for specific ...
Third Stage of Labor
Fourth Stage of Labor
Premature Labor
Clinical Features
Diagnostic Testing
Management
Premature Rupture of Membranes
Clinical Features
Diagnostic Testing
Management
Chorioamnionitis
Vertical Transmission of Human Immunodeficiency Virus
Complicated Delivery
Foundations
Dystocia and Malpresentation
Breech Delivery
Diagnostic Testing
Management
Shoulder Dystocia
Diagnostic Testing
Management
Face, Brow, and Compound Presentations
Multiple Gestations
Diagnostic Testing
Management
Umbilical Cord-­Related Emergencies
Umbilical Cord Prolapse
Clinical Features
Diagnostic Testing
Management
Cord Entanglement
Postpartum Hemorrhage
Clinical Features
Differential Diagnosis and Management
. Accounting for 75% to 90% of cases, the most common cause of serious immediate postpartum hemorrhage is laxity of the uterus a...
. Maternal birth trauma is the second most common cause of postpartum hemorrhage, accounting for up to 20% of cases. Associated ...
. Approximately 10% of postpartum hemorrhage cases are due to retained placental tissue. Normally, the plane of cleavage between...
. All women with postpartum hemorrhage should receive tranexamic acid (1 g IV) and should also be evaluated for disseminated int...
. In the presence of ongoing hemorrhage and retained products of conception, attempts to remove the placenta manually are indica...
. Pelvic bleeding postpartum can be difficult to control. Hysterectomy as a solution results in infertility and brings with it a...
. When uterine bleeding is severe and uncontrolled, and embolization or hysterectomy are not available, uterine packing may be u...
. Although they are commonly applied on delivery of the placenta, uterotonic agents also have special application in the case of...
. Rarely, hemorrhage continues, despite the interventions outlined. In the case of life-­threatening obstetric bleeding, an emer...
Uterine Inversion
Foundations
Clinical Features
Management
Uterine Rupture
Foundations
Clinical Features
Diagnostic Testing
Management
Amniotic Fluid Embolism
Postpartum Venous Thromboembolism
Postpartum Endometritis
Postpartum Problems
Peripartum Cardiomyopathy
Postpartum Depression
Clinical Features
Management
references
177 - Trauma in Pregnancy
Anatomic Changes in Pregnancy
Physiologic Changes
Cardiovascular
Pulmonary
Gastrointestinal
Specific Disorders
Blunt Trauma
Interpersonal Violence
Falls
Penetrating Trauma
Fetal Injury
Placental Injury
Uterine Injury
Diagnostic Testing
Changes in Laboratory Values with Pregnancy
Laboratory
Kleihauer-­Betke Test and Fetomaternal Hemorrhage
Radiography
Ultrasonography
Computed Tomography and Magnetic Resonance Imaging Scans
Special Procedures
Diagnostic Peritoneal Lavage
Management
Maternal Resuscitation
Primary Survey
. The general principles of airway management are discussed in Chapter 1. Oxygen therapy should be instituted early in the traum...
. Intravenous access with two large-­bore catheters above the diaphragm is preferred. Maternal blood pressure and heart rate are...
Secondary Survey
. Fetal evaluation in the secondary survey focuses on the fetal heart rate and detection of fetal movement. When the presence of...
Mother Stable, Fetus Stable
Mother Stable, Fetus Unstable
Mother Unstable, Fetus Unstable
Defibrillation
Resuscitative Hysterotomy
Disposition
References
178 - Care of the Geriatric Patient
Foundations
Specific Issues and Disorders
Comprehensive Geriatric Assessment
Cognitive Deficits: Delirium and Dementia
Delirium
Dementia
Functional Decline, Vulnerability, and Frailty
Frailty
Goals of Care, Transitions of Care, and Palliative Care
Transitions in Care
Goals of Care and Palliative Care
Nonspecific Complaints and Atypical Presentations
Acute Coronary Syndrome
Syncope
Abdominal Pain
Infections
References
179 - Geriatric Trauma
Foundations
Background and Importance
SPECIFIC ISSUES
Age as a Trauma Triage Criterion
Mechanisms of Injury
179
Comorbidities
Medications
ATLS Assessment
Airway
Breathing
Circulation
Disability
Exposure
Secondary Assessment
Laboratory Testing
Common Injuries in Older Adults
Traumatic Brain Injury (TBI)
Vertebral Fractures and Spinal Cord Injuries
Thoracic Trauma
Fragility Fractures
References
180 - Geriatric Drug Therapy
Foundations
Pharmacokinetics
180
Pharmacodynamics
Specific Disorders
Polypharmacy and Drug Interactions
Potentially Inappropriate Medications
Beers Criteria
STOPP and START Criteria
Anticoagulation and Bleeding
Neurologic Conditions
Analgesia
Clinical Pharmacy Services
References
181 - Geriatric Abuse and Neglect
Background
Epidemiology and Scope of the Problem
Clinical Features
Observation and Medical History
Physical Examination
Diagnostic Testing
Diagnostic Imaging
Screening
Management
Emergency Medical Services
Trauma-­Informed Care
Documentation
Reporting
Collaboration with the Community
Resources
Specific Issues
Elder Mistreatment in Institutions
Self-­Neglect
References
182 - The Immunocompromised Patient
Foundations
Physiology
Immunity and Immune Deficiency
Non–Microbe-­Specific Immunity
. Physical barriers, the first line of defense against microorganisms, consist of intact skin, mucosa, cilia, biofilm, gastric a...
. The initial inflammatory response to microbial invasion promotes phagocytosis and microbial killing while activating the immun...
. The reticuloendothelial system, composed of tissue macrophages and their blood-­borne counterparts, monocytes, removes particu...
Adaptive (Microbe-­Specific) Immunity
. Each B cell produces a single microbe-­specific antibody type. Stimulation by an antigen (or microbe) causes proliferation of ...
. Immunoglobulin M (IgM) is the first immunoglobulin to appear in response to a new antigen. Although it has less affinity at bi...
. The complement cascade, a complex interaction of 30 proteins, is another crucial component of humoral response. Complement is ...
. Cell-­mediated immunity (CMI) includes immune responses mediated by T lymphocytes, natural killer (NK) cells, and mononuclear ...
. Granulocytic phagocytes are the cellular effectors of microbe killing, engulfing them and enzymatically lysing their cell memb...
Specific Disorders
Solid Organ Transplants
Cancer
Neutropenia
Background
Febrile Neutropenia Evaluation Pitfalls
Evaluation and Management
. The Infectious Disease Society of America and the American Society of Clinical Oncology recommend antibiotic therapy within 60...
Risk Assessment and Disposition
Children With Cancer and Febrile Neutropenia
Non-­Neutropenic Conditions in the Cancer Patient
The Solid Organ Cancer Patient Without Neutropenia
Impaired Cell-­Mediated Immunity
. L. monocytogenes is one of the more common bacterial organisms infecting cancer patients with impaired CMI. Listeria infection...
. Tuberculosis and other mycobacterial diseases may produce severe disease in those with defective CMI and be manifested as feve...
. Infections with Cryptococcus neoformans and Cryptococcus gattii occur in patients with Hodgkin and non-­Hodgkin lymphoma, chro...
. Reactivation of central nervous system infection with the protozoan T. gondii occurs most often in patients with hematologic c...
. The most common viruses producing serious infections in cancer patients with defective CMI are varicella-­zoster, herpes simpl...
Humoral Immune (B-­Cell) Defects
Disruption of Natural Barriers
Opportunistic Infections Mimicking Neoplasm
Diabetes
Alcohol Use Disorder and Cirrhosis
Renal Failure
Splenectomy, Hyposplenia, and Functional Asplenia
Immunosuppressive Therapy
Corticosteroids
Other Immunosuppressive Medications
References
183 - The Solid Organ Transplant Patient
Introduction
Pathophysiology
Anatomy
Infection
. Infections within the first month of transplantation often relate to postoperative intensive care and surgical site complicati...
. Infections occurring within the first year of transplantation are generally divided into two categories: reactivation of laten...
Rejection
. Desensitization regimens decrease circulating antibodies likely to react with donor antigens in patients sensitized to incompa...
. Induction immunosuppression is employed in the pre-­ or peri-­transplantation period. Antithymocyte globulin (ATG) and alemtuz...
Maintenance Immunosuppression
. The calcineurin inhibitors tacrolimus and cyclosporine have greatly improved patient-­ and allograft-­related outcomes. Howeve...
. Sirolimus and everolimus are two drugs in the mammalian target of rapamycin (mTOR) class. mTOR is key in the pathway for T cel...
. Azathioprine is an antimetabolite derivative of 6-­mercaptopurine and inhibits both DNA and ribonucleic acid synthesis to supp...
. Corticosteroids have a wide range of effects on the immune system. Every effort is made to minimize corticosteroid use to prev...
. Belatacept is a fusion protein that blocks T cell co-­stimulation at CD28 and is used primarily in kidney transplantation to a...
Organ-­Specific Considerations
Heart Transplantation
Anatomic Considerations
Infection
Rejection
Drug Toxicity
Kidney Transplantation
Anatomic Considerations
Infection
Rejection
Drug Toxicity
Liver Transplantation
Anatomic Considerations
Infection
Rejection
Drug Toxicity
Lung Transplantation
Anatomic Considerations
Infection
Rejection
Drug Toxicity
Pancreas Transplantation
Intestinal and Multivisceral Transplantation (IMVT)
Vascularized Composite Allografts
Other Considerations
Post-­Transplantation Malignancy
Post-­Transplantation Lymphoproliferative Disorder
Viral Hepatitis in Solid Organ Transplantation
Trauma
Eligible Organ Donors
Pregnancy and Solid Organ Transplantation
Psychological Aspects
Disposition
Acknowledgements
References
184 - The Morbidly Obese Patient
Foundations
Pathophysiology
Changes to Respiratory Mechanics
Obstructive Sleep Apnea and Obesity Hypoventilation Syndrome
Changes in Pharmacokinetics
Antibiotics
Sedatives and Induction Agents
Neuromuscular Blocking Agents
Anticoagulation
Trauma Considerations
Bariatric Surgery
Overview
Laparoscopic Gastric Band
Sleeve Gastrectomy
Roux-­en-­Y Gastric Bypass
Procedural Difficulties
Lumbar Puncture
Venous Access
Cardiopulmonary Resuscitation
Endotracheal Intubation
Ventilator Management
Challenges with Hospital Equipment
Imaging Challenges
References
185 - The Combative and Difficult Patient*
Foundations
Clinical Presentation
Patient Characteristics
Initial Patient Evaluation
Management
Verbal Management Techniques
Physical Restraints
Chemical Restraints
. Benzodiazepines, particularly lorazepam (Ativan) and midazolam (Versed), are often used in the ED for rapid tranquilization of...
. Antipsychotic medications play a prominent role in the chemical restraint of the violent ED patient. These medications include...
. Benzodiazepines and typical antipsychotics are commonly used in combination for chemical restraint. In a 2016 meta-­analysis o...
. Ketamine is a dissociative anesthetic with a good safety profile used to manage the violent and acutely agitated patient in th...
Post-­Restraint Medical Evaluation
Disposition and Medical Clearance
Assault and Hostage Situations
The Difficult Patient
Foundations
Specific Disorders
Attention-­Seeking Patients
Demanding Patients
Repeat Visitors
Self-­Destructive Patients
References
186 - Multiculturalism, Diversity, and Care Delivery
Background and Importance
Rationale For Cultural Competence
Changing Demographics
Tests and Treatments
Health Outcomes
Failure of Trust
Specific Issues
Communication and Use of Interpreters
Disability and Accommodations
Overview
The Hearing Impaired
The Homeless
Prisoners
The Undocumented
Cultural Competence
Appreciation of Different Beliefs, Values, and Experiences
Recommendations
References
187 - Human Trafficking
Background and Importance
Epidemiology
Trafficking Typologies
Global and US Prevalence
Demographics of Trafficked Persons
Recruitment and Control Tactics
Impact On Health
Substance Use
Mental Illness
Pregnancy
Specific Issues
Recognition and Assessment
Indicators and Red Flags
Trafficking Inquiry
Use of Professional Interpreters
Evaluation and Treatment
Trauma-­Informed Approach to Care
Multidisciplinary Response
Disposition
Admission versus Discharge
Safety Planning
Resources
Special Considerations
Mandatory Reporting
Medical Record Documentation
Diagnostic Codification
Law Enforcement Considerations
Barriers to Identification and Care
References
188 - Sexual Minority Populations (LGBTQ)
Background and Importance
Terminology and Concepts
Historical Context
Identity
Specific Issues
Factors Affecting Equitable Care
Legal Barriers
Sexual Minority Parental Barriers
Barriers to Health Care Access
Health Care Experience
Provider Education
Health Disparities
Transgender Health
Medical Gender Affirming Therapy and Complications
. For the transgender female, medical gender affirmation therapy commonly includes hormone supplementation with androgen blockin...
. The most common gender affirming medical treatment utilized by transgender men is testosterone. It can be administered IM, sub...
Surgical Gender Affirming Therapy and Complications
. Gender affirming surgeries for transgender women included genital procedures such as orchiectomy, vaginoplasty involving the c...
. Mastectomy is one of the most commonly requested surgery by transgender men. They experience the same rate and type of complic...
Physical Examination
Special Populations
Youth
Elders
People of Color
References
189 - Social Determinants
Foundations
Specific Issues
Patient and Provider Factors
A large number of patient and provider factors affect the care of patients (Table 189.1).2a
Language
Health Literacy
Insurance and Access to Care
Employment, Income, and Financial Strain
Food Insecurity
Homelessness and Housing
Transportation
Immigration Status
Education
Legal Concerns
Justice Involvement
The Built Environment
Management
Overview
Health Care Access and Literacy
Health Care Coverage
Disability and Loss of Employment
Challenges with Employers
Finding Employment
Income Support
Management of Food Insecurity
Health Care Based Resources
Community-Based Resources
Public Programs
Housing and Homelessness
Transportation Challenges
Immigration Status
Adjustment of Status
Victims of Violence and Crime
Refugees and Asylees
Hospital Safe Spaces Initiatives
Immigration Status and Public Charge
Education-Related Challenges
Domestic Concerns and Social Isolation
Legal Concerns
Legal Assistance
Patients in Police Custody
Tickets and Outstanding Warrants
References
190 - Community Violence
Foundations
Population Characteristics and Violence
Specific Issues
Root Causes of Community Violence
Psychological and Mental Health
Hospital-­Based Violence Intervention Programs
Boston University HVIP Model
References
191 - Sexual Assault
Foundations
Clinical Features
Differential Diagnoses
Diagnostic Testing
Sexually Transmitted Infections
Drug-­Facilitated Sexual Assault
Evaluating the Victim of Attempted Strangulation
Management
Medical Forensic Examination
General Principles of Evidence Collection
Special Techniques
. Colposcopy is a diagnostic procedure to illuminate, magnify, photograph, or digitally record external and internal genital str...
. Toluidine blue dye (TBD) is a stain that adheres to nuclei in damaged epithelial cells and has not been shown to interfere wit...
. An alternative light source (ALS) uses ultraviolet light to fluoresce biologic material. In sexual assault examinations, the A...
Special Populations
Older Adult Sexual Assault
Male Sexual Assault
Disposition
Testifying in Court
References
192 - Intimate Partner Violence and Abuse
Foundations
Background
Causes and Natural History of Intimate Partner Violence
Identification
Screening
Clinical Features
Injuries and Comorbidities
Questioning Injury Presentations
Specific Issues
Gynecologic-­Related Presentations
Mental Health Presentations
Alcohol and Drug Use and Intimate Partner Violence
Chronic Medical Conditions
Pain Syndromes
Human Trafficking
Diagnostic Testing
Management
Physician-­Delivered Messages
Documentation
Immigration Issues
Referral
Danger Assessment
Mental Health Screening
Privacy and Confidentiality Considerations
Involvement of Law Enforcement Agencies
Intimate Partner Violence Coding and Diagnosis
Disposition
References
e1 - Global Emergency Medicine
The Academic Practice of Global Emergency Medicine
Specific Issues
History of Global Emergency Medicine
Global EM Organizations
Areas of Focus in Global Emergency Medicine
Education
Systems Development (Systems Strengthening)
Research
National Societies
Policy
Humanitarian Assistance
Direct Clinical Care
Clinical Rotations Abroad
Preparation of the Traveler
Safety and Security
Research Ethics in Global EM
References
e2 - Humanitarian Aid in Disaster and Conflict
Foundations
Types of Humanitarian Emergencies
Natural Disasters
Disease Epidemics/Pandemics
Armed Conflict
Specific Issues
Standards in Humanitarian Response
International Law
Codes of Conduct
Sphere Standards
Priorities in Global Humanitarian Emergencies
Protection
Rapid Assessment
Food, Water, and Shelter
Health Care
Transition and Exit
International Actors in Humanitarian Response
Response Organizations
United Nations
Foreign Governments
Militaries
Individual Responders
Coordination of Humanitarian Response
Ongoing Coordination
The Emergency Clinician in Humanitarian Crises
Preparing for Humanitarian Response
Training for Humanitarian Response
Choosing a Deployment
Safety and Security
Ethical Dilemmas
Conclusion
References
e3 - Emergency Ultrasound
For the complete chapter text, go to ExpertConsult.com. To access your account, look for your activation instructions on the ins...
Foundations
Specific Issues
Basic Ultrasound Information
Physics and Knobology
Transducer Selection
Focused Assessment with Sonography in Trauma
Image Acquisition
Pathology
Special Considerations
Biliary
Image Acquisition
Pathology
Urinary Tract Ultrasound
Image Acquisition
Pathology
Abdominal Aorta
Image Acquisition
Pathology
Cardiac/Hemodynamic Assessment
Image Acquisition
Pathology
Airway/Thoracic Ultrasound
Image Acquisition
Pathology
Ultrasound in Early Pregnancy
Image Acquisition
Pathology
Deep Venous Thrombosis
Image Acquisition
Pathology
Ocular Ultrasound
Image Acquisition
Pathology
Soft Tissue Ultrasound
Image Acquisition
Pathology
Musculoskeletal Ultrasound
Image Acquisition
Pathology
Bowel Ultrasound
Pediatric Emergency Ultrasound
Ultrasound for Procedural Guidance
Vascular Access Procedures
Drainage Procedures
Localization Procedures
References
e4 - The Geriatric Emergency Department
Principles
Background/Foundations
Specific Disorders/Issues
Geriatric Emergency Department Guidelines
Staffing and Administration
Equipment and Supplies
Education
Policies, Procedures, and Protocols
Follow-­Up and Transition of Care
Quality Improvement Measures
Conclusion
References
e5 - End of Life
Foundations
Palliative Care
Overview
Palliative Care in the Emergency Department
Hospice Care
Overview
Hospice and the Emergency Department
End-­of-­Life Trajectories and Prognostication
Common Procedures and Interventions Faced at the End of Life
Intubation and Mechanical Ventilation
Cardiac Arrest
Advance Care Planning and Advance Directives
Overview
Goals-­of-­Care Discussions
Pain
Dyspnea
Death in the ED
Death Notification and Breaking Bad News
Viewing the Body
Family Presence During Resuscitation
Field Death Pronouncement
References
e6 - Bioethics
Foundations
Ethics and Emergency Medicine
Specific Issues
Bioethics and the Law
e6
Rights and Duties
Values
Society’s Values
Patient Values and Ethical Decisions
Fundamental Bioethical Principles
Nonmaleficence and Autonomy
Beneficence
Justice
Truth-­Telling
Confidentiality Versus Privacy
Professional Values
Safety: A Unique Value
Organizational and Institutional Values
Professional Codes
Applying Bioethics
Emergency Clinician/Patient Relationship
Recognizing Ethical Problems
Prioritizing Conflicting Principles
Case Example: Conflicting Bioethical Principles
Professional Value Conflicts
Rapid Ethical Decision-­Making Model
Advance Directives
Consent
Decision-­Making Capacity
Surrogates
Family
Surrogate Lists
Bioethics Committees and Consultants
Emergency Clinicians
Courts
Resuscitation Ethics
Futility
Withholding Versus Withdrawal of Treatments
Palliative Care
Notifying Survivors
Viewing Resuscitations
Postmortem Teaching
Resuscitation Research
Public Policy And Bioethics
Restricted Access to Emergency Medical Care
Morality of Triage Decisions
Physician Response to Risky Situations
References
Audiovisual Recordings and Social Media Use
A Global Perspective
e7 - Emergency Medical Treatment and Labor Act and Medicolegal Issues
Medical Screening Examination
Emergency Medical Condition
National Emergencies or Disasters
Sexual Assault Cases
Police-­Requested Blood Alcohol Tests
Policies, Procedures, and Practice Guidelines
Central Log
Medical Record
Stabilization Requirements
Disposition Issues Under Emergency Medical Treatment and Labor Act
Admission
“Discharge” or “Transfer” to Home
Discharge or Transfer from the Emergency Department to an On-­Call Physician’s Office
Follow-­Up Care After Discharge from the ED
Transfers to Other Acute Care Hospitals
Duty to Accept Appropriate Transfers from Other Hospitals
Duty to Report Transfer Violations
Consent For Medical Care
Informed Consent
Federal Versus State Laws
Emergency Clinician Role in the Consent Process
Implied Consent in Emergency Situations
Minors
Minors Accompanied by a Parent or Legal Guardian
Unaccompanied Minors
Incompetent or Incapacitated Adults
Other Special Populations of Patients
Prisoners
Alcohol-­Intoxicated Patients
Patients Given Pain Medications
Refusal Of Medical Care
Informed Refusal
Determining Competence
Ensuring an Informed Decision
Involving Others
Documenting Appropriately
Federal Rules
Leaving Without Being Seen
Leaving Against Medical Advice
Parent or Guardian Who Refuses Care or Blood Transfusions for a Minor
Jehovah’s Witnesses
Adult Blood Transfusions
Competent Adult
Unconscious or Medically Incompetent Adult
Reporting Requirements
References
e8 - Quality Improvement and Patient Safety
Background
Work Systems
Resilience
Sources of Failure in Emergency Care
Communication and Interruptions
Workspace Design
Crowding
Information Gaps
Performance-­Shaping Factors
Violation-­Producing Factors
Teamwork
Efficiency/Thoroughness Trade-­Off
Authority Gradients
Cognitive Processes
Fatigue and Shift Work
Problem Areas in Emergency Care
Triage
Technical Procedures
Laboratory Tests
Radiology Studies
Transitions in Patient Care
Orphaned Patients
Medications
Summary
References
e9 - Patient Experience in the Emergency Department
Foundations
Specific Issues
Challenges and Opportunities
Focusing on Communication
Wait Times and Expectation Setting
Discharge Instructions
Summary
References
e10 - Wellness, Stress, and the Impaired Physician
Foundations
Wellness Strategies
Individual
Health Care Organizations
External Environment
References
e11 - Forensic Emergency Medicine
Forensic Evaluation of Handgun Injuries
. Handguns are the most common firearm available. There are four categories of handguns: (1) the single-­shot weapon (usually a ...
. The cartridge, or round, is composed of the primer, cartridge case, powder, and bullet (Fig. e11.1). The bullet is the project...
Forensic Aspects of Rifles
Forensic Aspects of Shotguns
Forensic Aspects of Air Guns/Rifles
Epidemiology
Clinical Features
Errors of Interpretation and Terminology
Handgun Entrance Wounds
. There are three subcategories of contact wounds: (1) tight contact, in which the muzzle is pushed hard against the skin; (2) l...
. Close range is the maximum range at which soot is deposited on the wound or clothing. The muzzle to target distance is usually...
. Tattooing, or stippling, is pathognomonic for an intermediate-­range gunshot wound. Tattooing appears as punctate abrasions an...
. The distant or long-­range wound is inflicted from far enough away that only the bullet makes contact with the skin. There is ...
. Atypical entrance wounds occur when a bullet encounters an intermediate object, such as a window, wall, or door, before striki...
Handgun Exit Wounds
. A shored exit wound is a wound that has an associated false abrasion collar. If the skin is pressed against or supported by a ...
Centerfire Rifle Wounds
Shotgun Wounds
Clinical Features of Firearm Injuries
Diagnostic Testing
Differential Diagnosis
Management and Disposition
Head and Neck Injuries
Thoracic Injuries
Abdominal Injuries
Extremity Injuries
Soft Tissue Injuries
Evidence
Conclusions
Forensic Aspects of Physical Assault
Perspective
Blunt Force Pattern Injuries
Pattern Contusions
Pattern Abrasions and Lacerations
Sharp Force Pattern Injuries
Thermal Pattern Injuries
Chemical Injuries
Forensic Aspects of Motor Vehicle Trauma
Perspective
Motor Vehicle Collisions
Motorcycle Collisions
Evaluation of Motor Vehicle Collisions
Pattern Injuries
Trace Evidence
Evaluation of Pedestrian Collisions
Pattern Injuries
Interfacing with the Law
Law Enforcement Exemptions to the Health Insurance Portability and Accountability Act
Mandatory Reporting
Subpoenas and Court Depositions
References
Forced Blood Draws
e12 - Emergency Medical Services: Overview and Ground Transport
Development of Emergency Medical Services
Specific Issues
Emergency Medical Service Systems
Private and Public Agencies
Basic Life Support and Advanced Life Support Service
Single-­Tiered, Multitiered, and First Responder Systems
Levels of Provider and Scope of Practice
Emergency Medical Responder
Emergency Medical Technician
Advanced Emergency Medical Technician
Paramedic
Material Resources
Medications
Equipment
Ambulances
Communications
Access
Emergency Medical Dispatch
Systems Status Management and Flexible Deployment
Field Communications
Oversight
Federal
State
Local
Medical Director
Indirect Medical Oversight
Direct Medical Oversight
Airway Support and Respiratory Emergencies
Interventions
Medications
Cardiovascular Emergencies
Interventions
Medications
Traumatic Emergencies
Interventions
Interfacility And Specialized Transports
Acknowledgments
References
e13 - Air Medical Transport
Specific Issues in Air Medical Transport
Administrative Structure of Air Transport Systems
Types of Transports
Air Medical Aircraft
Helicopters (Rotor-­Wing Aircraft)
Airplanes (Fixed-­Wing Aircraft)
Air Medical Flight Crew
Medical Direction
Safety
Landing Zones
Specific Disorders
Trauma
Burn Victims
Cardiac Disorders
Stroke
High-­Risk Obstetrics Patients
Neonates and Children
References
Future of Air Medical Transport
e14 - Disaster Preparedness
Surge Capacity
Definitions
Classic Terminology
Hazard Vulnerability Analysis
Specific Issues In Disaster Management
Triage
Routine Multiple-­Casualty Triage
Catastrophic Casualty Management
Vulnerable Triage Populations
Special Triage Categories
Care of Populations with Functional or Access Needs
Out-­of-­Hospital Response
Emergency Medical Services System Protocols
Incident Management System
Organization of the Out-­of-­Hospital Disaster Scene
Planning and Hospital Response
Comprehensive Emergency Management
Hospital Disaster Response Plan
. In a large-­scale disaster, each individual hospital may need to remain self-­sufficient for 48 to 72 hours or longer. Disaste...
Basic Components of a Hospital Comprehensive Disaster Response Planning Process
. The interdepartmental planning group (frequently referred to as the disaster or emergency preparedness committee) is composed ...
. A full inventory of the hospital’s resources is necessary, including equipment, space, and personnel. It is also necessary to ...
. The HICS implements an organized approach to disaster management by establishing lines of authority and decision responsibilit...
. The media can be an important source of information but can also significantly disrupt the hospital’s disaster response. Arran...
. Communication systems are probably the most important but also most vulnerable component of a disaster plan. Redundant systems...
. The disaster plan should include a roster of all critical positions with relevant personnel and establish a reliable method fo...
. A systematic approach to patient management is necessary to maximize resources. This includes protocols for decontamination, t...
. On rare occasions, the hospital structure or critical infrastructure will be damaged, forcing facility evacuation. After hospi...
. Disaster exercises are one of the more effective ways of familiarizing hospital staff with their responsibilities. All hospita...
Toxic Disasters (Hazardous Material)
Disaster Stress Management
Personal Preparedness
Disaster Management and Response Organizations within the United States Government
Department of Homeland Security
Urban Search and Rescue (ESF #9 of the National Response Framework)
Department of Health and Human Services
National Disaster Medical System
Centers for Disease Control and Prevention
Department of Veterans Affairs
Department of Defense
Future Directions
References
e15 - Weapons of Mass Destruction
Specific Disorders
Nuclear and Radiologic Devices
Foundations
Clinical Features
Management
Biologic Weapons
Foundations
Clinical Features
Management
Anthrax
. Bacillus anthracis, a gram-­positive, spore-­forming bacterium, is the causative agent of anthrax (“woolsorter’s disease”). Th...
. After phagocytosis by macrophages, the spores germinate and are transported to the tracheobronchial lymph nodes, where the bac...
. Traditional treatment of anthrax infection has been with penicillin. However, weapons-­grade anthrax is probably resistant to ...
Plague
. Plague has been a human pathogen since antiquity. Many regions of the world, including Asia and India, are witnessing the thir...
. Primary pneumonic plague results when bacilli are inhaled into the lungs. The mortality rate approaches 100% if it is not trea...
. The preliminary diagnosis of plague is clinical. Few diseases other than plague cause fulminant gram-­negative pneumonia assoc...
. Antibiotic treatment is essentially identical for all three types of plague (Box e15.6). The same caveats for the use of fluor...
Smallpox
. Smallpox was eradicated in 1980. The only known repositories of the variola virus, the etiologic agent of smallpox, are in the...
. The disease manifests clinically in several forms. Variola major and variola minor represent 90% of the cases. Variola major i...
. As with anthrax and plague, the initial diagnosis of smallpox is clinical. Other illnesses resembling smallpox include chicken...
. For confirmation of the diagnosis, vesicular fluid or scabs are sent for electron microscopic examination or tissue culture. P...
. No proven therapy exists for humans infected with smallpox who become symptomatic. However, antiviral agents such as tecovirim...
Chemical Weapons
Nerve Agents (Sarin, Tabun, Soman, and VX)
. Nerve agents are organophosphates. They inhibit the enzyme acetylcholinesterase, blocking the degradation of acetylcholine at ...
. Symptoms are receptor dependent. Stimulation of muscarinic receptors produces miosis, salivation, rhinorrhea, lacrimation, bro...
. Decontamination of victims exposed to sarin vapor requires removal of clothing. People contaminated with VX or liquid sarin sh...
Vesicants (Mustard)
. Vesicants (blistering agents) are chemical warfare agents that induce blister formation on contact with skin. Terrorists could...
. The exact mechanism is unknown, but the agent damages DNA, causing eventual cell death. These effects are similar to radiation...
. Single-­ and three-­color detector papers exist for individual use. Treatment is supportive and includes decontamination (to p...
Cyanides (Blood Agents)
. Cyanide molecules, most typically hydrogen cyanide or cyanogen chloride, bind to cytochromes within mitochondria and inhibit c...
. Low-­dose exposures result in tachypnea, headache, dizziness, vomiting, and anxiety. Symptoms subside when the patient is remo...
. Victims should be removed from the area, have their clothing discarded, and receive oxygen. If no improvement occurs, the cyan...
Pulmonary Intoxicants (Phosgene and Chlorine)
. Pulmonary or choking agents cause an inflammatory reaction when they come into direct contact with the eyes and upper airway. ...
. Exposure to pulmonary intoxicants results in a latent period between 20 minutes and 24 hours, dependent on the chemical, amoun...
. Clothing should be removed to prevent secondary exposure. Strict activity limitation, including litter evacuation followed by ...
Blast Injuries from Conventional Explosives
Foundations
Clinical Features
Management
References
. Primary blast injury produces barotrauma, with air-­containing organs such as auditory, pulmonary, and gastrointestinal being ...
. Blast lung injury is a major cause of morbidity and mortality both at the scene and at the hospital among initial survivors. S...
. Secondary blast injury is the most common cause of morbidity and mortality following a blast event. These injuries are caused ...
. Tertiary injuries result from individuals being thrown by the blast wind. The most common types of tertiary blast injuries are...
. Quaternary blast injuries comprise all explosion-­related injuries, illnesses, or diseases not due to primary, secondary, or t...
e16 - Tactical Emergency Medical Support and Urban Search and Rescue
Principles
Background
Organizational Principles and Objectives
Special Issues
Tactical Emergency Medical Support Providers and Scopes of Practice
Casualty Care
Care Under Fire
Tactical Field Care
Combat Casualty Evacuation Care
Committee for Tactical Emergency Casualty Care
. To meet the specific operational scenarios and terminology used in the civilian sector, the first phase of care under TECC is ...
. Indirect threat care can be initiated once the casualty is in a relatively safe area, with proper cover and less chance of res...
. The final phase of care under TECC is called evacuation care, when the casualty is moved to a definitive treatment facility. M...
Tactical Team Health
Active Shooter Incidents
Future Directions
Urban Search And Rescue
Medical Team Operations in Urban Search and Rescue
Medical Team Tasks
Predeployment
Deployment
Confined Space Rescue
Specific Medical Challenges
Crush Injury and Crush Syndrome
Environmental and Hazardous Materials Exposures
References